How can health accounts inform health sector investments? Lessons from country applications

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Abt Associates Inc.

In collaboration with:

Avenir Health | Broad Branch Associates | Development Alternatives Inc. (DAI) | Johns Hopkins Bloomberg School of Public Health (JHSPH) |

Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG)

Experts

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Heather Cogswell, MPH, MBA

Associate/Economist, Abt Associates Inc.

7+ years of experience in health data collection, analysis, and application

Former: Jhpiego, ADVIZOR Solutions, Bright Hope International

Moderator

Presenters

Tesfaye Dereje, MA

Resource Tracking Lead/Economist, Abt Associates Inc.

15 years of experience in the health sector: health finance and policy

Former: UNICEF/Federal Ministry of Health, Ethiopia

Karishmah Bhuwanee, MSc

Associate/Economist, Abt Associates Inc.

12 years of experience in health financing in international development

Former: ODI/Ministry of Health Burundi, Crown Agents, N M Rothschild

Outline

Overview of Health Accounts

Using Health Accounts to inform Resource Mobilization

Using Health Accounts to inform Pooling

Using Health Accounts to inform Purchasing

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What are Health Accounts?

HA are based on the System of Health Accounts framework (SHA 2011)

Tool that tracks both the magnitude and flow of resources in the health

sector

Uses a comprehensive approach, looking at TOTAL resource flows to

the sector

public, private, and donor contributions

Uses a standard set of tables to organize flow of

resources in an easy-to-understand manner

Provides room for countries to incorporate their

country-specific categories for looking at the

spending breakdown (sub-classification)

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Global application of SHA 2011 framework

Countries Conducting HA By Region: 38 African countries; 9 American; 11 Middle Eastern; 10 European; 16 Asian

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Health Accounts provides snapshots of the

three health financing functions

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How are resources

RAISED?

HOW funds are managed?

WHO manages funds? Who DELIVERS health

goods and services?

What INPUTS are consumed in

the delivery of health services?

What TYPE of

services are

delivered?

What are the population

CHARACTERISTICS?

HEALTH FINANCING FUNCTION #1:

RESOURCE MOBILIZATION

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Resource Mobilization: How sustainable is

financing for health?

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0

10

20

30

40

50

60

70

80

90

100

Sh

are

of

Go

vern

men

t sp

end

ing

ou

t o

f T

HE

Share of Government Spending as % of Total Health Spending

Low income Middle income High income

Source- National Health Accounts reports

India: Health Accounts and the establishment of

National Rural Health Mission

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• India’s 2004-05 HA showed low public spending

for health compared with high OOP payment

• Led to the establishment of the National Rural

Health Mission to increase public financing for

health

• Additional $3.3 billion was invested in the health

sector

11.5

23.3

41.1

74.9

0

20

40

60

80

2005-06 2006-07 2007-08 2008-09

INR

, bill

ion

National Rural Health Mission expenditure

Source- Ministry of Health and Family Welfare, Govt of India

$4.5 $5.6

$7.1

$16.1

$20.8

0

5

10

15

20

25

1995/96 1999/00 2003/04 2007/08 2010/11

US

$

Health spending per capita

• HA highlighted low investments in health and

led to push to increase resources for health

• Government spending on health (as a

proportion of GGE) increased from 5% to 5.6%

between 2007/08 and 2010/11.

• Revenue retention policy enabled facilities to

keep and reinvest user fees in the facility

Ethiopia: Revenue retention at health-

facility level

13

Ethiopia: Revenue retention at health-

facility level

BEFORE AFTER

14

0

100

200

300

400

500

600

700

Per

cap

ita

spen

din

g (

US

D)

Low Income Middle Income High Income

Resource Mobilization: Is health funding

sufficient to achieve international benchmarks?

Essential Package of

Health Services

($60)

12 Source- National Health Accounts reports

HEALTH FINANCING FUNCTION #2:

RISK POOLING

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What are the opportunities to increase

pooling of health resources?

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Financing scheme spending by country

OOP Voluntary insurance Government Other

Source- Countries National Health Accounts reports

Are households incurring catastrophic

spending?

