BNHA 1997-2007 Final Report

8/12/2019 BNHA 1997-2007 Final Report

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Bangladesh National

Health Accounts 1997-2007

Health Economics Unit (HEU)Ministry of Health and Family Welfare

Government of the Peoples Republic of Bangladesh


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Table of Contents

Executive Summary ................................................................................................................ 1

Total Health Expenditure (THE) ...........................................................................................1

THE by Financing Agent .......................................................................................................1

THE by Provider ....................................................................................................................2

THE by Function....................................................................................................................3

Health Spending by Division.................................................................................................4

International Comparison.......................................................................................................4

I. Background ..................................................................................................................... 5National Health Accounts (NHA)..........................................................................................5

NHA in Bangladesh ...............................................................................................................5

Organization of the Report.....................................................................................................6

II. Total Health Expenditure (THE) ...................................................................................... 7

III Total Health Expenditure (THE) by Financing Agent ...................................................... 9

IV Total Health Expenditure (THE) by Provider ................................................................. 13

V Total Health Expenditure (THE) by Function ................................................................ 17

VI THE by Geographical Division ...................................................................................... 23

VII International Comparison .......................................................................................... 26

VIII Changes in BNHA Estimates for Previous Years...................................................... 28

Changes in Estimates ...........................................................................................................28

Revisions to the BNHA Framework.....................................................................................29Definitional Revisions..........................................................................................................30

Revisions in Data Sources and Estimation Methods ...........................................................30

Annex I: Overview of BNHA Framework............................................................................... 36

Annex II: Description of Methods/Sources ............................................................................ 43

Public Sector Data Processing ............................................................................................44

Private Sector Data Processing...........................................................................................47

Annex III: Tabular Annex ...................................................................................................... 53


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List of Tables

Table 2.1: Total Expenditure on Health, 1997 - 2007 ............................................................. 7

Table 3.1: Total Expenditure on Health by Financing Agent, 19972007............................. 10

Table 3.2: THE as Percentage of GDP (current price) by Financing Agent, 1997-2007....... 11

Table 3.3: Health Expenditure in Public Sector by Financing Agent, Selected Years .......... 12

Table 4.1: Total Health Expenditures by Provider of Health Services, Selected Years........ 13

Table 4.2: Hospital Expenditures by Provider, Selected Years ............................................ 14

Table 4.3: Ambulatory Health Care Expenditure, Selected Years ........................................ 15

Table 4.4: Flow of Funds to Provider by Financing Agent, 2007 .......................................... 16

Table 5.1: Total Health Expenditures by Function of Health Services, Selected Years........ 17

Table 5.2: Inpatient and Outpatient Curative and Rehabilitative Care, Selected Years........ 18

Table 5.3: Public Expenditure by Function of Health Services, 2007 ................................... 19

Table 5.4: Private Sector Expenditure by Function of Health Services, 2007 ...................... 20

Table 5.5: Ancillary Services to Healthcare Expenditure, Selected Years............................ 20

Table 5.6: Medicine and Other Medical Goods Expenditure, Selected Years ...................... 21

Table 5.7: Prevention and Public Health Services Expenditure, Selected Years ................ 21

Table: 5.8: Health Administration and Insurance, Selected Years........................................ 22

Table 6.1: Geographical Distribution of Total Health Expenditure, 1997-2007..................... 23Table 6.2: Per Capita Spending on Health by Geographic Region, 2007............................. 24

Table 6.3: MOHFW Per Capita Spending on Health by Geographic Region, 2007.............. 25

Table 7.1: Comparison of Health Expenditure of Selected Countries, 2007......................... 26

Table 7.2: Comparison of Health Indicators of Selected Countries, 2006 ............................ 27

Table 8.1: Changes in NHA estimates: NHA3 and earlier rounds ...................................... 28


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List of Figures

Figure 4.1: Total Health Expenditures by Provider of Health Services, 2007 ....................... 14

Figure 5.1: Services of Curative Care 1997-2007................................................................. 18

Figure 5.2: Public Sector Expenditure by Function of Health Services, 2007....................... 19

Figure 6.1.Percentage Share of Total Health Expenditure by Geographical Region........ 24

List of Annex Tables

Table A1: Total Health Expenditure by BNHA Funding Sources and Year

Table A2: Percentage Distribution of Total Health Expenditure by BNHA Funding Sourcesand Year

Table A3: Total Health Expenditure by BNHA Provider and Year .........................................

Table A4: Percentage Distribution of Total Health Expenditure by BNHA Provider and Year

Table A5: Total Health Expenditure by BNHA Provider and Year .........................................

Table A6: Percentage Distribution of Total Health Expenditure by BNHA Function and Year

Table A7: Total Health Expenditure by ICHA Provider and Year

Table A8: Percentage Distribution of Total Health Expenditure by ICHA Provider and Year

Table A9: Total Health Expenditure by ICHA Function and Year

Table A10: Percentage Distribution of Total Health Expenditure by ICHA Function and Year

Table A11: Total Health Expenditure by ICHA Financing Agent and Year

Table A12: Percentage Distribution of Total Health Expenditure by ICHA Financing Agentand Year

Table B1: Cross-Classification of BNHA Expenditures by Provider and Financing Agent ofHealth Services, 1997



Table B4: Cross-Classification of BNHA Expenditures by Provider and Financing Agent ofH lth S i 2000


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Table C1: Cross-Classification of BNHA Expenditures by Function and Financing Agents ofHealth Services, 1997

Table C2: Cross-Classification of BNHA Expenditures by Function and Financing Agents of

Health Services, 1998







Table C9: Cross-Classification of BNHA Expenditures by Function and Financing Agents of

Health Services, 2005Table C10: Cross-Classification of BNHA Expenditures by Function and Financing Agents of

Health Services, 2006


Table D1: Cross-Classification of BNHA Expenditure by Function and Provider 1997


Table D3: Cross-Classification of BNHA Expenditure by Function and Provider 1999Table D4: Cross-Classification of BNHA Expenditure by Function and Provider 2000





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Notes:

Taka = Bangladeshi currency unitUS$ 1 = Taka 69 (approx. in July 2007) [All $ referred to in the text indicates US$]

Taka values converted into dollar ($) using exchange rates (below) for corresponding years.

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

1US $=Taka 42.70 45.46 48.06 50.31 53.96 57.44 57.90 58.94 61.39 67.08 69.03

GDP at current

price (in billion

Taka)

1,807 2,002 2,197 2,371 2,535 2,732 3,006 3,330 3,707 4,157 4,725

GDP in US$

(in billion)

42.32 44.03 45.71 47.12 46.99 47.56 51.91 56.49 60.39 61.97 68.45

Population(Million)

124.0 125.9 127.7 129.5 130.0 132.9 134.8 137.7 138.6 140.6 143.9


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Bangladesh National Health Accounts 1997-2007 Page 1

BANGLADESH NATIONAL HEALTH ACCOUNTS 1997-2007

Executive Summary

This is the third report on Bangladesh National Health Accounts (BNHA), which has been

developed and updated based on the System of Health Accounts (SHA) (OECD, 2000)

classification. It tracks total health expenditure in Bangladesh between fiscal years 1997 and

2007, cross-stratified and categorized by financing agent, provider and function on an annual

basis. The overall aim of the endeavor is to inform national policy makers and other

stakeholders of the magnitude and profile of health spending. It also serves in

institutionalizing monitoring of health outlays.

The BNHA framework used in the earlier rounds of NHA has been revised in this round

through extensive consultations with key officials of the government of Bangladesh, relevant

development partners and the NHA steering committee. New estimation methods and data

sources have been used to improve private expenditure estimates. Revisions to framework

and definitions and classifications have been made.

Total Health Expendi ture (THE)

BNHA definition of Total Health Expenditure (THE): it measures the final use of resident

units of health care goods and services, gross capital formation in health care provider

industries plus education and research expenditures of all healthcare providers during the

accounting period.

For Bangladesh, THE is estimated at Taka 159.91 billion ($2.32 billion) in 2007, Taka 73.8

billion ($1.4 billion) in 2001, and Taka 48.47 billion ($1,1 billion) in 1997. THE as a percent

of Gross Domestic Product (GDP) was almost constant at 2.7% during 1997-2000 period,

which crossed the 3% mark in 2002. In 2007, THE as a percent of GDP was 3.4%. Per

capita spending on health was Taka 391 ($9.2) in 1997, Taka 568 ($10.5) in 2001 and Taka

1,111 ($16.1) in 2007.

