The document summarizes key findings from Bangladesh's National Health Accounts for 1997-2015. It finds that total health expenditure has been increasing in nominal and real terms, reaching $37 per capita in 2015. However, Bangladesh has one of the lowest shares of THE to GDP among SAARC countries. While private health expenditure as a share of THE is rising, public expenditure share has declined. Out-of-pocket spending by households remains the highest in the region. The largest share of funds is spent on medicines and medical goods.

1. Bangladesh National Health AccountsBangladesh National Health Accounts
1997-20151997-2015
Pre lim inary Finding s
September 2017

2. National Health Accounts-NHANational Health Accounts-NHA
It tends to answerIt tends to answer
How much is spent for health?
Who pays, how much?
How the expenditures are distributed across
different services and across different providers?
Who is benefited how much ? (Income groups,
regions, diseases etc.)
2

3. Use of NHA informationUse of NHA information
Most often quoted data (THE, OOPS…)
Widely used by Government and DP
Global monitoring UHC - health financing
Helps tracking health expenditure trends
Monitoring Goal 8 RFW of 4th
HPNSP
 % of THE funded from public sector
3

4. GuidelinesGuidelines
NHA follows standard guidelines as it:
Makes cross-national comparisons
Provides international validation
Saves time and cost
It is partly customized to the
national situation
4

5. Global Guidelines – evolving towards more precisionGlobal Guidelines – evolving towards more precision
5

6. NHA Frameworks over timeNHA Frameworks over time
Pre 2000
No global framework
Ad-hoc national standards & international frameworks
Lack of comparability in international estimates
System of National Accounts (SNA)
Not widely used for health
2000
OECD System of Health Accounts (SHA)
First global standard
Endorsed by WHO for international reporting
2011
System of Health Accounts 2011
Updated SHA
Agreed and adopted by OECD, Eurostat, WHO
6

7. Features of SHAFeatures of SHA
Provides explicit and comprehensive
boundary of health and health related
production
Analyses health expenditure in three core
dimensions: financing sources, providers
and functions
Detailed sets of classifications for the uses
of spending: providers and functions
Linkages with other international
classifications including SNA
Basis for adaption to meet specific national
requirements
FunctionsFunctions
Financingsources
Financingsources
7

8. NHA in BangladeshNHA in Bangladesh
BNHA-IBNHA-I
produced in
1998
1996/97
ADB funded
BNHA-IIBNHA-II
produced in
2003
1996/97-
2001/02
DFID funded
BNHA-IIIBNHA-III
produced in
2010
1996/97-
2006/07
GIZ funded
BNHA-IVBNHA-IV
produced in
2015
1996/97-
2011/12
Rockefeller
funded
8

9. Institutionalizing NHA processInstitutionalizing NHA process
Started with outsourcing – moving towards in-house work
Institutionalization started in 2011 with a costed action
plan
Three committees formed:
National Steering Committee
Stakeholder Coordination Committee
Technical Working Committee
BNHA Cell formed in July 2012 with representations
from HEU, BBS, IHE, ICDDR-B and DI, support from WB
Dhaka Office
Working arrangements with Partners (BBS, icddr, b, IHE
and DI) outlined through signing MoU in 2013
9

10. Preparation of BNHA - V : Data CollectionPreparation of BNHA - V : Data Collection
((Public Sector)Public Sector)
Public expenditure data are collected from 14
different ministries and all autonomous bodies and
institutions

11. Preparation of BNHA - V : Data CollectionPreparation of BNHA - V : Data Collection
(Private Sector)(Private Sector)
Primary data collection
Instruments developed/updated
Different Sampling frame developed/updated for
Private clinics/ hospitals/ diagnostics survey
Corporation survey (those have health expenditures)
NGO Survey
Insurance expenditure survey done through IDRA
Secondary data collection
Medicine expenditure from IMS & DGDA
Household Income and Expenditure Survey data from BBS
11

12. Data processing & analysisData processing & analysis
Using data from multiple sources cross
checking, corroboration & validation
Interpolation and extrapolation done in
case of data gap
Checking trends of various components
and comparing them with National
Accounts
12

13. Total Health Expenditure (THE)Total Health Expenditure (THE)
SHA 2011: Final consumption expenditure of
resident units on health care goods and services
Human capital (training, research)
and physical capital formation an
investment, not included in SHA THE
Bangladesh National Health Accounts (BNHA)
includes capital investment under THE
13

