Policy and Practice Resource allocation and budgetary …8)1024.pdf · Resource allocation and budgetary mechanisms for decentralized health systems: experiences from Balochistan,

Resource allocation and budgetary mechanismsfor decentralized health systems: experiencesfrom Balochistan, PakistanAndrew Green,1 B. Ali,2 A. Naeem,3 & D. Ross4

This paper identifies key political and technical issues involved in the development of an appropriate resourceallocation and budgetary system for the public health sector, using experience gained in the Province ofBalochistan, Pakistan. The resource allocation and budgetary system is a critical, yet often neglected, component ofany decentralization policy. Current systems are often based on historical incrementalism that is neither efficient norequitable. This article describes technical work carried out in Balochistan to develop a system of resource allocationand budgeting that is needs-based, in line with policies of decentralization, and implementable within existingtechnical constraints. However, the development of technical systems, while necessary, is not a sufficient conditionfor the implementation of a resource allocation and decentralized budgeting system. This is illustrated by analysingthe constraints that have been encountered in the development of such a system in Balochistan.

Keywords: Pakistan; health care rationing; budgets; financial management; public sector; health servicesaccessibility; community health services, organization and administration; models, economic.

Voir page 1033 le resume en francais. En la pagina 1034 figura un resumen en espanol.

Background

Health sector reform is now amain focus of attentionfor the ministries of health in many developingcountries. Policy discussions often focus on thedevelopment of a more efficient service throughinitiatives such as distinguishing between the func-tions of ‘‘purchasing’’ and ‘‘provision’’, the develop-ment of the public/privatemix, greater autonomy forhospitals, and the development of district-basedsystems. Critical to the last of these is the develop-ment of appropriate systems for allocating resourcesfrom central to lower administrative levels. For manycountries, the existing system of allocating resources,particularly financial resources, to lower levels in thehealth service is inconsistent with decentralizationpolicies and the pursuit of equity. However, lessattention has been paid to the development ofresource allocation processes.

This article analyses issues involved in thedevelopment of such resource allocation and budget-ary systems, drawing on the experience of workconducted under the Balochistan Health SystemsStrengthening Component (BHSSC) of the SecondFamily Health Project (FH2P). The BHSSC seeks todevelop institutional capacity to support a moredecentralized and effectively functioning districthealth system. These objectives are directly linkedinto the wider Government of Balochistan’s SocialAction Programme (SAP), which places priority onprimary care services and decentralization from theprovincial level towards district-based management.

The decentralization strategy being developedand implemented within the project is basedprimarily around the strengthening of districtmanagement and planning capacity brought aboutby increasing management skills, improving manage-ment systems and developing more decentralizedorganizational structures. This is combined with astrengthening of provincial planning systems toprovide strategic policy guidance to districts andbuilds upon earlier work carried out to establish aprovincial health planning system (1). Within such adecentralization process, one necessary preconditionfor achieving equity is the development of systemsfor allocating resources to districts in line with healthneeds. The objective is to develop an approach thatallows for central resource planning and local healthcare programming (2). The present article is limited toa consideration of resource allocation within thegovernment health sector and does not consider theoverall levels of sectoral funding or resource flows to

1 Senior Lecturer in Health Planning and Economics, Nuffield Institutefor Health, University of Leeds, 71–75 Clarendon Road, Leeds L52 9PL,England (e-mail: [email protected]); and Consultant to the SecondFamily Health Project, Balochistan, Pakistan. Correspondence shouldbe addressed to Mr Green at the former address.2 Associate Professor and Chairperson, Department of AdministrativeSciences, University of Balochistan, Balochistan, Pakistan; andConsultant to the Second Family Health Project, Balochistan, Pakistan.3 Assistant Professor, Department of Administrative Sciences,University of Balochistan, Balochistan, Pakistan; and Consultant tothe Second Family Health Project, Balochistan, Pakistan.4 Assistant Director of Primary Care, East Riding Health Authority,Yorkshire, England; and former Health Planning and ManagementAdviser, Health System Strengthening Component, Second FamilyHealth Project, Balochistan, Pakistan.

Ref. No. 99-0174

Policy and Practice

1024 # World Health Organization 2000 Bulletin of the World Health Organization, 2000, 78 (8)

nongovernmental elements. The resource allocationand budgeting system in Balochistan is primarilyincrementalism. There are various weaknesses,including, most importantly, mismatches betweenthe population health needs, the requirements ofexisting facilities, and the budgets set. The strategyadopted by the project to initiate a more appropriateresource allocation system has involved the follow-ing: analysis of previous resource allocation patterns;development of proposals for modifying resourceallocation systems; and development of necessarysupport systems and organizational structures forlinking the resource allocation process into theprovincial and district planning and budgetingsystems. Despite these technical developments, theproject has been unable to produce significantchanges in the allocation processes. This is largelythe result of failing to gain sufficient support in keyareas of government, at both the political andbureaucratic level.

The objectives of this article are as shownbelow.. First, we explore the more technical issues

involved in resource allocation in developinghealth systems, an area in which little has beenpublished.

. Second, through an analysis of the Balochistanpublic health sector, we illustrate that technicalsolutions alone, in the absence of wider politicalownership, will not lead to change. It is argued thatany redesign needs to take place within a specifichealth system context, and this is illustrated withan assessment of the Balochistan system.

. Finally we examine the strategy adopted inBalochistan to move from the current inappropri-ate system to a more appropriate one through aphased approach, and draw lessons from theexperiences and difficulties encountered.

Approaches to resource allocationand budgeting

Resource allocation is taken to be the overallallocation of financial resources to decentralizedmanagement areas within the government healthservice. It is closely related to budgeting, which isconcerned with statements of specific expenditureplans within these broad allocative ceilings.

An effective resource allocation mechanism is akey factor in supporting decentralized health systems,which are deconcentrated, i.e. responsibility andauthority are decentralized within the public healthsystem. This contrasts with a devolved system, wherelocal government takes responsibility for healthcare (3). Mechanisms for devolved systems requiredifferent decision-making and allocative processes (4)and are not discussed here. Decentralization (5)provides an opportunity to respond to local needswithin a national equity-focused policy for allocatingresources, though there are potential dangers ininappropriate decentralization (6). Misallocation of

financial resources is widely accepted as an importantcause of poor health service performance and inequity(7). Frequently, previous budget allocations (incre-mentalism), current service or facility patterns, capitaldevelopments or political factors heavily influenceresource allocation. Such approaches fail to addressefficiency and equity objectives.

