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Main report:

Accompanying this report is a series of country case studies. Lessons from the Democratic Republic of Congo, Ethiopia, Kyrgyzstan, Lao PDR, Pakistan, the Solomon Islands and Ukraine highlight challenges, successful practices, and actionable policy recommendations across a wide range of country contexts:

Case study series with foreword:

Report highlights:

• Budget execution data show that there is considerable underspending across low and lower-middle income countries. On average, countries underspend their health budgets by 13% ¨C the equivalent of about US$ 4 per capita. This is more than what many countries spend on primary care and represents an enormous missed opportunity. It also undermines efforts to increase health budgets as ministries of health can¡¯t ask for more when they are struggling to spend what they have.

• Underspending a health budget can mean deprioritizing health across government. It¡¯s not just the budget that determines government priorities but what happens as the budget is implemented. For example, in low and lower-middle income countries, budgets in health tend to be executed at a lower rate than in education. If this happens across government, it means health gets deprioritized during the budget implementation process.
• Effective budget execution requires ministries of finance, health, and local government to work closely together, communicate, and build trust across all stages of the budget cycle.
• Being deliberate, not reactive, is important. A prioritization process can anticipate budget execution problems, such as cash rationing, and make a response more purposeful and effective.
• Being purposeful about expenditure controls and delegating authority also matters. Budget execution is not just about compliance, but also about empowerment and accountability. More deliberate application of expenditure controls and delegating authority to lower levels in government can help bring about better budget execution practices.
• Country experience shows the importance of understanding the political economy dynamics to anticipate potential budget execution challenges and design strategies to navigate them.