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 partic...
Outline
 What

is NHA?
 SHA Framework
 Use of NHA
 NHA in Bangladesh
 Selected BNHA results
 Institutionalization of...
Definition of NHA


NHA constitute a systematic,
comprehensive and consistent monitoring
of resource flows in a country’s...
Boundaries of NHA




National health expenditure encompasses
all expenditures for activities whose
primary purpose is t...
NHA provides comprehensive
information on resource flows







Where do the resources come from?
Where do the resou...
SHA 2011 Framework
Raising
funds

Financing
Revenues

Schemes

Production

Purchasing

Factors of provision

Providers

Co...
SHA 2011 Framework: Current
Health Spending
Consumer health
interface

Financing
schemes (HF)

Healthcare
Consumption

Hea...
Linkage between Health System and
Health Accounts Frameworks
Health system
functions
 Governance
Stewardship

Health
acco...
Changes in SHA Framework
Dimensions
Consumption

Core Classifications

Extensions

Healthcare Functions (HC)
-

Beneficiar...
1.1 THE = CHE + HK
(SHA 1.0)
(SHA 2011)




CHE: an aggregate covering all spending
on healthcare that falls within the
...
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 ac...
Financing
Financing schemes (HF)
financing arrangements through which health
services are paid (e.g. tax based Govt, socia...
Production


Providers






Primary Providers: health care for final consumption is
their primary activity or service...
Consumption


Functions: Curative care, rehabilitative
care, long term care



Beneficiaries: By age, sex, geography,
ar...
Use of NHA


Policy tool






Inform policy makers about entire health sector
Enable informed policy decisions
Infor...
UHC Cube and NHA



X axis: population
coverage
Z axis: service coverage






Size of benefit package
depends on tot...
NHA in Bangladesh
History of NHA in Bangladesh


First NHA






Second NHA






conducted in 1998
ADB funded
estimated NHA for 19...
History of NHA in Bangladesh
(contd.)


Implementation of international standards (System
of Health Accounts, SHA)



...
Flow of Funds in BNHA
Financing Sources
Taka

Financing Agents
Taka

Providers
Health services
& Functions

Beneficiaries
...
BNHA Framework




Incorporates a health funding dimension (financing
agent) and does not attempt a funding source
class...
Financing Agent


General Government





Ministry of Health and Family Welfare
Other Ministries
Local Government
Soc...
Financing Agent (Contd.)


Private Sector








Private Insurance
Community Insurance
Non-profit Institutions/NGO...
Providers








General Administrations of Health
Public Health Programs
Hospitals
Nursing and Residential Care F...
Functions (Core)







Services of Curative Care
Services of Rehabilitative Care
Services of Long term Nursing Care...
Functions (Health Related)




Capital Formation
Health Education and Training
Health Research
Data Sources: Public Sector
BNHA
Code

BNHA-Financing Agents

BF1

General Government

BF1.1.1

Ministry of Health and Fam...
Data Sources: Private Sector
and Rest of the World (ROW)
BNHA
Code

BNHA-Financing Agents

BF2

Private Sector

BF2.2

Pri...
Data Analysis






Used data from multiple sources for
making NHA estimates guided by SHA and
WHO guidelines
Interpola...
Selected BNHA Results
Total Health Expenditure
(THE) in Bangladesh






THE in 2007 was Taka160.9 billion (US2.3
billion) compared to Taka 4...
THE in Bangladesh is lowest in SAARC
countries except Myanmar


THE in selected countries (2008)

Maldives Sri
Lanka
Per ...
Growth of THE





The health sector experienced double digit
growth since 1997 with exception of 2003
Over the 1998–20...
Bangladesh spends more on
health as economy grows
$500
$450
$400
$350
$300
$250
$200
$150
$100
$50
$0

$341 $350 $358

$36...
THE as % of GDP is increasing but public
spending on health remained flat around
1% of GDP

4%

4%
3%

2.7%

2.7%

2.7%

3...
Households contributed to
increases in THE
THE, Public spending on health and Households OOP as % of GDP
4%

3%

2.7%

2.7...
Households spend nearly two
thirds of OOP on medicines

100%

80%

74%

72%

71%

70%

69%

67%

66%

65%

64%

63%

63%

...
Households spends mostly at
drug outlets/ pharmacies
OOP spending by type of provider in 2007.
Other , 1%
Hospital, 16%

A...
THE by Function in 2007

Health Admin ,
1.40%

Capital
Formation,
6.30%

Preventive and
Public health,
11.20%

Medicine an...
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...
Institutionalization of NHA


What is institutionalization of NHA?







