Assessment OF UHC Performance Monitoring System and UHC Budget and Expenditure Analysis in Pakistan

June 2022 ACRONYMS ACKNOWLEDGEMENTS The report was prepared as one of the deliverables of the Public Financial Management and Health Financingpillar of the World Bank’s Pakistan Health Support Programmatic Advisory Services and Analytics (ASA)(P175571). This report is led by Qurat ul Ain Hadi (Financial Management Specialist, ESAG1). The report’sdevelopment was supported by a World Bank governance and health team including: Hammad Yunus (PublicFinancial Management [PFM] Consultant) and Tayyeb Masud (Health Specialist Consultant). It was funded byG4GFF, that is, the governance window of the Global Financing Facility and the Global Alliance for Vaccinesand Immunization (GAVI) Alliance. The team gratefully acknowledges Najy Benhassine (Country Director for Pakistan), Hisham Waly (GovernancePractice Manager, ESAG1) and E. Gail Richardson (Operations Manager, LCC3C). The report also benefitedfrom the valuable inputs provided by Jahanzaib Sohail, (Health Specialist, HSAHP)Raymond Muhula (SeniorGovernance Specialist, ESAG 1), Aleksandar Kocevski (Senior Operation Officer, ESAG 1) and Akmal Minallah(Senior Financial Management Specialist, ESAG 1) and comments of peer reviewers: Michael Kent Ranson(Senior Health Economist, HHNGE), Timothy Stephen Williamson (Senior Governance and public sectorspecialist, EPSPF), Richard Anthony Sutherland (Governance Specialist, EPSPF) and Juliette Puret, (SeniorHealth financing expert GAVI). We also gratefully acknowledge the partnership and support of the Ministry of National Health Services,Regulation and Coordination (MONHSRC), the Finance Division and Provincial Finance Departments, theDistrict Health Offices Primary Health Care Centers, and the Controller General of Accounts (CGA).Theyhelped the Bank team to complete this task by providing useful comments and insights throughout the process.The team would also like to acknowledge the support provided by the staff of the Ministry of National HealthServices, Regulation and Coordination (MONHSRC) and the World Bank, in particular Dr. Sabeen Afzal(Deputy Director), who provided guidance and facilitated the whole process, including communications withprovincial authorities. We would also like to thank Ms. Lubna Yaqoob, and Dr. Raza Zaidi as well as otherkey officials at the Ministry of Health, Provincial Departments, United Nations agencies, non-governmentalorganizations/ international non-governmental organizations (NGOs/INGOs) and other stakeholders. FOREWORD In 2019, the Federal Government of Pakistan enacted a Public Financial Management (PFM) Law.It wassubsequently supplemented by the “Financial Management and Power of Principal Accounting OfficersRegulation 2021”, the aim of which was to strengthen PFM at the line ministry level. To this end, the PFM Law of2019 requires each line ministry to have Chief Finance and Accounting Officers and Internal Auditors to improvefinancial management and the internal control environment. Under the law, all line ministries, including healthhave been obligated to submit performance-based reports to the Parliament. Each province is also preparing its own PFM law, in fact Balochistan have promulgated their own PFM Actin September 2020 and June 2022, respectively.Health managers have shown a particular interest in theperformance evaluation to ensure proper oversight of health performance indicators, particularly the one linkedto Universal Health Coverage (UHC) to ensure service access and equity. This report provides information aboutsystem challenges that prevent effective oversight and hinder accurate financial and performance reporting forthe UHC. The report also suggests ways to improve financial and output health data to enable performancemonitoring, as well as to increase the availability of useful information to decision makers. CONTENTS Executive Summary.........................................................................................................................................81. Introduction.................................................................................................................................................121.1Universal Health Coverage (UHC).............................................................................................................................................................. 121.2UHC Reporting – Government Accounting System......................................................................................................................... 131.3Structure of the Report and Relevance.................................................................................................................................................. 132. UHC Budget and Expenditure Performance Analysis...................................................................................142.1Province-level Analysis..................................................................................................................................