Institutionalization of National Health Accounts:A Global Strategic Action Plan (GSAP)

Charu C. Garg, Vaibhav Gupta, Rubama Ahmed, and Mahesh Shukla

Human Development Network, World Bank

GSAP Structure

Section I: Introduction • Need for NHA and NHA Institutionalization

Section II: Defining and Measuring NHA Institutionalization

Section III: Framework for Institutionalization

Section IV: Roadmap• Key Strategies for NHA Institutionalization (at Global and National Levels)

• Phasing Strategy

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Goal: by 2020• At least 100 countries will have institutionalized NHA• 147 countries will have produced health accounts at least once

Objectives:• Develop strategies to achieve above goal• Build global consensus around these strategies• Obtain global commitment to implement these strategies

GSAP presents a series of specific global, regional, and national level

strategies

Goal and Objectives

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NHA is widely used to measure the financial status of the health system

NHA provides critical information:• resource gaps and advocacy• resource allocations, planning, and policy design• track health system performance

More countries are adopting the NHA framework Donor fatigue has become a pressing issue NHA is a global public good which will be under-produced if left

alone to the market Supporting institutionalization is cost-effective

Call for Action

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What is NHA Institutionalization?

Routine government-mandated production and utilization of a minimum set of “globally” agreed health

expenditure data using a standard HA framework

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Suggested Indicators to Measure NHA Institutionalization

Key Elements Indicators

NHA is government mandated

Law/regulation empowering entity and mandating production • Identified home for NHA• Government budget marked for NHA work

NHAs are a regular/routine activity

NHAs are conducted and data is reported annually• Public data collected and compiled every year • Private data collected at least once in 5 years and

estimated every year NHA methodology applied consistently

Data is consistent with:• NHA boundary definition• NHA classifications (for example, local classifications

are mapped to NHA classifications)

Minimum set of “globally agreed data produced”

• All global key indicators are reported • At least one NHA table is available

Data is utilized and disseminated

• NHA data is used for reporting health expenditures in government documents

• Core data is available publicly on website

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First, countries have been assessed on four simple criteria: •Consistent production of NHA data•Consistent use of NHA data• Adequate financial, human and infrastructure capacity to routinely produce and use health accounts• Use of health accounts methodology

Next, countries have been grouped under the following categories:

1. Institutionalized – all 4 criteria met

2. Almost institutionalized – 3 criteria met

3. Insufficient progress towards institutionalization – 1 or 2 criteria met

4. Not institutionalized – no criteria met

Measuring Institutionalization

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Countries at Varying Stages of Institutionalization - 1

Institutionalized* Almost institutionalized

Insufficient progress

No progress

AFR Burkina Faso, Ethiopia, Kenya, Malawi, Mali, Mozambique, Namibia, Niger, Nigeria, Rwanda, Uganda, Zambia

Benin, Botswana, Burundi, Congo, Gambia, Ghana, Guyana, Liberia, Madagascar, Mauritius, Senegal, South Africa, Tanzania, Togo, Zimbabwe

Angola, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Côte d'Ivoire**, D R Congo**, Equatorial Guinea, Eritrea, Gabon, Guinea, Guinea-Bissau, Lesotho, Mauritania, Sao Tome and Principe, Sierra Leone, Somalia, Sudan** ,Swaziland

EAP Australia, China, Japan, Malaysia, New Zealand, Philippines, Republic of Korea, Thailand, Vietnam

Indonesia, Mongolia, Samoa

Fiji, Micronesia, Papua New Guinea, Palau, Tonga, Vanuatu

American Samoa, Cambodia, Cook Islands, DPR of Korea, Kiribati, Lao PDR, Marshall Islands, Nauru, Niue, Singapore, Solomon Islands, Timor-Leste, Tuvalu

ECA Armenia, Austria, Belgium, Bulgaria, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Hungary, Iceland, Ireland, Lithuania, Luxembourg, Netherlands, Norway, Poland, Portugal, Romania, Russian Federation, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom

Cyprus, Greece, Italy, Kyrgyzstan, Turkey, Ukraine

Albania, Bosnia and Herzegovina,Kazakhstan, Latvia, Republic of Montenegro

Andorra, Azerbaijan, Belarus, Croatia, Kosovo, Macedonia, Malta, Moldova, Monaco, San Marino, Tajikistan** ,Turkmenistan, Uzbekistan

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Institutionalized* Almost institutionalized

Insufficient progress

No progress

LAC Guatemala, Mexico Bolivia, Brazil, Chile, Colombia, Ecuador, El Salvador, Jamaica, Nicaragua, Peru, Uruguay

Antigua and Barbuda, Argentina, Bahamas, Costa Rica, Dominican Republic, Haiti, Honduras, Panama, Paraguay, Suriname, Trinidad and Tobago

Barbados, Belize, Cuba, Dominica, Grenada, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Venezuela

MNA Israel, Jordan, Lebanon, Morocco, Tunisia

Algeria, Bahrain, Djibouti, Egypt, Iran , Yemen

Iraq, Kuwait, Libyan Arab Jamahiriya, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, United Arab Emirates, West Bank and Gaza

SAR Bangladesh, India, Sri Lanka

Maldives, Myanmar, Nepal, Pakistan

Afghanistan**, Bhutan, Brunei, Seychelles

*Canada and USA have also institutionalized**Currently in the process of producing NHA for the first time in 2010

Countries at Varying Stages of Institutionalization - 2

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Framework for Institutionalization

By understanding why countries have been unable to institutionalize NHA (problems and their causes), seven core dimensions have been defined

Strategies and the specific actions that each stakeholder can take have been identified accordingly

Countries need to assess constraints, plan strategies, and implement the plan

GoalsConstraints

to achieving goals

Causes of problems

Strategies to solve

problems

Mapping Stakeholders –defining a role for

each

GSAP Objective #1:Develop strategies to achieve the goal- 100 countries to have institutionalized NHA by 2020

Both at global, regional,

and country level

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Framework Derived from Key Constraints- Lessons from Case Studies, Questionnaires, and Consultations

EnvironmentGovernance / Legislation/ Coordination

Lack of mandate; perceived to be donor driven; lack of coordination between key stakeholders

ResourcesPrimarily Human and Financial

Inadequately trained staff; low technical capacity; uncertain funding,High cost due to reliance on external staff and one off surveys

Data Collection Problems of availability, access, and inconsistency between NHA data needs and standard surveys and available data; not easily extractable;few (if any) linkages with public expenditure management

Data Management Absence of long-term strategy to store, manage and use data; no standard estimation methods,

Information Products

Stress on extended NHA matrices; strategy not linked to incremental process and policy needs; subaccounts missing key NHA data

Quality of Data and Estimates

Problems of timeliness, frequency, consistency and comprehensiveness in existing data; inconsistent methodology; poor validity checks.

Dissemination and Use

Link to policy unclear; disconnect between producers of NHA and users; weak dissemination strategy; statistical reporting in countries not referring to indicators produced from NHA data

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Strategic Actions Required at the Global Level

Commit long-term to NHA institutionalization

Fund routine production of NHA not one-off exercises

Introduce cost-reducing mechanisms e-tools, regional database of consultants, surveys

Harmonize donor efforts global consensus on a list of minimum indicators with other GHIs

Build awareness of NHA use South-South learning forums, integration with resource tracking

tools)

Pass resolutions mandating NHA institutionalization e.g. supported by global agencies including WHO, World Bank, IMF

Enforce conditionality for loans and grants e.g. GFATM, GAVI

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Mandate and ensure a long term commitment to produce and use NHA

e.g. national decree or legislation

Ensure that adequate resources are available firm financial commitment from the Ministry of Finance

Harmonize national efforts NHA Steering Committee

Fund routine production and use of NHA increased investments in data automation and electronic filing systems