Research has been carried out on resourceallocation between different activities (8, 9) and thecost-effectiveness of particular interventions. How-ever, less attention has been paid to allocationsbetween different geographical administrative areas,reflecting perhaps the relatively recent interest indecentralization. While the first of these possibilitiesfocuses on efficiency, the second is more concernedwith issues of equity. Despite the development ofcomplex systems of resource allocation in industria-lized countries, there are relatively few documentedexamples of needs-based resource allocation systemsin developing countries. Examples include PapuaNew Guinea, which developed a complex goalprogramming model (10), Zambia (11) and SouthAfrica (12).

An equity-focused policy would require a shiftin resource allocation, away from a mechanism basedon existing facilities, to one based on an assessmentof the needs of particular areas and their populationgroups. Fig. 1 sets out a conceptual model for such aprocess. One of the best documented examples ofthis approach is the United Kingdom NationalHealth Service (NHS), which in the 1970s developeda resource allocation formula (13) based on a modelwith the following components:– the health needs of a specified population;– the relative costs of different services;– the relative costs associated with different areas;– the costs associated with non-service delivery,

such as teaching costs;– the use by patients in one area of services in

another (cross-boundary flows).

Within a public sector resource allocation system, afurther criterion may be the level of private sectorhealth care, as this may reduce the potential need forpublic sector resources.

The most contentious of these components isthe assessment of needs. Potential measures include acombination of the following:– the size of the population;– age and sex ratios;– direct measures of morbidity;– mortality ratios as an overall proxy for different

levels of health need;– specific indicators of deprivation (to reflect

potentially higher levels of relationship betweenmorbidity and mortality, and higher health carecosts).

In the NHS resource allocation model, need was splitinto different components including the following:acute care, maternity, chronic and psychiatric, eachwith different proxy measures. Issues over measure-

Resource allocation and budgetary mechanisms for decentralized health systems

1025Bulletin of the World Health Organization, 2000, 78 (8)

ment (e.g. 14, 15) have centred around whethermortality is a good proxy for morbidity; whetherincluding wider causal deprivation indices, alongsidedirect health measures, leads to double counting ofneed; whether morbidity measures are influenced byaccessibility to services; the weighting given todifferent aspects; whether the actual funding basedon components of need are translated into equivalentservices at the local level; and which services should becentrally provided. Such formulae have tended toconcentrate on allocation of recurrent funding, withcapital allocations being related to existing capitalstock.

There are further issues around the implementa-

tion of such formulae. These include those discussedbelow.. The optimal speed of implementation. This is

related, in part, to the absorptive capacity ofunder-funded areas; the ability to reduce fundingof ‘‘over-resourced’’ areas; the overall growth offunding; and the political strength of differentareas and their ability to resist a relative reductionin allocation.

. The need to take account of local revenuegeneration. Some areas, because of their economicconditions, may be able to raise revenue locally(through user charges, for example). Under anequity-focused system, such areas might beexpected to receive fewer funds from a central

source. Compensatory mechanisms, however,may discourage local revenue generation.

. The existence of adequate information systems. Acomplex system that is not backed up byappropriate and credible information, such as dataon population size, can become easily discredited.

. The dangers of perverse incentives, which sendthe wrong ‘‘signals’’ to managers. The mostobvious of these is where high measures of healthare seen to be ‘‘rewarded’’ by high resource flows,with no compensating mechanism to encouragemanagers to improve the health situation.

. The difficulties of incorporating cross-boundaryflows, without encouraging cost-shunting. Wherepatients may cross health care ‘‘boundaries’’ toseek care from neighbouring health services, somemechanism is required to recompense the receiv-ing health authority for the additional workload.Without this there is a danger of patients beingencouraged to seek health care from outsidetheir catchment areas, particularly when the costis high.

As a result of such constraints, and in particular thepaucity of good information, countries considering theadoption of such formulae may need to start with verybasic allocative formulae, based primarily or wholly onpopulation distribution, before developing moresophisticated formulae such as those used by theNHS. Over time, it would be possible to incorporatean element of, or surrogate for, ‘‘need’’ without gettinginvolved in formulae that are too complex. Suchindicators may be used to weight basic populationdata, to reflect differing levels of need in similar-sizedpopulations. In Balochistan, an example might befemale literacy rates, which in many parts of theprovince are extremely low and, given the relationshipbetween female education and health status, mayprovide a potential added measure of need.

Diagnosis of the situationin Balochistan

Any redesign of a resource allocation and budgetarysystemhas to take into consideration the health systemto which it applies. Universal systems of reform areunlikely to be successful (16). The following sets outkey features of the Balochistan health system whichhave a bearing on the form of allocative system.

The health care systemBalochistan Province is situated in the aridmountain-ous south-western quadrant of Pakistan. The 26 dis-tricts of the province are themain administrative unit.Balochistan’s total population is estimated to bearound 6.6 million, but densities are low (19 per km2)and predominantly rural in distribution. Health statusis poor, with an estimated infant mortality of 180 per1000 (17).

Policy and Practice

1026 Bulletin of the World Health Organization, 2000, 78 (8)

The health care system is based aroundgovernment provision of services, although there isa significant and growing private sector that accountsfor around half of all service delivery (18). Stateservices are organized into a variety of primary levelservice delivery outlets feeding into small districtlevel hospitals. Larger hospitals and training institu-tions are located mainly in Quetta, the provincialcapital. There are various poorly integrated verticalprogrammes. The health care system suffers from anumber of deficiencies attributable, in part, toproblems in the planning and management ofservices. Most notable among these are high ratesof staff absenteeism, limited availability of drugs andsupplies, and a critical shortage of female healthworkers. The resultant poor quality of service leads tolow levels of utilization and limited impact uponhealth problems. In such a context a resourceallocation system needs to pay particular attentionto its impact on quality and utilization.

Existing resource allocation andbudgeting systemThe existing resource allocation and budgetingsystem is based upon budgetary demand coveringboth the development and revenue sides of thebudget. In the Pakistan public sector, the termsrevenue and development budgets are used to denotewhat elsewhere may be known as the recurrent andcapital budgets. The system was designed to be‘‘bottom-up’’ and as such is consistent with adecentralized approach. In theory, budget submis-sions are proposed by budget holders, typicallydistrict health officers, responsible for districtprimary care services, and hospital medical super-intendents. However, the failure of the majority ofbudget holders to participate in the process haseffectively led to a centralization of the processwithinthe provincial Health Department. Any submissionsare aggregated, reviewed and subjected to centralmodification and political influences. No clear policyguidelines or estimates of future financial availabilityare applied in drawing up the budgets. While somenorms are deployed, it is widely recognized that theseare outdated and bear little relation to real servicecosts. Although adjustment is made centrally inrecognition of new facilities, the main allocativedriver is the historical budget rather than health orhealth service needs. This leads to the practice ofbudget holders using the virement process (transferof items from one financial account to another) to tryto adjust budgets after they have been set, rather thanformulating robust initial budgets, even thoughvirement is itself a cumbersome process. Specificaspects of the system are discussed further below.