THE by Financing Agent

The four major sources of financing agents are households, government (public sector),


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Bangladesh National Health Accounts 1997-2007 Page2

crossing the 60% mark in 2003, and 65% in 2007. The government is the second largest

financing agent making up for 26% of THE in 2007. Its share, however, has been on the

decline over the 1997 and 2003 period. Public sectors contribution to THE was 36.5% in

1997, 31% in 2000, and 28% in 2003. During the 2004-07 period it flacutated between 26%

and 28% of THE. ROWs contribute a sizeable amount of their assistance through the

government or through NGOs. Their direct contribution has hovered at around 8% since

2001. NGOs share of financing from its own sources has remained around 1% to 2% over

the 1997-2007 period.

For public sector financing, primarily the Ministry of Health and Family Welfare (MOHFW)

serves as a financial intermediary of the GOB receiving funds from the Ministry of Finance

(MOF). Of the total amount of public sector health financing, MOHFWs share was Taka

40.1 billion ($581 million) which is 97% of the total public financing in 2007. MOHFW uses

these funds primarily by disbursing them to its healthcare providing units. MOHFW in

addition to its own providers, through transfers and grant-in-aids to NGOs, also implement

health, family planning and maternal and child health activities.

Over the years, governments expenditure on health as a percent of GDP has not increased.It has remained between 0.98% (1997) to 0.81% (2005) for the period 1997-2007. During the

late 1990s, households health expenditure as a percent of GDP was around 1.6%

compared to a little over 2% in recent years. ROWs share as percentage of GDP also

increased - from around 0.15% during 1997-99 to about 0.26% during 2002-07.

Contributions of private firms and NGOs as a percent of GDP have remained stable during

1997-2007.

NGOs expenditure, using its own funds, as a percent of GDP has remained stable over the

years between 0.03% and 0.05%. They rely much more on external funding from the

government as well as development partners in implementing health care related activities.

Private firms in Bangladesh do not finance much in the health sector. Its share of GDP in

2007 was 0.01%.

THE by Provider

As providers of health services, pharmacies (retail outlets for drugs and medical goods),

hospitals and ambulatory health services are dominant. Their respective contributions to

THE in 2007 were 43.2%, 26.2% and 24.2% respectively in 2007. The share of private and

NGO hospitals as percent of THE show significant growth over the years 3.5% in 1997,


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During the 1997-2007 period, ambulatory healthcare expenditure was between 23% (2007)

and 25.8% (1997) of THE.

Expenditure in Private/NGO hospitals in 2007 was Taka 2.35 billion ($34 million), which

constitute 54% of total outlay in hospital services. Their expenditure in 1997 was Taka 1.95

billion ($28.3 million), making up for 22.5% of total expenditure by hospitals.

The Ministry of Health and Family Welfare (MOHFW) manages the District and General

Hospitals across the country, expending Taka 3.73 billion ($54 million) in 2007, which is

around 8.5% of total outlay through hospital services. Although Upazila or below level public

facilities continue to be a large provider of health services in terms outlays in these entities,

their relative share has declined from 33.1% (Taka 2.87 billion) in 1997 to 25.8% (Taka 4.02

billion) in 2001 and 23.7% (Taka 10.38 billion) in 2007.

Over the years, expenditures through home health care providers have increased

considerably from Taka 1.76 billion ($41 million) in 1997 to Taka 7.62 billion ($110 million) in

2007. There has been a significant decline in expenditure from Taka 2.16 billion ($50.6

million) in 1997 to Taka 706 million ($10.2 million) in 2007 of providers categorized under theAll Other Out-Patient Community and Other Integrated Care Centres category. This

decrease can partly be explained by the enhanced role of NGOs in service delivery and

largely due to the up gradation of ambulatory care health providers into hospital facilities.

THE by Function

Sales of medicine and other medical goods are the largest component of expenditure in2007 in terms of functional classification -- Taka 74 billion (US$1.07 billion) in 2007, around

46.4% of THE; curative care services is the second largest function -- Taka 45.3 billion

(US$657 million), which is approximately 28.3% of THE. Collective health care, which is

inclusive of maternal and child health and family planning, constitute 11.3% (Taka 18 billion

in 2007) of THE.

The share of services for inpatient curative care has increased steadily over the years, while

outpatient cares share has declined. More specifically, in 1997, the share of inpatient

curative care was 10.4% while that of outpatient care was around 8.6%; presently they are

around 14.3% and 9% respectively. Prevention and public health services share of THE

was 15.4% in 1997, peaking in 2001 (17.9%), and 11.3% in 2007.


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and Child Health (42.5%) and Family Planning and Counseling (40.2%) are the two major

activities in terms of outlays. Health awareness creation (12.5%) and prevention of

communicable disease (3.6%) are the other areas of intervention. Over time, more

resources have been allocated for health awareness creation as evidenced in terms of

nominal expenditure and relative share of THE. Expenditures on family planning and

counseling have declined as a percent of THE from 69.7% in 1997 to 40.2% in 2007.

Health Spending by Division

There are health related expenditures that are difficult to apportion amongst the six

administrative divisions of the country. This category of expenditure has been classified ascentral expenditure. The central expenditure amounts to 14% of THE in 2007. In 2007, the

share of THE of the six divisions are 33%, 17%, 14%, 9%, 6% and 5% for Dhaka,

Chittagong, Rajshahi, Khulna, Sylhet and Barisal respectively. A comparison of per capita

health spending by geographical region in 2007 shows that Barisal is a significantly low

expenditure division.

International Comparison

Comparisons among selected South Asian countries show that at $307, Malaysia had the

highest per capita expenditure on health in 2007 and Bangladesh the lowest per capita

expenditure at $16. THE as share of GDP constitutes 3.4% for Bangladesh; Pakistan has

the lowest share at 2%. Bangladeshs public expenditure constitutes 25.8% of THE, similar

to that of India (25.4%). Private expenditure as percentage of THE accounts for 74% in

Bangladesh, 83% in Pakistan and 52% in Sri Lanka.

Compared to its neighbors, Bangladesh fares moderately well on selected health indicators.

China has the highest life expectancy at birth at 73 years, while life expectancy at birth for

both Bangladesh and India is 63 years. Malaysia boasts all births occurring in the presence

of a skilled attendant and a correspondingly low Infant Mortality Rate (IMR) at 10 per 1,000

live births. Bangladesh reports a low 20% of assisted births, while the IMR is 52.


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BANGLADESH NATIONAL HEALTH ACCOUNTS 1997-2007

I. Background

National Health Accounts (NHA)

National Health Accounts (NHA) is a tool, which describes the expenditure flows both

public and private within the health sector of a country. They describe, in an integrated

way, the sources, uses and channels for all funds utilized in the whole health system. NHAshows the amount of funds provided by major financing agents (e.g. government, firms,

households), and how these funds are used in the provision of final services, organized

according to the institutional entities providing the services (e.g. hospitals, outpatient clinics,

pharmacies, traditional medicine providers) and types of service (e.g. inpatient and

outpatient care, dental services, medical research, etc.).

Under NHA, health expenditures are grouped into two categories: (a) direct healthexpenditures; and (b) health related expenditures. Direct health expenditures include

outlays on goods or services that attend to: provision of care, prevention and public health,

stewardship and general administration. Health-related expenditures encompass such

activities as education and training of health personnel, research and development in health,

food, hygiene and water control, environmental health, capital formation, etc. The sum of

direct health expenditure and capital formation plus education and research expenditures of

all healthcare providers is defined as Total Health Expenditure (THE).

NHA in Bangladesh

This report provides data on health expenditure in Bangladesh for the 1997-2007 periods by

BNHA classification of provider, function, financing agent and administrative divisions. To

ensure comprehensiveness, consistency and international comparability, the SHA

framework and private expenditure guideline developed by OECD has been closely followed

to classify data sources and in estimation procedures. The Bangladesh National HealthAccounts (BNHA) framework is linked to SHAs International Classification for Health

Accounts (ICHA). However, adaptations have been carried out to make the framework and

classifications relevant to the Bangladeshi health sector. The conceptual framework for

BNHA encompasses definitions of what constitutes health expenditure, varied

di ti d th i ifi ti ll th diff t i tit ti i l d


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Organization of the Report

This report presents, based on both BNHA and SHA classifications, national health

expenditure estimates by financing agent, by functional use, by provider and by geographical

classification. Whilst estimates for 1997-2007 are included in this report, much of the

discussion is on the most recent year results, i.e. 2007. Trends in expenditure pattern by

financing agent, provider, function and region have also been highlighted.

