Public Expenditure Tracking Survey in Health 2006
Tajikistan, 2006
Identification
TJK_2006_PETS_v01_M
Public Expenditure Tracking Survey in Health 2006
| Name | Country code |
|---|---|
| Tajikistan | TJK |
Public Expenditure Tracking Survey (PETS)
A Public Expenditure Tracking Survey (PETS) is a diagnostic tool used to study the flow of public funds from the center to service providers. It has successfully been applied in many countries around the world where public accounting systems function poorly or provide unreliable information. The PETS has proven to be a useful tool to identify and quantify the leakage of funds. The PETS has also served as an analytical tool for understanding the causes underlying problems, so that informed policies can be developed. Finally, PETS results have successfully been used to improve transparency and accountability by supporting "power of information" campaigns.
PETS are often combined with Quantitative Service Delivery Surveys (QSDS) in order to obtain a more complete picture of the efficiency and equity of a public allocation system, activities at the provider level, as well as various agents involved in the process of service delivery.
While most of PETS and QSDS have been conducted in the health and education sectors, a few have also covered other sectors, such as justice, Early Childhood Programs, water, agriculture, and rural roads.
In the past decade, about 40 PETS and QSDS have been implemented in about 30 countries. While a large majority of these surveys have been conducted in Africa, which currently accounts for 66 percent of the total number of studies, PETS/QSDS have been implemented in all six regions of the World Bank (East Asia and Pacific, Europe and Central Asia, Latin America and Caribbean, Middle East and North Africa, South Asia and Sub-Saharan Africa).
The health care system in the Republic of Tajikistan has required a substantial reform in order to adequately meet the health needs of the population and to ultimately lower morbidity and mortality rates.
In order to support future reform efforts, a Public Expenditure Tracking Survey (PETS) was carried out in 2006 by the World Bank and the Tajikistan government with the financial support from the UK's Department for International Development. The study was designed to provide information on where and on what health care funds were spent and which institutions within the government - both central and local - had the greatest influence on the allocation of resources. The PETS aimed to collect budget data at each level that public resources passed through before reaching frontline providers such as hospitals and clinics.
The structure of the health care system in Tajikistan in 2000s has remained similar to the Soviet model, with the State as the main provider of care services. The administration of the services has been divided into four levels: central, oblast, rayon, and jamoat.
At the time of the study, public resources devoted to health care were very low. An estimated 1.1 percent of GDP was allocated by all levels of government to health. The state of health facilities was so poor that underfunding was easily apparent. The 2005 Poverty Assessment identified that the bulk of health expenditures in Tajikistan were paid out-of-pocket by individuals either as formal or informal payments. The largest category of private medical spending was on pharmaceuticals. Moreover, even the more affluent members of the population indicated that they did not seek health care in some instances because of the high cost. Thus, the main objective of this research was to assist the Tajik government in improving the public financial system to ensure efficient and appropriate use of scarce resource.
The survey collected data on 317 health facilities and 1,282 health facilities employees from 30 rayons (districts) nationwide.
Sample survey data [ssd]
- Rayon Administrations;
- Central Rayon Hospitals;
- Jamoat Administrations;
- Health Facilities;
- Health Facilities Staff.
Scope
- This study focuses on budget management issues including budget preparation, allocation, execution, internal and external control, and financial reports.
- The PETS will examine budget rules and discretionary authority in budget management at each level of local government.
- The PETS analyzes the allocation of resources for wages and non-wage inputs to gain insight on how much was allocated and how much was received.
- The analysis of non-protected expenditures including drugs, food, medical equipment, repair and maintenance, and travel budget including fuels is also crucial for improving quality of health care.
- The PETS includes an analysis of immunization. The purpose of the immunization component is to fill in gaps in knowledge, both at the country level and more globally, on the reliability and predictability of resource flows to front line providers.
- The PETS does not include an analysis of the procurement system in the health sector.
