L8 uhc-nha-tb

Under JPG Teaching Fellowship

Permission from JPGSPH

CoE-UHC

National Health Accounts (NHA)

Tahmina Begum

7 June, 2013

Objective

At the end of the session learners

will learn about basic concept of

National Health Accounts and its

use particularly in Bangladesh.

Outline

What is NHA?

SHA Framework

Use of NHA

NHA in Bangladesh

Selected BNHA results

Institutionalization of NHA

Definition of NHA

NHA constitute a systematic,

comprehensive and consistent monitoring

of resource flows in a country’s health

system for a given period and reflect the

main functions of health care financing:

resource mobilization & allocation, pooling

and insurance, purchasing of care and the

distribution of benefits (WHO).

Boundaries of NHA

National health expenditure encompasses

all expenditures for activities whose

primary purpose is to restore, improve and

maintain health during a defined period of

time.

This definition applies regardless of the

type of the institution or entity providing or

paying for the health activity.

NHA provides comprehensive information on resource flows

Where do the resources come from?

Where do the resources go?

What kinds of services and goods do they

purchase?

Who provides what services and goods?

What inputs are used for providing

services?

Who benefits from the spending?

SHA 2011 Framework

Financing Revenues Schemes

Production

Factors of provision Providers

Consumption/Use Health Functions Beneficiaries

Raising

funds

Pooling

funds

Purchasing

SHA 2011 Framework: Current Health Spending

Consumer health

interface

SHA Accounting Framework

Service Provision

Health

Financing

Healthcare Consumption

Financing

schemes (HF)

Revenues of

financing

schemes (FS)

Financing

Agents (FA)

Health functions

(HC)

Beneficiaries

(HB)

Providers

(HP)

Factors of

provision

(FP)

Financing

interface

Provision

interface

Source: WHO

Linkage between Health System and Health Accounts Frameworks

A System of Health Accounts (SHA) 2011

GovernanceStewardship

Resource generationhuman, physical

and knowledge

Financingcollecting,

pooling and purchasing

Service deliverypersonal and

population based

Quality of services

Accessibility Equity of

utilisation Efficiency of

the system Transparency

and accountability

Innovation

Health Equity in health Financial risk

protection Responsiveness

Health system functions

Health accounts

dimensions

Instrumental objectives

Ultimate objectives

Consumption

Financing Provision

Changes in SHA Framework

Dimensions

Core Classifications

Extensions

Consumption Healthcare Functions

(HC)

- Beneficiaries (HB)

- Products

Provision Healthcare Providers

(HP)

- Capital Formation

(HK)

- Factors of Provision

(FP)

- Trade

Financing Financing Schemes

(HF)

- Revenues of

Financing Schemes

(FS)

- Financing Agents (FA)

New

New

1.1 THE = CHE + HK (SHA 1.0) (SHA 2011)

CHE: an aggregate covering all spending

on healthcare that falls within the

functional boundary (which excludes

capital spending)

HK: includes all spending on capital

formation in a supplementary account

NHA Framework

System of Health Accounts (SHA)

SHA 2000

SHA 2011

NHA measures actual expenditures

NHA provides comprehensive information on resource flows

Why financial flow information is

important?

Why measures actual expenditures

Financing

Financing schemes (HF)

financing arrangements through which health

services are paid (e.g. tax based Govt, social health

insurance, OOP, rest of the world)

Revenues of financing schemes (FS)

types of revenue funding schemes (e.g. govt transfer,

direct foreign transfer, compulsory prepayment)

Financing Agents (FA):

institutional units implementing schemes (e.g.

central govt, insurance companies, foreign govt.,

households)

Production

Providers Primary Providers: health care for final consumption is

their primary activity or service (e.g. hospitals, ancillary

services, provider of preventive care)

Secondary Providers: health care for final consumption

constitutes less than 50 % of their output, VA or turnover

(e.g. insurance administration, rest of economy)

Factors of Provision Factor inputs used by health care providers to generate

the goods and services consumed or the activities

conducted in the system (e.g. HRH, Pharmaceuticals)

Consumption

Functions: Curative care, rehabilitative

care, long term care

Beneficiaries: By age, sex, geography,

area

Use of NHA

Policy tool

Inform policy makers about entire health sector

Enable informed policy decisions

Inform external funders’ decisions

Monitoring tool

Monitor UHC progress

International comparison

Spending trends

UHC Cube and NHA

X axis: population coverage

Z axis: service coverage Size of benefit package

depends on total resources: premium contribution, government tax, and OOP

Measured by GGHE, as % THE or %GGE

Y axis: level of financial risk protection, Depends on the extent of

cost covered by schemes

Measured by OOP as % THE

Source: Viroj Tangcharoensathien, IHPP, Thailand

NHA in Bangladesh

History of NHA in Bangladesh

First NHA

conducted in 1998

ADB funded

estimated NHA for 1996-97

Second NHA

conducted in 2002

DFID supported

revised NHA-I estimates and made new estimates up to 2002

Third NHA

conducted in 2008-2009

GIZ TC

made new NHA estimates for 2003-2007 and revised the earlier

estimates

History of NHA in Bangladesh (contd.)