14. THE Estimates BNHA 1997-2015THE Estimates BNHA 1997-2015
& Earlier Rounds& Earlier Rounds
Year
THE estimates under BNHA (million taka)
BNHA-IBNHA-I BNHA-IIBNHA-II BNHA-IIIBNHA-III
BNHA-BNHA-
IVIV
BNHA-VBNHA-V
1997 54,698 55,763 48,699 46,356 46,772
2002 88,113 82,978 81,488 81,559
2007 160,899 153,887 157,103
2012 325,094 323,437
2013 353,960
2014 398,420
2015 451,889
③ Changes in definition / base-year
Changes in estimates happened due to:
① Use of actual audited data
②Changes in estimation methods
④ Better knowledge on all types of healthcare facilities
Share of THE in GDP
BNHA-IBNHA-I BNHA-IIBNHA-II BNHA-IIIBNHA-III BNHA-IVBNHA-IV BNHA-VBNHA-V
3.03% 3.09% 2.70% 2.57% 2.27%
3.23% 3.04% 2.98% 2.60%
3.41% 3.26% 2.86%
3.28% 3.07%
2.95%
2.97&
2.98%
14

15. Per capita THE during 1997-2015 grew aroundPer capita THE during 1997-2015 grew around
6% annually in real terms6% annually in real terms
Year
Per capita THE (Current and constant price using 2015 as base year)
Current TakaCurrent Taka Constant TakaConstant Taka Current (US $)Current (US $) Real growth rate (%)Real growth rate (%)
1997 382 1,083 $ 09
2002 615 1,384 $ 11 7.1
2007 1,105 1,907 $ 16 6.4
2012 2,156 2,585 $ 27 2.4
2013 2,318 2,593 $ 29 0.3
2014 2,575 2,727 $ 22 5.1
2015 2,882 2,882 $ 37 5.7
Average
1998-2002 503 1,208 $10 6.0
2003-2007 859 1,639 $14 6.7
2008-2012 1,694 2,324 $ 23 6.3
2013-2015 2,592 2,734 $ 33 3.7
1998-2015 1,281 1,892 $ 18 5.9
15

16. Year
THE (BNHA 1997-2015)
Current (Taka) Current (US $)
Purchasing Power
Parity (PPP) Taka
Purchasing Power
Parity (PPP) $
1997 382 $ 09 1,115 $ 26
2002 615 $ 11 2,181 $ 38
2007 1,105 $ 16 4,131 $ 60
2012 2,156 $ 27 6,936 $ 88
2013 2,318 $ 29 7,146 $ 89
2014 2,575 $ 22 7,437 $ 96
2015 2,882 $ 37 7,936 $ 102
Per capita THE in 2015 increased toPer capita THE in 2015 increased to
US$ 37 in 2015 from US$ 27 in 2012US$ 37 in 2015 from US$ 27 in 2012
16

17. Share of THE byShare of THE by
Division 2015Division 2015
THE per capita byTHE per capita by
Division 2015Division 2015
17

18. OOPS as a share of THE increased to 67% inOOPS as a share of THE increased to 67% in
2015 while public share remained the same2015 while public share remained the same
1
Voluntary health insurance, NIPISH/NGO,
Corporations-autonomous bodies-private companies
18

19. Public spending on health grew but at a slowerPublic spending on health grew but at a slower
pace than private spending during 1997-2015pace than private spending during 1997-2015
Billion Taka
• Public expenditure in nominal terms have increased every year
19

20. Consequently public share of THEConsequently public share of THE
has been declining over the yearshas been declining over the years
20

21. THE by Revenues of Financing Schemes 2015THE by Revenues of Financing Schemes 2015
21

22. The largest share of THE is spent onThe largest share of THE is spent on
medicines and medical goodsmedicines and medical goods
22

23. 23
Largest share of OOPS was spent onLargest share of OOPS was spent on
medicines and medical goods in 2015medicines and medical goods in 2015

24. Drug outlets are the largest provider in 2015Drug outlets are the largest provider in 2015
Million Taka
24

25. Spending at hospitals (as providers) duringSpending at hospitals (as providers) during
1997-20151997-2015 Million Taka
36%
40%
24%
25