Making NHA data routinely available
Produc...
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...
Strengths (Contd.)






BNHA Cell in HEU already established
HEU already formed institutional
partnership with BBS, I...
Challenges







Insufficiency of staff with technical ability
to manage the NHA process
Dependence on external fun...
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L8 uhc-nha-tb

  1. 1. Under JPG Teaching Fellowship Permission from JPGSPH CoE-UHC
  2. 2. National Health Accounts (NHA) Tahmina Begum 7 June, 2013
  3. 3. Objective At the end of the session learners will learn about basic concept of National Health Accounts and its use particularly in Bangladesh.
  4. 4. Outline  What is NHA?  SHA Framework  Use of NHA  NHA in Bangladesh  Selected BNHA results  Institutionalization of NHA
  5. 5. 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).
  6. 6. 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.
  7. 7. 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?
  8. 8. SHA 2011 Framework Raising funds Financing Revenues Schemes Production Purchasing Factors of provision Providers Consumption/Use Health Functions Pooling funds Beneficiaries
  9. 9. SHA 2011 Framework: Current Health Spending Consumer health interface Financing schemes (HF) Healthcare Consumption Health functions (HC) Beneficiaries (HB) Revenues of financing schemes (FS) Providers (HP) Financing Agents (FA) Financing interface Source: WHO Factors of provision (FP) SHA Accounting Framework Health Financing Service Provision Provision interface
  10. 10. Linkage between Health System and Health Accounts Frameworks Health system functions  Governance Stewardship Health accounts dimensions Consumption  Resource generation human, physical and knowledge  Financing collecting, pooling and purchasing  Service delivery personal and population based Financing Instrumental objectives  Quality of services  Accessibility  Equity of utilisation  Efficiency of the system  Transparency and accountability  Innovation Provision A System of Health Accounts (SHA) 2011 Ultimate objectives  Health  Equity in health  Financial risk protection  Responsiveness
  11. 11. Changes in SHA Framework Dimensions Consumption Core Classifications Extensions Healthcare Functions (HC) - Beneficiaries (HB) Products New Capital Formation (HK) Provision Healthcare Providers (HP) Factors of Provision (FP) Financing Trade New Revenues of Financing Schemes (FS) - Financing Agents (FA) Financing Schemes (HF)
  12. 12. 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
  13. 13. NHA Framework  System of Health Accounts (SHA)    SHA 2000 SHA 2011 NHA measures actual expenditures
  14. 14. NHA provides comprehensive information on resource flows   Why financial flow information is important? Why measures actual expenditures
  15. 15. 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) 
  16. 16. 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)
  17. 17. Consumption  Functions: Curative care, rehabilitative care, long term care  Beneficiaries: By age, sex, geography, area
  18. 18. 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
  19. 19. 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,   Source: Viroj Tangcharoensathien, IHPP, Thailand Depends on the extent of cost covered by schemes Measured by OOP as % THE
  20. 20. NHA in Bangladesh
  21. 21. History of NHA in Bangladesh  First NHA     Second NHA     conducted in 1998 ADB funded estimated NHA for 1996-97 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
  22. 22. 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
  23. 23. Flow of Funds in BNHA Financing Sources Taka Financing Agents Taka Providers Health services & Functions Beneficiaries (by age, sex, region, disease, income group)
  24. 24. 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
  25. 25. Financing Agent  General Government     Ministry of Health and Family Welfare Other Ministries Local Government Social Security Funds
  26. 26. Financing Agent (Contd.)  Private Sector       Private Insurance Community Insurance Non-profit Institutions/NGOS Private companies Households Rest of the World
  27. 27. 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
  28. 28. 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
  29. 29. Functions (Health Related)    Capital Formation Health Education and Training Health Research
