Honduras PETS Volume I
64692 v1
PUBLIC EXPENDITURE TRACKING AND SERVICE DELIVERY SURVEY – EDUCATION AND HEALTH IN HONDURAS
Volume I
September2010
Latin America and the Caribbean Regional Office
Public Expenditure Tracking and Service Delivery Survey– Education and Health in Honduras
Copyright © 2010 by The International bank for Reconstruction and Development / The World Bank, 1818 H street, N.W.
Washington, D.C. 20433, U.S.A.
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ABBREVIATIONS AND ACRONYMS
ADEL / Local Development AssociationAIN-C / Atención Integral a la Niñez en la Comunidad (Comprehensive Community Child Health Services)
AMHON / Association of Municipalities of Honduras
Sida / Agencia Sueca para el Desarrollo Internacional (Swedish Agency for International Development)
CBOs / Community-based organizations
CCERP / Consejo Consultivo de la Estrategia para la Reducción de la Pobreza
CEB / Centro de Educación Básica (Centre of Basic Education)
CEPREB / Centro de Educacion Prebasica (Centre for Prebasic Education)
CESAMO / Centro de Salud Urbana (UrbanHealth Centre)
CESAR / Centro de Salud Rural (Rural Health Centre)
CLIPPER / Periferal clinics
CMH / Honduras Medical Association
CMI / Maternal and Child Centre
CONEANFO / National Commission for the Development of Non-Formal Education
CPME / Comision Presidencial de Modernizacion del Estado (Presidential Commission for State Modernization)
EFA / Programa Educación para Todos (Education for All)
ERP / Estrategia para la Reducción de la Pobreza (Poverty Reduction Strategy)
ETSDS / Expenditure Tracking and Service Delivery Survey
FHIS / Fondo Hondureño de Inversión Social (Social Investment Fund)
FONAC / Foro Nacional de Convergencia (National Convergence Forum)
GDP / Gross Domestic Product
GOH / Government of Honduras
HDI / Human Development Index
HR / Human Resources
IDB / Inter-American Development Bank
IHSS / Instituto Hondureño de la Seguridad Social (Social Security Institute)
INE / Instituto Nacional de Estadística (National Institute for Statistics)
INFOP / Instituto Nacional de Formación Profesional (National Institute of Vocational Training)
INPREMA / Instituto Nacional de Previsión del Magisterio
Lps / Lempiras
MDG / Millenium Development Goals
MG / Matrícula Gratis
MLps / Million Lempiras
MOE / Ministry of Education
MOF / Ministry of Finance
MOH / Ministry of Health
NAS / Nueva Agenda de Salud (New Health Agenda)
NGOs / Non-governmental organizations
PIU / Project Implementation Unit
PMA / Programa Mundial de Alimentos (World Food Organization)
PNS / Plan Nacional de Salud (National Health Plan)
PN / Plan Nacional (National Plan)
POA / Plan Operativo Anual (Annual Operational Plan)
PROHECO / Programa Hondureño de Educación Comunitaria (Honduras Community Education Program)
PTA / Parent/Teacher Association
RHD / Regional Health Department
SE / Secretaría de Educación (Ministry of Education)
SEFIN / Secretaría de Finanzas (Ministry of Finance)
SIAFI / Sistema Integrado de Administración Financiera (Integrated Financial Management System)
SIARH / Sistema Integrado de Administración de los Recursos Humanos (Integrated System for the Administration of Human Resources)
SIARHD / Sistema Integrado de Administración de los Recursos Humanos Docentes (Integrated System for the Administration of Human Resources in Education)
SIERP / Sistema de Información para la Estrategia para la Reducción a la Pobreza (Poverty Reduction Strategy Information System)
SS / Secretaría de Salud (Ministry of Health)
STS / Staff Tracking Survey
TSC / Tribunal Superior de Cuentas (Supreme Audit Institution)
UMCE / External Unit for Measuring Education Quality
UNAH / Universidad Nacional Autónoma de Honduras (National Autonomous University of Honduras)
UNAT / Unidad de Apoyo Técnico
UPEG / Unidad de Planificación y Evaluación de la Gestión (Planning and Evaluation Unit)
WB / World Bank
INDEX
Volume I
Acknowledgements
Executive Summary
Volume II
Chapter I – Methodological Approach...... 9
Objective...... 9
Overall Approach...... 11
Chapter II - Expenditure Tracking and Service Delivery Survey in Education...... 14
Basic Education Sector Issues...... 14
Organization of the Honduran Educational System...... 15
Analytical Framework and Survey Design...... 20
Education Infrastructure and Working Environment...... 26
The Flow of Human Resources in Public Primary Education...... 31
The “Matrícula Gratis” Transfer Program...... 43
The Flow of Textbooks...... 49
School Lunch Program (“Merienda Escolar”)...... 53
Parental Involvement...... 55
Role of Municipalities in the Education Sector...... 57