26. Regional comparison: 2014Regional comparison: 2014
Expenditure and selected IndicatorsExpenditure and selected Indicators
Life Expectancy at birth (yrs) 72 69 68 66 68 66 75
Infant Mortality Rate 32 28 39 41 31 67 09
Under 5 Mortality Rate 40 34 50 52 31 83 10
Maternal Mortality Rate 188 156 181 184 275 184 31
Source: World Bank
26

27. THE as % of GDP in Bangladesh – one ofTHE as % of GDP in Bangladesh – one of
the lowest among SAARC countriesthe lowest among SAARC countries
2008 2009 2010 2011 2012 2013 2014
SAARC Countries
Afghanistan 8.3 9.4 9.2 7.9 8.8 8.1 8.2
Bangladesh 2.8 2.9 3.1 3.2 3.1 2.9 2.8
Bhutan 6.6 6.0 5.2 4.7 3.7 3.8 3.6
India 4.3 4.4 4.3 4.3 4.4 4.5 4.7
Maldives 9.3 9.2 7.9 8.1 9.2 11.2 13.7
Nepal 6.4 6.4 6.4 6.7 5.9 5.7 5.8
Pakistan 3.3 2.9 3.0 3.0 2.8 2.7 2.6
Sri Lanka 3.4 3.4 3.4 3.3 3.2 3.7 3.5
Source: Global Health Expenditure Database, WHO website
27

28. Public expenditure as % THE is the lowestPublic expenditure as % THE is the lowest
among SAARC Nationsamong SAARC Nations
2008 2009 2010 2011 2012 2013 2014
SAARC Countries
Afghanistan 17 27 31 26 34 33 36
Bangladesh 34 34 34 33 32 28 28
Bhutan 85 81 88 88 73 73 73
India 27 28 27 27 27 28 30
Maldives 76 73 67 69 71 74 78
Nepal 42 44 45 48 42 39 40
Pakistan 26 27 32 31 37 37 35
Sri Lanka 46 46 45 42 38 57 56
Source: Global Health Expenditure Database, WHO website
28

29. Household OOPS as % THE is the highestHousehold OOPS as % THE is the highest
among SAARC countriesamong SAARC countries
2008 2009 2010 2011 2012 2013 2014
SAARC Countries
Afghanistan 83 72 69 73 65 67 64
Bangladesh 60 61 61 61 63 67 67
Bhutan 15 18 11 12 26 25 25
India 64 63 63 64 65 64 62
Maldives 18 21 27 25 24 22 18
Nepal 48 45 45 41 46 49 48
Pakistan 66 64 61 61 55 55 56
Sri Lanka 44 44 45 48 49 41 42
Source: Global Health Expenditure Database, WHO website
29

30. Bangladesh Paradox: exceptional health achievement
despite economic poverty.
One of the great mysteries in global health
Unusual success
-The Lancet Series Nov, 2013
Health sector in BangladeshHealth sector in Bangladesh
Financing vs. Performance
30

31. Major findingsMajor findings
Health expenditure increasing both in nominal and
real terms
Private expenditure as share of THE increasing
while public expenditure share has declined
Household OOP dominates THE, expenditure on
drugs by households as % share declining
Expenditure on Curative care increasing faster
than increase in preventive care
31

32. Policy suggestionsPolicy suggestions (Health Financing)(Health Financing)
Increase Govt. allocation (fiscal space)
Improve efficiency in utilization (financial, non-financial)
Pre-payment
Treatment protocols
Health technology Assessment
32

33. Policy suggestionsPolicy suggestions (Governance)(Governance)
 Regulations related to pricing, quality and
investment policies in private sector
 Rational use (drug policy)
 Generic prescription
 Listing OTC drugs
 Restriction - dispensing antibiotics

34. THANKS
34

35. Next stepNext step
Production of sub-Accounts based on
BNHA 2015 estimates:
Disease Specific Accounts (DSA)
Malaria-TB-HIV-AIDS Accounts.
Policy Briefs
35

36. National Health Accounts-NHANational Health Accounts-NHA
NHA is a statistical process that
identifies total health expenditure
traces the sources of health expenditure
shows the distribution of funds by functions
(prevention and curative services etc.)
traces the channels of distribution of funds by
inputs (pay & salaries, medicines etc.).
36

