Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

National Health Accounts and its policy use in Ethiopia

World Public Health Congress, Addis Ababa, April 24, 2012.

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

1. Country profile

2. Health financing in Ethiopia

3. NHA in Ethiopia

4. Major NHA findings (from four NHA rounds)

5. NHA policy use

6. Conclusion

Outline

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

General Country Profile

• 9 regional states and two city admins

• Over 82 million population

• 1.1 million sq. km.

Map of Ethiopia

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

Health financing in Ethiopia

• Health was/is generally under financed• Ethiopia recognized the need for clear financing

policy and developed/approved the HCF strategy in 1998

• Overall, health financing evidence was lacking• NHA has been critical in generating health financing

evidence since 2000.

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

FINANCING SOURCES FINANCING AGENTS PROVIDERS Ministry of Finance Ministry of Health MoH Facilities

University and Teaching Organizations University and Teaching Facilities (incl. Ministry of Education)

Public Firms Social Health Insurance Organizations Other Ministry and Public Facilities (parastatals) Other Ministries and Public Organizations Private Facilities Private Firms Insurance Schemes- Private and Semi-Public Pharmacies

Private Firms Donor/NGO Facilities Donors Donors

Households* Households *Dashed Arrow Represents Expenditures that were

Transferred DIRECTLY to Providers from Sources

Health financing in Ethiopia (3): The ‘spider web’ flow of funds…

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

NHA in Ethiopia

• Ethiopia conducted four NHA– First round in 2000 based on 1995/96 spending

• General NHA only– Second round in 2003 based on1999/00 spending

• General NHA only – Third round in 2007 based on 2004/05 spending

• General NHA• Child health and reproductive health

subaccounts

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

NHA in Ethiopia (2)

• Fourth round in 2010 based on 2007/08– General NHA– HIV/AIDS subaccount– Child health subaccount– Reproductive health subaccount– Malaria subaccount– TB subaccount– Health information system (HIS) subaccount

All rounds of NHA financed by USAID through the HSFR Bilateral project

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

NHA in Ethiopia (3): Data Collection Methodology (Fourth NHA)

Primary Sources: For the first three rounds 1-3 household income, consumption and expenditure

/HHICES/ data was used.

General HH survey: A total of over 10,000 households surveyed by a local consultant using a survey tool developed and used in other countries and contextualized to the Ethiopian situation.

Targeted HIV/AIDS survey (sample of PLWHA): About 4,000 PLWHA were interviewed on their health service utilization.

Institutional surveys: Donors, local and international NGOs, private and parastatal employers, and insurance enterprises;

Secondary sources: All relevant documents (published and unpublished) were collected by the NHA

team from all sources; Audited government account (MOFED).

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

NHA in Ethiopia (3): INSTITUTIONAL SURVEYS: (Fourth NHA)

Donors (Bilateral and Multilateral): Census of 31 donors. Twenty five partners (81%) filled in and returned the questionnaire.

NGOs (International and Local): Census of 251 NGOs (95 international and 156 local NGOs. 86 (about 90%) and 138 (88%)  of international and local NGOs respectively filled in and returned the questionnaires.

Employers (Parastatals and private employers): 214 private enterprises (employers) 15% of the total 2,915 private sector employees. 30 public enterprises/parastatals 30% of 108 public enterprise/employers.

• Ethiopian Air Lines, Ethiopian Electric Power Corporation, Ethiopian Telecommunication Corporation & Commercial Bank of Ethiopia were also covered in the study.

• A total of 198 (about 80%) of the 248 employers filled-in and returned the questionnaires.  Insurance: All 10 were surveyed and completed the questionnaire (1 public, 9 private).

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

Source of Finance 2004/05 2007/08 Change

Government 145,501,590(28%) 248,527,277(21%) 71%

Households 160,042,854(30%) 441,064,781(37%) 176%

Rest of the world 192,293,175(37%) 466,628,078(39%) 143%

Public enterprises 13,796,059(3%) 16,235,732(1.37%) 18%

Private employers 6,129,755(1%) 12,978,643(1.09%) 112%

Local NGOs and other private funds 3,966,145(1%) 3,786,513(0.54%) -5%

Total 521,729,581.43 1,189,221,027.39 128%

NHA findings: Comparison between 3rd and 4th NHA Financing sources (in US$).

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

NHA Findings

• Overall spending in health is increasing overtime

• Total health spending: Birr 11, 123, 022,113 Billion (USD1.2 Billion) in 2007/08.

• 128% increase from 2004/05.

• Per capita health expenditure estimated to be USD 16.1(increased from USD 7.1 in 2004/05)

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

NHA findings: Source of health financing in 2007/08 (Fourth NHA)

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

NHA Findings: Trends in Per Capita Health Expenditure in USD

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

Policy use of NHA

The last four NHA round evidences used:

As input for FMOH and partners evaluation of subsequent health sector development programs (HSDP)

Input for designing HSDP including HSDP-IV;

Generate evidence on health sector spending in HSDP priority areas;

NHA evidence is used in policy dialogue and negotiation with health sector development partners

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

Policy use of NHA (2)

Used in health financing reforms initiation and implementation: To convince law makers and finance that health is not adequately

financed, and government budget allocation for health is increasing overtime

Enabled ratification of HCF reform legal frameworks and guiding implementation of the reforms including revenue retention and use at health facility level

Systematizing fee waiver system The evidence also revealed the burden on households:

The showed the need for risk pooling and financial protection: CBHI under piloting and legal framework put in place for SHI,

and will start very soon

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

Conclusion

• Ethiopia substantially benefited from conducting subsequent rounds of NHA

• NHA evidence was useful for initiation and implementation of the various financing reforms

• Recognized the usefulness of the evidence, • Ethiopia needs to speed-up institutionalization of

NHA

04/10/23

Health Sector FinancingReform Project

Federal DemocraticRepublic of Ethiopia

Ministry of Health

Thank You

04/10/23