Public Expenditure Tracking Survey in Health 2004
Brazil, 2003 - 2004
Identification
BRA_2004_PETS_v01_M
Public Expenditure Tracking Survey in Health 2004
| Name | Country code |
|---|---|
| Brazil | BRA |
Public Expenditure Tracking Survey
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).
Brazil has made significant progress in human development over the last decade, thanks to a series of policy innovations, and equity of access has increased considerably. In health, consolidation of government health financing, the organization of the sector into a country-wide system (Unified Health System, or SUS) and the greater emphasis on primary care have been critical for these improvements.
Increasing the efficiency and effectiveness in the use of health resources to contain rising costs is perhaps the greatest challenge facing the Brazilian health system.
Brazil’s federal structure and the decentralized nature of the SUS make the financial flows difficult to track and monitor. Despite continuous upgrading, existing information systems do not permit accurate identification of how resources are allocated within the context of SUS, nor how expenditures are executed and services provided at the health unit level. Information is lacking regarding how much SUS as a whole (including the federal, state and municipal governments) spends on hospital and primary care. The levels of efficiency in health service provision are not systematically documented.
This study assesses how the processes of allocation, transfer and utilization of resources are conducted at the different levels of the system. The study provides valuable information regarding the reality of the executing units of the system and how these relate to the central levels. It also seeks to identify problems related to financial flows, analyze how resources are used at the local level, and estimate their impact on the efficiency and quality of health services in general. In this respect, the study provides a basis for improving the entire cycle of public resource management processes (i.e., planning, budgeting, budget execution, input management, and health service production) in the health sector.
The survey was based on a sample of six states, 17 municipalities in those six states, and 49 hospitals and 20 outpatient units in the sampled municipalities. While the sample is not statistically representative of SUS as a whole because of its small size, an effort was made to capture a variety of situations found in the Brazilian federation so that the findings would exemplify typical conditions found in SUS.
Sample survey data [ssd]
- Ministry of Health;
- State Health Secretariats;
- Municipal Health Secretariats;
- health units (hospitals and outpatient clinics).
Scope
| Topic | Vocabulary |
|---|---|
| Health Systems & Financing | World Bank |
Coverage
States of Amazonas, Ceará, Mato Grosso, Rio de Janeiro, Rio Grande do Sul and São Paulo.
Producers and sponsors
| Name |
|---|
| Ministry of Health, Brazil |
| World Bank |
Sampling
The sample selected for the study was designed in order to highlight the regional variations between the health units and at the same time to keep logistical costs to a minimum. For these reasons, a non-randomized sampling in three stages was chosen: first, the sample covered states, second, the municipalities located in those states, and third, health units located within the municipalities. This sampling structure was chosen in order to permit tracking of the resource flows within a particular state and the cross-referencing of information at the three levels of the research.
Initially, the sample took into account six states with their respective state health secretariats, 18 municipalities and 76 health units (52 hospitals and 24 outpatient clinics). As a result of data collection being abandoned in one particular municipality as well as in a number of health units, and given the difficulty of accessing certain information, the final sample encompassed 17 municipalities (Municipal Health Secretariats), 49 hospitals (public and philanthropic), and 20 outpatient clinics (state and municipal).
Although the resulting sample reflects the very different circumstances existing within Unified Health System (SUS), it is too small for each stratum of units and consequently does not allow statistical extrapolation of the results.
In the sampling exercise, states were selected to represent each of the six Brazilian major regions (for the southeast region two states were included given the population density and a high concentration of health establishments). One of the main criteria for selection was to reflect the diversity in size and different characteristics of the states, municipalities and health units.
Municipalities were selected on the basis of size. State capitals were included, plus one middle-sized municipality per state (roughly 200,000 inhabitants) and at least one small-sized municipality (of approximately 50,000 inhabitants). The resulting sample of municipalities could be considered reasonably representative of the diverse nature of SUS.
The hospitals selected were required to meet the following requirements: to attend mainly to SUS users, to have a minimum of 50 beds, to possess reasonable information systems and to be broadly representative of SUS as such. Various hospitals were included in the sample that had been included in other recent studies which made it possible to cross-reference and compare information. The proposed distribution focused on public hospitals since the main thrust of the study concerned budget relationships and transfers of resources. This sample was stratified by size (medium-sized/big and small hospitals) and sphere, in order to try and obtain a sufficient number of units of each type to produce representative results. Efforts were also made to include hospitals with different characteristics such as those that undertake teaching and research and public hospitals administered under different kinds of management arrangements.
