NEPAL NATIONAL HEALTH ACCOUNTS 2012/13 TO 2015/16

Transcription

1 \ NEPAL NATIONAL HEALTH ACCOUNTS 2012/13 TO 2015/16 [Document subtitle] Abstract [Draw your reader in with an engaging abstract. It is typically a short summary of the document. When you re ready to add your content, just click here and start typing.] Health Financing Unit, MoHP [ address]

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3 Nepal National Health Accounts 2012/ /16 Government of Nepal Ministry of Health and Population June

4 About the Publication: report was prepared adhering to System of Health Accounts 2011 (SHA 2011), a global standard framework for producing health accounts with necessary refinements relevant to the country context. This report provides the estimates of healthcare expenditures occurred in the health system of Nepal estimated based on the preestablished expenditure boundaries, data sources, classification codes and estimation methodology. All reasonable precautions have been taken to justify the information presented in this publication. The estimates presented in this report could be further improved. Readers are welcome to contact the NHA team with suggestions and/or for further clarifications. This report does not present or suggest the policy implications of healthcare expenditures. While limited analysis has been done in this report, it is the responsibility of the readers and stakeholders to use, interpret, and draw inferences from the data in this publication. This report is also available online at If any changes in estimates due to improvements are made, the latest version for the most up to date report will be made available online. Published by: Health Financing Unit Human Resource and Financial Management Division Ministry of Health and Population Government of Nepal Copyright Ministry of Health and Population Recommended Citation: MoHP (2018). Nepal National Health Accounts, 2012/ /16, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal Contributors: Jhabindra P. Pandey, Roshan Karn, Dej Krishna Shrestha, Charu C. Garg, Ghana P. Neupane Contact: For further information on the publication please contact Health Financing Unit Human Resource and Financial Management Division Ministry of Health and Population Ramshahpath, Kathmandu, Nepal hefumoh@gmail.com Tel: i

5 Message- Minister of Health official letter head ii

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7 Message- State Minister of Health - official letter head iii

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9 Foreword - official letter head iv

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11 Acknowledgement - official letter head v

12 Advisory Committee Chairperson : Members : Chief, Human Resource and Financial Management Division, Ministry of Health and Population Chief, Policy Planning and International Cooperation Division, Ministry of Health and Population : Chief, Public Health Administration, Monitoring and Evaluation Division, Ministry of Health and Population : Executive Director, Social Health Security Development Committee : Deputy Director General, Central Bureau of Statistics : Member Secretary, Nepal Health Research Council : Chief, Account Section, Ministry of Health and Population : Chief, Account Section Department of Health Services : Representative, World Health Organization, Nepal Country Office : Representative, Nepal Health Economics Association Member Secretary : Director, Health Financing Unit, Ministry of Health and Population Technical Working Committee Chairperson : Members : Director, Health Financing Unit, Ministry of Health and Population Director (Statistics), Ministry of Health and Population : National Professional Officer (M&E), WHO, Nepal Country Office : Director, National Accounts Section, Central Bureau of Statistics : Director, Household Survey Section, Central Bureau of Statistics : Statistical Officer, Health Management Information System, Department of Health Services : Medical Record Officer, Health Management Information System, Department of Health Services : Chief, Research Section, Nepal Health Research Council : Research Associate, Nepal Health Research Council : Technical Advisor, Health Financing, GIZ, Support to the Health Sector Program : Representative, Nepal Health Sector Support Program : Representative, The World Bank Group, Nepal Member Secretary : Section Officer, Health Financing Unit, Ministry of Health and Population i

13 Table of Contents Abbreviations and Acronyms... iv Executive Summary... vi Major Indicators from NHA Estimates for Nepal, Fiscal Year 20012/13 to 2015/16... ix 1. Introduction Context and Background Objectives of Fifth Round of Nepal National Health Accounts Methodology Data Collection, use of HAPT and HAAT for Analysis and Validation General Health Accounts Results Current Health Expenditure (CHE) Capital Formation (HK) Total Health Expenditure (THE) General Government Health Expenditure (GGHE) Revenues of Health Care Financing Schemes (FS) Health Care Financing Schemes (HF) Health Care Financing Agents (FA) Health Care Providers (HP) Factors of Health Care Provision (FP) Health Care Functions (HC) Diseases/Health Conditions (DIS) Out-of-Pocket Spending (OOP) Data Sources and Estimation Government Bilateral and Multilateral Donors / External Development Partners (EDPs) Non-Government Organizations (NGOs) Employers Private Insurance Companies Households Diseases/Health Conditions Refinements Over the Previous NNHA Limitations in Estimations of this Round of NNHA Recommendations for the Future NNHA References General Health Accounts Results Tables to Annex A: Detailed NHA Cross-Tables to Annex B: NHA Classifications i