Main Findings and Policy Recommendations...... 59
Chapter III - Expenditure Tracking and Service Delivery Survey in Health...... 66
Health Sector Issues...... 66
Organization of the Health Sector...... 67
Analytical Framework and Survey Design...... 71
Sector Financing Flows and Expenditure Allocation...... 76
Facilities’ Financing Patterns and Resource Flows...... 81
The Flow of Human Resources...... 90
The Flow of Pharmaceuticals and Supplies...... 97
Management at the Facility level...... 100
The user’s perspective...... 120
Role of the Municipalities in the Health Sector...... 124
Main Findings and Policy Recommendations...... 126
References...... 130
ANNEXES
annex 1. Methodological/sampling
annex 2. instruments
List of Tables
Table 1. Education and health service providers included in the sample...... 12
Table 2. School Sample...... 22
Table 3. Beneficiary-level databases...... 25
Table 4. School sample, Physical Plant and Teachers...... 27
Table 5. Quality of the physical plant (%), by school type...... 28
Table 6. Teacher sample...... 29
Table 7. Teachers in the sample, by grade and school type...... 29
Table 8. Characteristics of Teachers Selected for the Sample by School Type...... 30
Table 9 Survey schools not found in official ministry database, excluding PROHECO schools...... 32
Table 10. Survey Teachers not found in ministry database (Subset “C U D”)...... 33
Table 11. Teacher salary regressions...... 36
Table 12. School director opinions on teacher absenteeism...... 38
Table 13. Teacher absenteeism: 2008 school days missed, by survey...... 39
Table 14. Teacher absences (days), during 2008 School year...... 41
Table 15. Determinants of the probability that the teacher was absent for at least one day during the week prior to the survey. (MECOVI 2004) 42
Table 16. Uses of MG funds (% of MG recipients reporting use)...... 46
Table 17. School management of funds...... 47
Table 18. Ministry of Education 2008 mathematics textbook distribution strategy...... 50
Table 19. Textbook flow and stock...... 51
Table 20. Number of additional textbooks teachers needed, by school type (Teacher survey)...... 52
Table 21. Percentage of textbooks per student according to school director survey, by school type....52
Table 22. Schools that receive PMA food by school type (2008)...... 54
Table 23. Parent rating of their child's public school (%)...... 55
Table 24. Parent characteristics, by relation to the PTA...... 56
Table 25. Municipal spending on the education sector, per expenditure category, as percentage of source of funding 57
Table 26. Municipal spending on education per category of expenditure...... 58
Table 27. Municipal spending on education per source of income, as reported by the municipalities...58
Table 28. Comparative international health indicators, 2006...... 66
Table 29. Health facilities in Honduras, 2007...... 68
Table 30. Main characteristics of the departments included in the survey...... 73
Table 31. Final survey sample...... 73
Table 32. Analytical matrix and data sources...... 76
Table 33. Health spending and sources by subsystem, Honduras, 2006...... 79
Table 34. Mean total expenditure reported by type of facility, 2006-2008 (in thousand Lempiras)....86
Table 35. Budget and expenditure by type of facility, 2008...... 87
Table 36. Mean income from user charges by type of facility and service...... 88
Table 37. Mean hospital expenditure by line item...... 89
Table 38. Average number of staff by type of facility....... 92
Table 39. Discrepancies in personnel information across sources...... 93
Table 40. Composition of staff sample...... 94
Table 41. Personnel by level of education...... 95
Table 42. Main obstacles to work achievement...... 95
Table 43. Mean gross monthly wage by type of facility and profession (in Lempiras)...... 96
Table 44. Procurement authority by type of supply, 2008...... 99
Table 45. Mean losses and waste in stock management...... 100
Table 46. Classification of facilities according to type, management model, and hierarchy...... 103
Table 47. Lines of authority between central levels and facilities...... 104
Table 48. Existence and type of councils or committees in facility governance...... 105
Table 49. Presence of users’ committees by facility type and management model...... 107
Table 50. Level of managerial autonomy by type of facility...... 108
Table 51. Mean physician productivity by type of facility (number of visits/hour contracted), 2006-2008 117
Table 52. Problems affecting quality of care...... 119
Table 53. Distribution of users simple by type of facility...... 120