This report includes three separate annexure. The first two annexure are brief technical

notes that are aimed at providing complementary information to the reader. Annex I

presents an overview of the BNHA framework adopted for NHA3. A discussion on methodspursued as well as the multiple sources used in obtaining data for NHA3 is detailed in Annex

II. Detailed statistical tables for the 1997-2007 periods appear in Annex III.


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II. Total Health Expenditure (THE)

Bangladesh National Health Accounts (BNHA) defines Total Health Expenditure (THE) as: it

measures the final use of resident units of health care goods and services plus gross capital

formation in health care provider industries (institutions where health care is the predominant

activity) plus education and research by health care provider institutions. THE definition

established in earlier NHA rounds have been adhered to under NHA3. This approach of

estimating THE is different from the System of Health Accounts (SHA) defined THE, as SHA

excludes health education and research expenditure from it.

For Bangladesh, THE is estimated at Taka 159.91 billion ($2.32 billion) in 2007, Taka 73.8

billion ($1.4 billion) in 2001, and Taka 48.47 billion ($1,1 billion) in 1997 (Table 2.1 and

Figure 2.1). THE as a percent of Gross Domestic Product (GDP) was almost constant at

2.7% during 1997-2000 period, which crossed the 3% mark in 2002. In 2007, THE as a

percent of GDP was 3.4%. The real (adjusted for inflation) growth rate of THE has ranged

from 5.5% (1997 to 1998) to 17.9% (2005 to 2006). Per capita spending on health was Taka

391 ($9.2) in 1997, Taka 568 ($10.5) in 2001 and Taka 1,111 ($16.1) in 2007 (Table 2.2,Figure 2.1).

Total Health Expenditure (THE) for Bangladesh during 1997-2007 ranged from Taka 48.47

billion ($1.14 billion) in 1997 to Taka 159.91 billion ($2.32 billion) in 2007 (Table 2.1 and

Figure 2.1). Health spending as a percentage of GDP has increased monotonically, albeit at

a slow pace over this period currently it is around 3.4% compared to 2.7% in 1997 and

2.9% in 2001. The real (adjusted for inflation) growth rate of THE has ranged from 5.5%(1997 to 1998) to 17.9% (2005 to 2006). Per capita spending on health was Taka 391

($9.15) in 1997 and Taka 1,111 ($16.1) in 2007 (Table 2.2, Figure 2.1).

Table 2.1: Total Expenditure on Health, 1997 - 2007

Year Total HealthExpenditure

(THE)

(Million Taka)

THE(Million

US$)

THE aspercent-

age of GDP

(%)

GDP in RealTerms (Base Year

1995-96) (Million

Taka)

THE at ConstantPrice (Base Year1995-96) (Million

Taka)

Growth Rateof THE

(Current

Market Price)

Growth Rateof THE (Base

Year Price

1995-96)1997 48,471 1,135 2.7 1,762,596 47,280

1998 53,344 1,173 2.7 1,870,984 49,859 10.10% 5.50%

1999 59,138 1,231 2.7 2,017,236 54,300 10.90% 8.90%

2000 65,167 1,295 2.7 2,306,505 63,398 10.20% 16.80%


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Table 2.2: Per Capita Expenditu re on Health , 1997 2007 (Current p rice)

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Per Capita Expenditure (Taka) 391 424 463 503 568 621 662 738 840 982 1,111

Per Capita Expenditure (USD) 9.2 9.3 9.6 10.0 10.5 10.8 11.4 12.5 13.7 14.6 16.1

Per Capita Real CapitalExpenditure (in Taka)

381 396 425 490 557 604 634 697 789 917 1,037

Per Capita Real CapitalExpenditure (in USD)

8.9 8.7 8.9 9.7 10.3 10.5 10.9 11.8 12.8 13.7 15.0

THE under BNHA does not include transportation cost relating to seeking treatment byhouseholds due to estimation complexities. For instance, hhouseholds living in rural areas

or in small towns while attending to medical needs in a large town or city include additional

chores (e.g. shopping, visiting relatives). The difficulties in isolating transport cost directly

associated with health care justified in non-inclusion of this expenditure. Expenditure on

home nursing care is another area where no data or any reliable estimate is available for

Bangladesh. Home care nursing services is primarily provided by family members, and it is

difficult to impute their time allocated for such services and their corresponding opportunity

cost. Albeit home nursing care is included under BNHA framework, THE estimated under

BNHA did not attempt to measure it.

Figure 2.1: Total Expenditu re on Health, 1997-2007 (Taka Billion)

4.85 5.33

5.916.52

7.388.25

8.92

10.16

11.64

13.81

15.99

2.68 2.66 2.69 2.752.91

3.02 2.97 3.05

3.143.32 3.38

-

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

(BillionTaka)

-

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

(THEas%o

fGDP

THE THE t f GDP

l d h l l h 9


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III Total Health Expenditure (THE) by Financing Agent

Most countries, under the NHA framework, disaggregate source of health financing into two

categories public and private. In Bangladesh, NGOs and external development partners

(donors) are active players in the health sector in the provision of financing and/or services.

Hence, outlays of these two entities have been explicitly identified in many instances in this

report. Rest of the World (ROW) expenditure includes all foreign development partners

expenditure excluding funding directly provided to the Government of Bangladesh (GOB) by

them.

Households pay for major share of the health expenditure in Bangladesh, whose relative

share has been on the increase over time. In 1997, households accounted for 57% of THE

crossing the 60% mark in 2003, and 65% in 2007. The government is the second largest

financing agent making up for 26% of THE in 2007. Its share, however, has been on the

decline over the 1997 and 2003 period. Public sectors contribution to THE was 36.5% in

1997, 31% in 2000, and 28% in 2003. During the 2004-07 period it flacutated between 26%

and 28% of THE. ROWs contribute a sizeable amount of their assistance through the

government or through NGOs. Their direct contribution has hovered at around 8% since2001. NGOs share of financing from its own sources has remained around 1% to 2% over

the 1997-2007 period.


serves as a financial intermediary of the Government of Bangladesh (GOB) receiving funds

from the Ministry of Finance (MOF). Of the total amount of public sector health financing,

MOHFWs share was Taka 40.1 billion ($581 million) which is 97% of the total publicfinancing in 2007. MOHFW uses these funds primarily by disbursing them to its healthcare

providing units. MOHFW in addition to its own providers, through transfers and grant-in-aids

to NGOs, also implement health, family planning and maternal and child health activities.

During the late 1990s, households health expenditure as a percent of GDP was around

1.6% compared to a little over 2% in recent years. ROWs share as percentage of GDP also

increased - from around 0.15% during 1997-99 to about 0.26% during 2002-07.

Contributions of the public sector, private firms and NGOs as a percent of GDP have

remained stable during 1997-2007.



B l d h N ti l H lth A t 1997 2007 P 10


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THE in 2007 a share that was in decline during the preceding decade (37% in 1997).

Private firms outlays are primarily in the form of insurance premiums for employees. As a

financing agent, private firms outlay was Taka 652 million ($9.45 million) in 2007. However,

direct healthcare expenditure made by private firms, which are not funded through insurance

coverage, are not covered under this round of BNHA. Attempts were made to capture such

expenditure but most of the large firms providing such services to their employees (tea

gardens) refused to participate in the study.

The share of NGO financing from own source has been between 1.1% to 1.7% over the

1997-2007 period. Development partners contribute a sizeable amount of their assistance

through the government or through NGOs. Funds provided to the government are

embedded in the government expenditure estimate while direct assistance given to NGOs is

reflected in Rest of the World (ROW) column of Table 3.1. ROWs expenditure through

NGOs varied from 4.7% to 9.1% during the 1997-2007 period.

Table 3.1: Total Expenditu re on Health by Financing Agent, 19972007

Public sector Households Private Firms NGO Rest of the World THE

Year Taka

Million

Row % Taka

Million

Row % Taka

Million

Row % Taka

Million

Row % Taka

Million

Row % Taka

Million

1997 17,682 36.5% 27,573 56.9% 370 0.8% 548 1.1% 2,299 4.7% 48,471

1998 18,341 34.4% 31,055 58.2% 388 0.7% 685 1.3% 2,874 5.4% 53,344

1999 19,291 32.6% 35,071 59.3% 241 0.4% 849 1.4% 3,687 6.2% 59,138

2000 20,217 31.0% 38,719 59.4% 634 1.0% 1019 1.6% 4,578 7.0% 65,167

2001 23,128 31.3% 43,456 58.9% 293 0.4% 1260 1.7% 5,659 7.7% 73,796

2002 25,223 30.6% 48,944 59.3% 323 0.4% 1265 1.5% 6,772 8.2% 82,527

2003 24,810 27.8% 54,461 61.1% 494 0.6% 1422 1.6% 8,004 9.0% 89,190

2004 29,316 28.8% 61,078 60.1% 426 0.4% 1579 1.6% 9,235 9.1% 101,634

2005 29,918 25.7% 74,506 64.0% 449 0.4% 1765 1.5% 9,734 8.4% 116,372

2006 38,696 28.0% 86,419 62.6% 530 0.4% 1954 1.4% 10,530 7.6% 138,129

2007 41,318 25.8% 103,459 64.7% 652 0.4% 2092 1.3% 12,391 7.7% 159,911

Total Health Expenditure (THE) as percentage of Gross Domestic Product (GDP) had been

almost constant at 2.7% during 1997-2000 period. In recent years, it has slowly but steadily

increased - 3.0% in 2002 to 3.4% in 2007 (Table 3.2). The overall rise in THE as a

percentage of GDP has been primarily due to household and ROWs increased outlay.