Overall budget structuresOne of the issues surrounding the development ofresource allocation processes relates to the complexityof the relationships between the existing budgets. InBalochistaneachhealthcare systemmayhaveanumber

of budgets, the minimum usually being a recurrentand a capital budget. In addition there may be budgetstreams associated with project activity. For example,there is a permanent (on-going) budget, which isroutinely approved with some inflator, as well as twoforms (new and continuing activities) of a temporarybudget, which are set out each year in the schedule ofnew expenditure. The relationship between these isshown diagrammatically in Fig. 2. In addition, a multi-donor supported Social Action Programme (SAP) hasbeen set up, which though in theory is fully integratedinto the government budget system, continues to beviewed in some quarters as an additional budgetprocess. As personnel costs are contained within thepermanent budget, they are largely protected frombudgetary cuts. This has led to a 50% increase inallocation to personnel costs since 1981, and aconcomitant relative decrease in non-salary items.

Alongside the revenue budgets (the ultimateresponsibility of the provincial FinanceDepartment),there are development budgets in the form of theAnnual Development Programme (ADP) that arecontrolled by a separate Planning and DevelopmentDepartment. In theory an ADP comprises a numberof planning proposals which set out the developmentand revenue implications of a project for overallapproval. In practice the revenue implications areconsidered less critically at the time of the ADP.

The number and type of budgets tend to causeconfusion, particularly in terms of the relationshipbetween development items and on-going revenueitems. First, as a result of the stringent controls on theuse of the permanent revenue budget by the FinanceDepartment, a habit has arisen of using the develop-ment budget to finance what effectively are ongoingrevenue items. Second, the parallel nature of therevenue budgets, which now include an allocation forSAP activities, leads to complexities in budgetingprocedures and a danger of overemphasis on processrather than strategy. In addition, the lack of linkagebetween development and revenue budgeting has ledto an over-extension of future revenue requirements.



The potential scale of this problem is exemplified inTable 1, which sets out the gross long-term revenueimplications of the 1995–96 ADP. At constant prices,a 22% real increase would be required to accommo-date the projected revenue implications in 1998–99.This problem is a product of both a failure in the pastto recognize the critical strategic importance ofviewing the two forms of budget together and, partlyas a result of this, the lack of coordination between thetwo budget arms of the Department.

In addition to the aspects discussed above, theinternal budget structures are complex and involve alarge number of budget heads and line items (known asobjects of classification). This is the result of a growthin activities without a concomitant rationalization ofbudget structures, and makes allocations difficult toanalyse, monitor and change. As we have seen,different budgets (e.g. revenue, development andSAP) have different decision-making and accountingsystems, leading to inconsistencies. In Balochistan,powers for virement are extremely centralized at avariety of levels (Directorate, Secretary of Health, orFinance Department) and are dependent on the formand level of re-appropriation/virement that is re-quired. While more robust budget formulation wouldreduce the need for virement during the year, it isinevitable that some re-appropriation is likely to benecessary. This complexity, together with the cen-tralized control on virement or powers, leads to anover-rigidity in the system and to difficulties in budgetformulation and management at the district level.

Financial guidelinesThe development of decentralized district budgetsneeds to occur within a framework of overall policyguidelines. In particular, guidance is needed onoverall health strategy, on the criteria by whichresources are to be allocated, and on likely levels offuture budget growth. Without such a framework,decentralization can easily become fragmented anddecentralized plans become unsustainable.

This is well illustrated by the situation inBalochistan, where there are a lack of useful explicit

central financial guidelines. There are three levels atwhich the issuance of guidelines would help.Currently the provincial Finance Department doesnot provide global sectoral revenue budget estimatesfor the following year. This causes difficulties for theDepartment of Health, which is forced to develop itsbudget in the absence of guidance as to the likelyoverall budget levels. Similarly the Planning andDevelopment Department does not provide anyformal estimate of the likely capital allocation for thefollowing year. In the absence of any centralguidance, the Department of Health, in turn, doesnot provide any guidance for service managersconcerning their likely allocation.

Information baseAny budget system needs to be based on robustinformation that includes health needs, servicepatterns, and costs. Information systems may notexist for providing the appropriate information forallocating resources to decentralized levels. ForBalochistan there is a significant lack of informationabout either utilization or health care costs, both ofwhich are critical for the development of budgets.Although a health management information system isbeing developed and should eventually assist inproviding health utilization data, it will be some timebefore it is in a position to provide such informationroutinely. One particular difficulty relates to popula-tion data, where there are concerns over the reliabilityof estimates based on outdated and disputed 1981census data. A census was carried out in 1998 whichmay therefore overcome this constraint to a significantdegree. This is further discussed below.

Professional expertiseUp till nowwe have focused on the budget structuresand processes. In addition, it is essential that anyallocative process be handled by staff with appro-priate professional expertise and who recognize thecritical importance of budgets for achieving policy.

The current allocative process in Balochistan isadministered predominantly by clerics, and thoughformally there are various points at which there isadministrative or technical scrutiny and approval, inpractice it is minimal. Linked to much of the above,either as a cause or effect, is a general lack ofbudgeting expertise in theDepartment ofHealth. Forexample, there is no professional accountant — amajor constraint on the system and a reflection of themedicotechnical dominance in the Department ofHealth. This, linked to the lack of budgeting skills atthe service manager level, is an important factor inbudgeting failures. There has been little training inbudgeting and this, combined with the complexity ofthe process, is a disincentive to active involvement byprofessional or policy-level staff. The situation isexacerbated by the frequent transfer of professionalstaff, which has caused problems in maintainingcontinuity.

Table 1. Additional revenues required to meet projected healthbudgetsa

Sector Additional revenues required % of(Rs x 106) Total

1996–97 1997–98 1998–99 Long-termrecurrent

requirements

Primary 35.8 51.4 122.2 467.0 79Secondary 0.0 0.0 6.9 14.1 2Tertiary 0.0 37.5 59.4 101.5 17Support 0.0 5.7 11.0 12.3 2Total 35.8 94.6 199.6 594.9 100

a The projected data were based on the implications of the Balochistan 1995–96 AnnualDevelopment Programme, Balochistan Department of Health Development Budget. See ref. 19.

