|
|
|
||
|
THE STATE OF BUDGET TRANSPARENCY AND PUBLIC CONTROL OVER HEALTH CARE SPENDING IN REPUBLIC OF MACEDONIA Pavlina Petrova I. Macedonian Health Care System - Source of Financing and Division of Responsibilities The health care in R. Macedonia is almost entirely a national function. The country has a single payer system of national health insurance, primarily financed through the public sector Health Insurance Fund (HIF), which collects earmarked payroll contributions and receives certain central budget transfers. Subsequently it allocates resources to health care institutions. Although negotiated by the Ohrid Framework Agreement the intended real decentralization of the health care functions in R. Macedonia did not happen. Art. 3 of the Framework Agreement explicitly includes health care in the list of services for which the powers of elected local governments should be reinforced and their competencies should be substantially enlarged. The health care decentralization is also included in the Constitutional amendments and is obliquely referred to in the legislative annex of the Framework Agreement. In the spirit of the Framework Agreement, the initial draft of the Law on Local Self-Governance (LLSG) proposed an ambitious decentralization of health care functions, which however raised considerable concern among the sector experts. According to the experts’ opinion, such a wide decentralization would complicate the ongoing reform within the sector. Shifting facilities to local governments would make privatization more difficult and could also lead to a highly inefficient use of facilities, as many municipalities were seen to be too small to permit all but the most rudimentary forms of primary care to be provided on an efficient scale. The municipalities could, of course, address this problem by sharing facilities through a referral system, but this would be rather difficult to be organized under the present political conditions and interethnic relations. These were the main reasons why the provisions regarding the role of municipalities in the health care sector were considerably amended prior to the final vote by Parliament. Under the adopted version, the municipal role in the health care facilities’ management was limited to representation in the local boards of the public health care organizations. Under the final LLSG version, municipalities nevertheless take on responsibility for public health education, health improvement, contagious disease control and occupational health. The law also decentralizes responsibility for assistance to the population with special needs - mentally ill, victims of child abuse, etc. This provision has little immediate significance since with the exception of a few pilot programs financed by the World Health Organization and NGOs, there are only few Government programs for people with special needs, which could be decentralized.[1] II. Legal preconditions for transparency of budget process on central and local government level II.1. Transparency of the budget process on central government level According to the provisions of the Macedonian Constitution the state budget and the balance of payments of the Republic shall be prepared by the Government and adopted by the Parliament. Since the meetings of the Parliament are open to the public such a requirement should represent a precondition for transparency of budget issues on central government level. The Constitution, however, allows the Parliament to decide whether to work with or without public presence, which makes the transparency not fully guaranteed.[2] The transparency of budget spending is further provided by the Law on Budgets, which introduces specific relevant requirements for the Minister of Finance. According to the law provisions, every year, in the second half of July, the Minister should present to the Government an overview of the budget implementation and the Republic debt status for the current fiscal year. The overview should contain comparative figures for the actual and budgeted levels of incomes, expenditures, budget deficit and debts. The deviations from the budget should be accompanied by explanation. In fact, the Macedonian Finance Minister makes monthly reports on the budget implementation, which are publicly available on the ministry official website. The budget implementation is subject to internal and external audit. According to the provisions of the Law on Budgets all central and local budget units and extra-budgetary funds are required to establish internal audit body. If they do not establish such a body, the internal audits would be done by the Ministry of Finance auditors. In all cases, the Ministry of Finance is the body responsible for conducting the central internal audit of the budget implementation in all central and local budget units, as well as extra-budgetary funds. The external budget audit is done by the State Audit Office [3] (SAO). According to the Law on State Audits, SAO is responsible for assessing the budget implementation from the following aspects: a) conformity with the law; b) economy, effectiveness and efficiency of expenditures [4]. SAO makes at least one audit per year of the entire central and local budget spending as well as of the expenditures covered by funds from the EU and other international institutions. SAO reports are presented to the Parliament. Within 14 days after the presentation they should be pasted on the SAO website as well. Responsible for the transparency of SAO work is the Chief State Auditor (CSA). The CSA is the person responsible for pasting the SAO reports on the Web and for keeping the public informed about the SAO audit results by giving press conferences or using other means of communication with the media. The CSA and his/her deputy are directly appointed by the Parliament for a 10 years mandate, which should make them independent and resistant to political pressure. Under the present political model in Macedonia, however, where the executive power has great influence over the parliamentary decisions, such resistance is not entirely guaranteed. As