Bangladesh National Health Accounts 1997 2007 Page 11


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government as well as development partners in implementing health care related activities.Private firms in Bangladesh do not finance much in the health sector. Its share of GDP in

2007 was 0.01%.

Table 3.2: THE as Percentage of GDP (current pr ice) by Financing Agent, 1997-2007

Year Public sector Households PrivateFirms

NGOs Rest of theWorld

THE as % ofGDP

1997 0.98% 1.53% 0.02% 0.03% 0.13% 2.68%

1998 0.92% 1.55% 0.02% 0.03% 0.14% 2.66%

1999 0.88% 1.60% 0.01% 0.04% 0.17% 2.69%

2000 0.85% 1.63% 0.03% 0.04% 0.19% 2.75%

2001 0.91% 1.71% 0.01% 0.05% 0.22% 2.91%

2002 0.92% 1.79% 0.01% 0.05% 0.25% 3.02%

2003 0.83% 1.81% 0.02% 0.05% 0.27% 2.97%

2004 0.88% 1.83% 0.01% 0.05% 0.28% 3.05%

2005 0.81% 2.01% 0.01% 0.05% 0.26% 3.14%

2006 0.93% 2.08% 0.01% 0.05% 0.25% 3.32%

2007 0.87% 2.19% 0.01% 0.04% 0.26% 3.38%


serves as a financial intermediary of the Government of Bangladesh (GOB) receiving fundsfrom the Ministry of Finance (MOF). To a significantly lower level, other ministries including

the Ministry of Home Affairs also receives funds from MOF for health related activities. Of

the total amount of public sector health financing, MOHFWs share was Taka 40.1 billion

($581 million) which is 97% of the total public financing in 2007. MOHFW uses these funds

primarily by disbursing them to its healthcare providing units. MOHFW through transfers and

grant-in-aids to NGOs, implement health, family planning and maternal and child health

activities.

Alike other ministries, MOHFW expenditure are funded and categorized under two

government budget classifications: (a) Revenue Budget; and (b) Development Budget or

Annual Development Program (ADP). The revenue budget is financed by GOBs tax and

non tax revenues including borrowing from the domestic market and self financing by



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Bangladesh National Health Accounts 1997 2007 Page 12

Table 3.3: Health Expenditure in Public Sector by Financing Agent, Selected Years

1997 2001 2004 2007BNHA Code Financing Agent

TakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.%

BF1 General Governmen t 17,682 100% 23,128 100% 29,316 100% 41,318 100%

BF1.1.1. Minist ry of Healthand Family Welfare

16,979 96.0% 22,339 96.6% 28,446 97.0% 40,096 97.0%

BF1.1.1.1 Revenue Budget 7,991 45.2% 10,800 46.7% 15,046 51.3% 23,073 55.8%

BF1.1.1.2 Development Budget 8,989 50.8% 11,539 49.9% 13,400 45.7% 17,022 41.2%

All Other Mini str ies 702 4.0% 790 3.4% 870 3.0% 1,222 3.0%

BF1.1.3 Ministry of Home Affairs 68 0.4% 61 0.3% 76 0.3% 264 0.6%

BF1.1.6 Other Ministries andDivisions

444 2.5% 476 2.1% 481 1.6% 549 1.3%

BF1.1.7 Local Government 191 1.1% 253 1.1% 313 1.1% 409 1.0%



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g g

IV Total Health Expenditure (THE) by Provider

The three major providers of health services are drug outlets, hospitals and ambulatory

health services. Providers of ambulatory health care primarily include outpatient services

offered by general physicians, family planning centers, and medical and diagnostic

laboratories.

In 2007, according to Table 4.1, drug outlets accounted for Taka 69.15 billion ($1 billion),

hospital expenditure was Taka 41.89 billion ($607 million) and that of ambulatory care was

Taka 38.64 billion ($560 million). Figure 4.1 provides the percent distribution of different

health care providers expenditure. The share of drugs and medical goods retail outlets

have remained steadily around 41-44% during the decade of 1997-2007 (Table 4.1).

Hospitals share as a provider have increased steadily through the years from 17.9% in

1997 to 21.1% in 2001 and 27.3% in 2007 (Table 4.1). During the 1997-2007 period,

ambulatory healthcare expenditure was between 23% (2007) and 25.8% (1997) of THE.

Public health programs, primarily administered by the MOHFW, witnessed a decline in

nominal terms when compared between the late 1990s and recent years (Table 4.1). As apercent of THE, its share is presently around 1.1% compared to 8.5% in 1997 and 3.9% in

2001 (Table 4.1).

Table 4.1: Total Health Expendi tures by Provider of Health Services, Selected Years

1997 2001 2004 2007BNHACode

ProvidersTaka

Million

Col.% Taka

Million

Col.% Taka

Million

Col.% Taka

Million

Col.%

BP1 General Administrationof Health 1,046 2.2% 727 1.0% 1,716 1.7% 1,770 1.1%

BP2 Public Health Programmes 4,103 8.5% 2,854 3.9% 1,465 1.4% 2,097 1.3%

BP3 Hospitals 8,677 17.9% 15,579 21.1% 26,087 25.7% 43,710 27.3%

BP5 Providers of AmbulatoryHealth Care 12,483 25.8% 22,041 29.9% 28,710 28.2% 36,858 23.0%

BP7 Drug and Medical GoodsRetail Outlets 21,212 43.8% 31,343 42.5% 41,914 41.2% 69,147 43.2%

BP8 Other Industries(Rest of the Economy) 949 2.0% 1,249 1.7% 1,741 1.7% 6,330 4.0%

BP9 Rest of the World 2 0.0% 2 0.0% 2 0.0%

THE Total Health Expenditure48,472 100% 73,796 100% 101,634 100% 159,911 100%



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Figure 4.1: Total Health Expenditures by Provider of Health Services, 2007

Providers of

Ambulatory Health

Care

23.05%

Drug and Medical

Goods Retail Outlets

43.24%

Other Industries (Rest

of the Economy)3.96%

Hospitals

27.33%

Public Health

Programmes

1.31%

General Administration

of Health

1.11%

The Ministry of Health and Family Welfare (MOHFW) manages the District and General

Hospitals across the country, expending Taka 3.73 billion ($54 million) in 2007, which is

around 8.5% of total outlay through hospital services. Although Upazila or below level public

facilities continue to be a large provider of health services in terms outlays in these entities,

their relative share has declined from 33.1% (Taka 2.87 billion) in 1997 to 25.8% (Taka 4.02billion) in 2001 and 23.7% (Taka 10.38 billion) in 2007 (Table 4.2).

The medical college hospitals are teaching hospitals which also offer inpatient and outpatient

care. There are public as well as private medical college hospitals. Total expenditure by

these entities collectively was Taka 907 million ($21.3 million) in 1997 and Taka 2.24 billion

($32.5 million) in 2007. As a percent of total expenditure in hospitals, medical college

hospitals share was 5.1% in 2007. The share of total hospital expenditure for specialized

hospitals was 3.5% and that of medical university and post graduate institutes was 0.8% in

2007.