Policy and Practice


Political contextThe political context, within which decentralizationtakes place, is critical to the type of decentralizationand its success. In Balochistan a number of issues areimportant in this respect, including the politicalrelationship between the national and provincialgovernments, the frequent changes in government,the role of the military in politics, and the strength ofthe medical profession and its role within health caremanagement. The fragile and transitory nature ofgovernment tends to result in a short-term policyperspective and a desire to maintain central politicalcontrol that may run counter to the development ofmore rational and decentralized systems of budget-ing. Finally, in a system where public sector salariesare very low, the potential for themisuse of power forindividual financial gain cannot be ignored.

The products of all this are budgets andpatterns of resource allocation with high degrees ofinequity and inefficiency. The budgets that result areas described below.. Inefficient between-line items, particularly be-

tween salary and non-salary items. For example,salary costs may be as high as 80% of total costs inprimary level facilities (19).

. Inequitable between similar service units. Forexample, allocations to hospitals with apparentlysimilar capacity or demands (as indicated by thenumber of beds or utilization levels) can vary byup to a factor of two, and to primary facilities by asmuch as five (20).

. Inequitable between populations with apparentlysimilar health needs. For example, allocations percapita to primary level services by district varyfrom 18 to 159 Rs (US$ 1.00 = ca. Rs 32 at thetime of the 1995–96 ADP), with an overallprovincial average of Rs 37 per capita (20).

The above-mentioned constraints were analysed at anearly stage in theBHSCCproject, fromwhich it becameclear that the allocative systemwasnotworking in awaythat would either induce efficient practice or promoteequity between districts, regardless of how the latterwas defined and measured. This situation has led to adeep sense of frustration at various levels of the healthservice, but in particular at the level of the districts.Overall, thebudgetingandresourceallocationsystemisviewed as an obstacle rather than a support to thedevelopment of decentralized health care. It was clearthat the project would need to put emphasis onimproving the resource allocation system as part of itsdecentralizationobjectives.We turnnowto theoptionsthat were considered.

Modifying the resource allocationand budgeting system

Technical and organizational design issuesDescribed below is the process of modifying theresource allocation system operating within Balochi-stan. The following refers to intraprovincial resource

allocation, rather than interprovincial, and only torevenue budgets. It was accepted early on that itwould be impossible to include development budgetsin the system redesign and that they would have to betied into the budgeting system through the planningprocess for the medium term. Within Balochistan, itwas agreed that the general criteria for choosing anallocative system to districts were as follows:– impact on equity;– impact on efficiency ;– transparency;– feasibility including data availability, technical

capacity to operate, ability to reduce over-capacitywhere appropriate, and capacity to absorb growthwhere appropriate;

– consistency with other government systems;– flexibility to allow medium- to long-term refine-

ment.

Alternative modelsFollowing diagnosis of the existing situation, criteriawere applied to four potential allocative models,including the current one. All the models require amechanism for allocating a portion of the overallDepartment of Health budget to cover central costsand those programmes that cannot be managed bydistricts. These include central and divisional admin-istration, tertiary hospitals and other institutions andtraining. While it is possible to envisage a situationwhereby the bulk of these are also decentralized withdistricts purchasing them back, this is unlikely to befeasible for some time given current managerial andinformation constraints.

Model A. Incrementalist (current model).

District budgets are based on the previous year’sallocation (or expenditure), increased pro rata,though the possibility exists for new budgets to beadded through the annual schedule of new expendi-ture. Though this approach is administrativelysimple and non-threatening it neither promotesefficiency nor equity.

Model B. Health facility requirement. Bud-gets would be set to ensure that the major existingprimary and secondary level facilities are providedwith adequate resources to allow them to operateeffectively and more efficiently. This would not leadto an improvement in the distribution of resourcesbetween districts. However, it would improve thequality of care at existing facilities, and indeedprovides rewards to facilities with high utilizationrates. This is an important feature in the Pakistanisystem where there is no reward, and indeed somedisincentives, for improving utilization at facilitiesthat are currently under- or inappropriately re-sourced. Budgets would take into account the realcosts and utilization rates of existing facilities.However, to avoid major swings in allocation todifferent districts, whichmight run counter to equity,ceilings on increases would need to be set. Suchceilings could initially be based on a crude per capitabasis and would take into account absorptive



capacity. Explicit prioritization would also need to bemade between facilities within districts, as thisapproach on its own will not lead necessarily toadequate overall resource levels in districts. Districtswould have to make their own prioritizationdecisions between facilities, based on their assess-ment of differential need. Some training would berequired for district managers and central staff, butthe close links to existing facilities would mean that itwas politically acceptable and intuitively understand-able. A systemwould need to be put in place to ensurethe above elements were handled at both provincialand district levels.

Model C: Health service requirements. Thethird approach is an enhancement of the second.Through strong links into district planning, budgetsare tied more closely to the overall health servicerequirements of the district population, rather thanthe health facility requirements. Districts which,through the planning process, are considered to beunderserved would receive particular planning atten-tion and above average allocation growth rates.Development expenditure that is related to plans, andsubsequent revenue implications, would be a majormechanism for this. Judgements as to which districtswere underserved, and to what degree, would beformed on the basis of similar information to that inModel D (e.g. population and morbidity), but wouldnot be tied formally into a formula. There would besimilar implementation implications as to Model B,but an additional need for strengthened centralplanning capacity.

Model D: Population-based resource alloca-

tion. The final model involves the allocation ofresources on the basis of population, possiblyweighted by factors such as age, sex, specific healthneeds, density, cross-boundary flows and differentcosts of health care delivery. Under this, districtmanagers set specific budgets within an overallallocation provided by the formula. In a system ofpurdah, the ability to access services anonymouslymay be important and may lead to additional cross-boundary flows (21).

The main strength of this model lies in thepotential to promote equity. Similar training require-ments to those of the other models would be needed.However, the weaknesses in the current informationsystem constitute a major constraint to this model.Furthermore the political opposition from ‘‘losing’’districts could be major obstacle.