Introduce cost-reducing mechanisms modifying national level household and budget surveys to include

more NHA category questions

Disseminate and share NHA data

Strategic Actions Required at the National Level

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Roadmap: Revisiting the Challenge100 countries institutionalized by 2020

2010: Where we are now

2020: Where we want to be

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Achieving the Goal

Importance of indicators determining success towards institutionalization

Gov. health

investments

Financial resources

Governance and institutional

effectiveness

Donor commitment and

conditionality

Government commitment

Government capacity to produce and use NHAs

NHA utility to Government

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Greater utilization of NHA data by governments

Government capacity to produce and use NHAs

Government commitment to produce and use NHAs

Dev. partners’ commitment and conditionality

Methods to Achieve the Results OutlinedIndependent variables Proxy Variables

NHA Utility to the Government Ordinal Policy use of NHA in the past

Government commitment to NHAs

Ordinal NHA production record

Government capacity to produce and use NHAs

Continuous WB country policy and institutional assessment score, 2008 and Bertelsmann Transformation Index 2010 (Management Index)

Development partner commitment and/or conditionality

Ordinal Past record

Overall governance and institutional effectiveness

Continuous WBI world governance indicators dataset 2008 (of all countries)

Government investments in health

Continuous General government expenditure on health as % of total government expenditure

Financial resources available to government for producing and using NHAs

Ordinal Country per capita income

•Logistic regression model to estimate the likelihood of country institutionalizing NHA

•Variables linked to determinants of institutionalization and measured by proxy measures

Country attributes• Political will , government commitment

• Capacity and resources to routinely produce and use

• Government investments in health

• Governance , institutional effectiveness

 NHA attributes • Utility to country

• Relative advantage over existing tools and mechanisms

• Communicability and ease of use

Development partner attributes • Consistent, harmonized and long term

support

• Conditionality: implied or expressed

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100 countries to have institutionalized NHA by 2020• 58 countries to institutionalize in 10 years (in addition to 42 already

institutionalized)• 20 more countries start producing NHAs (in addition to 127 countries with

production experience as of now)

Four cohorts of 106 countries enter institutionalization mode in 2011• 2011-16 Cohort. 38 countries at an advanced stage of institutionalization• 2011-17 Cohort. 24 countries with insufficient progress toward

institutionalization but with stronger NHA capacity• 2011-18 Cohort . 24 countries with insufficient progress toward

institutionalization but with weaker NHA capacity • 2011-20 Cohort. 20 (out of 67) countries with no previous experience of NHA

production

Phasing Support for Institutionalization

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Cost Estimates and Risk Analysis

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Cost Estimates• Price tag is perceived to be high• Required investment and resources are likely to depend on:

oFocus countriesoTypes of activities that will be fundedo Extent of support that countries need

Risk Analysis and Mitigation Strategies• Priorities of countries – change of administration, conflicts• Priorities of development partners change – competing priorities with

other development sectors and also within health sector

Work in Progress….

Next Steps

• Build global consensus around strategies discussed

• Obtain global commitment to implement strategies

• Minimum 10-year support from development

partners: requires strong commitment

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Equal Partners in Action

Equal ownership of GSAP from all partners

Consensus on length and breadth of support

• financial, technical assistance, advisory

Agreement on focus countries

Timeline proposal (leading up to the global

consultation)

Common materials (PPTs, informational brochure)

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“How-to Institutionalize” Manual

Objective: Guide countries on the necessary steps required to institutionalize in both an efficient and cost-effective manner

• Guidelines to be based on five country pilots and ten country case studies, past country experiences, and peer-reviewed literature on the topic

Primary Audience: Country officials, research and policy institutes, universities, external agencies supporting NHA institutionalization

Contents: Action steps and practical guidance notes; examples of good practice- pitfalls or failures; checklists; catalogue of learning resources; references; useful websites and tools

Next Steps: Draft the manual, present it to World Bank Internal Steering Committee and NHA Advisory Group ; followed by development partners and the wider audience

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Work under consideration….