Table 4.2: Hospital Expendi tures by Provider, Selected Years

1997 2001 2004 2007BNHACode

ProvidersTakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.%

BP3 Hospi tals 8,677 100% 15,579 100% 26,087 100% 43,710 100%

BP3.1 Medical University Hospitaland Post Graduate Institutes

138 1.6% 205 1.3% 251 1.0% 349 0.8%

BP3.2 Medical College Hospitals 907 10.5% 1,149 7.4% 1,826 7.0% 2,237 5.1%

BP3.3.1 MOHFW District/ GeneralHospitals

1,203 13.9% 1,909 12.3% 3,757 14.4% 3,726 8.5%



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Ambulatory health care providers are primarily involved in providing services directly to

outpatients who do not require inpatient care. These services are provided by both the

medical health services and public health services. The major providers in this group are:

family planning centers, general physicians, home health care providers, and medical and

diagnostic laboratories. Home healthcare providers include NGOs door-to-door services

primarily on family planning and maternal and child health. Of the Taka 36.86 billion ($534

million) spent on such services (Table 4.3). The respective shares of major ambulatory care

providers in 2007 were: 28.1% (family planning centers), general physicians (25.7%), 20.7%

(home health care providers), and 17.4% (medical and diagnostic laboratories).

Over the years, expenditures through home health care providers have increased

considerably from Taka 1.76 billion ($41 million) in 1997 to Taka 7.62 billion ($110 million) in

2007. There has been a significant decline in expenditure from Taka 2.16 billion ($50.6

million) in 1997 to Taka 706 million ($10.2 million) in 2007 of providers categorized under the

All Other Out-Patient Community and Other Integrated Care Centres category. This

decrease can partly be explained by the enhanced role of NGOs in service delivery and

largely due to the up gradation of ambulatory care health providers into hospital facilities.

Table 4.3: Ambulatory Health Care Expenditure, Selected Years

1997 2001 2004 2007BNHACode

ProvidersTakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.%

BP5 Providers of AmbulatoryHealth Care

12,482 100% 22,041 100% 28,710 100% 36,858 100%

BP5.1 General Physicians 2,957 23.7% 4,728 21.4% 6,367 22.2% 9,461 25.7%

BP5.2 Dentist 64 0.5% 124 0.6% 189 0.7% 311 0.8%

BP5.5.1 Homeopathic 430 3.4% 747 3.4% 878 3.1% 1,135 3.1%

BP5.5.2 Ayurvedic/Unani 460 3.7% 450 2.0% 589 2.1% 852 2.3%

BP5.6.1 Family Planning Centres 3,237 25.9% 7,947 36.1% 8,365 29.1% 10,346 28.1%

BP5.6.9 All Other Out-PatientCommunity and OtherIntegrated Care Centres

2,157 17.3% 1,966 8.9% 2,141 7.5% 706 1.9%

BP5.7 Medical and DiagnosticLaboratories

1,417 11.4% 2,844 12.9% 4,086 14.2% 6,429 17.4%

BP5.8 Providers of Home HealthCare Services

1,760 14.1% 3,237 14.7% 6,095 21.2% 7,618 20.7%

Households are the largest financing source or agent to the providers, amounting to Taka

104 billion ($1.51 billion) in 2007. They spend a considerable amount (66.4%) is spent on



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Table 4.4: Flow of Funds to Provider by Financing Agent, 2007

BNHACode

Publicsector

Households PrivateFirms

NGOs Rest ofthe World

Total

BP1 General Admini strationof Health

1,754 16 1,770

Row % 99.1% 0.0% 0.9% 0.0% 0.0% 100.0%

Col % 4.2% 0.0% 2.4% 0.0% 0.0% 1.1%

BP2 Public Health Programmes 2,097 2,097

Row % 100.0% 0.0% 0.0% 0.0% 0.0% 100.0%

Col % 5.1% 0.0% 0.0% 0.0% 0.0% 1.3%

BP3 Hospitals 20,013 16,393 37 1,029 6,239 43,710Row % 45.8% 37.5% 0.1% 2.4% 14.3% 100.0%

Col % 48.4% 15.8% 5.6% 49.2% 50.4% 27.3%

BP5 Providers Of AmbulatoryHealth Care

11,717 17,926 1,063 6,152 36,858

Row % 31.8% 48.6% 0.0% 2.9% 16.7% 100.0%

Col % 28.4% 17.3% 0.0% 50.8% 49.6% 23.0%

BP7 Drug And Medical Goods

Retail Outlets

68,547 600 69,147

Row % 0.0% 99.1% 0.9% 0.0% 0.0% 100.0%

Col % 0.0% 66.3% 92.0% 0.0% 0.0% 43.2%

BP8 Other Industries(Rest of the Economy)

5,736 594 6,330

Row % 90.6% 9.4% 0.0% 0.0% 0.0% 100.0%

Col % 13.9% 0.6% 0.0% 0.0% 0.0% 4.0%

THE Total Health

Expenditure (THE)

41,318 103,459 652 2,092 12,391 159,911

Row % 25.8% 64.7% 0.4% 1.3% 7.7% 100.0%

Col % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%



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V Total Health Expenditure (THE) by Function

Disaggregation by key BNHA functional classifications shows that drug retail services andservices of curative care account for the major shares of THE at 46.4% (Taka 74.24 billion)

and 28.3% (Taka 45.33 billion) in 2007 (Table 5.1). These two categories are followed by

prevention and public health services at Taka 18.1 billion (11.3%). Prevention and public

health services include maternal and child health, family planning and awareness programs.

Capital formation includes both capital formation and depreciation, i.e. capital consumption

of domestic healthcare provider institutions (excluding: retail sale and other providers of

medical goods). It constitute around 6.3% of THE in 2007.

An overview of outlays for selected years reveals no significant variation in relative share of

the different functional outlays. Expenditure on medicine has remained within 43% to 47%

of THE (Table 5.1), while services of curative care have been between 25% and 30%. The

contributions of health education, training and research to THE is insignificant.

Table 5.1: Total Health Expendi tures by Function of Health Services, Selected Years

1997 2001 2004 2007BNHACode

FunctionTakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.%

BC1 Services ofCurative Care

12,358 25.5% 20,984 28.4% 30,161 29.7% 45,330 28.3%

BC.2 Services ofRehabilitative Care

120 0.2% 88 0.1% 140 0.1% 188 0.1%

BC.4 Ancillary Services to

Healthcare

1,420 2.9% 3,090 4.2% 4,572 4.5% 7,476 4.7%

BC.5 Medicine and OtherMedical Goods

21,674 44.7% 32,173 43.6% 45,199 44.5% 74,237 46.4%

BC.6 Prevention and PublicHealth Services

7,438 15.3% 12,700 17.2% 13,663 13.4% 18,076 11.3%

BC.7 Health Administrationand Insurance

1,333 2.7% 1,312 1.8% 1,507 1.5% 2,242 1.4%

BCR.1 Capital Formation 3,333 6.9% 2,307 3.1% 5,198 5.1% 10,130 6.3%

BCR.2 Health Educationand Training

784 1.6% 1,119 1.5% 1,157 1.1% 2,181 1.4%

BCR.3 Health Research 12 0.0% 21 0.0% 33 0.0% 44 0.0%

THE Total HealthExpenditure

48,471 100% 73,796 100% 101,634 100% 159,911 100%



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In Bangladesh inpatient care is primarily for curative purpose. Of the Taka 23 billion ($333

million) spent on inpatient care in 2007, 99.4% was spent on curative care and 0.6% on

rehabilitative efforts (Table 5.2). Outpatient care expenditure is mainly in the form of curative

care (64.1%) and basic medical and diagnostic services (34.1%) as reflected for year 2007.

Table 5.2: Inpatient and Outpatient Curative and Rehabilitative Care, Selected Years

1997 2001 2004 2007BNHACode

FunctionTaka

Million.Col.% Taka

MillionCol.% Taka

MillionCol.% Taka

MillionCol.%

Inpat ient Care 5,098 100.0% 8,905 100.0% 14,634 100.0% 22,990 100.0%

BC.1.1 Inpatient Curative Care 5,047 99.0% 8,839 99.3% 14,531 99.3% 22,850 99.4%

BC.2.1 Inpatient RehabilitativeCare

51 1.0% 66 0.7% 104 0.7% 139 0.6%

Outp atient Care 7,381 100.0% 12,167 100.0% 15,666 100.0% 22,528 100.0%

BC.1.3.1 Basic Medical andDiagnostic Services

3,065 41.5% 4,477 36.8% 5,479 35.0% 7,693 34.1%

BC.1.3.2 Outpatient Dental Care 64 0.9% 124 1.0% 203 1.3% 336 1.5%

BC.1.3.9 All Other OutpatientCurative Care

4,182 56.7% 7,544 62.0% 9,948 63.5% 14,450 64.1%

BC.2.3 Outpatient RehabilitativeCare

70 0.9% 22 0.2% 36 0.2% 49 0.2%

Spending on inpatient curative care has increased steadily over the years. More specifically,

in 1997, inpatient curative care use accounts for 41% of total curative care expenditure while

it was around 50% in 2007 (Figure 5.1). The establishment of several modern specialized

hospitals and the up gradation of government hospitals at the district and Upazila levels in

recent years have contributed in increased inpatient curative care spending. The arrival of a

handful of large sized private tertiary hospitals in Dhaka city, and a few in Chittagong cityhave dissuaded many patients to seek foreign treatment.