37. International Classification of HealthInternational Classification of Health
Expenditure (ICHA)Expenditure (ICHA)
 SHA 1.0
 Health care by function (ICHA-HC)
 Health care by provider industry (ICHA-HP)
 Sources of health care financing (ICHA-HF)
 SHA 2011
 Health care by function (ICHA-HC)
 Health care by provider industry (ICHA-HP)
 Health financing schemes (ICHA-HF)
 Financing agents (ICHA-FA)
 Revenues of health financing schemes (ICHA-FS)
37

38. Taka
Flow of FundsFlow of Funds
Health services
and Functions
Taka
Financing Schemes
Revenues of
Schemes
•Government schemes
•Voluntary health insurance
schemes
•Non-profit institution/NGO
financing schemes
•Corporations, autonomous
bodies and private companies
(other than health insurance)
•Out-of-pocket household
expenditure excluding cost-
sharing
•Rest of the World voluntary
schemes
Providers
Beneficiaries
(by age, sex, region, disease, income group)
38

39. Per capita THE and GDP : 1997-2015Per capita THE and GDP : 1997-2015
(Current and constant price using 2015 as base year)
Year
Per capita THE Per capita GDP
CurrentCurrent
TakaTaka
ConstantConstant
TakaTaka
CurrentCurrent
(US $)(US $)
Real growthReal growth
rate (%)rate (%)
Current
Taka
Constant
Taka
Current
(US $)
1997 382 1,083 $ 09 18,834 45,721 $ 394
2002 615 1,384 $ 11 7.1 23,695 53,347 $ 413
2007 1,105 1,907 $ 16 6.4 38,661 66,727 $ 560
2012 2,156 2,585 $ 27 2.4 70,329 84,325 $ 889
2013 2,318 2,593 $ 29 0.3 78,515 87,838 $ 982
2014 2,575 2,727 $ 22 5.1 86,857 91,958 $ 1,118
2015 2,882 2,882 $ 37 5.7 96,671 96,671 $ 1,245
Average
1998-2002 503 1,208 $10 6.0 20,916 50,371 $ 409
2003-2007 859 1,639 $14 6.7 31,505 60,298 $ 499
2008-2012 1,694 2,324 $ 23 6.3 55,721 76,608 $ 760
2013-2015 2,592 2,734 $ 33 3.7 87,348 92,156 $ 1,115
1998-2015 1,281 1,892 $ 18 5.9 44,597 67,381 $ 64939

40. Household consumption and OOPS by quintilesHousehold consumption and OOPS by quintiles
Quintiles
Urban expenditure Rural expenditure
Annual
Household
Consumption
Expenditure
(Million
Taka)
Annual
Household
OOP Health
Expenditure
(Million
Taka)
OOP as % of
Consumption
Annual
Household
Consumption
Expenditure
(Million
Taka)
Annual
Household
OOP Health
Expenditure
(Million
Taka)
OOP as % of
Consumption
Quintile 1 --
Poorest 20%
131,792 2,962 2.25% 272,506 7,304 2.68%
Quintile 2 197,813 4,353 2.20% 376,727 10,405 2.76%
Quintile 3 261,416 5,730 2.19% 472,459 16,316 3.45%
Quintile 4 368,690 9,800 2.66% 608,270 22,990 3.78%
Quintile 5 –
Richest 20%
739,235 29,177 3.95% 1,081,430 48,017 4.44%
Overall 1,698,950 52,022 3.06% 2,811,390 133,213 4.74%
40

41. Private sector data collectionPrivate sector data collection
 100% coverage of
small providers
(Insurance Company
and Autonomous
Bodies)
 Sample survey of large
providers (hospital,
diagnostic facilities,
NGOs etc.)
 The World Bank’s
Enterprise Surveys
(ES) collect data from
key manufacturing
and service sectors in
every region of the
world

