In 2005, Vietnam’s legislature voted to develop a new health insurance system that would reduce most citizens’ out-of-pocket health-care costs and instructed the health ministry to take steps to make care more accessible, more affordable, and more effective—especially for those who lived in remote, mountainous regions. One of the challenges was how to manage scarce resources in order to constrain soaring costs. Another was how to coordinate with provinces and local governments (districts and communes)—which controlled much of the country’s health-care spending—in order to achieve national priorities, such as improved preventive care. During the next several years, the health ministry’s Department of Planning and Finance worked with those subnational units to improve the financial information system, hone strategies and plans, and align activities. By 2014, Vietnam’s government had more than tripled its per-capita health-care spending—to US$48.82 in 2014 from US$15.52 per capita in 2005, in current US dollars—a rate of growth that outpaced the average in both low-income and lower-middle-income countries. Although the ministry still struggled to keep patients’ costs down, the share of out-of-pocket spending fell to 45% in 2015 from 67% in 2005, according to government figures.

ISS staff members drafted this case study based on interviews conducted in Hanoi, Vietnam by Simon Engler and Huong Dang in May, June, and August 2018. Case published in May 2019. This case is part of an ISS series on linking health priorities to the budget process.

Ethiopia’s Federal Ministry of Health was struggling to meet its goals in 2014 despite impressive gains in the health of its citizens during the previous 20 years. A new minister and his leadership team reached out for ideas by engaging Ethiopia’s regions, districts, and communities—an essential step in a large and ethnically diverse society. They then developed an ambitious transformation program to help realize the government’s national aspirations for health care, including commitments made to achieving the Millennium Development Goals. To bring their vision to fruition, however, the minister and his team had to link priorities to the budget process and use the health budget as a management tool. The ministries of health and finance matched goals and targets to available resources and worked to create actionable plans. And health officials took steps to build cooperation and extend coordination at every level of government in Ethiopia’s federal system. Technical and capacity constraints—plus unexpected political upheaval beginning in late 2015—slowed implementation, but in 2018 a new administration was taking steps to address those challenges.

Gordon LaForge drafted this case study based on interviews conducted in Addis Ababa, Ethiopia, in October 2018. Case published January 2019.

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In its 2006 national vision to end poverty, Ethiopia set its sights on becoming a middle-income country by 2025. It was a hugely ambitious goal for a country that, at the time, was one of the poorest in the world. To support development objectives put on hold during a decade of political turbulence, including a costly border war with Eritrea that drained public coffers, the Ethiopian government sought to expand its resources by significantly boosting tax revenues. The new plan called for a sharp increase in the ratio of tax revenue to the size of the economy—and within four years. The government merged its separate customs and domestic tax offices into a single entity and restructured the new agency’s operations along functional lines, increased salaries, adopted stringent anticorruption rules, implemented a modern information technology system, and launched public awareness campaigns. It was important that the new revenue authority worked to improve its coordination with the tax offices of subnational governments, which operated with substantial independence under the country’s federal system. Although unproven charges of corruption against the Ethiopian Revenues and Customs Authority’s long-serving director general in 2013 stalled progress, a new round of IT and legal reforms in 2016 helped increase tax collection significantly: to US$7.8 billion in 2017 from US$1.3 billion in 2006 (measured in constant 2010 US dollars). Nonetheless, revenue gains continued to lag behind economic growth. In 2018, under a new prime minister, the government began to take further steps to strengthen tax collection.

Leon Schreiber drafted this case study based on interviews conducted in Addis Ababa, Ethiopia, in October 2018. Case published December 2018.

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In 2012, Colombia’s public health system was headed for bankruptcy. The country had made significant progress on important public health priorities: expanding immunizations, reducing infant mortality, and attaining near-universal insurance coverage. But a Constitutional Court ruling that the government had to pay for almost all health services and technologies for those it subsidized, combined with rising pharmaceutical prices, was pushing the budget into deficit. Economist Alejandro Gaviria became minister of health and social protection amid that simmering crisis. To contain spiraling costs while enabling the sector to focus on some of its priorities, he worked to create new legislation that would limit the services the government would cover, regulate the drug market, and adjust an incentive structure that had lowered accountability and encouraged excess. In parallel, budget officials in the health ministry, the Ministry of Finance and Public Credit, and the National Planning Department tried to improve financial management of the system in order to increase efficiency and reduce costs. In the end, some of Gaviria’s efforts paid off and the ministry averted immediate insolvency, but as of 2018, the viability of Colombia’s health-care system remained in doubt even as health indicators improved.

Gordon LaForge drafted this case study based on interviews conducted in Bogota, Colombia in September 2018. Case published November 2018.