Figure 5.1: Services of Curative Care 1997-2007

15,000

20,000

25,000

MillionTaka



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Prevention and public health services classification covers maternal and child healthcare,

family planning services, immunization services, school health services, prevention of

communicable diseases, etc. In the BNHA context, prevention of HIV/AIDS has been

included under this category.

Explored through functional disaggregation, hospital services and prevention and public

health services account for the two largest shares of public expenditures 32.6% and 27.5%

respectively (Table 5.3, Figure 5.2). Capital formation (which includes both capital

formation and depreciation, i.e. capital consumption of domestic healthcare providing

institutions) comes to about 17.9%.

Table 5.3: Public Expend iture by Function of Health Services, 2007

BNHA code Function of health services Million Taka %

BC.1 Curative Care Services 13,463 32.6

BC.2 Services of Rehabilitative Care 188 0.5

BC.4 Ancillary Services to Healthcare - -

BC.5 Medicine and Other Medical Goods 5,690 13.8BC.6 Prevention and Public Health Services 11,348 27.5

BC.7 Health Administration and Insurance 1,627 3.9

BCR.1 Capital Formation 7,396 17.9

BCR.2 Health Education and Training 1,587 3.8

BCR.3 Health Research 18 0.0

Total 41,318 100

Figure 5.2: Public Sector Expenditure by Function of Health Services, 2007

Services of

Rehabilitative Care

Services of CurativeCare

32.6%

Health Research

0.0%

Health Education and

Training

3.8%Capital Formation17.9%

Health Administration

and Insurance

3.9%



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Medicines and medical goods, and hospital services are the two major functional categories

under private expenditures 57.8% and 26.9% respectively (Table 5.4). Ancillary services

account for 6.3%, which includes services provided by paramedical or medical technical

personnel with or without the direct supervision of a doctor.

Table 5.4: Private Sector Expenditure by Funct ion o f Health Services, 2007

BNHA Code Function of health services Milli on Taka %

BC.1 Services of Curative Care 31,867 26.9%

BC.4 Ancillary Services to Healthcare 7,476 6.3%

BC.5 Medicine and Other Medical Goods 68,547 57.8%

BC.6 Prevention and Public Health Services 6,728 5.7%BC.7 Health Administration and Insurance 615 0.5%

BCR.1 Capital Formation 2,734 2.3%

BCR.2 Health Education and Training 594 0.5%

BCR.3 Health Research 33 0.0%

Total 118,593 100

Ancillary Services to Healthcare comprises a variety of services provided in stand-alonecenters. These are mainly performed by paramedical or medical technical personnel with or

without the direct supervision of a medical doctor, such as laboratory and diagnostic

imaging. In Bangladesh, most of the expenditure under this functional category is on

diagnostic imaging and laboratory services. In 2007, Taka 6.4 billion ($93 million) was spent

on diagnostic imaging, and Taka 1.05 million ($15.2 million) on laboratory services; their

relative shares being respectively 86% and 14% (Table 5.5).

Table 5.5: Ancil lary Services to Healthcare Expenditure, Selected Years

1997 2001 2004 2007BNHACode

FunctionTakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.%

BC.4 Ancill ary ServicesTo Healthcare

1,420 100.0% 3,090 100.0% 4,572 100.0% 7,476 100.0%

BC.4.1 Laboratory Services 3 0.2% 247 8.0% 486 10.6% 1,047 14.0%

BC.4.2 Diagnostic Imaging 1,417 99.8% 2,844 92.0% 4,086 89.4% 6,429 86.0%

Functional activities comprising medicine and medical goods dispensed to outpatients and

the services connected with dispensing, such as retail trade, fitting, maintenance, and

renting of medical goods and appliances Medicines sold with or without prescription



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Table 5.6: Medicine and Other Medical Goods Expenditure, Selected Years

1997 2001 2004 2007BNHACode

FunctionTakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.%

BC.5 Medicine and OtherMedical Goods

21,674 100.0% 32,173 100.0% 45,199 100.0% 74,237 100.0%

BC.5.1.1 Medicines 21,113 97.4% 31,180 96.9% 43,440 96.1% 71,205 95.9%

BC.5.2.1 Glasses and OtherVision Products

552 2.5% 947 2.9% 1,608 3.6% 2,804 3.8%

BC.5.2.2 Orthopaedic Appliancesand Prosthetics

1 0.0% 3 0.0% 6 0.0% 10 0.0%

BC.5.2.3 Hearing Aids 8 0.0% 43 0.1% 146 0.3% 218 0.3%

A total of Taka 18.1 billion ($262 million) was spent on prevention and public health services

in 2007 (Table 5.7). Of the various components under this activity, Maternal and Child

Health (42.5%) and Family Planning and Counseling (40.2%) are the two major activities in

terms of outlays. Health awareness creation (12.5%) and prevention of communicable

disease (3.6%) are the other areas of intervention. Over time, more resources have been

allocated for health awareness creation as evidenced in terms of nominal expenditure and

relative share of THE. Expenditures on family planning and counseling have declined as apercent of THE from 69.7% in 1997 to 40.2% in 2007.

Table 5.7: Prevention and Public Health Services Expenditu re, Selected Years

1997 2001 2004 2007BNHACode

FunctionTakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.%

BC.6 Prevention and PublicHealth Services

7,438 100.0% 12,700 100.0% 13,663 100.0% 18,076 100.0%

BC.6.1.1 Maternal and ChildHealth

1,396 18.8% 3,273 25.8% 4,178 30.6% 7,685 42.5%

BC.6.1.2 Family Planningand Counseling

5,187 69.7% 7,879 62.0% 7,394 54.1% 7,263 40.2%

BC.6.2 School Health Services 8 0.1% 10 0.1% 12 0.1% 17 0.1%

BC.6.3 Prevention ofCommunicable Disease

159 2.1% 169 1.3% 248 1.8% 659 3.6%

BC.6.4 Prevention of Non-Communicable Disease - 0.0% - 0.0% 8 0.1% 131 0.7%

BC.6.5 Occupational Healthcare 53 0.7% 438 3.5% 169 1.2% 75 0.4%

BC.6.9 Health AwarenessCreation

637 8.6% 931 7.3% 1,655 12.1% 2,246 12.4%



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Table: 5.8: Health Administ ration and Insurance, Selected Years

1997 2001 2004 2007BNHACode

FunctionTakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.% TakaMillion

Col.%

BC.7 Health Administr ationand Insurance

1,333 100.0% 1,312 100.0% 1,507 100.0% 2,242 100.0%

BC.7.1.1 General GovernmentAdministration of Health(Except Social Security)

1,331 99.9% 1,302 99.2% 1,494 99.2% 2,227 99.3%

BC.7.2.2 Private Health InsuranceAdministration

2 0.1% 10 0.8% 13 0.8% 16 0.7%



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VI THE by Geographical Division

Estimating THE by geographical region is a new attribute under this round of NHA. This

attribute has enriched NHA3 and it can now produce expenditure estimates at theadministrative Divisional level. Unavailability of data beyond divisional level has restrained

estimates of THE at the district and upazila level. However, it is possible to track the

Ministry of Health and Family Welfare (MOHFW) spending down to Upazila under the

current NHA.

Assigning a geographical region to all types of healthcare expenditure is not always possible

as there are central level (mostly administrative) expenditures where the entire country is the

beneficiary. For example, public health expenditures made on awareness creation is an

expenditure where defining geographical boundaries is not feasible. Expenditures of such

nature which resist being classified under any specific geographical region is, thus, treated

as central. Table 6.1 provides the geographical distribution of THE for Bangladesh since

1997.

The percentage share of THE by geographical region has not witnessed much change

between 1997 and 2007 except for Dhaka division and Central. THE for Dhaka division in

1997 was Taka 10.65 billion, which comprises 22% (Table 6.1, Figure 6.1). In 2007, THE for

Dhaka division was Taka 54.36 billion in 2007 translating to 33%. In 1997, the central level

expenditure accounted for 28% of THE, a share that has decreased to 14% in 2007 largely

due to private sector health spending as well as investment in Dhaka division. Khulna,

Sylhet and Barisal are the three divisions where the percentage share of THE is found to be

much lower compared to other geographical regions.