14 List of Figures Figure 1: Tri-axial Accounting Framework of SHA Figure 2: CHE and HK in Current Price and CHE and HK as a Percentage of GDP... 4 Figure 3: Breakdown of Capital Expenditure 2015/ Figure 4: Trend of Total Health Expenditure in Current and Constant Prices... 5 Figure 5: Trend of THE as a Percentage of GDP... 6 Figure 6: Trend of Per Capita THE in Current and Constant Prices (NPR)... 6 Figure 7: Breakdown of GGHE... 7 Figure 8: Trend of General Government Health Expenditure as a Percentage of General Government Expenditure... 7 Figure 9: GGHE as a Percentage of General Government Expenditure in South-East Asian Countries Figure 10: Trend of GGE as a Percentage of GDP and GGHE-D as a Percentage of GHE... 8 Figure 11: General Government Health Expenditure as a Percentage of Current Health Expenditure... 9 Figure 12: Per Capita Government and Private Health Expenditure from Domestic Sources in Purchasing Power Parity ($International)... 9 Figure 13: CHE Distribution by Revenues of Health Care Financing Schemes Figure 14: Trend of CHE Distribution by Revenues of Health Care Financing Schemes Figure 15: CHE Distribution by Institutional Units Providing Funds to Financing Schemes Figure 16: Trend of CHE Distribution by Institutional Units Providing Funds to Financing Schemes Figure 17: CHE Distribution by Health Care Financing Schemes Figure 18: Trend of CHE Distribution by Health Care Financing Schemes Figure 19: CHE Distribution by Health Care Financing Agents Figure 20: Trend of CHE Distribution by Health Care Financing Agents Figure 21: CHE Distribution by Health Care Providers Figure 22: Trend of CHE Distribution by Health Care Providers Figure 23: CHE Distribution by Factors of Health Care Provision Figure 24: Trend of CHE Distribution by Factors of Health Care Provision Figure 25: CHE Distribution by Health Care Functions Figure 26: Trend of CHE Distribution by Health Care Functions Figure 27: CHE Distribution by Diseases/Health Conditions Figure 28: CHE Distribution by Diseases/Health Conditions Figure 29: Diseases Burden Ranking, Both Sexes, 2001 and Figure 30: Distribution of Diseases/Health Conditions Expenditures by Level of Care Figure 31.a Diseases/health conditions Wise Distribution by Sex Figure 31.b Diseases/health conditions Expenditures Distribution by Age Figure 32: Disease wise Expenditure Distribution by Financing Schemes Figure 33: Trend of OOP Spending as Compared to Other Financing Schemes Ratios as Percentage of CHE 21 Figure 34: Trend of OOP as a Percentage of CHE in South-East Asian Countries Figure 35: Household OOP Spending by Types of Services and Goods Figure 36: Household OOP Spending by Types of Providers Figure 37: Household OOP Spending by Diseases/Health Conditions Figure 38.a Incidence of Catastrophic Household OOP on Health (Threshold = 10%) Figure 38.b Incidence of Catastrophic Household OOP on Health (Threshold = 25%) Figure 39.a Percentage of Population Impoverished due to OOP Spending (at 1.90 Int. $) Figure 39.b Percentage of Population Impoverished due to OOP Spending (at 3.10 Int. $) ii

15 List of Tables Table 1a. Macro Data Table 1.b. Major Indicators from 2000/01 to 2015/ Table 2. Distribution of CHE by Revenues of Health Care Financing Schemes Table 3. Distribution of CHE by Institutional Units Providing Revenues to Financing Schemes Table 4. Distribution of CHE by Health Care Financing Schemes Table 5. Distribution of CHE by Health Care Financing Agents Table 6. Distribution of CHE by Health Care Providers Table 7. Distribution of CHE by Factors of Health Care Provision Table 8. Distribution of CHE by Health Care Functions Table 9. Distribution of Disease/Health Conditions Expenditures According to Age, 2014/ Table 10. Distribution of Disease/Health Conditions Expenditures According to Sex, 2014/ Table 11. Distribution of Disease/Health Conditions Expenditures According to Age, 2015/ Table 12. Distribution of Disease/Health Conditions Expenditures According to Sex, 2015/ Table 13. Distribution of OOP Expenditure by Health Care Functions Table 14. Distribution of OOP Expenditure by Health Care Providers Table 15. Distribution of Capital Formation iii