Each of the resource allocation models hasadvantages and disadvantages. While there wasgeneral support for Model D in principle, it wasinitially felt that it would be impossible to introduce inthe short-term, largely as a result of the lack ofconfidence in the population data. Instead aprogressive movement through the models towardsModel D was chosen. The current incrementalistapproach (Model A) is widely regarded as inap-propriate. Development of better systems to meetthe operating requirements of current facilities(Model B) would improve their technical efficiency

and engender support in the system for the budgetingprocess. However, it was recognized that this shouldonly be an intermediate step since this, by itself, willnot overcome the inefficient and inequitable dis-tribution of current primary and secondary levelresources. Model C (through its strong emphasis onlinks between planning and budgeting) would allow agreater development of health needs sensitivity andresponsiveness. The last stage in the progressiontowards full budgetary decentralization would in-volve the allocation of resources on the basis ofpopulation, weighted to incorporate other aspects ofneed (Model D).

Supporting componentsThere are various components required in order todevelop the chosen allocative system, including thosediscussed below.

Improved informationAs we have seen, information systems appropriate tothe development of a decentralized resource allocationsystem may not be available and will need to bedeveloped through both routine data collection andresearch. Within Balochistan, development of a healthmanagement information system is proceeding. Fullprovincial coverage has been achieved in primary levelfacilities, and a substantial amount of health serviceactivity data is now flowing through the system. Thiswill eventually provide more detailed information onnon-financial inputs and service outputs.

Studies have been undertaken to develop arange of unit costs of routine activities in primarylevel facilities and district hospitals (22, 23). The firstof these studies provided important information onthe actual costs and ‘‘standard’’ levels of resources forprimary facilities, taking account of utilization, casemix and other district level costs such as supervisionand monitoring (Table 2).

The difference between actual costs andstandard requirements gives an indication of the‘‘funding gap’’ to be filled if services are to run at animproved level of efficiency under Model B. Differ-ential funding needs can be calculated on a districtbasis and under-funding of existing facilities occurringin the primary health sector can now be estimated.Furthermore, up until 1998–99 it had been expectedthat SAP would provide real significant increases inhealth sector spending. This would permit the use of apolicy of differential growth (based on the relative sizeof the gap) to under-resourced areas, rather thanachieving resource shifts by cutting absolute alloca-tions to ‘‘over’’-resourced areas. This, it had beenhoped, would minimize political opposition from‘‘losing’’ districts. Unfortunately, the 1998–99 budgetsuffered a significant cross-sector cut in response togovernment concerns over increasing regional poli-tical tension following nuclear testing.

One of the major constraints against developinga population-based allocative formula was the lack ofgeneral confidence in the official population figures

Policy and Practice


and the political ramifications of these for differentpopulation groups. However, in 1998 a census wascarried out, the results of which, formally at least, areexpected to be accepted. One result of the census hasbeen an indication that the Department of Healthwould now be prepared to consider a faster movetowards incorporation of population in any formula.

Development of central planning and budget-

ing systems.Decentralization is often interpreted as aweakening of the central position. This, we wouldsuggest, is misguided. Instead, a change in role isneeded, with concomitant energy put into aredevelopment of this role. Within Balochistan,annual guidelines (24) have been developed whichprovide specific guidance on service policy, andbroad service delivery targets. All these elements arecombined to form the district planning and budget-ing guidelines, designed to be issued annually tobudget holders by the central health planning unit. InBalochistan, the Planning Cell was supported by theproject to produce financial guidelines for districtofficers. In developing these it was proposed, interalia, that:– no district would be allowed to suffer a real net

loss in resource levels;– targets would be set to guide managers in the line

item allocation of funds within their overallbudget: in particular, these would focus onincreasing the size of the non-salary budget;

– hospitals and central programmes would receiveincreases in line with inflation.

Development of district planning and budget-

ing systems. One of the key rationales for thedevelopment of a decentralized system is the abilityto develop plans for districts based on their specificneeds, within an overall policy envelope. In Balochi-stan, a district planning cycle has been developed (25)that enables district officers to relate their identifiedhealth problems to implementable solutions. Servicemanagers are encouraged to define objectives linked tointerventions and activities for the coming three years.Using the resource guidelines and financial informa-tion, the intention is that they are then able to developmore rational and appropriate development andrevenue budgets. These budgets can then be sub-mitted to the centre for checking and consolidationprior to submission to the Department of Finance.

Implementation experiencesThe above section has outlined the technical workcarried out to develop an improved allocative system,consistentwith the stated decentralization aims of theDepartment of Health. This section describes theimplementation history of this aspect of the project.

Following early preparatory work, agreementwas reached on the way forward as described earlier.Costing studies were then carried out; and training inthe development of district plans and budgetsprovided. Initially the BHSSC project was designedto operate province-wide. The financial year 1996–97

was used as a trial year to introduce revised planningand budgetary processes. District plans and devel-opment budgets were developed by 12 of the26 districts in the province. Unfortunately, inade-quate time was set aside to prepare revenue budgetsand no district was able independently to submit aworked proposal. Due to the limited success of thedistrict-level budgeting process, central allocationguidelines based on unit cost information wereapplied to existing district budgets. This producedmore rational, but still centrally generated, draftdistrict budgets for 1997–98. Insufficient ‘‘owner-ship’’ within the Budget Section of the DepartmentofHealth, however, led to even these drafts not beingaccepted and introduction of the system beingdelayed a further year.

Following a mid-term review of the overallproject, it was decided to focus more intensively onsix trial districts. Though this had little effect on thedesign issues for a resource allocation system, it didhave implications for the human resource aspects ofthe project. By concentrating resources on a limitednumber of districts it was, in theory, possible toprovide greater support for the development of theirbudgeting and planning capacity. However, thegeneral problem of frequent staff transfers, referredto earlier, lessened the actual impact of this.Furthermore, the concentration on trial districts gaverise to (unfounded) suspicions that the allocationsystem might favour such districts in terms of theoverall level of resources. Inevitably also the shift infocus to trial districts lessened the inputs of theproject at the provincial level.

The trial districts, with technical support fromthe project, produced draft budgets for 1998–99, butthese were not accepted by the Department of Health,ostensibly on the grounds that they were late. Theprocess was started earlier in the following year andtrial districts again produced draft budgets for 1999–2000 based on their facilities’ needs and using theinformation provided from the costing studies. Again,however, they were not incorporated in the con-solidated budget, with concerns about the favouredstatus of the trial districts again being voiced.Following the 1998 population census the Depart-ment of Health is now considering a shift to centrallydetermined budgets on the basis of a complexcombination of population and facilities (in effect a

Table 2. Revenue costs per month for types of primary care facilitya

Civil dispensaries Basic health units Rural health centres

Budget Personnel Budget Personnel Budget Personnelallocation cost allocation cost allocation cost

(Rs) (%) (Rs) (%) (Rs) (%)

Actual costs 21 062 81 21 062 81 46 043 80Standard 42 455 52 54 555 49 210 213 46requirements

a Actual personnel costs and standard requirement personnel costs are expressedas a percentage of their respective budget allocations. See ref. 22.



combination of Model B andModel D). However, theproject is drawing to an end and no changes are likelyto be seenwithin the next year, with any future changeslikely to be implemented through SAP.