Table 6.1: Geographical Distr ibut ion o f Total Health Expenditure, 1997-2007

Regio n 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Values are in Million Taka

Central 13,478 14,044 14,982 8,977 11,511 13,324 12,996 16,434 16,316 22,881 21,731

Dhaka 10,655 12,105 13,912 17,536 20,506 23,961 27,013 30,994 39,316 45,771 54,365

Chittagong 9,106 10,131 11,304 13,812 14,417 15,305 16,428 17,803 19,785 22,701 27,540

Rajshahi 6,975 7,806 8,653 11,312 12,489 13,571 14,864 16,411 18,333 21,039 25,140

Khulna 3,773 4,241 4,748 6,134 6,665 7,294 7,945 8,857 9,903 11,196 13,672

Barisal 1,855 2,079 2,312 3,250 3,671 4,155 4,617 5,266 6,122 6,966 8,413

Sylhet 2,630 2,938 3,227 4,146 4,537 4,919 5,328 5,868 6,597 7,574 9,049

Bangladesh 48,471 53,344 59,138 65,167 73,796 82,527 89,190 101,634 116,372 138,129 159,911

PercentageDistribution



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The central outlay is apportioned to all Bangladesh citizens, while per capita expenditure by

division has been estimated by taking into consideration the population base of each

respective region. A comparison of per capita health spending by geographical region in

2007 shows that Barisal is a significantly low expenditure division. Per capita healthspending for Barisal in 2007 was Taka 446 (US$ 6.50), almost one third of the national per

capita health expenditure (Table 6.2).

Table 6.2: Per Capita Spending on Health by Geographic Region, 2007

GeographicalRegion

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Central 109 112 117 69 89 100 96 119 118 163 151Dhaka 304 340 386 479 558 638 709 797 1,004 1,152 1,337

Chittagong 398 437 480 579 601 625 661 701 774 876 1,038

Rajshahi 245 270 295 380 418 444 479 518 575 651 760

Khulna 273 302 333 424 459 492 528 576 640 713 851

Barisal 114 126 138 191 215 238 261 292 337 378 446

Sylhet 351 387 419 531 578 613 655 706 789 893 1,042

Bangladesh 391 424 463 503 564 621 662 738 840 982 1,111

Figure 6.1.Percentage Share of Total Health Expenditure by Geographical Region

A comparison of MOHFW spending by geographical region shows that per capita health

THE 1997

Central

28%

Rajshahi

14%

Khulna8%

Barisal

4% Sylhet

5%

Dhaka

22%Chittagong

19%

THE 2007

Chittagong

17%

Rajshahi

16%

Khulna

9%

Barisal

5%

Dhaka

33%

Central

14%

Sylhet

6%



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Table 6.3: MOHFW Per Capita Spending on Health by Geographic Region, 2007

Region Population(2007)

(in millions)

MOHFWExpenditure

(Million Taka)

Per capita spending(Taka)

Per capita spending(US$)

Central 143.91 19,802 138 $2.0Dhaka 40.67 4,988 123 $1.8

Chittagong 26.53 3,947 149 $2.2

Rajshahi 33.10 5,316 161 $2.3

Khulna 16.06 2,629 164 $2.4

Barisal 18.87 1,664 88 $1.3

Sylhet 8.69 1,336 154 $2.2

Bangladesh143.91 39,681 276 $4.0



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VII International Comparison

Comparisons among selected South Asian countries show that Malaysia had the highest percapita expenditure on health in 2007 -- $307. Bangladesh had the lowest per capita

expenditure at $16, followed by Pakistan ($18) and Nepal ($20). Total Health Expenditure

(THE) as share of GDP constitutes 3.4% for Bangladesh; Pakistan has the lowest share at

2% while Nepals share is 5.2%.

The Bangladesh NHA framework (BNHA) includes a mapping table, thereby enabling BNHA

components to be defined in terms of ICHA classification. Accordingly, to allow inter-country

comparison, ICHA classification was used in defining and estimating the private sector. The

private sector thereby includes households, NGOs and rest of the world entities.

Bangladeshs public expenditure constitutes 25.8% of THE, similar to India (25.4%). Private

expenditure as a percentage of THE account for 74.2% in Bangladesh,and 74.6% in India.

Pakistans private expenditure as share of THE is 83.2% while Sri Lankas corresponding

figure is 52.5%.

Table 7.1: Comparison o f Health Expenditu re of Selected Countr ies, 2007

Country Per capitaExpenditure ($)

THE % of GDP Public Exp(% of THE)

Private Exp(% of THE)

Bangladesh $16 3.38 25.8 74.2

India $35 3.6 25.4 74.6

Malaysia $307 4.4 44.4 55.6

Pakistan $18 2.0 16.8 83.2

Sri Lanka $70 4.2 47.5 52.5

Nepal $20 5.2 36.4 63.6

China $112 4.5 45.3 54.7

Source: WHO estimates for countr y NHA data (http://www.who.int/nha/country/bgd/en/)

Among the South Asian countries compared in Table7.2, China and Sri Lanka performs

better on all the basic health indicators presented. Bangladesh fares moderately well on

some indicators, relative to its neighbors. China has the highest life expectancy at birth at73 years while Pakistan and Nepal have the lowest at 62 years; life expectancy for both

Bangladesh and India is 63 years. Malaysia boasts 100% of all births occurring in the

presence of a skilled attendant and correspondingly low Infant Mortality Rate (IMR) at 10 per

1,000 live births. Similarly Sri Lanka and China have 97% and 98% births assisted by skilled



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Table 7.2: Comparison of Health Indicato rs of Selected Countries, 2006

Country Life expectancyat birth (years)

Infant mortality rate(per 1,000 live births

Birth skilledattendant (%)

Contraceptiveprevalence (%)

Bangladesh 63 52 20 58.1

India 63 57 47 56.3

Malaysia 69 10 100 n.a.

Pakistan 62 78 54 27.6

Sri Lanka 69 11 97 70

Nepal 62 46 19 48

China 73 20 98 90.2

(Source: World Health Statistics 2008, World Health Organization)



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VIII Changes in BNHA Estimates for Previous Years

Changes in Estimates

THE as percentage of GDP was reported to be 2.94% in 1997 and 3.12% in 2002 under

NHA2, while NHA3 revisions led to the corresponding figures of 2.68% (1997) and 3.02

(2002). Downward revisions of selected expenditures (e.g. drugs) under NHA3 contributed

to a lower THE in this round than the preceding NHA effort. In the absence of such scrutiny

and subsequent adjustments, the aggregate estimates between the two rounds of NHA

would not have been much different.

Table 8.1 shows changes in NHA3 estimates compared to the revised estimates of NHA2.

Comparisons of government spending under NHA2 and NHA3 vary markedly Taka 13,450

million in 1997 (Table 3.8) and Taka 18,597 in 2002 (Table 3.8) under NHA2; the

corresponding figures for NHA3 are Taka 17,682 (1997) and Taka 25,223 (2002) -- a portion

of external funding is embedded in the CGA accounts. In addition, CGA only reports those

as expenditure for a particular year if the actual payment is made within the financial yearboundary. Otherwise it is reported as expenditure for the following year.

Development partners outlays under NHA2 are higher than the revised estimates under

NHA3. In 1997, NHA2 reports that development partner expenditure on health was Taka

5,842 million, while NHA3 estimates it to be Taka 2,299. In 2002, NHA2 donor funding was

quoted as Taka 11,745 compared to Taka 6,772 for the same year under NHA3 definitions

and estimation.

As teaching and training expenditures are estimated separately from patient-care in medical

college hospital expenditures, hospital expenditures relating to patients was estimated to be

much lower under this round of estimates Taka 907 million (NHA3) compared to Taka

2,205 (NHA2) in 1997, and Taka 1,289 (NHA3) versus Taka 4,247 (NHA2) in 2002.