Table 54. Most frequent diagnoses or symptoms driving patients to the facility...... 121
Table 55. Perceived quality of care and facilities...... 122
Table 56. Payments made for care received...... 122
Table 57. Users payments by type of service and type of facility, 2008 (in Lp)...... 123
Table 58. Municipal spending on education per category of expenditure...... 125
Table 59. Municipal spending on education per source of income, as reported by the municipalities..125
List of Figures
Figure 1. Origin and destination of public expenditure flows...... 19
Figure 2. Personnel databases...... 33
Figure 3. Structure and levels of the public health system in Honduras...... 68
Figure 4. Composition of national health expenditure, 2006...... 77
Figure 5. Institutions and Financial Flows in the Health System, Honduras...... 78
Figure 6. Distribution of health spending by category of expenditure, MOH, Honduras, 2006...... 80
Figure 7. Spending composition by type of input, MOH, Honduras 2006...... 80
Figure 8. Financing sources by type and model of facilities, 2008...... 82
Figure 9. Financing sources for public hospitals, 2008...... 82
Figure 10. Financing sources of public health centers (reported), 2008...... 82
Figure 11.a-e: Responsibility for procurement and payments by type of facility...... 85
Figure 12. Difficulties in budget execution at facility level (proportion of those facilities having their own budget) 89
Figure 13. Mean expenditure composition by line item, 2008 (Hospitals and Clinics only)...... 90
Figure 15. Responsibilities for paying, hiring, firing and transferring personnel...... 91
Figure 16. Facilities staff broken down by professional category, 2008...... 91
Figure 17. Coexistence of multiple staff contracting regimes...... 94
Figure 18. Proportion of workers moonlighting, by profession...... 97
Figure 19. Responsibility for drugs procurement by facility type and model...... 98
Figure 20. Frequency of ratios between amount reported by management and recorded in stock cards for 10 most important drugs, 2008 100
Figure 21. Ratios between quantities physically observed and recorded in stock cards, 117 facilities, 2008 100
Figure 22. Management model by type of facility...... 101
Figure 23. Main functions of facility committees by type of committee...... 106
Figure 24. Main responsibilities of committees by type of facility...... 106
Figure 25. Presence of users’ committee by type of facility...... 107
Figure 26. Proportion of facilities with their own separate budget...... 108
Figure 27. Residual claimant status regarding budget savings...... 109
Figure 28. Residual claimant status regarding user charges...... 110
Figure 29. Main bases for planning in the sampled facilities, 2008...... 111
Figure 30. Priority programs and activities cited for Plan 2009 Priority #1 Priority #2....112
Figure 31. Accounts rendering by authority...... 113
Figure 32. Monitoring and control of expenditures at the facility level...... 114
Figure 33. Most commonly used management tools...... 114
Figure 34. Maintenance systems by type of facility...... 115
Figure 35. State of installations by type of facility...... 116
Figure 36. Main activities undertaken by the facilities...... 117
Figure 37. Hospital efficiency and productivity...... 118
Figure 38. Outpatient productivity (total outpatient services per staff) across facilities...... 119
Figure 39. Age composition of patients...... 120
Figure 40. Proportion of municipal budgets spent on health, 2008...... 124
Acknowledgements
This study has been conducted per the request of the Ministry of Finance and the Social Cabinet of Honduras. It has been a long journey that started back in 2007 with the design of the project and finished in 2010 with the presentation of this report. Despite numerous unexpected incidences on the road – including floods and heavy rains, teachers’ strikes, institutional changes and a political crisis that left the country isolated and put “on hold” externally-funded programs – the team persisted in its effort to bring to light the conditions under which education and health services are delivered in the country, especially to the poor. We hope that this study becomes a useful instrument for the new administration to improve these services, and for the Honduran citizens to demand quality of service in accordance with the level of resources invested in these sectors.
The study has been carried out in collaboration with the following actors from the international community, who contributed with financial support and/or technical specialists: DFID, SIDA, and the Interamerican Development Bank.