16 Abbreviations and Acronyms AHS AIN ANC CBO CBS CHE DDCs DFID DoHS DHO DIS EDPs FA FCGO FP FS.RI GBD GDP GGE GGHE-D GGHE HA HAAT HAPT HC HF HIV/AIDS HK HMIS HP HPs ICD ICHA IHME INGOs IP Annual Household Survey Association of International Non-Governmental Organizations Antenatal Care Community Based Organization Central Bureau of Statistics Current Health Expenditure District Development Committees Department for International Development Department of Health Services District Health Office Disease Classification External Development Partners Health Care Financing Agents Financial Comptroller General Office Factors of Health Care Provision Institutional Units Providing Revenues to Financial Schemes Global Burden of Disease Gross Domestic Product General Government Expenditure Domestic General Government Health Expenditure General Government Health Expenditure Health Accounts Health Accounts Analytical Tool Health Accounts Production Tool Health Care Functions Health Care Financing Schemes Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Capital Formation Health Management Information System Health Care Providers Health Posts International Classification of Diseases International Classification for Health Accounts Institute for Health Metrics and Evaluation International Non-Governmental Organizations Inpatient iv

17 MoFALD MoHP NNHA NCDs NGOs NH NPISH NPR OECD OOP OP PHCC PHFS PNC PPP RH RHD SH SHA SHI SHSDC SOEs STDs SWC TABUCS THE UHC UNICEF USAID USD VDCs VPDs WHO ZH Ministry of Federal Affairs and Local Development Ministry of Health and Population Nepal National Health Accounts Non-Communicable Diseases Non-Governmental Organizations National Hospital Non-Profit Institutions Serving Households Nepalese Rupees Organization for Economic Co-operation and Development Out-of-Pocket Outpatient Primary Health Care Center Public Health Facility Survey Perinatal Care Purchasing Power Parity Regional Hospital Regional Health Directorate Specialized Hospital System of Health Accounts Social Health Insurance Social Health Security Development Committee State Owned Enterprises Sexually Transmitted Diseases Social Welfare Council Transaction Accounting and Budget Control System Total Health Expenditure Universal Health Coverage United Nations Children s Fund United State Agency for International Development United States Dollar Village Development Committees Vaccine Preventable Diseases World Health Organization Zonal Hospital v

