The document discusses National Health Accounts (NHA) in Bangladesh. It provides definitions of NHA according to WHO as a systematic monitoring of health resource flows. It summarizes the Bangladesh NHA (BNHA) framework which incorporates financing agents and providers. Key results from BNHA show total health expenditure increasing from 1997 to 2007 with households contributing through out-of-pocket payments mostly for medicines. While GDP spending on health increased slightly over time, public spending remained around 1% of GDP.

1. Under JPG Teaching
Fellowship
Permission from JPGSPH
CoE-UHC

2. National Health
Accounts (NHA)
Tahmina Begum
7 June, 2013

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

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. 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. 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. SHA 2011 Framework
Raising
funds
Financing
Revenues
Schemes
Production
Purchasing
Factors of provision
Providers
Consumption/Use
Health Functions
Pooling
funds
Beneficiaries

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. 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. 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. 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. NHA Framework

System of Health Accounts (SHA)



SHA 2000
SHA 2011
NHA measures actual expenditures

14. NHA provides comprehensive
information on resource flows


Why financial flow information is
important?
Why measures actual expenditures

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. 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. Consumption

Functions: Curative care, rehabilitative
care, long term care

Beneficiaries: By age, sex, geography,
area

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. 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. NHA in Bangladesh

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. 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. Flow of Funds in BNHA
Financing Sources
Taka
Financing Agents
Taka
Providers
Health services
& Functions
Beneficiaries
(by age, sex, region, disease, income group)

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. Financing Agent

General Government




Ministry of Health and Family Welfare
Other Ministries
Local Government
Social Security Funds

26. Financing Agent (Contd.)

Private Sector






Private Insurance
Community Insurance
Non-profit Institutions/NGOS
Private companies
Households
Rest of the World

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. 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. Functions (Health Related)



Capital Formation
Health Education and Training
Health Research

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. 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. 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. Selected BNHA Results

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. 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. 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. 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. 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. 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. 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. 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. 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. Distribution of THE is not
equitable
Source: BNHA 1997-2007.

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. 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. Three aspects of NHA
institutionalization



Data collection
Data production
Policy use

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. 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. 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