it is mentioned in the 2003 Nations in Transit report, the real distribution of power in Macedonia is not determined by Constitution but by party membership. “Parliament passes legislation, elects the head of the government (prime minister), and appoints judges. When the ruling party has a parliamentary majority, it has effective control over all three branches of government.” [5] The transparency of budget spending is partially provided also by the Law on Public Procurement (LPP). The LPP requirements are mandatory for: - all central government bodies and bodies of local government units; - legal entities of public interest, which do not have economic or profitable character and which are largely financed by the government bodies or the bodies of the local government units or which are subject to control of their operations by the government bodies or the bodies of the local government units or which have more than half of the members of their managing, supervisory or other body appointed by government bodies or the bodies of the local government units; - public enterprises, joint stock companies and limited liability companies in which the state or local government units have dominant direct or indirect influence through ownership, i.e. if they hold larger equity share in the company, have majority vote of shareholders and appoint more than half of the members of managing or supervisory board of the enterprise and the company; - civic associations and foundations to which the law grants public authorizations. LPP regulates also the special manner and procedure for performing public procurement by legal entities performing one or several activities in the field of water supply, energy, transport, telecommunications, utilities or public enterprises on the basis of special or exclusive rights granted by competent government bodies or the bodies of the local government units by law. According to the LPP provisions all entities mentioned above are obliged to have a public procurement register with the following content: - number and date of the procurement decision; - item and value of procurement; - type of procurement procedure; - number of submitted bids and their value; - number of acceptable bids; - lowest and highest price of bids; - criteria applied for the selection; - decision for selection of the most favorable bidder; - price of selected bid; - name, surname and address of selected bidder; - complaints submitted by bidders; - outcome of the complaints; - number, date and value of the concluded contract and Annex to the contract. The data listed above should be entered into the register within 10 days after the contract signing. Within 30 days after the contract signing it should be sent to the Public Procurement Bureau (PPB) and should be published on the PPB website [6]. PPB is a state administrative body within the Ministry of Finance, which is responsible for the development of the public procurement system via securing legality, rationality, efficiency and transparency in the implementation of public procurement and shall stimulate the competition and equality of the bidders in the public procurement procedures. PPB maintains an integrated public procurements register and specific sub-registers for all public funding users. The registers provide conditions for transparency and at least ex-post public control over the budget spending. II.2. Transparency of the budget process on local government level According to the Macedonian Constitution the right of citizens to local self-government is guaranteed. The units of local self-government (municipalities) are financed from their own sources of income, determined by law, as well as by funds from the Republic. Except from the laws quoted above the transparency of local government budget issues is provided also by the Law on Local Self-Governance and the Law on Financing the Local Self-Government Units. According to the provisions of Law on Local Self-Governance the local government budget and balance of payments should be prepared by the mayor and adopted by the Municipal Council. The Municipal Council hearings are public. The Municipal Council has the right to exclude the public presence in certain cases but never when the hearing concerns budget issues, balance of payments and urban plans. The Law on Financing the Local Self-Government Units provide the specific requirements regarding local government budget procedures - budget’s preparation, implementation, auditing, reporting, etc. According to the law provisions the Mayor, besides the annual budget report, should present to the Ministry of Finance also quarterly budget reports, which are public and should be published after their approval. II.3.Transparency of the Macedonian Health Insurance Fund Since the Macedonian Health Insurance Fund (HIF) along with the Macedonian Pension Fund is one of the largest extra-budgetary funds in Macedonia its transparency of spending is provided by the same laws that provide the central budget transparency in the country. The transparency of HIF spending however is an issue of great concern in Macedonia. According to an IMF report from 2004 [7]: “While there is some evidence of progress in fighting corruption in the public sector, governance at the HIF remains weak and has contributed to non-transparency, high costs and mismanagement.” According to the same IMF report: “The inefficiency and corruption in the state Health Insurance Fund (HIF) and state-owned healthcare institutions are the major source of poor performance in the health system”. According to the World Bank FYR Macedonia Decentralization Status Report “The healthcare system is plagued by financial problems, mismanagement (in both HIF and health care institutions), and questionable spending priorities.” [8] The World Bank and the IMF are currently cooperating to assist the Macedonian Government to improve the HIF management and to reduce the opportunities for corruption and mismanagement. The World Bank is also supporting the Government in its commitment to audit the Health Insurance Fund and to implement cost