| Topic | Vocabulary |
|---|---|
| Health | World Bank |
| Health Systems & Financing | World Bank |
Coverage
National
Producers and sponsors
| Name |
|---|
| Ministry of Health |
| Ministry of Finance |
| Executive Office of the President |
| World Bank |
| Name |
|---|
| Department for International Development |
Sampling
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The Universe of Health Facilities. At the time of PETS 2006 in Tajikistan, there was no sample frame of health providers in the country. The starting point was to build the sample frame from which to draw a representative sample for the PETS. A local Tajik firm, Zerkalo, was hired to compile the full list of health facility in the country during August 2006. The firm came back with a full list of facilities with a breakdown along a number of variable such as location (Oblast, rayon and jamoat if applicable), rural/urban, type of the facility, number of beds when in-patients services are provided and whether the facility is public or private. Since only public facilities will be interviewed during this PETS all the private facilities have been excluded from the sample frame for the sampling. Overall, there are 60 rayons (districts) in Tajikistan plus Dushanbe. The jamoat is the administrative entity just below the rayon. Jamoats matter in the PETS because they handle public resources. There are 356 jamoats in Tajikistan. However, for the purpose of the sampling strategy, cities and urban settlements which can be considered as "urban" jamoats are included which brings the total to 445 jamoats. The list of facilities identified 2617 public facilities in the country including the CRHs which are sampled with certainty whenever the rayon is selected. Therefore, Central Rayon Hospitals (CRH) have been excluded form the sample frame which left 2559 health facilities to choose from.
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Selection of Rayons. Tajikistan counts 5 oblasts or regions and 61 rayons. Dushanbe, the capital city, enjoys a special status and is considered both as an oblast and rayon by itself for the survey's purpose. For the survey, the overall 'optimal' number of rayons is fixed at 30. Dushanbe is included in the sample with probability one because of its importance. Two other rayons, Varzob among the Rayons of Republic Subordination (RRS), and Dangara in the Khatlon oblast are also purposively chosen because the survey result will be used as a baseline for future evaluation of per capita financing scheme that is being piloted in the two rayons. The remaining twenty-seven rayons are allocated across the four strata using proportionate allocation which allows each oblast to contribute to the sample in proportion to its importance in the universe. The rayons have been sampled with probability proportional to size (PPS).
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Sampling of Jamoats. The initial sampling strategy was to randomly sample ten facilities in each of the rayons. However, given that jamoats play a central role in the financing of facilities and the important number of jamoats, randomly selecting the facilities within each rayon would have brought about a very high number of jamoats to survey resulting in a sharp increase in the survey cost. Therefore, in each rayon four jamoats have been sampled with equal probability of selection. When there are four jamoats or less in the rayon, all jamoats are chosen with probability one. In the end, 107 jamoats were included in the survey.
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Sampling of Health Facilities The final step consists of selecting the facilities. Within the facilities under the authority of the four jamoats that were selected in the preceding phase ten facilities were randomly chosen.
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Selecting Staff and Staff Sampling Weights. In each facility, seven staff members have been randomly selected for the staff survey. Facilities with seven or fewer employees are "take-all" cases i.e. all staff have been administered the questionnaire. The computation of the staff probability of selection is simply the minimum between one and seven divided by the number of employees in the facility. The weight of the staff is the inverse of that probability. However, because of absent staff, sometimes in facilities with, say, 5 employees only 3 questionnaires have been filled out. An adjustment procedure needs then to be used to account for the absent staff. This procedure is relevant only in facilities where the staff size is lower than 7 and in which employees were missing in action at the time of the survey.
The survey team visited a total of 326 facilities. However, the team wasn't able to collect data about nine of them for two reasons: either because the head of facility was absent and nobody was able to provide answers or the facility is no longer in operation. Six facilities fall within the last category.
Detailed information about response rates is available in "Tajikistan Second Programmatic Public Expenditure Review" (p. 117) in external resources.
Survey instrument
Tracking public expenditure in the health sector requires designing appropriate instruments in order to collect budget data at each level public resources went through before reaching frontline providers. In Tajikistan, this includes at local level Rayons, Central Rayon Hospitals, Jamoats and health facilities. This section describes the survey questionnaires that were designed in close collaboration with the key government counterparts in Ministries of Health, Finance, and Executive Office of the President (EOP). A consultation workshop with key counterparts was held with representatives of these agencies to discuss comments. Their inputs were incorporated in the final draft questionnaires. The field survey was administered by Zerkalo, a local survey company.
Six questionnaires were designed for this study.
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Rayon (District) Questionnaire was applied to the rayon administration and responded by rayon financial department. The rayon questionnaire tracked budgetary revenues (tax and non tax and transfers from republican budget and subsidies) as well as additional resource both in cash and in kinds contributed to the health sector budget by government at various levels, donors, local communities, etc. On the expenditures side, the rayon questionnaire tracked allocation of budgetary resource to key sectors (general administration, education, health, and housing and communal services), allocation of resource within the health sector (by economic classification, function, and by budget institution unit). The questionnaire also examined the role and responsibilities of the rayon chairman in budget preparation, execution as well as issues in financial reporting, internal and external audit. Information from the rayon questionnaire can be cross validated with information from central rayon hospital and jamoat questionnaires. However, cross validation of information with the facility questionnaire is not possible as rayon allocates budgetary fund to health through central rayon hospitals and jamoats.