Implementation of international standards (System

of Health Accounts, SHA)

BNHA I (1998): Draft SHA 2000 consulted

BNHA II (2003): SHA 2000 incorporated into

classifications

BNHA III (2010): Capacity to report all SHA 2000

tables

Implementation of a dual reporting system meeting

both Bangladesh and global standards

HEU/MOHFW leadership in all three rounds

Flow of Funds in BNHA

Taka

Financing Sources

Financing Agents

Taka

Providers

Health services

& Functions

Beneficiaries (by age, sex, region, disease, income group)

BNHA Framework

Incorporates a health funding dimension (financing agent) and does not attempt a funding source classification

Funds received by government from foreign development partners treated as government outlay

Financing Agent

General Government

Ministry of Health and Family Welfare

Other Ministries

Local Government

Social Security Funds

Financing Agent (Contd.)

Private Sector

Private Insurance

Community Insurance

Non-profit Institutions/NGOS

Private companies

Households

Rest of the World

Providers

General Administrations of Health

Public Health Programs

Hospitals

Nursing and Residential Care Facilities

Providers of Ambulatory Care

Drug and Medical Goods Retail Outlets

Other Industries

Functions (Core)

Services of Curative Care

Services of Rehabilitative Care

Services of Long term Nursing Care

Ancillary and Other Medical Goods

Collective Health Care (Prevention and

Public Health Programs)

Health Administration and Insurance

Functions (Health Related)

Capital Formation

Health Education and Training

Health Research

Data Sources: Public Sector

BNHA

Code

BNHA-Financing Agents Data Source

BF1 General Government

BF1.1.1 Ministry of Health and Family Welfare

(MOHFW)

1. Controller General of Accounts, Ministry of Finance

(MOF)

2. Line Directors Office, MOHFW

3. Finance Division, MOHFW

4. Directorate of Health, MOHFW

5. Directorate of Family Planning, MOHFW

BF1.1.2 Ministry of Defense 1. Ministry of Defense

BF1.1.3 Ministry of Home Affairs 1. Controller General of Accounts, MOF

BF1.1.5 Railway Division 1. Zonal Headquarter, Dhaka

2. Zonal Headquarter, Chittagong

3. Zonal Headquarter, Rajshahi

BF1.1.7 Local Government 1. Ministry of Local Government

2. City Corporation Offices at Divisional Headquarters

Data Sources: Private Sector and Rest of the World (ROW)

BNHA

Code

BNHA-Financing Agents Data Source

BF2 Private Sector

BF2.2 Private Insurance (other than Social

Insurance)

1. Private Insurance Companies Survey

2. Household Income and Expenditure Survey, Bangladesh

Bureau of Statistics (BBS)

3. Bangladesh National Accounts, BBS

BF2.3 Private Community Insurance 1. NGO Survey

BF2.4 Households 1. Private Hospital and Clinics Survey

2. Household Income and Expenditure Survey, BBS

3. Bangladesh National Accounts, Bangladesh BBS

4. IMS Pharmaceutical Survey

5. Health and Demographic Survey, BBS

6. Morbidity and Health Status Survey, BBS

BF2.5 Non-Profit Institutions/NGOs 1. NGO Survey

2. Development Partner Survey

BF2.6 Corporations and Autonomous Bodies 1. Corporations and Autonomous Bodies Survey

BF3 Rest of the World

1. NGO Survey

2. Development Partner Survey

3. Controller General of Accounts, MOF

Data Analysis

Used data from multiple sources for making NHA estimates guided by SHA and WHO guidelines

Interpolation and extrapolation was done in case of data gaps by applying appropriate guidelines

Checked trends of various components and compared them with National Accounts

Selected BNHA Results

Total Health Expenditure (THE) in Bangladesh

THE in 2007 was Taka160.9 billion (US2.3

billion) compared to Taka 48.7 billion

(US$1.1 billion) in 1997

Per capita THE was US$16 in 2007

Adjusted for Purchasing Power Parity

(PPP), per capita THE was $46 in 2007

THE in Bangladesh is lowest in SAARC countries except Myanmar

THE in selected countries (2008)

