We are staff working in the health sector in the Solomon Islands. We have agreed that the inability to spend funds allocated for annual operational plans and budgets is the most immediate constraint to health service provision. It is at the centre of declining staff commitment and the erosion of community confidence in health services, compromising the authority of service directors and creating pressures on higher level services.

The creation of operational plans and budgets requires a considerable amount of work on forecasting activities, particularly in identifying the cost of implementation and the sources of funds. Annual planning starts with an assessment of what might be achieved in the forthcoming year. These plans are often not prioritised and are unrealistic, and budgets are sometimes overestimated. Staff who make funding submissions are trained as clinicians or public health staff, not versed in financial processes and untrained in the applications of financial instructions.

The inclusion of external funds in annual plans and budgets depends on funding ceilings agreed with MHMS centrally. Criteria for funding releases and acquittals are not clearly understood at the provincial level. The perception that funding will be released at agreed levels and within timelines may be unrealistic given that funding processes are not well understood and that the human resource capacity to implement plans is often overestimated.

Despite significant improvement to the availability of health information, there is little use of such information in preparing annual plans, resulting in the inclusion of activities that may produce limited health gains or divert staff from higher priority concerns. Proposed budgets may be based on an idealistic approach to achieving gains that are beyond the capacity of staff to achieve, or on the assumption that development partner funds are unlimited.

Variable timing of funding releases results in implementation of activities in periods inconsistent with the annual plan, while planned activities are deferred until funding becomes available. Once the annual plan is prepared and agreed, monitoring of implementation needs to be more frequent and active, and plans adjusted in response to changing circumstances and funding availability.

Currently, the introduction of new activities is constrained by a freeze on new public service positions. Overloading of activities on some cadres, particularly nurses, occurs when new programs are commenced without an increase in staff. The effects of task overloading, the inability to conduct activities as planned, or reduced access to training, results in staff losing commitment or leaving the service to pursue other interests, further contributing to staff shortages.

At times, funding is available from development partners and NGOs but is not itemised in annual plans and budgets, while Ministry funding is itemised but often delayed by approvals and tender board processes. Necessary supplies, equipment and staff may not be available when they are planned for, resulting in deferred activities and concentration on activities generated by other interest groups. These uncertainties contribute to declining staff commitment, increased absenteeism, difficulties in delegation and a perceived loss of management authority.

The most concerning effect of implementation failures is the loss of community trust in service providers, particularly at the periphery. Failure to implement activities or to attend planned community gatherings for service provision results in communities not attending future meetings. The loss of trust in health workers generates a perceived need in the community to bypass primary health services to access higher-level services, particularly at the National Referral Hospital (NRH) in Honiara. The pressure on NRH has become a major issue requiring a strategy to improve primary and secondary services at local levels.

We propose that the allocation of staff time to activities generated by external donors should only be considered when they are detailed and confirmed within annual plans. Provincial and program directors need to encourage external donors to prepare resource allocations for inclusion in annual plans and budgets and to ensure that funding releases are consistent with Solomon Islands financial systems.

Staff at or promoted to Grade 7 must receive training on budget preparation and government financial instructions from MHMS accounting staff to correct misunderstandings that result in procedural delays.

While it is necessary to have systems that guard against misuse or wastage of resources and corruption, the failure to fully communicate bureaucratic processes for supply and funding is an important issue with significant effects. There is an apparent perception among external donors that the health system can accommodate additional objectives without inclusion in annual plans or within the capacity of available human resources. Those who provide development assistance must ensure that their goodwill adheres to the principles of social responsibility and does not undermine the systems that are designed to coordinate planning and resourcing of services that are essential to the health of the people.

This article is based on a paper produced by participants of the first cohort in the Postgraduate Certificate in Health Leadership and management at the Solomon Islands National University (SINU). Read the full paper here. 

A post by the same authors on preventing implementation being overwhelmed by planning can be found here.