The power of plans and budgets

Tonga has some difficult choices ahead about financing its health system, especially with the country’s alarmingly high rates of non-communicable diseases.

Tonga is a small island nation with an ancient history. In 2015, though, Tongans are in the midst of setting the groundwork for a thoroughly modern future, with a King newly crowned and preparations for the 2019 Pacific Games underway.

Health is another area to which Tongans have been turning their attention of late – and not a moment too soon. Rates of non-communicable disease (NCD), such as cardiovascular disease and diabetes, have reached alarming levels, and absorb some 20 per cent of government health spending. As of 2013, nearly 60 per cent of adult Tongans were classified as obese; 28 per cent were smokers in 2011. And more often than not, diseases are not diagnosed until they have reached advanced stages, when patients require expensive acute care.

In response to this crisis, several programs aimed at combatting NCDs have recently been implemented. These include the introduction of a cadre of dedicated NCD nurses and the establishment of TongaHealth, a health promotion foundation. Tonga also has a history of allocating a relatively large proportion of the national budget to health; according to the most recent WHO statistics, expenditure on health accounts for around 14 per cent of Tongan government spending.

Despite these positive steps, Tonga remains caught in what has been described as a ‘pincer movement’: the current and anticipated costs of health care are outpacing projected available funding and economic growth. Difficult decisions must be made about which health services can and should be provided – particularly given that Tonga is committed to providing universal health coverage. An evaluation conducted by the World Bank in 2009 concluded that efficiency savings – effectively, getting ‘more health for the money’ – is the most feasible and sustainable means of financing Tonga’s health system going forward.

Public finance management (PFM) is a critical, but often underutilised, tool that can assist in this task. Though PFM reforms have been a focus of development partners across much of the world, it has been noted that PICs have a particularly acute need for sound PFM as these economies tend to be heavily dominated by the public sector. A recent review of PFM reform efforts in the Pacific confirmed the need to tailor PFM to countries’ specific contexts and capacities.

With respect to health systems, PFM makes clear the importance of ensuring that high priority activities and system capabilities are resourced, and that there are feedback mechanisms in place to test if those resources are achieving the desired impacts – neither of which can be accomplished without robust planning and budgeting systems.

Planning and budgeting for health in a PFM framework was the focus of a recent one-day workshop in Nuku’alofa, held in collaboration with the Asia and the Pacific Policy Society. Nearly 50 MPs, public servants from health and finance ministries, town and district officers, and interested members of the public converged on the Fa’onelua Convention Centre to hear from representatives of both ministries, as well as researchers and consultants from throughout the Pacific and Australia, on how PFM can contribute to improved efficiency in the health sector.

To be sure, achieving this efficiency will take time and political will; making systemic change inevitably does. While the workshop was meeting, a petition was being circulated in Parliament in favour of implementing dialysis treatment in Tonga – a life-saving, but prohibitively expensive intervention. Such propositions highlight both the kinds of dilemmas that Tongans and their government are facing, and the need to make sure that more cost-effective ways of addressing the underlying causes of NCDs are prioritised and appropriately resourced. Prioritising PFM will go a long way towards ensuring that these changes are implemented and sustained, setting the foundations for good policy and good health well into Tonga’s modern future.