18 Executive Summary National Health Accounts is designed to track health expenditure in the systematic, comprehensive, and consistent manner by estimating the expenditures incurred for consumption of health care services and goods in a country for the reference year. Development and practice of the NHA provide evidence to help policy-makers, non-governmental stakeholders, and managers to make better decisions in their efforts to improve the health system. This is the fifth round of Nepal National Health Accounts (NNHA) which covered the four fiscal years from 2012/13 to 2015/16 and was conducted from March 2017 to May The production of NHA in Nepal was initiated back in the year 2000 and till the date, four rounds of NNHA have been completed. In this round, necessary adjustment of some variables and addition of disease accounts for the first time in the NNHA have been done. The objective of this round of NNHA was to estimate and track the spending by government, household, external donors, national and international NGOs, private sectors, employers, insurance providers etc. in the country s health system and how the funding was used to deliver the health services and goods to the people. The purpose was to understand country s health financing landscape and the mechanism through the evidences based on health spending, and find the answers to the key policy questions to inform policy decisions for health financing reforms. This round of NNHA estimates was based on the six-dimension classification of System of Health Accounts (SHA) 2011 Framework, a globally standardized process for systematic description and reporting of financial flows related to health care in a defined territory. The health expenditure data was collected from various primary and secondary sources and were reviewed for completeness and comprehensiveness. Health Accounts Production Tool (HAPT) was used for data validation and analysis. The estimated Current Health Expenditure (CHE) in the current price was NPR billion (6.3% of Gross Domestic Product (GDP)) and the capital expenditure was NPR 9.70 billion (0.4% of GDP) in the year 2015/16. More than half of the total capital investment was made in the residential and nonresidential buildings. Total Health Expenditure (THE) was estimated at NPR billion (USD 1.43 billion) which was 6.7% of GDP and the per capita THE was NPR 5216 (USD 49) in the year 2015/16. General Government Health Expenditure (GGHE) from all the sources was NPR billion (26.7% of THE and 1.8% of GDP) where one third was spent on the curative services followed by preventive care (24.7%) and capital formation (24.1%) in the year 2015/16. In the context of financing sources and their institutional arrangements, households Out-of-Pocket (OOP) payment at 55.4% of all the current funds for health care services and goods, was the major source of funding the health system of the country in the year 2015/16. Next to the household, the government funded 18.6% of CHE from its domestic revenues followed by NPISH (12.0%) and direct foreign transfers were 8.6%. Among the multilateral and bilateral donors, the major funds were from the USAID (2.4%), GAVI (1.9%), DFID (1.5%), UNICEF (1.4%) and WHO (0.9%). Households were the largest agents of their own health spending by managing 55.4% of CHE. The expenditure from government scheme was 21.7% of CHE, out of which 17.5% was managed by Ministry of Health and remaining by local government and other government entities. Similarly, voluntary prepayments from NGOs, rest of the world financing and enterprises pooled and managed 12.1%, 8.6% and 1.9% of CHE respectively in the year 2015/16. Almost 33.8% of CHE was made at pharmacies and providers of medical goods. Two-thirds of all health care provider expenditures occurred at the public health facilities of which 74.5% occurred at the primary and secondary care level health facilities in the year 2015/16. Health expenditure exclusively at primary facilities was as high as 12.2% of CHE. Among the hospitals, most of spending occurred at the private hospitals (8.5% of CHE) followed by public hospitals (6.6%). Government was the major source of funding for public health facilities. Foreign sources and household s OOP had considerable financial contribution at public health facilities. In the classification of the total inputs made to produce health services and goods in the year 2015/16, the highest expenditure was incurred on pharmaceuticals and medical goods (38.1% of CHE) while 31.2% vi

19 of CHE was spent on the health care services, followed by 13.8% of CHE on the wages and salaries paid to the health workers. By healthcare functions, more than one-third of CHE was made for the medicines and medical goods (34.5%), while curative care drew 32.0%, where 12.4% and 11.5% of CHE incurred for the outpatient and inpatient cares respectively. A large proportion (18%) of CHE was incurred on the preventive programs. Overall spending on the medical laboratory, imaging, and patient transportation service was around 6.2% of CHE in the year 2015/16. Under the CHE distribution of diseases categories, the majority (26.7% of CHE) of spending incurred for the non-communicable diseases followed by infectious and parasitic diseases (20.5%) and the reproductive health (6.4%) in the year 2015/16. Spending incurred for the nutritional deficiencies and injuries were 6.3% and 2.5% respectively. Summary of Health Accounts Result (Fiscal Year 2015/16) Direct Foreign Transfers, 8.6 % Rest of the World, 8.6 % Unspecified Health Care Providers, 4.4 % Rest of The World, 1.9 % Rest of Economy, 0.5 % Other Health Care Service, 3.7 % Governance, Health Sys. & Financing Adm., 4.9 % NPISH, 12.0 % Health Care System Adm. & Financing, 5.1 % Preventive Care, 13.6 % Preventive Care, 18.0 % Other/Unspecified Diseases/Conditions, 34.1 % Corporations, 1.9 % Household OOP, 55.4 % Non-Disease Specific, 3.5 % Injuries, 2.5 % Retailers and Other Providers of Medical Goods, 34.8 % Pharmaceuticals, Therapeutic Appliances & Medical Non/Durable Goods, 35.5 % Households, 55.4 % Noncommunicable Diseases, 27.2 % Enterprise, 1.9 % Vol. Health Insurance, 0.4 % Ancillary Services, 6.0 % Ancillary Services, 5.9 % NPISH, 12.1 % Ambulatory Health Care, 13.7 % Unspecified Curative Care, 4.8 % Nutritional Deficiencies, 6.3 % Voluntary Prepayment, 0.4 % Transfers Distributed by Govt. from Foreign Origin, 3.1 % State/Regional/Local Govt., 0.4 % Resi. Long-Term Care, 0.2 % Other/Unspecified Hospitals, 3.6 % Outpatient Curative Care, 15.8 % Reproductive Health, 6.4 % Transfers from Govt. Domestic Revenue, 18.6 % Central Govt., 21.3 % Specialized Hospitals, 6.3 % Pvt. General Hospitals, 5.4 % Inpatient Curative Care, 11.5 % Infectious & Parasitic Diseases, 20.0 % Pub. General Hospitals, 4.4 % Sources Schemes Level of Care Activities Diseases/Health Conditions The estimated household OOP spending was NPR 78,427 million (per capita NPR 2706), which was 55.4% of CHE in the year 2015/16. People are paying out of pocket mainly for the medicines and medical goods (63.4%), curative services (26.1%), and diagnostics and patient transportation (10.6%). Likewise, majority (62.6%) of the household OOP spending incurred at the retailers and other providers of medicines and medical products. The out of pocket expenditure made at the private hospitals was as high as eighty percent of total expenditure made at all kinds of the hospitals. Almost two-thirds of the total OOP spending on diseases was made for the NCDs and around 19.8% on the infectious and parasitic diseases. vii

