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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
Source: BNHA 1997-2007.
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
Source: BNHA 1997-2007.
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
Source: BNHA 1997-2007.
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.
Source: BNHA 1997-2007.
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
Source: BNHA 1997-2007.
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