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Central Rayon Hospitals (CRH) Questionnaire was applied to central rayon hospital administration responded by Head Doctor of Central Rayon Hospitals or by delegated staffs. Central rayon hospital plays an important role in allocating budgetary resources to health facilities included in the CRH network. These health facilities are not legal entities and therefore they do not have approved budgets based on organization. The questionnaire examines the role and responsibilities of the Head doctor of the central rayon hospitals. It tracks budgetary and non-budgetary revenues (in cash and in-kinds) as well as expenditure by economic, functional and budget institution of a central rayon hospital. Tracking of economic classification focuses on wage bill and other inputs including goods and services (foods, drugs, and travel expenses), repair and maintenance and communal services. However, cross validation of expenditures with health facilities is limited to payments of wage. Cross validation of expenditure on other inputs can not be done as there is no record on how much inputs health facilities received from the central rayon hospital. Central rayon hospital and jamoat have no financial relations as they both play role as paymaster to health facilities. Finally, the questionnaire examines the role of head doctor of the central rayon hospital in financial management as well as human resource management.
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Jamoat Questionnaire was applied to jamoat administration responded by jamoat chairman or an accountant. Similar to the rayon and central rayon hospital questionnaires, the jamoat questionnaire tracks budgetary and non-budgetary revenues as well as budgetary expenditure allocation (economic and functional). The wage expenditure can be cross validated with the facility questionnaire.
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Facility questionnaire was applied to health facilities and responded by Head doctor of the facility. As a facility is a service delivery unit, the questionnaire collected basic information about health facility that affects the ability to deliver health services. These include the number of population served, catchment areas, distance from centre/town, physical infrastructure, utility connections and availability, operating hours, medical infrastructure (beds, medical equipments, vehicles, etc). It also examines personnel management (recruitment, firing, and incentive), tracks revenues and expenditures both in cash and in kinds (drugs, food, fuel, and other material inputs) received and spent by a health facility. As a health facility other than a central rayon hospital has no approved budget, the questionnaire did not ask for approved and executed budget of a health facilities but asked for the estimated amount of resource received from either central rayon hospital or jamoat for delivery of health services in 2005. For tracking purpose, only payment of wage by health facilities can be cross validated with wage payments reported by central rayon hospitals and jamoats. Tracking of expenditures on inputs other than wages is limited due to poor keeping of payment records and time consuming in cross validation at both levels.
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Staff Questionnaire was applied to staff in sampling health facilities included in the survey. The questionnaire is designed to track payment of wage as it contributes to 60-80 percent of total health budget. In addition, the questionnaire is used to examine staff qualifications and training, workloads, pay and incentive, informal payments and other related human resource management issues that affect health service delivery. Finally, it examines service delivery activities to enable linkages with resource utilization.
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Immunization Questionnaire was part of PETS in order to fill in knowledge gaps on execution and distribution of immunization resources (funds and commodities) both at the country level and more globally. The result will shed light on policy areas where the budgeting, resource allocation, and budget execution processes can be strengthened to achieve maximal health impact. The questionnaire will track the flows of funds allocated specifically for immunization, their distribution, and sources (government and external resources). It will track a share of budgetary funds available to immunization services (as a proportion of total funds available to primary health care) and evaluate vaccine and safe injection commodities flows and distribution.
Data collection
| Start | End |
|---|---|
| 2006-11 | 2006-12 |
| Name |
|---|
| Center for Social Research "Zerkalo", Dushanbe, Tajikistan |
For data collection, eight enumerators groups were established. Each group comprised four persons and was responsible for data collection in four rayons except two of them which were assigned three rayons each. Each group had a head of the group, a senior enumerator and two enumerators. Questionnaires for rayons, CRHs as administrative units, as well as questionnaires on immunization had to be filled out only by heads of groups. However, the other members were also trained to fill questionnaires for jamoats, institutions, immunization, and staff.
Before starting the field work, a theoretical training of enumerators was organized October 9 - 12, 2006, in Dushanbe. Training was conducted jointly by the specialists of the World Bank and senior officials from "Zerkalo," a company doing the fieldwork.
Additional training was organized in each Oblast by specialists from "Zerkalo" with the support of the survey coordinator from the World Bank. Upon completion of training, each specialist worked with one enumerator group in each region during two days, monitored their work and made necessary comments and corrections.