0

10

20

30

40

50

60

70

80

Per

cen

tag

e o

f O

OP

sp

end

ing

OOP spending as % of total health spending

Low income Middle income High incomeSource- National Health Accounts reports

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Indonesia: tracking progress towards UHC

for 250 million people

• Pro-poor insurance scheme (Jamkesmas) has been

expanding population coverage and benefits

• National health insurance (JKN) has combined 5

insurance schemes to become the primary

mechanisms for achieving UHC

• Use of Health Accounts to measure progress of

JKN

46.7% 46.9%

44.9%

43.8%

40%

42%

44%

46%

48%

50%

2010 2011 2012 2013

Out-of-Pocket spending as % of total health expenditure

Source- National Health Accounts reports 16

Egypt: assessing the effectiveness of

National Health Insurance Scheme

0

10

20

30

40

50

60

1994/95 2000/01 2003/04 2006/07

% of Population Insured by HIO

0

10

20

30

40

50

60

70

80

1994/95 2001/02 2007/08 2008/09

OOP spending as percentage of total health spending

• Egypt has been expanding its National Health Insurance

scheme to provide financial risk protection to its population

• Egypt used HA with coverage data to assess the

effectiveness of health insurance schemes

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Source- National Health Accounts, HIO

HEALTH FINANCING FUNCTION #3:

PURCHASING

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Health Accounts and purchasing function

Does spending respond to the disease burden?

Use of spending, disease burden data, and costing data

Is spending aligned with national priorities?

Are there opportunities to increase the efficiency of

spending on inputs?

Spending data can be compared with output and outcome data to

Identify areas of concern e.g. potential efficiency challenges

Compare spending and health performance with peer countries

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Namibia: Using HA to reallocate resources

to disease burden

• Reproductive health is stated-priority for Namibia in

order to stop increasing trend of maternal mortality

• 2008/09 Health Accounts: 10% of spending on RH

vs. 29% for HIV/AIDS

• Using Health Accounts for greater advocacy led to

450% increase in spending on RH (2012/13 Health

Accounts)

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Caribbean: Using Health Accounts to

reallocate resources to national priorities

• Prevention spending = 3% of spending in Barbados

(2012-13 HA) and 4% in Dominica (2011-12 HA)

• NCDs account for approx. 80% of deaths

• Treatment of increasing burden of NCDs is

unsustainable → prevention is crucial

• In 2015, both countries introduced 10% excise tax

for sugary drinks (Barbados, Dominica) and sugary

foods (Dominica)

• Revenues raised will be allocated to health sector,

including health prevention and promotion

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Using health spending and output data to

inform efficiency

Sierra Leone 2013

Cambodia 2012

B. Faso 2013

Burundi 2013

Benin 2013

DRC 2013

Cote d'Ivoire 2013 Liberia 2012

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

- 20 40 60 80 100

% in

stit

uti

on

al d

eliv

erie

s

Spending per woman of reproductive age US$

Maternal health spending per capita vs. % institutional deliveries

Sierra Leone 2013

Cambodia 2012

Burkina Faso 2013

Namibia 2013

Burundi 2013

Benin 2013

DRC 2013

Niger 2013

Liberia 2012

20

30

40

50

60

70

80

- 5.0 10.0 15.0 20.0 25.0

% F

P n

eed

s m

et

FP spending per woman of reproductive age

FP spending per capita vs. % FP needs met

22 Source- National Health Accounts reports, DHS, WHO

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Karishmah

Bhuwanee Heather

Cogswell

Tesfaye

Dereje

Q&A

Resources: www.hfgproject.org

Briefs

Follow the Money: Making the Most of Limited Health Resources

Policy Primer: Using Health Accounts to End Preventable Child and Maternal Deaths

Production and Use of Health Accounts in India: What Can We Learn from the Experience so Far?

System of Health Accounts 2011: What is SHA 2011 and How Are SHA 2011 Data Produced and Used?

System of Health Accounts (2011) and Health Satellite Accounts (2005): Comparison of Approaches

Tracking Urban Health Expenditures – Preliminary Results from Secondary Analysis of Bangladesh National Health Account

Understanding Health Accounts: A Primer for Policymakers

Health Accounts Reports

Comptes de la Sante au Burundi: 2012-2013

Dominica 2010-2011 National Health Accounts and HIV Subaccounts

Namibia 2012-13 Health Accounts Report

Saint Kitts and Nevis 2011 National Health Accounts and HIV Subaccounts

Questions? Email us at: [email protected].

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Thank You!

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www.hfgproject.org

@HFGProject