  30. 30. Data Sources: Public Sector BNHA Code BNHA-Financing Agents BF1 General Government BF1.1.1 Ministry of Health and Family Welfare (MOHFW) Data Source 1. 2. 3. 4. 5. Controller General of Accounts, Ministry of Finance (MOF) Line Directors Office, MOHFW Finance Division, MOHFW Directorate of Health, MOHFW 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. 2. 3. Zonal Headquarter, Dhaka Zonal Headquarter, Chittagong Zonal Headquarter, Rajshahi BF1.1.7 Local Government 1. 2. Ministry of Local Government City Corporation Offices at Divisional Headquarters
  31. 31. Data Sources: Private Sector and Rest of the World (ROW) BNHA Code BNHA-Financing Agents BF2 Private Sector BF2.2 Private Insurance (other than Social Insurance) Data Source 1. 2. 3. Private Insurance Companies Survey Household Income and Expenditure Survey, Bangladesh Bureau of Statistics (BBS) Bangladesh National Accounts, BBS BF2.3 Private Community Insurance 1. NGO Survey BF2.4 Households 1. 2. 3. 4. 5. 6. Private Hospital and Clinics Survey Household Income and Expenditure Survey, BBS Bangladesh National Accounts, Bangladesh BBS IMS Pharmaceutical Survey Health and Demographic Survey, BBS Morbidity and Health Status Survey, BBS BF2.5 Non-Profit Institutions/NGOs 1. 2. NGO Survey Development Partner Survey BF2.6 Corporations and Autonomous Bodies 1. Corporations and Autonomous Bodies Survey BF3 Rest of the World 1. 2. 3. NGO Survey Development Partner Survey Controller General of Accounts, MOF
  32. 32. 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
  33. 33. Selected BNHA Results
  34. 34. 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
  35. 35. THE in Bangladesh is lowest in SAARC countries except Myanmar  THE in selected countries (2008) Maldives Sri Lanka Per capita, 769 187 PPP Percent 13.7 4.1 GDP India Nepal Pakistan Bangladesh Myanmar 122 66 62 46 27 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.
  36. 36. 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
  37. 37. Bangladesh spends more on health as economy grows $500 $450 $400 $350 $300 $250 $200 $150 $100 $50 $0 $341 $350 $358 $364 $361 $358 $385 $410 $13 $9 $9 $10 $10 $436 $441 $14 $15 $476 $16 $11 $11 $11 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 GDP per capita Source: BNHA 1997-2007. THE per capita $18 $16 $14 $12 $10 $8 $6 $4 $2 $0
  38. 38. THE as % of GDP is increasing but public spending on health remained flat around 1% of GDP 4% 4% 3% 2.7% 2.7% 2.7% 3.0% 2.9% 2.8% 3.0% 3.1% 3.2% 3.3% 3.4% 3% 2% 2% 1.0% 1% 0.9% 0.9% 0.9% 0.9% 0.9% 0.8% 0.9% 0.8% 0.9% 0.9% 1% 0% 1997 1998 1999 2000 THE Source: BNHA 1997-2007. 2001 2002 2003 Public spending 2004 2005 2006 2007
  39. 39. Households contributed to increases in THE THE, Public spending on health and Households OOP as % of GDP 4% 3% 2.7% 2.7% 2.7% 2.8% 2.9% 3.0% 3.0% 3.1% 3.2% 3.3% 3.4% 2.0% 2.1% 2.2% 2% 1.6% 1.7% 1.8% 1.8% 1.8% 1.5% 1.6% 1.0% 0.9% 0.9% 0.9% 0.9% 0.9% 0.8% 0.9% 0.8% 0.9% 0.9% 1997 1% 1.6% 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 0% THE Source: BNHA 1997-2007. HH spending Public spending
  40. 40. Households spend nearly two thirds of OOP on medicines 100% 80% 74% 72% 71% 70% 69% 67% 66% 65% 64% 63% 63% 2003 2004 2005 2006 2007 60% 40% 20% 0% 1997 1998 1999 2000 Source: BNHA 1997-2007. 2001 2002
  41. 41. Households spends mostly at drug outlets/ pharmacies OOP spending by type of provider in 2007. Other , 1% Hospital, 16% Ambulatory care provider, 17% Drug and medical goods retail outlets, 66% Source: BNHA 1997-2007.
  42. 42. THE by Function in 2007 Health Admin , 1.40% Capital Formation, 6.30% Preventive and Public health, 11.20% Medicine and Medical Goods, 46.10% Health Research, 0% Health Education and Training, 1.30% Curative care, 28.60% Rehab care, 0.10% Ancillary services, 4.80%
  43. 43. Distribution of THE is not equitable Source: BNHA 1997-2007.
  44. 44. 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
  45. 45. 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
  46. 46. Three aspects of NHA institutionalization    Data collection Data production Policy use
  47. 47. 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
  48. 48. 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
  49. 49. 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

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