saving measures, which will include new tenders for pharmaceuticals and other efficiency gains. Meanwhile, aiming to improve the financial flows tracking, the Ministry of Finance has taken steps to transfer the HIF’s account balances into the Treasury Single Account. Another step toward bettering transparency of HIF work and spending was to publish the findings of the SAO’s financial audit, which included critical remarks on inefficiency and fraud. III. Access to information in R. Macedonia The Macedonian budget related legislation creates preconditions for transparency of budget information. However, clear legislative procedures for providing free access to that information are not developed yet. Although the fact that “ensuring maximal transparency” is one of the most repeated phrases in all government documents and strategies, till January 2006 Republic of Macedonia was still one of the two SEE countries where a Law on Free Access to Public Information was not adopted yet. The first draft of the law was initiated and prepared by experts from the NGO sector already in the year 2002 [9]. During the last 3 years it underwent substantial changes and on 25 January 2006 was finally adopted. Its implementation will start in June 2006 until when the secondary legislation, specifying the detailed procedures, must be ready. The free access to information is a constitutionally guaranteed civil right in R. Macedonia. In contrast to the rest of the basic human rights, however, exercising the right to free access to public information insists for certain actions on behalf of the state. This is the reason why the procedure for accessing public information as well as the corresponding restrictions must be defined by law. The newly adopted Law on Free Access to Public Information regulates the procedure for exercising the right to free access to public information possessed by the central and local government bodies, public institutions and services, public enterprises, as well as legal entities and natural persons with public authorities granted by law (all those named - information holders). According to the law provisions the free access to information shall be available to all legal entities and natural persons in R.M. Each seeker has the right to access to public information from the information holders on the grounds of a request. The law however provides 9 exemptions, where the free access to public information could be restricted. The information holders will be able to reject a request for access to information, if the information refers to: Since the budget information is not explicitly mentioned as an exemption, where restricted access to information is allowed, it is supposed that it will be freely accessible. Moreover, the information holders cannot refuse to provide information even in the cases quoted above, if the public interest by publishing is larger than the consequences on the protected interest. With regard to budget information it should be undisputable that the transparency of budget spending is a matter of public interest. The open question here is how the judgment whether the public interest is larger will be done? The law provides special obligations for the information holders, which are obliged to make the information of public interest available to the public, including enabling free access to information on the organization, authority and expenses of work. According to the law provisions, access to public information could be requested by an oral or written request. The information should be submitted in the requested form, except if: the requested information already exists in a previously prescribed form; or is already accessible to the public; or if it is more appropriate to submit the information in a different than requested form, for which the information holder should explain the reason. The latter formulation might create serious difficulties in obtaining the requested budget information in the most appropriate (allowing public control) form. In any case the adoption of the Law on Free Access to Public Information creates additional mechanisms for public control over the budget spending. It also creates favorable conditions for the emergence of the so called ‘budget watch groups’, which main goals are achieving better transparency of budget process and exercising public control over the budget spending. Before the law adoption such groups would hardly receive information needed for analyses, because there was no legal ground and procedure for requesting such data. Some information on the budget issues, including budget spending, could be found on the websites of the relevant bodies. However, the information is too aggregated and does not allow profound detailed analyses. Therefore the recent adoption and future implementation of the Law on Free Access to Public Information are crucial for the efficient budget watch model functioning. The practice will show if and what law adjustments will be needed in order to assure maximal transparency and public control over the budget process. The experience of the other SEE countries suggests that getting the administration used to release information will be a long process in which all society players have a clear role. At first place the state authorities should forget the current centralist style of administration, where having information is considered as a privilege of the state only. At second place the citizens, media and civil society as a whole should start requesting information and exercising their constitutional right to know. The practice from the region shows that the state will continue being reluctant to releasing information to the general public for a long while, if the civil society and the court system do not force it to comply with the law provisions. That makes the strong and active civil society and the efficiently functioning court system being crucial players in that process. Unfortunately, currently in Republic of Macedonia both players are quite weak and it would be rather difficult to play properly their parts in the process.