42. Private data collection : SamplingPrivate data collection : Sampling
 The recommended formula for
calculating sample size follows:
 where
 N= population size
 P= population proportion
 Q=1-P
 k= desired level of precision
 is the value of the normal
standard co-ordinate for a
desired level of confidence, 1-α
1]^)).(
1
.(
11
[ 2^
2
1
−
−
+=
αz
k
PQN
N
N
n
2
1
αZ
NN PP QQ kk nn
5050 0.90.9 0.10.1 5.0%5.0% 2.692.69 4242
100100 0.90.9 0,10,1 5.0%5.0% 2.692.69 7272
200200 0.90.9 0.10.1 5.0%5.0% 2.692.69 113113
300300 0.90.9 0.10.1 5.0%5.0% 2.692.69 140140
400400 0.90.9 0.10.1 5.0%5.0% 2.692.69 158158
500500 0.90.9 0.10.1 5.0%5.0% 2.692.69 171171
10001000 0.90.9 0.10.1 5.0%5.0% 2.692.69 207207
1000010000 0.90.9 0.10.1 5.0%5.0% 2.692.69 254254
100000100000 0,90,9 0.10.1 5.0%5.0% 2.692.69 260260
100000000100000000 0.90.9 0.10.1 5.0%5.0% 2.692.69 260260
2
1
αZ
This method guarantee that the population
parameter is within the 5% range of the
observed sample estimate for 90% cases

43. Private sector :Private sector : AnalysisAnalysis
Follow OECD/WHO
guidelines for private
expenditure analysis
Use only national level
primary and secondary
survey data
Data collection from
provider side is
encouraged
Tabulation of data
from multiple sources

44. Data analysis :Data analysis : Tabulation of dataTabulation of data
Data sourcesData sources
Million TakaMillion Taka
20152015
% of private consumption% of private consumption
IMS estimates on pharmacy salesIMS estimates on pharmacy sales
Pharmacy wholesale (audited by IMS) 130,578
Share of pharmacy sales market audited by IMS 98%
IMS estimates of TOTAL pharmacy sales without sales markup 133,243
Pharmacy retail sales (@15% markup)Pharmacy retail sales (@15% markup) 153,230153,230 1.4%
National Accounts derived estimatesNational Accounts derived estimates
Private consumption of Pharmaceutical products 184,665 1.7%
HIES household survey estimatesHIES household survey estimates
Households expenditure on medicine (30 days recall) 228,725 2.1%
Households expenditure on medicine (One year recall) 236,666 2.2%
Indirect estimates based on ratio of household consumption from household surveyIndirect estimates based on ratio of household consumption from household survey
Household medicines expenditure (12 months data) 366,148 3.3%
Household medicines expenditure (30 days data) 327,964 3.0%
Value of Western medicine producesValue of Western medicine produces
Total production 177,329
Export 7,615
Import 8,760
Net Production/Consumption 178,474
Sales value Net Production/Consumption 214,168214,168 2.0%
Composite estimateComposite estimate
Households expenditure at pharmaciesHouseholds expenditure at pharmacies
194,948194,948 1.78%1.78%

45. Data analysis :Data analysis : Tabulation of dataTabulation of data
Data sourcesData sources
Million TakaMillion Taka
20152015
% of private% of private
consumptionconsumption
THE (MillionTHE (Million
Taka)Taka)
OOP (MillionOOP (Million
Taka)Taka)
OOP as % ofOOP as % of
THETHE
IMS estimates on pharmacy salesIMS estimates on pharmacy sales
Pharmacy wholesale (audited by IMS) 130,578
Share of pharmacy sales market audited by IMS 98%
IMS estimates of TOTAL pharmacy sales without sales
markup
133,243
Pharmacy retail sales (@15% markup)Pharmacy retail sales (@15% markup) 153,230153,230 1.4% 410,171 260,797 64%
National Accounts derived estimatesNational Accounts derived estimates
Private consumption of Pharmaceutical products 184,665 1.7% 441,606 292,232 66%
HIES household survey estimatesHIES household survey estimates
Households expenditure on medicine (30 days recall) 228,725 2.1% 485,666 336,202 69%
Households expenditure on medicine (One year recall) 236,666 2.2% 493,607 435, 531 70%
Indirect estimates based on ratio of household consumption from household surveyIndirect estimates based on ratio of household consumption from household survey
Household medicines expenditure (12 months data) 366,148 3.3% 623,089 473,715 76%
Household medicines expenditure (30 days data) 327,964 3.0% 584,905 435,531 74%
Value of Western medicine producesValue of Western medicine produces
Total production 177,329
Export 7,615
Import 8,760
Net Production/Consumption 178,474
Sales value Net Production/Consumption 214,168214,168 2.0%2.0% 471,110471,110 321,735321,735 68%68%
Composite estimateComposite estimate
Households expenditure at pharmaciesHouseholds expenditure at pharmacies
194,948194,948 1.78%1.78% 451,889451,889 303,079303,079 67%67%