Conclusions and lessons to be drawn

In this article we have described one aspect of abroader decentralization project. A number of otheraspects are ongoing (including the development ofdecentralized planning capacity and monitoringprocesses). However, it is clear that the technicalwork carried out to support the development of theresource allocation and budgeting system in line withdecentralization has not yet led to change. Although itis expected that when this project ends the technicalaspects of the work will be taken over by thecontinuing SAP processes, it is important to analysethe implementation failure and see what lessons canbe drawn for other decentralization processes. Thecauses of failure identified in the article aresummarized in Table 3.

One useful framework for analysis of the sortof policy changes discussed here is that proposed byWalt &Gilson (26), which suggests the need to assessnot only the policy content but also the context, processes,

and actors. The focus of the project’s work in this areawas on the content of the reform to the allocative andbudget system, with considerable attention beingpaid to alternative models and their technicalrobustness. As part of this, the context in which thereforms were being proposed was analysed, payingparticular attention to the wider government plan-ning and budgeting systems, information availability,and skill levels. Possibly insufficient attention waspaid to the decision-making culture. The culture ofcentralized decision-making and an attendant proce-durally driven bureaucracy, coupledwith the frequenttransfer of staff, means that decentralization bothchallenges the organizational and managementculture and is in fact high risk, albeit with highpotential returns in terms of health impact.

The process of change to a new system requiressupport at all levels. The project had always recognizedthe sources of resistance to decentralization broadly,

and budgeting and resource allocation in particular.Unfortunately, the level and sources of resistance tonew systemswas underestimated. Various actors can beidentified as perceiving the process as threatening.These include the following: the senior professionalsin the Health Directorate concerned at a loss of role,status and power; clerical staff currently responsiblefor centralized budgeting concerned about the devel-opment of a system which may sideline them; andother central departments, most importantly theDepartment of Finance, concerned about the poten-tial dangers of decentralization. In addition, politiciansable to use the current allocative system as a means ofmaintaining a political base may be resistant. Under-pinning all of this is the critical issue as to whetherthere is shared understanding of and genuine supportfor equity, the main driving force behind a needs-based resource allocation system.

Lastly, there are questions as to the process

adopted by the project to introduce the changes. Thechanges were driven externally by a project operatingclose to, but largely external to, the governmentsystems. As such it may have underestimated theneed for greater internal ownership or championingof the changes by either a senior bureaucrat orpolitician. The shift by the project halfway throughfrom a province-wide intervention to one using trialdistricts may also have led to a reduced opportunityfor change. Under a province-wide approach greatersupport from potential winners may have beenfeasible, and accusations of favouring trial districtswould not have been possible.

What lessons can be drawn?. First, it is easy to underestimate the various

sources and depth of resistance. Greater attentionneeds to be given to the political dimensions ofsuch projects, to seek ownership of the process ofchange. While resource allocation may appear as a‘‘technical’’ issue, it clearly is muchmore than that.Furthermore, the type of changes involved in anew resource allocation system may be viewed astechnically challenging by staff with little manage-ment, let alone economic, training and as suchresisted. Under such circumstances, projects needto recognize that the processes of change mayneed to be slower to develop a critical mass forchange. This unfortunately, does not accord easilywith the time horizons of most projects. Further-more, a clear and strong champion is needed fromwithin the system. However, one of the structuraldifficulties with donor projects is that they tend tooperate in parallel with the mainstream govern-ment system. The SAP, which is designed as anintegral part of government, does in theoryprovide greater opportunity for genuine owner-ship to be developed. It is possible that the degreeof genuine commitment to equity objectives couldhave been explored further with an analysis of the

Table 3. Causes of intervention failure

Lack of appropriate credible information on health needs and service costsResistance from politiciansResistance from bureaucrats and health service mangersLack of clear and shared understanding and commitment to equityComplex budget structuresCentralized decision-making processes and cultureInterventions from project external to governmentDifficulty of reforming one public sector in isolationDifficulty of using trial districtsLack of appropriate budgeting skillsLack of central guidelines

Policy and Practice


variations in health outcomes between districts (asopposed to inputs).

. Second, it needs to be recognized that, indecentralization projects, as much attention needsto be given to supporting the necessary changes atthe centre as at the periphery. While the districtstaff embraced the technical proposals, the majorresistance was encountered at the centre.

. Third, it is worth recognizing the difficulty ofreforming one element of the public sector inisolation. Many of the problems faced by thehealth sector were shared by, or arose from, othersectors. It is certainly arguable that single-sectorreform may not be feasible, though it can also beargued that a single-sector ‘‘lead’’ may benecessary to pilot new government-wide ap-proaches. However, in these cases, centralgovernment support is assumed. Within thehealth sector itself, it may be that in areas suchas resource allocation reform, changes need to beintroduced simultaneously across the systemrather than through trial districts.

. Fourth, while the attempt to improve the resourceallocation system may appear as a failed interven-tion, it is important to recognize three positiveoutputs of the process. First, as a result of theproject, technical capacity has improved in anumber of areas. Health economics capacity, withpractical costing skills, has been developed within

the University of Balochistan. This has led topositive collaboration with benefits to all partiesand has provided the Planning Cell with access toexternal technical resources. Second, the skills andinterest of district managers has also shown notablequalitative improvement and there is a broaderrecognition amongst this group of the potentiallyimportant role of a district manager under anappropriate decentralized system. Third, the tech-nical work that has been carried out will form thebasis for change when there is greater politicalreadiness to adopt genuine decentralization. n

AcknowledgementsThe work reported in this article was carried out aspart of a project funded by the United KingdomDepartment for International Development (DFID).The views expressed are, however, not necessarilyendorsed by DFID. The overall FH2P is additionallycofunded by the World Bank, Kreditanstalt furWiederaufban (KfW) and the Government ofBalochistan, and has the objectives of improvingthe health status of the population of Balochistan;increasing the effectiveness of the existing health carenetwork; and building institutional capacity to realizethe above objectives and set the stage for futureinterventions. We acknowledge the helpful com-ments made by reviewers of the article.

