CAPÍTULO IV: ÉTICA Y EVOLUCIÓN
4.6 El lenguaje de la evolución
After a period of decline in the 1990s, there has been a steady and general increase in both nominal and real financial resources for the health sector during the period under evaluation.49 Combined on-budget and off-budget estimates increased in real terms from
approximately USD 140 million in FY 2000 to almost USD 430 million in FY 2006.50
The public health sector in Tanzania receives significant funds from both domestic and external sources with external sources predominating in the early part of the period and domestic sources dominating slightly towards the end of the period. The domestic com- ponent increased to constitute 55% of total estimates by FY 2006. It should be noted however that this does not take account of the significant volume of external funding flowing to the HIV/AIDS sector. The domestic component also includes general budget support from DPs.
49) In the interest of brevity, the tables and charts presenting financial data analysed in this section are presented in Annex 5. The data is mainly derived from the PERs for the health sector. As indicated in the PER, queries remain for some of the data and it may be revised with the release of the PER for FY 2007.
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Real per capita public health expenditures also increased over the period, but were flat from FY 2002 to 2003, mainly due to a decrease in the foreign component of off-budget financing. The level observed for FY 2005 (approximately USD 9) is still well below the USD 12 target established in the 1993 Word Development Report and far below the USD 40 target for 2007 established by the Commission for Macroeconomics and Health for low-income countries in Sub-Saharan Africa.51
Source: Own calculations based on PER FY 2004, FY 2005, FY 2006, IMF International Financial Statistics, and Bank of Tanzania
Note: 1999-2006 average exchange rate used
In 2001 in Abuja, the GoT, together with other countries, committed to reserving 15% of its national budget for health. In the first three years of the period under evaluation (2000-2003) health sector expenditures measured as a share of total Government spend- ing increased from roughly 7 to 10.5% (including Consolidated Fund Service charges) and from roughly 9 to 12.5% (excl. CFS). Tanzania was apparently on track to meeting the 15% target under the Abuja Declaration. However, the following three years saw a decline followed by modest growth. The health sector’s share of total GoT spending is yet to reach the level observed in FY 2003, let alone the Abuja target.
51) Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health. WHO, Geneva, 2001. P.171.
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The table below demonstrates the development of on-budget and off-budget budget esti- mates for the evaluation period. The share of on-budget estimates of total estimates has increased from approximately 60 to 80% over the period of evaluation.
Table 4: Public Expenditure on Health: On- and Off Budget Estimates, Real Terms in USD million.
FY 2000 2001 2002 2003 2004 2005 2006 On-Budget 90.3 115.o 153.4 180.9 204.o 262.7 345.9 Off-Budget 53.3 57.5 63.4 45.6 66.5 89.4 81.7 Total 143.6 172.5 216.8 226.6 270.5 352.1 427.5
Source: Own calculations based on PER FY 2004-06, IMF International Financial Statistics, and Bank of Tanzania.
Note: 1999-2006 average exchange rate used. Figures rounded.
Increases in On-Budget Resources
The biggest single contributing factor to the rise in on-budget resources during the evalu- ation period has been a steady increase in Government of Tanzania financing from just over USD 50 million in FY 2000 to just under USD 200 million in FY 2005. GoT con- tributions accounted for between 65 and 75% of on-budget sector expenditure during the period.
A much smaller proportion of Government funding is channelled through the Accoun- tant General’s Office in the form of contributions to the National Health Insurance Fund (NHIF). While increasing over the period (FY 2006 saw a doubling of the budg-
eted contribution) it currently represents less than 5% of total budget estimates to the sector.
Defining On and Off-Budget Financial Resources
The FY 2006 PER for the health sector defined five different categories of financial resources.
On Plan Incorporated into planning documents, for health the MTEF and LGA plans.
On Budget Captured within the official budget estimates as submitted to the national
assembly.
On Treasury Funding channeled through the exchequer and channeled fully in harmony with
GoT systems. Domestic resources and general budget support are on treasury.
On Account Funding which, whether on treasury or not, is incorporated into financial
reporting by the sector.
On Report Funding which is reported on in the regular monitoring documents of the sector.
There has also been a significant increase in DP on-budget funding of the health sector in Tanzania during the evaluation period, most significantly in the form of the HBF. The HBF increased steadily from FY 2000 before falling back in FY 2004 and rising again in FY 2005. Some key informants attributed the FY 2004 decline to DFID’s decision to move its contribution from the HBF to GBS. According to MOHSW staff, this resulted in only 50% of prior funding being allocated to the health sector.