Survey instrument
The questionnaires were applied in the course of interviews with state health secretaries or someone designated by them (normally a professional charged with a specific area with access to the necessary information); municipal health secretaries (or designates); directors of hospitals; and directors of outpatient departments/clinics. Moreover, concurrent side interviews were undertaken with staff from a number of different technical and administrative divisions with the aim of clarifying and amplifying the research findings. Finally, together with the application of the questionnaire, reports and other supporting documents were requested relating to budgets, plans, management reports, etc.
The internal structure of the questionnaires was common to all types of units researched (SES and SMS, hospitals and outpatient clinics), although obviously the content of each section is specific to each type of unit.
The basic format of the questionnaire was organized around planning and budget allocation and implementation processes and the main inputs used in health service delivery (i.e., materials and medical drugs, human resources and equipment/installations). The component sections of the questionnaire were the following:
• Section A - Information from the secretariats or health units. This section gives the identity details of the units researched, the name of the person responsible for the unit and details about the profile and type of unit (in the case of hospitals and outpatient clinics, the number of beds and services on offer are included).
• Section B - Budgetary planning and processes. This section examines the budget and planning process at its different stages, the degree of autonomy in the preparation and implementation stages of the budget, the delays in releasing and applying funds, the differences between the values requested, approved and executed, including the use of the ‘up-front’ payment/petty cash system.
• Section C - Purchases, materials and drugs management. This section deals with information regarding the purchasing and storage systems, including pharmacy. Surveys were done basically to elucidate the physical condition of stocks, delays in bidding processes and the impact of these elements on service delivery.
• Section D - Equipment and installations. This section examined the equipment estate, covering inter alia the frequency rate of breakdowns/breakages in addition to examining the physical conditions of installations.
• Section E - Human resources. Information was sought in the section regarding the staff, its distribution, qualifications, absenteeism and any failure to comply with working hours.
• Section F - Hospital and outpatient clinic expenditure. In this section data was sought on the expenditure by type and receipts by source, together with an analysis of the service providers and the impact of receipts from SUS on overall expenditure.
• Section G - Hospital and outpatient clinic productivity. Data was collected regarding the productivity of the units and, wherever possible, performance and quality indicators were calculated.
Supplementary documentation requested included:
• Municipal/State Health Agenda (2002-2003);
• Municipal/State Health Plan (2002-2003);
• Current Multi-Year Plan (referring to health);
• Budget Guidelines Law (2002-2003);
• Municipal/State Health Budget (2002-2003);
• Documentary evidence of present budget execution (2002 and first half of 2003);
• Municipal/State Balance Sheets, Annex 2, 6 (Health section),10 and 11, for 2002;
• Management Reports (2002).
• Personnel Allocation Chart
• Organization chart of Institution
Data collection
| Start | End |
|---|---|
| 2003-11 | 2004-03 |
Fieldwork was organized on the basis of one team for each state included in the sample. A field supervisor was designated for each state to coordinate a team of 2 to 4 interviewers who had the task of covering the units within the targeted state. The supervisor was charged with coordinating the team under his/her control, planning the logistical arrangements for the field research and, once this had been done, to check consistency of data, organize supplementary documentation, draft field reports together with a rendering of accounts and forward everything to the project coordinating office via electronic medium (for questionnaires) and the postal service.
Supervisors and field researchers received guidance concerning the project as well as training to apply the data collection instruments.
In order to understand the resource flows within the context of SUS and to be able to track them effectively, data collection was undertaken at four distinct empirical levels: the Ministry of Health (through existing databanks), State Health Secretariats (SES), Municipal Health Secretariats (SMS) and health units (comprising hospitals and outpatient clinics). A strategy for data collection was developed that included in situ consultation and secondary data analysis in an effort to obtain a reliable picture of each type of establishment.
Data Access
Public Use File
Use of the survey data 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.
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_BRA_2004_PETS_v01_M
| Name | Affiliation | Role |
|---|---|---|
| Antonina Redko | DECDG, World Bank | DDI documentation |
2011-09-20
Metadata version
v01 (September 2011)