Resume

Allocation de ressources et mecanismes budgetaires pour des systemes de santedecentralises : experience du Beloutchistan (Pakistan)Le present article decrit le travail accompli au Belout-chistan (Pakistan) dans le cadre du deuxieme projet desante familiale (composante Renforcement des systemesde sante du Beloutchistan). Il s’agissait d’elaborer unsysteme de sante publique permettant d’allouer desressources et d’etablir un budget, qui soit fonde sur lesbesoins et realisable malgre les difficultes techniqueslocales, comme les lacunes du systeme d’information. Lesysteme envisage devait par ailleurs etre conforme a lapolitique du Beloutchistan consistant a decentraliser lesecteur de la sante publique. Le systeme actuel est basesur une augmentation progressive des allocationsbudgetaires fixees precedemment et il n’est ni efficaceni equitable. Pour remedier a la situation, nous avonscerne les principales questions politiques et techniquesqui entrent en ligne de compte dans l’elaboration d’unsysteme plus approprie d’allocation de ressources et debudgetisation.

Nous avons commence par exposer differentesmethodes d’allocation de ressources du niveau central ala peripherie et etudie les elements techniques utilisespour determiner une formule applicable a un tel transfert.Nous avons presente un modele conceptuel d’allocationde ressources en fonction des besoins et examine lesconditions necessaires a la mise en œuvre de ce modele.Nous avons ensuite decrit le systeme de sante actuel duBeloutchistan, en mettant l’accent sur les mecanismes

budgetaires. Ceux-ci sont complexes, car il y a plusieursbudgets qui sont tous controles de maniere differente.Les decisions sont souvent prises pour des raisonsadministratives plutot que strategiques et elles peuventetre influencees par des facteurs politiques. Il s’ensuitque les budgets sont inefficaces et inequitables. Pourelaborer un systeme d’allocation plus rationnel, nousavons envisage quatre options. Celles-ci sont decrites,ainsi que les criteres retenus pour degager un accord surle systeme qui a finalement ete choisi. Malgre cet accord,le systeme n’a pas ete pleinement mis en œuvre etl’article tente d’analyser les raisons de cet echec partiel.

On peut tirer les lecons suivantes de l’experiencedu Beloutchistan.. Premierement, il est facile de sous-estimer les sources

et l’ampleur de la resistance. C’est la un obstaclemajeur a l’application d’une nouvelle politique, car leprocessus de changement qui doit aboutir a sonadoption exige un soutien a tous les niveaux.Cependant, plusieurs groupes voient dans ceprocessus une menace, et il est primordial de savoirsi l’equite, principal element moteur d’un systemed’allocation de ressources fonde sur les besoins,beneficie d’un reel et large soutien. En outre,l’habitude de la centralisation de la prise de decisionet de la bureaucratie proceduriere, combinee avec lamutation frequente de personnel, fait que la



decentralisation met en danger la culture del’organisation et de la gestion et qu’elle estconsideree comme un grand risque. Il faut doncaccorder une plus grande attention aux dimensionspolitiques des projets de decentralisation et recon-naıtre que les reformes doivent parfois etre plus lentesafin de degager une masse critique favorable auchangement. De plus, on a besoin d’un chef de fileincontestable et puissant qui soit issu du systeme.Toutefois, l’une des difficultes structurelles inherentesaux projets des donateurs est qu’ils tendent afonctionner parallelement au systeme gouverne-mental traditionnel.

. Deuxiemement, dans les projets de decentralisation, ilfaut appuyer les changements necessaires avec autantde vigueur au niveau central qu’a la peripherie.

. Troisiemement, il convient de reconnaıtre la difficultede reformer un seul element du secteur public. Bon

nombre des problemes qui se posent dans le secteurde la sante sont communs a d’autres secteurs, ouproviennent de ceux-ci, et l’on peut soutenir que lareforme d’un seul secteur n’est pas realisable.

. Quatriemement, si la tentative d’ameliorer le systemed’allocation de ressources peut paraıtre un echec, il estimportant de relever les resultats positifs du processus.Grace au projet, les capacites techniques ont eterenforcees dans plusieurs domaines. On a constate unenette amelioration qualitative des competences et del’interet des administrateurs de district, lesquels sont deplus en plus nombreux a reconnaıtre le role potentiel-lement important d’un administrateur de district dansun systeme convenablement decentralise. Le travailtechnique qui a ete accompli permettra d’operer lechangement lorsque la volonte politique de procedera une veritable decentralisation sera plus grande.

Resumen

Asignacion de recursos y mecanismos presupuestarios para sistemas de saluddescentralizados: la experiencia del Baluchistan (Pakistan)En este artıculo se describe el trabajo llevado a cabo en elBaluchistan (Pakistan) como parte del Segundo Proyectode Salud Familiar (Componente de Fortalecimiento de losSistemas de Salud del Baluchistan). El objetivo consistıaen desarrollar en el marco de la salud publica un sistemade asignacion de recursos y elaboracion presupuestosque estuviera basado en las necesidades y fueserealizable a pesar de las limitaciones tecnicas existentesa nivel local, relacionadas, por ejemplo, con el sistema deinformacion. El sistema tenıa que ser tambien coherentecon la polıtica baluchistanı de descentralizacion delsector de la salud publica. Actualmente el sistemavigente en el Baluchistan se basa en un gradualismohistorico y no es ni eficiente ni equitativo. Para abordaresta cuestion hemos identificado diversas cuestionespolıticas y tecnicas fundamentales para el desarrollo deun sistema mas apropiado de asignacion de recursos ypreparacion de presupuestos.

Empezamos exponiendo a grandes rasgos distin-tos enfoques para asignar recursos de zonas centrales azonas perifericas, examinando diversas cuestionestecnicas relacionadas con la eleccion de la formulaidonea para determinar esas asignaciones. Se presentaun modelo conceptual para establecer una asignacion derecursos basada en las necesidades, examinandoseparalelamente los requisitos de aplicacion de un sistemade esa naturaleza. A continuacion se describe el actualsistema de salud del Baluchistan, prestando especialatencion al sistema presupuestario. Es este un sistemacomplejo, con varios presupuestos, controlados todosellos de diferente manera. Las decisiones se adoptan amenudo con criterios administrativos antes que estrate-gicos, y pueden verse influidas por factores polıticos. Elresultado son unos presupuestos ineficientes y noequitativos. A fin de desarrollar un sistema de asignacionmas racional, consideramos cuatro opciones. Sedescriben dichas opciones, ası como los criteriosutilizados para llegar a un acuerdo respecto al sistema

finalmente elegido. Pese al acuerdo logrado, el sistemano se ha llevado a la practica en su totalidad, por razonesque se intenta analizar en el artıculo.