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In 2009, South Africa's health-funding system teetered on the verge of collapse. Despite the adoption of a transparent and credible budget framework in 1994, large parts of the public health system suffered from chronic overspending and poor financial control. As wage hikes and supply costs ate into the health budget and as government revenues plummeted in the wake of the 2008 global financial crisis, the national health department had to find ways to preserve priorities, linking them more effectively to the budget. The department won agreement on a list of non-negotiable expenditure items to protect in provincial budgets, used earmarked conditional grants to channel funds to key programs, cut medicine costs by improving central procurement, rolled out a new information technology system, and improved its monitoring of provincial finances. Although the country's nine provincial health departments had important roles to play, most of them struggled. However, the Western Cape was able to set a model by controlling personnel costs, improving monitoring, and creating incentives for health facilities to collect fees. Nationally, total per-capita government revenues dropped by 5% in the immediate aftermath of the financial crisis and grew only slowly thereafter, but the health sector's strategy helped ensure progress on its key priorities even as resources fluctuated.

Leon Schreiber drafted this case study based on interviews conducted in Pretoria and Cape Town, South Africa, in August 2018. Case published October 2018.

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In June 2012, Rwanda’s national land registry completed a nearly four-year project that mapped every one of the country’s 10.4 million parcels and prepared title documents for 8 million landholders. It was an unprecedented accomplishment in a country in which lack of land titling had weighed on the economy and led to escalating conflict over access to land. The mapping program promised to reduce tensions by establishing an orderly system for registering and transferring landownership. However, the system could work only if Rwandans registered every transaction, and in 2012, a survey found that only about one of every eight landowners had even bothered to pick up their official titles. The registry urgently had to both make it easier to register transactions and build public awareness about the importance of keeping the land database up-to-date. A registry team launched a nationwide campaign to raise awareness about the importance of titling and of reporting all land transactions. Managers simplified procedures and registration forms. And to provide greater access in rural areas, where titling was nearly unknown, the registry decentralized services and introduced a new software platform to speed transactions. By mid 2017, more than 7 million people had collected their titles, and registrations of sales, purchases, and other kinds of transfers had begun to improve. Still, the number of transactions reported in 2016 fell short of the registry’s target, indicating that further work lay ahead.

Leon Schreiber drafted this case study based on interviews conducted in Kigali, Musanze, and Huye, Rwanda, in June and July 2017. Fortunee Bayisenge, Lecturer and Dean of the Faculty of Development Studies at the Protestant Institute of Arts and Social Sciences, collaborated on the research. The British Academy-Department for International Development AntiCorruption Evidence (ACE) Program funded the development of this case study. Case published September 2017.

In the early 2000s, Tanzania struggled to protect the land rights of the 75% of its citizens who lived in rural areas. Rapid population growth and rising investment in commercial agriculture had increased land scarcity and created the potential for violent conflict in parts of the country. In accordance with the provisions of a new law, the national lands ministry launched a pilot project in 2004 to title 158 villages and more than 1,000 individual parcels. Building on lessons from the project, the government passed a new land-use planning act, created a new implementation program, and drew up a strategic plan to title rural land throughout the country. Starting in 2008, the lands ministry worked with community leaders to grant villages and their residents title documents that protected them from land grabbing. Villages also decided how they would use communal land and how they would set up committees to resolve boundary disputes. Officials constructed registry buildings in villages and districts to house title documents before surveying individual land parcels and handing over titles to village residents. By 2017, more than 11,000 of Tanzania’s approximately 12,500 villages had mapped their outer limits, and about 13% of villages had also adopted land-use plans. Of the approximately 6 million households located within rural villages, about 400,000 also had obtained individual title documents.

Leon Schreiber drafted this case study based on interviews conducted in Dar es Salaam and Arusha, Tanzania, in April 2017. The British Academy-Department for International Development Anti-Corruption Evidence (ACE) Program funded the development of this case study. Case published June 2017.

A 2017 workshop, Driving Change, Securing Tenure, profiled recent initiatives to strengthen tenure security and reform land registration systems in seven countries: South Africa, Canada, Jamaica, Kyrgyzstan, Mozambique, Australia and Tanzania.

Watch the video of Seraphia Robert Mgembe - Program Coordinator, MKURABITA

In May 2004, Colombia’s Office of the Presidency established a national-level agency, the Centro de Coordinación de Acción Integral, to manage the reintroduction of state institutions into areas that had been retaken from leftist guerrillas, right-wing paramilitaries and drug traffickers. The agency set up a central Bogotá office from which it coordinated work in so-called consolidation zones around the country. In many of these areas, the government had either been absent for decades or never present. In the words of Andres Peñate, former vice minister of defense and an architect of the initiative, “Although we were all Colombians, it was almost like conquering a different country.” Despite setbacks, by late 2009 the agency had received broad-based domestic and international endorsement.

Matthew Devlin and Sebastian Chaskel drafted this case study on the basis of interviews conducted in Colombia during October and November 2009. 

Associated Interview(s):  Diego Molano