On the part of the World Bank, this report has been prepared by a team led by Ana Bellver (LCSPS), Cristian Aedo (LCSHE), Christine Lao Pena (LCSHH) and Maria Eugenia Bonilla (LCSHH). This report would not have been possible without the support from Lidia Fromm and the group of national and international consultants that worked in the different stages of the project: John Edwards, education economist; Bernard Couttolenc, health specialist; and Helmis Cárdenas, Marco Moncada and Fidel Ordoñez from ESA Consultants.
The team would like to thank: Laura Frigenti, LCC2C country director; Geoffrey Bergen, Honduras country manager; Nick P. Manning, public sector manager; Keith Hansen, health sector manager; Chingboon Lee, education sector manager; Humberto López, lead economist; Sajitha Bashir; sector leader; and the three peer reviewers – Ritva Reinikka, sector director; Jerry La Forgia, lead health specialist; and Jeni Klugman, lead economist – and Ian Walker, lead economist for their support during the preparation of this study and their valuable comments.
It is not possible to name all of the Hondurans who have contributed in some way to this study, but we would particularly like to thank government counterparts from the Office of the Presidency, the Ministry of Education, the Ministry of Finance, the Ministry of Health, the Technical Support Unit of Presidency, and the Honduran Social Security Institute, for their involvement at the highest level, and the knowledge and valuable contributions of their technical teams.
Summary Report
- This report aims at providing the Government of Honduras (GOH) with a tool to improve efficiency in the management of existing public resources in the education and health sectors, in order to increase access and provide better education and health services to the poor.Specifically, the objectives of the study are to:
(i)Identify how resources are allocated and used in the education and health sectors;
(ii)Identify leakages and inefficiencies in the system;
(iii)Analyze how existing management models perform and how different public management instruments are applied in each sector; and
(iv)Issue recommendations for improving the management of resources in the education and health sectors.
- The education and health sectors account for 46.2 percent of Central Government expenditures and have been highlighted as major drivers of growth[1]. Furthermore, in order to achieve its Millenium Development Goals, Honduras needs to increase its social spending by 10.4 percent of GDP, which means nearly doubling it, or improving the efficiency of available resources by 89 percent (World Bank, 2007b). Given the limitations in raising public expenditure within the current macroeconomic context, the most feasible option is to try to increase efficiency in social spending, especially in health and education.
- The analysis presented in this report focuses on specific areas of interest that are described below. The main focus of the analysis in the education sector are the funds allocated to human resources given that it accounts for more than 80 per cent of the budget. Per the Government’s request, the tracking of funds allocated to three relatively new transfer programs(Merienda Escolar, Matricula Gratis, Textbooks) was also conducted. Contrary to the education sector, most financial transfers in the health sector are recorded in SIAFI and therefore, leakages of funds was not a concern but rather how those resources were used and accounted for. Given that the health sector is one of the most advanced in terms of planning and management tools the analysis of management practices across the different management models was the main focus of the analysis as well as the tracking of drugs and human resources.
- The report presents the methodology and main findings from the survey that was carried out between November 2008 and October 2009. The following four departments were selected -Copán, Francisco Morazán, Olancho and Yoro. In addition, twenty three municipalities municipalities within the four sampled departments were surveyed with the objective of assessing the role of local governments in the provision of education and health services.
- The report was commissioned by the Honduran Social Cabinet, the Presidency and the Secretary of Finance. In addition to the World Bank, other development partners that contributed to the study are the Inter-American Development Bank, DFID and Asdi. The principal target audience of this study is the Government of Honduras (GOH), followed by the external field-based partners involved in these sectors and civil society who are both users of social services and actual or potential agents of change in holding service providers and the Government accountable.
- The main recommendation of the report is that an effort should be made in order to improve the scope, quality and transparency of the information collected on the provision of education and health services. Basic information is needed about inputs – in particular, human resources and pharmaceuticals–, financial contributions –specially those of municipal governments, out-of-pocket and parent fees- and outputs – enrollment figures, medical visits, prescriptions. Without such basic information it is difficult to see how the government can improve the management of public resources in those two sectors. Moreover, users of public services are entitled to know how many resources are spent in health and education in their communities, monitor that they are used efficiently and hold service providers accountable.
The Education sector: Trapped in an off beam policy discussion