Despite fluctuations over time, the HBF has become a key source of financing for the health sector in Tanzania, especially for development expenditure (less so for recurrent expenditure, where domestic financing is still the main source). Development partners also provide on-budget support in the form of financing for specific projects and pro- grams. Except for FY 2004, this funding tracks well below HBF funding and has been very volatile over time.
Off-Budget Resources
In reviewing off-budget resources it is also useful to consider both domestic and foreign funding. Domestic off-budget resources are raised mainly through cost-sharing schemes. The combined contribution of the cost-sharing schemes is limited (estimated at USD 10.9 million in FY 2006) compared to the foreign financed component of off-budget health sector financing (USD 96 million in the same year). On the other hand, revenue raised through the cost-sharing schemes increased in nominal figures reaching its 2006 level from a base of USD 1.5 million in FY 2000. Data on these sources is not systemati- cally reported and consolidated at a central level, so estimates provided in annual PER reports understate the amounts they contribute.
While significant, the volume of external off-budget expenditure has been highly volatile, increasing from a low of USD 40 million in FY 2004 to a peak for the period of over USD 120 million the following year. Generally speaking off-budget foreign financing consists of projects financed by development partners as captured in the external finance database maintained by the Ministry of Finance.52
52) The data on off-budget external financing is based on crude estimates carried out by the PER team on the basis of data from the MOF external finances database.
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HIV/AIDS Finances
According to the most recent PER on HIV/AIDS expenditure, the most significant fund- ing mechanisms for HIV/AIDS activities are the Global Fund for AIDS Tuberculosis and Malaria (GFATM), the Presidents Emergency Programme for Aids Relief (PEPFAR),53
and the World Bank financed Tanzania Multi-sector AIDS Programme (TMAP). These have seen a tremendous increase in the course of the evaluation period. PEPFAR funding for example increased from roughly USD 45 million in FY 2005 to close to USD 100 mil- lion for the current FY54.
External HIV/AIDS support now exceed external on-budget resources for the health sec- tor and is second only to domestic on-budget resources for health.
Source: PER Health FY 2005, 2006 and PER Tanzania Public Expenditure Review Multi-Sectoral Review: HIV-AIDS, November 2003 and March 2007.
Note: Both sources rely on data from MOF database on externally financed projects. It has not been possible to ascertain whether some HIV-AIDS financed activities are double- counted in the sense they are included in both external-off-budget and external HIV-AIDS.
Almost all of DP support to HIV/AIDS spending was managed outside the Govern- ment’s accounts and systems in FY 2003 and 2004. The budgeted assistance for HIV/ AIDS will according to projections in the most recent PER for HIV/ADS amount to almost USD 350 million in FY 2007 with almost USD 300 million outside government accounts. Although the share managed outside government accounts has decreased slightly since FY 2004, it still accounts for the overwhelming majority.
53) Clearly this classification mixes multilateral global health initiatives (GFATM), a single-country large bilateral program supporting HIV/AIDS work (PEPFAR) and a national program with IFI support (TMAP). The characteristic these three programmes share is their very large scale and the fact they remain essentially off-budget (and sometimes go unrecorded in annual PER reports).
Even though funds such as the GFATM are managed outside the Government accounts, they are increasingly captured on the Government budget. Accordingly, the off-budget vs. on-budget debate is somewhat distorted by the fact that a significant proportion of on-budget funds are nevertheless managed through parallel DP-controlled systems. Council Own Sources
As already noted, off-budget finances are also raised by Councils in the form of dues and taxes. No reliable aggregated data is available to estimate the total of these funds and the share allocated to health. However, based on the review of CCHPs in the six focus coun- cils, it can be seen that revenue raised through own sources has constituted no more that 5% of total income for health in the councils for the period under evaluation. Councils are to a very large degree dependent on intergovernmental transfers and funding from development partners to operate health services.
Implications for Sustainability
The implications of all this for the sustainability of funding of the health sector are com- plex. On the one hand there are factors arguing for increased sustainability, including the increasing share of GoT funding for on-budget resources in the health sector and the growth (although limited) in the volume of funds from cost-sharing, the CHF and the NHIF. On the other hand, the very rapid rise in funding for HIV/AIDS, while appar- ently sustainable in the medium term given the commitments made by the programmes in question, may not be sustainable in the longer term given the relatively small propor- tion of overall HIV/AIDS expenditures provided from domestic sources.