Table 8.1: Changes in NHA estimates: NHA3 and earlier rounds

Source 1997

Taka

Million

1998

Taka

Million

1999

Taka

Million

2000

Taka

Million

2001

Taka

Million

2002

Taka

Million

Publ ic sector NHA3 17 682 18 341 19 291 20 217 23 128 25 223



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Source 1997

Taka

Million

1998

Taka

Million

1999

Taka

Million

2000

Taka

Million

2001

Taka

Million

2002

Taka

Million

Total Pri vate sect or NHA3 27,943 31,443 35,311 39,353 43,749 49,267

Total Pri vate 36,277 40,505 45,081 49,304 53,169 57,421

Household OOP NHA2 Table 3.8 35,293 39,579 44,021 48,110 51,911 56,092

Private enterprises NHA2 Table 3.8 979 917 1,048 1,178 1,231 1,297

Private insurance NHA2 Table 3.8 2 2 3 3 10 11

Community insurance NHA2 Table 3.8 3 7 9 13 17 21

Net changes between NHA3 and NHA2 -8,334 -9,062 -9,770 -9,951 -9,420 -8,154

Private sector (NGOs) NHA3 548 685 849 1,019 1,260 1,265

NGOs (Own) NHA2 Table 3.8 194 224 259 266 274 257

Net changes between NHA3 and NHA2 354 461 590 753 986 1,008

NGOs received from Donor NHA3 2,299 2,874 3,687 4,578 5,659 6,772

NGOs received from Donor Donor of Table 3.8 -

GOB received

Donor

1,091 1,236 1,972 4,385 6,306 7,264

Net changes between NHA3 and NHA2 1,208 1,638 1,715 193 -647 -492

Total Health Expenditure (THE)

as per BNHA

NHA3 48,471 53,344 59,138 65,167 73,796 82,527

Total Health Expenditure (THE)

as per BNHA

NHA2 Table 3.8 55,763 62,022 68,281 74,546 80,691 88,006

Net changes between NHA3 and NHA2 -7,292 -8,678 -9,143 -9,379 -6,895 -5,479

Revisions to the BNHA Framework

The Bangladesh National Health Accounts (BNHA) framework used in the earlier rounds of

NHA has been revised for NHA3 through extensive consultations with key officials of the

government of Bangladesh, relevant development partners and the NHA steering committee.

The revised NHA3 framework only incorporates a healthcare funding dimension, and does

not attempt a funding source dimension owing to problems of estimation and

operationalization of definitions.

From an operational viewpoint in Bangladesh except for private households funding



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Foreign development partners contribute to Bangladeshs health sector primarily through two

types of outlay (a) provide funds to the Government of Bangladesh; (b) provide funds to

NGOs and the private sector. Funds received by the government from the donors can be

either grants or loans. Funds received from foreign development partners is treated as a

government outlay, as it is consistent with NHA definition of financing agent as well as

GOBs accounting procedures and documentation.

Definition of Total Health Expenditure (THE) under BNHA differ from the SHA definition of

THE. BNHA includes education and research expenditures of all healthcare providers in

addition to SHA definition that isTotal expenditure on health measures the final use of

resident units of health care goods and services plus gross capital formation in health

care provider industries (institutions where health care is the predominant activity).

Definit ional Revisions

The methodology for estimating Development Partners (DP) expenditure under this round of

NHA is different from earlier rounds. In the earlier rounds, assumptions were made on the

amount of DP funding provided to the government and the NGOs healthcare programs.Under NHA3, only funds given to the NGOs by the DP are shown as the development

partners expenditure.

Hospital services provided by the government, the private sector and the NGO sector were

presented as three different types of providers in the earlier rounds of NHA. Under NHA3,

the private sector and NGO operated hospitals have been merged into one category called

Private/NGO hospital. The primary reason for this merger is that many of the NGO hospitalsare jointly owned by the NGO and private companies or individuals.

Revisions in Data Sources and Estimation Methods

The use of a more advanced methodology for private expenditure estimates as well as

changes in provider classification and lack of reliable information on funding sources impliesthat findings from this round of NHA will predictably vary from earlier rounds. Some of the

differences are due to differences in definition of provider classification and others owing to

the use of a different estimation strategy to estimate private spending. Presented below is

the summary of revisions to expenditure statistics for earlier years: (i) Total Health


P i t h lth dit d i t d b h h ld O t f P k t (OOP)


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Private healthcare expenditures dominated by household Out of Pocket (OOP)

payment are estimated as significantly lower compared to earlier estimates. Unlike

the efforts during the earlier rounds of NHA, reliance on a single data source for

private expenditures was avoided in this round.

The use of audited government expenditure data for reporting public healthcare

expenditure has led to new estimates for government expenditure.

The data sources used in the earlier rounds of NHA lacked a detailed breakdown of

central level expenditure, primarily by the health ministry secretariat. In the current

round of NHA, the CGA database, along with the supporting program documentation,

enabled identification and disaggregation of the health expenditures by provider

and/or by function instead of these expenditures being lumped under the category of

secretarial administrative expenditures. NHA3 revisions of the expenditure of district level general hospitals suggest lower

figures than estimated under NHA2 in 1997. A close review of secondary reports

and data suggest that some public health program expenditure as well as upazilas

(sub-district) were included under the district general hospital outlay for that period.

In subsequent years, more disaggregated data became available, and NHA3 was

able to further breakdown expenditures earlier lumped under the term administration

and insurance.



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Annexure

Annex I. Overview of BNHA Framework

Annex II. Description of Methods/Sources

Annex III. Tabular Annex



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Annex I: Overv iew of BNHA Framework1

The OECD SHA includes a three-dimensional classification system (ICHA), which has three

axes: financing agents (ICHA-HF), functions (ICHA-HC) and service providers (ICHA-HP).

To develop a BNHA framework that is compatible to the OECD SHA classification, a

mapping exercise was warranted. Each form of health expenditure (whether by source,

provider or function) was linked to a SHA-coded activity with a unique Bangladesh code.

What constitutes health expenditure, institutional entities, and types of disaggregation

formed the basis for deriving the Bangladesh National Health Accounts (BNHA) framework.

In the BNHA, expenditures are measured and organized on the basis of the entities

financing the expenditures, and those entities providing or using the health services funded

by these entities. Thus, expenditures are classified according to certain key dimensions of

analysis:

a. Financing agent

b. Providers of healthcare

c. Functions of healthcare and other health-related functionsd. Geographical division

The classification of entities within Bangladeshs healthcare system is critical for estimating

and structuring the countrys NHA. Two sets of entities must be defined: financing agents

and health providers. Entities are defined as economic agents, which are capable of

owning assets, incurring liabilities, and engaging in economic activities or transactions with

other entities. They can consist of individuals, groups of individuals, institutions, enterprises,government agencies, non-governmental organizations (NGOs), or other non-profit

institutions.

Not all categories of classification are available in Bangladesh at this time but they have

been retained to ensure the BNHA is flexible and able to accommodate any future changes

to the healthcare system. The tracking of these subcategories is highly dependent on data

availability at the relevant disaggregated levels. The categories chosen are also designed to

ensure that the BNHA classification is comparable to the OECD SHA.

a. Financing Agent


The second perspective focuses on the ultimate burden of financing borne by sources of


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funding. In this kind of analysis, the sources of financing of the intermediary sources of

funding (social security funds; private social and other private insurance) are traced back to

their origins. Additional transfers such as inter-governmental transfers, tax deductions;

subsidies to providers; and financing by the rest of the world are included to complete thepicture.

Tracking expenditure by sources of funding is difficult for government as well as non-

government entities. The Government of Bangladesh (GOB) does not track the source of

funding from external partners once it enters the existing Controller General of Accounts

(CGA) financial tracking system. NGOs in many instances cannot identify the source of

funding, as they receive money from financing intermediaries (e.g. another large local ofinternational NGO or GOB). Accordingly, BNHA is limited to expenditure analyses by the

financing agent only, and not by funding source for these two entities.

In line with OECD SHA practice, financing sources are grouped into two mutually exclusive

institutional sectors: (i) Public and (ii) Private. This broad grouping of sectors corresponds

both to general national income accounting practice, as well as NHA practice in most

countries.

Table 1: BNHA Classification of Healthcare Financing With ICHAs Comparison

BNHA Code BNHA-Financing Agent ICHACode

ICHA-Financing Agent

BF1 General Government HF1 General Government

BF1.1 General Government Excluding SocialSecurity Funds

HF1.1 General Government Excluding Social SecurityFunds

BF1.1.1 Ministry of Health & Family Welfare HF1.1.1 Central GovernmentBF1.1.1.1 Revenue Budget HF1.1.1 Central Government

BF1.1.1.2 Development Budget (ADP) HF1.1.1 Central Government

BF1.1.2 Ministry of Defense HF1.1.1 Central Government

BF1.1.3 Ministry of Home Affairs HF1.1.1 Central Government

BF1.1.4 Ministry of Education HF1.1.1 Central Government

BF1.1.5 Railway Division HF1.1.1 Central Government

BF1.1.6 All Other Ministries And Divisions HF1.1.1 Central GovernmentBF1.1.7 Local Government HF1.1.3 Local / Municipal Government

BF1.2 Social Security Funds HF1.2 Social Security Funds

BF2 Private Sector HF2 Private Sector

BF2.1 Private Social Insurance HF2.1 Private Social Insurance

Bangladesh National Health Accounts 199

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