Maldives Sri

Lanka

India Nepal Pakistan Bangladesh Myanmar

Per capita,

PPP

769 187 122 66 62 46 27

Percent

GDP

13.7 4.1 4.2 6.0 2.6 3.4 2.2

Source: WHO Department of Health Statistics and Informatics. "World Health Statistics 2011". Geneva: WHO.

http://www.who.int/whosis/whostat/2011/en/index.html. Retrieved 2012-06-12.For Bangladesh figures source is

“Bangladesh National Health Accounts (BNHA) 1997-2007”, HEU/DI 2010.

Growth of THE

The health sector experienced double digit

growth since 1997 with exception of 2003

Over the 1998–2007 period, the average

annual growth rate in THE in nominal terms

was 12.7%; 8% in real terms

Real growth in per capita health

expenditure between 1998 to 2007 averaged

6.4% per year

Bangladesh spends more on health as economy grows

$341 $350 $358 $364 $361 $358 $385

$410 $436 $441

$476

$9 $9 $10 $10

$11 $11 $11

$13 $14

$15 $16

$0

$2

$4

$6

$8

$10

$12

$14

$16

$18

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

$500

19971998199920002001200220032004200520062007

GDP per capita THE per capita

Source: BNHA 1997-2007.

THE as % of GDP is increasing but public spending on health remained flat around 1% of GDP

2.7% 2.7% 2.7% 2.8%

2.9% 3.0% 3.0%

3.1% 3.2%

3.3% 3.4%

1.0% 0.9% 0.9% 0.9% 0.9% 0.9%

0.8% 0.9%

0.8% 0.9% 0.9%

0%

1%

1%

2%

2%

3%

3%

4%

4%

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

THE Public spending


Households contributed to increases in THE

THE, Public spending on health and Households OOP as % of GDP

2.7% 2.7% 2.7% 2.8% 2.9% 3.0% 3.0% 3.1% 3.2% 3.3% 3.4%

1.5% 1.6% 1.6% 1.6% 1.7% 1.8% 1.8% 1.8%2.0% 2.1% 2.2%

1.0% 0.9% 0.9% 0.9% 0.9% 0.9% 0.8% 0.9% 0.8% 0.9% 0.9%

0%

1%

2%

3%

4%

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

THE HH spending Public spending


Households spend nearly two thirds of OOP on medicines

74% 72% 71% 70% 69% 67% 66% 65% 64% 63% 63%

0%

20%

40%

60%

80%

100%

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007


Households spends mostly at drug outlets/ pharmacies

Hospital, 16%

Ambulatory care provider, 17%

Drug and medical goods retail outlets, 66%

Other , 1%

OOP spending by type of provider in 2007.


THE by Function in 2007

Curative care, 28.60%

Rehab care, 0.10%

Ancillary services, 4.80%

Medicine and Medical Goods,

46.10%

Preventive and Public health,

11.20%

Health Admin , 1.40%

Capital Formation,

6.30%

Health Education

and

Training, 1.30%

Health Research, 0%

Distribution of THE is not equitable


Implications

Low public spending forces households to

spend more

Households spend a huge amount on

medicines and at drug stores/pharmacies

High households’ out of pocket payment

(OOP) may lead to impoverishment of

households

Current spending mechanism needs to be

more efficient and equitable to reduce

burden on households

Institutionalization of NHA

What is institutionalization of NHA?

Making NHA data routinely available

Producing NHA timely

Estimating NHA by using a standard

methodology

Relying on past NHA production methods

Using NHA results in policy making and

monitoring

Three aspects of NHA institutionalization

Data collection

Data production

Policy use

Strengths

Health Economics Unit of MOHFW

mandated to conduct NHA

Bangladesh implemented a dual reporting

system: meeting both Bangladesh and

international standards

Fully implemented international standards

by following the System of Health Accounts

(SHA) in the third round.

NHA data being used in policy documents

Strengths (Contd.)

BNHA Cell in HEU already established

HEU already formed institutional

partnership with BBS, IHE, ICDDR,B and

Data International

Focal point of BNHA Cell is from HEU

CGA officially agreed to provide electronic

data on public expenditure

Challenges

Insufficiency of staff with technical ability

to manage the NHA process

Dependence on external funds

Difficult access to private sector data

Non standardization of data reporting by

different financing stakeholders

Minimal IT support

Weak coordination and planning