84521 v1
                         Below the Glass Floor
             The analytical review of expenditure by provincial administrations
                                  on front line rural health
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Below the Glass Floor is a report that explores the impact of recent increases in operational function
grant funding to provinces to support rural health service delivery. It seeks to identify what expenditure
provinces have made to support and enable key front line service delivery activities such as; facility
operations, patrols, medical supply distribution, emergency patient transfer, rural water supply and
facility supervision. This top down trend analysis seeks to identify whether spending has been made in
these areas as a first step in understanding the effectiveness of the governments’ financial
arrangements. The next step is to triangulate the findings using field-based research that assesses what
impact the funding is having at the facility level.
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Below the Glass Floor opens this discussion and helps to inform and frame our thinking by exploring:
       Allocation of expenditure: whether enough is spent on front-line service delivery activities
       Accessibility of funding: whether the money is accessible to those staff who need to spend it
       Quality and effectiveness: setting the scene for the fieldwork phase to assess whether the
        service delivery money is being spent well
In addition to the framework above the findings highlight other observations and questions, such as:
       Functional responsibility: some key activities seem to have slipped through the cracks, who
        is responsible for them?
       Warrant/cash release: the timing, predictability and consistency of the grant release
        arrangements needs to improve. (see graphic below)
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Core funding from the national level for rural health needs to be timely and consistent
                  Chart: Cash release by February in 2008-2010 (ordered by region)


                             In 2010 – 9 provinces got enough, 6 provinces got zero




                            In 2009 – all Highlands and 4 Southern provinces get zero




                                In 2008 almost everyone got 50% which was good
Summary of findings on spending to support front line activities

  Rural Health Facility Operations (MPA 1)
    We certainly see increased spending in this area in 2009 and 2010 – eleven provinces spent between
      50-100% of what is estimated necessary. The question remains how much of this was eventually
      spent on facilities? Budget coding can be improved and sharpened in this area.
    In many instances, facility funds appear to be retained and managed from the provincial level. It
      invites the question as to whether this is an effective arrangement for facilities. Can facility staff
      access these funds as readily as they need to?
    Facility maintenance is a key activity. There needs to be greater direction and clarity on where the
      responsibility for this activity and the funding is best managed. Is that at the provincial, district or
      facility level?


  Outreach Patrols (MPA 2)
    In 2009 and 2010 we certainly see increased spending that may be in the outreach patrols space.
      However due to generalised coding it is difficult to know with certainty how much of this spending
      actually was on outreach patrols as opposed to other activities. Budget coding needs to improve.
    Facility based staff need easy access to funding for patrols. What is the best arrangement(s) to ensure
      this happens in practice?


  Distribution of Drugs and Medical Supplies (MPA 3)
    Two-thirds of provinces spent little or nothing on this activity in 2010.
    In 2011-12 the National Department of Health assisted by AusAID has commenced a program of
       procuring and distributing 40% and now 100% kits to rural facilities. This essentially recentralises a
       large part of the rural drugs and medical supply function.
    The distribution aspect of this function is noted as a provincial responsibility in the function
       assignment determination – with this recent change it needs to be made clear where the responsibility
       for the function now rests. Is it now a national function? Or is it a dual function, and if so, is there
       sufficient clarity on roles and responsibilities.


  Emergency Patient Transfer (about 23% of the NEFC cost estimate for rural health)
    Despite patient transfer being identified as a major cost in the NEFC cost study there appears to be
     little funding specifically allocated and spent by provinces on transfers from facilities to hospitals.
    As a matter of policy, should an amount be allocated in provincial budgets for patient transfer? If it is
     assumed as the responsibility of the patient's family, will it affect the access to hospital services for
     the poor?
    Where should the funding for this activity be managed from - should it be at the provincial, district or
     facility level? Or should it be distributed to more than one level?


  Clean Water Supply (about 19% of the NEFC cost estimate for rural health)
    Water supply is a major cost identified in the NEFC cost study.
    There is evidence of some spending on this activity across most provinces.
    Is this function a responsibility of provincial governments? And is it an activity for the rural health
      team to coordinate, administer and implement? If so, it should be noted in the function assignment
      determination (FAD) administered by DPLGA and funding to support the activity should be allocated.


  Supervisory activities
    There is little visible spending on provincial and district supervision activities. How is this critical
     activity funded? And is the current funding approach effective?