Nuestra experiencia en el Baluchistan nos haensenadovarias lecciones, segun se resumeacontinuacion.. En primer lugar, es facil subestimar las causas y la

magnitud de la resistencia a las medidas. Este factordificulta sobremanera la aplicacion de una nuevapolıtica, pues un cambio tal requiere apoyo a todoslos niveles. Sin embargo, diversos grupos ven en elproceso de cambio una amenaza, y una cuestiondecisiva es si existe o no un autentico apoyogeneralizado en favor de la equidad, concepto queconstituye la principal fuerza impulsora de un sistemade asignacion de recursos basado en las necesidades.Ademas, la existencia de una cultura de centraliza-cion de la adopcion de decisiones y de una burocraciadependiente de procedimientos, unida a los frecuen-tes traslados de personal, hacen de la descentraliza-cion tanto un desafıo para la cultura de laorganizacion y la gestion como un proceso de altoriesgo. Ası pues, es necesario prestar mas atencion alas dimensiones polıticas de esos proyectos, y admitirque a veces hay que frenar el ritmo de las reformaspara poder lograr una masa crıtica favorable alcambio. Ademas, hay que disponer de un aliadoinequıvoco y firme dentro del sistema. Sin embargo,una de las dificultades estructurales que plantean losproyectos de los donantes es que tienden a funcionarparalelamente al sector principal de la Administra-cion.

. Segundo, en los proyectos de descentralizacion hayque procurar apoyar tanto los cambios necesarios enel centro como los requeridos en la periferia.

. Tercero, conviene reconocer las dificultades quesupone intentar reformar por separado un elementodel sector publico. Muchos de los problemasafrontados por el sector de la salud afectaban

Policy and Practice


tambien a otros sectores, cuando no procedıan deellos, lo que respaldarıa la idea de que la reforma desectores aislados quiza no sea viable.

. Cuarto, si bien puede parecer que el intento demejorar el sistema de asignacion de recursos ha sidouna intervencion fallida, es importante reconocer losresultados positivos del proceso. Ası, como conse-cuencia del proyecto, la capacidad tecnica hamejorado en varias areas. Las aptitudes y los intereses

de los administradores de distrito han experimentadomejoras cualitativas, y entre esas personas hay unamayor conciencia del importante papel que puedellegar a desempenar un administrador de distrito enun sistema descentralizado. El trabajo tecnico que seha llevado a cabo sentara las bases para aplicar loscambios cuando exista una mayor voluntad polıticade proceder a una verdadera descentralizacion.

References

1. Green A et al. Health planning in Pakistan: a case study.International Journal of Health Planning and Management, 1997,12: 187–205.

2. Segall M. Planning and politics of resource allocation for primaryhealth care: promotion of meaningful national policy.Social Science and Medicine, 1983, 17: 1947–1960.

3. Collins C. Management and organization in developingcountries. Oxford, Oxford University Press, 1994.

4. Cassells A, Janovsky K. A time of change: health policy,planning and organization in Ghana. Health Policy and Planning,1992, 7: 144–154.

5. Mills A et al. Health system decentralization: concepts,issues and country experience. Geneva, World HealthOrganization, 1990.

6. Collins CD, Green AT. Decentralization and primary health care:some negative implications in developing countries. InternationalJournal of Health Services, 1994, 24: 459–476.

7. World Bank. World development report 1993. Investingin health. New York, Oxford University Press, 1993.

8. Mahapatra P, Berman P. Resource allocation for publichospitals in Andhra Pradesh, India. Health Policy and Planning,1995, 10: 29–39.

9. Murray CJL, Kreuser J, Whang W. Cost-effectiveness analysisand policy choices: investing in health systems. Bulletin ofthe World Health Organization, 1994, 72: 663–674.

10. Chae YM et al. Application of goal programming to improveresource allocation for health services in Papua New Guinea.International Journal of Health Planning and Management, 1989,4: 81–95.

11. Kalumba K. Towards an equity-oriented policy of decentraliza-tion in health systems under conditions of turbulence: the caseof Zambia. Geneva, World Health Organization, 1997(unpublished document WHO/ARA/97.2).

12. Doherty J, van der Heever A. A resource allocation formulain support of equity and primary health care. Johannesburg,University of Witwatersand, Centre for Health Policy, 1997,Paper No. 47 (248–250).

13. Resource Allocation Working Party. Sharing resourcesfor health in England. DHSS, London, 1976.

14. Mays N. Measuring need in the National Health Service ResourceAllocation Formula: standardized mortality ratios or socialdeprivation? Public Administration, 1987, 65: 45–60.

15. Carr-Hill R, Sheldon R. Rationality and the use of formulaein the allocation of resources to health care. Journal of PublicHealth Medicine, 1992, 14: 117–126.

16. Collins CD et al. International transfers of National HealthService reforms: problems and issues. Lancet, 1994,344: 248–250.

17. Government of Baluchistan. Ready reckoner ofhealth statistics. Quetta, Statistics Cell, Health Directorate, 1996.

18. Government of Pakistan. Pakistan Integrated HouseholdSurvey: final results. Islamabad, PIHS Project, Federal Bureauof Statistics, 1991.

19. Government of Baluchistan. Situational analysis of healthin Baluchistan. Quetta, Planning Cell, Health Department,1995.

20. Government of Baluchistan. Situational analysis of healthin Baluchistan. Quetta, Planning Cell, Health Department, 1993.

21. Tarin E, Thunhurst C. Community participation — with providercollaboration, World Health Forum, 1998, 19: 72–75.

22. Barkat A et al. Research study: unit costs of primary levelhealth care facilities. Quetta, Second Family Health Project,British Council, 1996.

23. Barkat A, Naeem A. Research Study: Unit costs of Divisionaland District Hospitals. Quetta, Second Family Health Project,British Council, 1997.

24. Government of Baluchistan. District planning and budgetingguidelines. Quetta, Planning Cell, Health Department, 1998.

25. Government of Baluchistan. District planning and budgetingmanual. Quetta, Planning Cell, Health Department, 1998.

26. Walt G, Gilson L. Reforming the health sector in developingcountries: the central role of policy analysis. Health Policyand Planning, 1994, 9: 353–370.



Documents

Policy and Practice Resource allocation and budgetary …8)1024.pdf · Resource allocation and budgetary mechanisms for decentralized health systems: experiences from Balochistan,