IV.1. Legal preconditions for public participation in R. Macedonia In R. Macedonia the public participation and public control over the budget spending could be exercised in different ways. On central government level the public participation and public control over the budget spending should be guaranteed by the mechanisms of the representative democracy. Citizens could participate in the decision making process through their legally elected representatives in the Parliament. In some limited number of cases the citizens could directly influence the work of the Parliament and its working bodies. According to the provisions of the parliamentary Rules of Procedures, for example, every citizen, group of citizens, institutions and associations has the right to initiate inclusion of certain issues on the draft agenda of the parliamentary working body session or even to start an initiative for passing a law, using the power of an authorized proposer. The Macedonian Constitution and the Rules of Procedures of the Parliament also allow citizens and mass media representatives to attend the parliamentary sessions and the parliamentary working bodies’ hearings, except in cases when the Parliament/working body has decided to work without public presence. Neither the Constitution nor the Rules of Procedures define the specific cases when the public presence exclusion is justifiable, which means that the Parliament is not restricted in excluding the public presence whenever it wants so. The transparency required of Parliament however is not particularly effective. Sessions of the Parliament are open to the public, but attendance is not encouraged. On local government level the legal mechanisms for public participation and public control over the budget spending are provided by the Constitution and the Law on Local Self-Governance. Art. 115 of the Constitution says that “In units of local self-government, citizens directly and through representatives participate in decision-making on issues of local relevance particularly in the fields of urban planning, communal activities, culture, sport, social security and child care, preschool education, primary education, basic health care and other fields determined by law.” The Law on Local Self-Governance provides the specific forms of public participation and public control over the local governments’ work. According to the provisions of law the Municipal Council hearings are public. In certain cases public presence could be excluded but never when the hearings concern budget issues, balance of payments and urban plans. The law contains a whole Chapter titled: “Direct Participation of the Citizens in the Decision-making Process in the Municipalities”. According to that chapter the citizens could directly participate in the decision-making process on issues of local importance through civil initiatives, citizens' gatherings and referendums. The expenses for execution of the direct participation of the citizens in the decision-making process shall be covered from the municipal budget. Civil initiatives The citizens have the right to propose to the municipal council to enact a certain act or to decide upon a certain issue within its authority, except for personnel and financial issues. If the proposal is supported by at least 10% of the voters in the municipality, that is in the neighbourhood self-government that a certain issue relates to, the council is obliged to discuss it not latter than 90 days after the initiative raising. The citizens should be informed about the decision. The fact that the financial issues are excluded from the right of civil initiatives could create difficulties in exercising effective public participation and public control over the local government spending. Citizens' Gatherings Citizens’ gathering could be convened by the municipality mayor upon his/her own initiative, at the request of the council or at the request of at least 10% of the voters in the municipality, that is in the neighbourhood self-government that a certain issue relates to. Citizens’ gathering could be convened for the territory of the entire municipality or for the territory of a neighbourhood self-government. The law provides obligation for the municipality organs within 90 days after the citizens’ gathering to review its conclusions and to take them into account when making decisions and determining measures on issues they relate to. Referendum The citizens could decide on issues of local importance also through referendums. The referendum could be initiated by at least 20% of the voters of the municipality. The referendum’s decision is binding for the Municipal council. According to the provisions of the Law on Local Self-governance every citizen has the right, individually or together with others, to submit appeals and proposals regarding the work of the municipal organs and administration. With regard to exercising this citizens’ right the law obliges the mayor: to create conditions for submission of appeals and proposals; to provide detailed reply for the appealer at the latest within 60 days after the receipt of the appeal, i.e. proposal; to submit