National health accounts were conducted in Côte d'Ivoire for the first time in 2007 and 2008 to estimate health spending. Total health expenditures increased 9.9% between 2007 and 2008. Households are the main source of health funding, contributing 69% of total health expenditures in 2008, mainly through high out-of-pocket spending on medicines. While total health spending per person is higher in Côte d'Ivoire than other sub-Saharan countries, government and donor contributions per person are much lower than household expenditures. Recommendations include developing policies to reduce out-of-pocket costs and give greater priority to primary healthcare.

1. National Health Accounts: What do they reveal in Côte d’Ivoire?Anne JuilletHealth Systems 20/20, Abt AssociatesJune 15, 2011Global Health ConferenceWashington, DC

2. IntroductionContextUntil 2009, Côte d’Ivoire did not have a comprehensive system to determine funds available for service provision within the health sectorObjectiveEstimate the contributions of different public and private stakeholders within the health sectorImprove financial managementEnsure that funding is effectively and adequately allocated;Provide data for decision-makers

3. MethodologyNational Health Accounts (NHA)Internationally recognized tool which synthesizes and monitors trends in health spendingIntegrates the collection, processing, and analysis of both primary (private enterprises, insurance companies, donors, and international NGOs) and secondary data (Ministry of Health, households, and national institutions)Examine health expenditures in Côte d’Ivoire in 2007 and 2008

4. ResultsHealth sector’s programmatic priorities in Côte d’Ivoire:Responsible, equitable and effective health system in which all the inhabitants of Côte d’Ivoire have access to quality care throughout the entire countrySpecific requirements: 1- Restore the health system in post-conflict areas 2- Base system on primary health care at district level 3- Improve availability and accessibility of essential medicines including ARVs, blood products, and vaccines 4- Implement new mechanisms of financing based on national or community solidarity

5. ResultsTotal expenditures on health increased by 9.9% between 2007 and 2008:2007: US $1,164,133,665 ( or US $58/person )2008: US $1,368,600,860 ( or US $66/person )Total spending on health in Côte d’Ivoire is much higher than in other sub-Saharan countries where the average is US $30/person

6. Contribution by person by funding source (US $)27.87029.747In 2008, household expenditures represented US $45.70/person, while the public sector spent US $11/ person and donors contributed US $9/person.

7. Per person household expenditure on health is 4 times that of national government spendingMain source of health funding: The Household- Households contributed to 69% of Total Health Expenditure (THE) in 2008

8. Main Financing Agent: The Household 96% of household spending goes directly towards health services (as opposed to insurance schemes).

9. Out-of-pocket (OOP) spending represents 66% of THE in 2008

10. Risk sharing (insurance) schemes are underdeveloped and not widely available throughout the country

11. Due to high OOP, risk of catastrophic expenses accrued by households is highMajority of OOP = Drugs76% of households’ OOP goes directly to medicines bought in private sector (higher prices than in public sector) because public procurement system is unable to meet demand from public sector facilities

12. 8% THE is dedicated to public health services

13. Expenditures on contagious diseases represent 5.3% of THE

14. Expenditures for maternal and child health care represent 2.6% of THEGovernment health expendituresAs a financing agent for health, the government spent: US $191.2 million in 2007 US $204.5 million in 2008Overall, the national budget’s contribution remains weak, as spending for health budget is 5% of the total national budget

15. Ministry of Health principal expenditures Public administration + Specialized facilities (incl. teaching hospitals)The MoH contributions are to public administration and to specialized facilities (as opposed to primary health care or public health programs)ConclusionsFunding is not aligned with the national strategy of enhancing access to health services for the most vulnerable populations Households purchase more expensive medicines from the private sector rather than the public sector Systems of prepayment are almost non-existentThe health system is centered around teaching hospitals and specialized establishments to the detriment of care provided at the secondary and primary levelsSpending on public health services represents only 8% of total spending of health in 2008