Taking into account that the interviewed institutions work five days a week, and only some work half a day on Saturdays, the field work was organized in such a way that each enumerators group spent five days in each of the rayon. Preliminary survey plans were developed for each group detailing responsibilities of each enumerator for each working day. Initially it was expected that during the first day each group will work jointly in a rayon interviewing the rayon administration and the Central Regional Hospital. During the following days the group has to divide into two subgroups, each headed by the head of the group and the senior enumerator. Each subgroup worked independently in different jamoats. In the evening all of the group members gathered in an agreed place and reviewed questionnaires they filled out. This plan was applied when possible but adjustments were made depending on circumstances. For example, the majority of surveyed rayons were opened on Saturdays.
The PETS was originally designed to track the health expenditures that reached health facilities at various administrative levels; however, it faces challenges due to a lack of approved health facility budgets. Central and oblast level facilities have separate budgets, while primary health care facilities such as Feldsher and Midwife/Maternity Point (FAPs), Rural Hospitals (SUBs),
Rural Physician Ambulatory Centers (SVAs), and rural medical houses do not have their own separate budgets approved. Tracking expenditures of facilities was not feasible as health facilities lacked information regarding funding allocated to them. It was a convention that a Central Rayon Hospital (CRH) and in some cases jamoat administration provided health facilities of a particular rayon with in-kinds inputs whose financing was a part of consolidated CRH and jamoat budgets. The PETS showed that only 35 percent of the facilities reported preparing a budget in 2005 but the desegregation by type of facility shows that only 31 percent of SVA and 18 percent of medical houses prepared a budget.
To overcome this lack of critical information, the PETS estimated the amount of resources that reached the facilities by using several questions regarding inputs received by the facilities during 2005. However, it is necessary to highlight the limitations of the findings regarding allocations and expenditures at the facility level. Since most facilities did not have budgets, the interviewee is asked to provide a self-assessment of how much support they received from government and external sources. It is impossible to verify this information given the lack of documentation and misinformation may be the result of recall difficulties. Furthermore, the questionnaire asked respondents at the facilities to provide an estimate of the monetary value of the drugs received which can't be corroborated and may be inaccurate. Additionally, the data from Gorno-Badakhshan Autonomous Oblast (GBAO) seems to present some discrepancies; most facilities in GBAO reported receiving support from government sources but there was no data regarding receiving support for drugs, food, and fuel.
Data processing
Each type of questionnaire was entered using a specific program designed under CSPro. Data entering started in parallel with the field work after the receipt of the first questionnaires in the office of "Zerkalo," a local company doing the fieldwork. From the second field work week, database inputs were sent to the World Bank office. After data entry, the database was converted into SPSS and STATA formats. Data input was fully completed on January 7, 2007. Database clearing started from this date and were completed by February 10.
Data codes for oblast, rayon, jamoat, and facility are based on the administrative code provided by the State Statistical Committee. The variable codes for survey data has 5 digits as follows: the first digit code represents type of questionnaires (e.g. r for rayon, c for central rayon hospital, j for jamoat, f for facility, and s for staff questionnaire); the second digit code represents a section in the questionnaire (beginning from 0, 1, ----, ); the third digit code represents the question number in the same section; the fourth digit code represents row number of the same question; and the fifth digit code represents column number of the same row and question.
All survey data are entered into STATA and SPSS. Data cleaning is carried out in conjunction with review of the survey questionnaire by the local survey team as well as reviews by the World Bank team on a weekly basis to ensure that errors are promptly remedied.
Data Access
Public use file
The use of this survey must be acknowledged using a citation which would include:
- the identification of the Primary Investigator (including country name)
- the full title of the survey and its acronym (when available), and the year(s) of implementation
- the survey reference number
- the source and date of download (for datasets disseminated online).
Disclaimer and copyrights
The user of the data acknowledges that the original collector of the data, the authorized distributor of the data, and the relevant funding agency bear no responsibility for use of the data or for interpretations or inferences based upon such uses.
Contacts
| Name | Affiliation | |
|---|---|---|
| Hooman Dabidian | World Bank | hdabidian@worldbank.org |
| Cindy Audiguier | World Bank | caudiguier@worldbank.org |
Metadata production
DDI_TJK_2006_PETS_v01_M
| Name | Affiliation | Role |
|---|---|---|
| Antonina Redko | DECDG, World Bank | DDI documentation |
2011-10-19
Metadata version
v01 (October 2011)