Online Program

Increasing transparency and financial accountability in the health sector: Why performance-based budgeting is not the answer

Monday, November 4, 2013 : 12:45 p.m. - 1:00 p.m.

Taryn Vian, SM, PhD, Department of Global Health, Boston University School of Public Health, Boston, MA
Performance-based budgeting (PBB) is a public finance reform meant to increase accountability, transparency, and effectiveness of government resource allocation. The purpose of this study is to describe and model the factors affecting progress of performance-based budgeting reform in hospitals in Lesotho. We analyzed four case studies each centered on a single hospital's implementation of PBB. Data included document review (budgets, plans) and 52 in-depth interviews. We apply an organizational change theory--the Transformational Change (TC) model--to describe progress in implementing PBB reform in Lesotho. The hospitals showed little progress in budget reform which means that the researchers cannot relate the model's constructs to differences in outcomes. However, the TC model provides a lens to understand why the reforms may have failed. Factors of particular relevance include absence of reform leadership, lack of alignment of the structures, resources, and capabilities needed to implement the reform, and poor integration of different professional groups and organizational units. Contrary to the model, we found that progress in public finance reform efforts requires prerequisites, including impetus to change and budget basics. Impetus to change includes Ministry of Health ownership of the reform and donor coordination. Internal pressure for reform may also be increased if managers see relative advantages to the new system. Budget basics are essential in order to strengthen financial accountability, which will in turn make sound financial information more widely available, increase trust, and allow greater control of corruption. These are essential ingredients in the pursuit of government accountability for performance.

Learning Areas:

Systems thinking models (conceptual and theoretical models), applications related to public health

Learning Objectives:
Explain the objectives and expected benefits of performance-based budgeting for the health sector Describe the factors which prevented Lesotho hospitals from implementing the PBB reform effectively Discuss how a theory of change can advance our understanding of challenges in reform implementation, and suggest ways to address those challenges through better reform design, inter-sectoral communication, and supports during the implementation process

Keyword(s): Accountability, Policy/Policy Development

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am Associate Professor of International Health and have conducted extensive research and consulting work in the areas of health financing policy, program evaluation, and fighting corruption through accountability and transparency in the health sector in more than 30 countries.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

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