the appeals and proposals that refer to the authority of the municipal organs to the responsible organ and to inform the appealer about it. In the course of preparation of the local government regulations the Municipal council or the mayor may previously organize public hearings or ask for citizens' proposals. However, since this is not explicit obligation it is not likely to happen. For reviewing issues and determining proposals regarding the quality of public services in the municipality a Council for Protection of Consumers could be established. The council could be consisted of representatives of larger groups of public services users. If established such a council could play crucial role in ensuring public participation and control over the local budget spending. IV.2. The role of the civil society in the public participation and budget watch process In spite of the existence of all those legal mechanisms for public control and participation in the decision making process, the lack of transparency continue to be a characteristic feature of the Macedonian political and business environment. Mainly because of the inactive and weak civil society the mechanisms for public participation and public control are not efficiently used yet. Nevertheless the existence of more than 5,500 registered civil society organizations in R. Macedonia, only very few of them deal with public policy issues and no one perform consistent and profound budget monitoring and control. It is true that the access to data needed for analyses is quite restricted, but it is also true that only few ones try to receive access to such data. There are no procedures and beaten paths for receiving budget information and exercising control over the budget spending in R. Macedonia, which makes the preparation of a budget watch model really needed instrument. The Budget watch model along with the recent adoption of the Law on Free Access to Public Information would support the emergence and the work of budget watch groups in R. Macedonia. IV.3. The role of mass media in the budget watch process In the absence of active NGO groups dealing with budget issues, the media remains the main source of information in that area. The Macedonian legislation gives special access to information to the media representatives. According to the provisions of the parliamentary Rules on Procedures the mass media representatives can attend the sessions of the Parliament and of the parliamentary working bodies and “shall have at their disposal the acts reviewed and adopted by the Parliament, the information and document materials regarding the issues reviewed at the Parliament and at the working bodies, the reports on the operations of the working bodies and the agreed minutes from the sessions, unless the Parliament i.e. the working body decides for certain issue to be reviewed without the presence of mass media representatives.” Of course, it is not clear why only the mass media representatives should have such rights and why for example the NGO representatives should not have the same explicit right to receive the documents mentioned above? Although the better ability to access information, the lack of capacity and the specificity of the mass media daily work do not allow preparing profound high quality analyses. The media representatives usually are able only to present the figures, to ask questions and to announce the ongoing budget issues related scandals. The mass media alone cannot ensure transparency and public control over the budget spending, but it could spread the information available, thus keeping the society informed about the ongoing processes. If the mass media starts cooperating with some budget watch groups, together they would provide conditions for better public control over the budget spending. -------------------------------------------------------------------------------- [1] FYR Macedonia Decentralization Status Report, World Bank Report N 24305, September 2003. [2] Neither the Constitution nor the Rules of Procedures of the Parliament define the cases when the public presence could be excluded. [3] Drzhaven Zavod za Revizija [4] In terms of that law: economy means - conducting the activity at minimized expenditures; efficiency means - achieving maximum effects at minimum possible expenditures; effectiveness means - achieving maximum program tasks. [5] Nations in Transit 2003 – Civil Society, Democracy, and Markets in East Central Europe and the Newly Independent States; Freedom House Foundation, 2004. [6] http://javni-nabavki.finance.gov.mk [7] Second Review under the Stand-By Arrangement and Ex Post Assessment of Performance under Fund-Supported Programs in R.M., IMF staff report, July 2004. [8] FYR Macedonia Decentralization Status Report, World Bank Report N 24305, September 2003. [9] The law was drafted within the framework of the project “Accountability in Western Balkans”, financed by the Finnish Government and implemented by Transparency International - Macedonia.
|
|||
data,
which according to the law represents classified information personal
data, which revealing would violate the personal data protection;