20 Key Messages The out of pocket expenditure for health care in Nepal continues to be high. OOP spending was 55.4% of CHE in the year 2015/16 and only 1% point lower than in 2009/10, though in the consecutive years after 2012/2013, OOP spending gradually has fallen but still higher. This shows that the country health system heavily relies upon the direct OOP payments from households to finance the health care. OOP expenditure for health care was mostly made for the pharmaceuticals and the private providers. Major OOP spending incurred at the private health facilities, though there was considerable OOP spending at the public health facilities. An analysis of financial hardship due to the high share of OOP spending revealed that nationally, there was incidence of catastrophic healthcare expenditure that further pushed people to impoverishment. Around 10.7% and 2.4% of households spent 10% and 25% of total household expenditure on health, which is regarded as a catastrophic expenditure at the 10% and 25% threshold. Additionally, because of high household OOP expenditure on health, 1.7% of people were pushed below the poverty line of $1.9 Int. $ PPP (Hui Wang et al 2018). Since Nepal is committed to the UHC, reducing OOP spending on healthcare is one of the major agenda of the nation. Necessary efforts should be made in the direction to reduce reliance on the direct OOP payment for health care. Over one-third of all the health care spending is made for the pharmaceuticals and the medical goods, establishing it as the predominant component in the Nepalese healthcare market. There is relatively lower spending on the total pharmaceuticals expenditure from prepayment funding such as insurance, government, external and NPISHs funds. Hence, the pharmaceuticals expenditure is largely dependent upon household OOP direct payment, which is as higher as two-thirds of total OOP. This implies that pharmaceuticals expenditure is one of the key drivers of escalating health expenditure and a major factor that influences the OOP spending to remain high. The OOP spending on the pharmaceuticals out of total OOP spending was highest among all the economic quintiles. Nationally, it was over three-quarters of total OOP spending on health, which denotes that households spending on pharmaceuticals and medical goods is one of the major drivers for the catastrophic health expenditure and further pushes people to impoverishment. There is urgent need of addressing high OOP spending on pharmaceuticals and medical goods. An emphasis on the pharmaceutical sector reform and insurance can contribute in reducing the high expenditure on the pharmaceuticals and medical goods (Hui Wang et al 2018). The healthcare spending on diseases, that could be classified, was highest for the non-communicable diseases (NCDs), though the spending on the parasitic and infectious diseases also remains high. The burden of disease also demonstrates that NCDs burden has risen in the last two decades. An analysis of household expenditure on diseases revealed that people are paying OOP more for the NCDs, whereas less than one-third is funded from the government and negligible from voluntary payments for the NCDs. Hence, households are getting more vulnerable towards the lower financial protection due to NCDs which could be addressed by the spending more through risk pooling prepayment rather than OOP direct payment. Also investing in preventive care for the NCDs can have greater impact on curtailing the incidence of the disease. In the last decade, financing the health system in Nepal followed almost similar pattern with some variations. The direct OOP payments while seeking the health care in the last decade have been stagnant. Though the overall health spending has increased and OOP spending has fallen. In recent years, the spending from the major prepayment, primarily the domestic government and external funds, and the other voluntary prepayments has not been increased in relative terms. Efforts have been made to cut down the higher direct payment, anticipated results have not been achieved in the current environment of resource constraints. In this context, alternative sources for financing through the prepayment should be identified and strengthened. viii

21 Classification code Ratio Value Per Capita Numerator Ratio Value Per Capita Numerator Ratio Value Per Capita Numerator Ratio Value Per Capita Numerator Major Indicators from NHA Estimates for Nepal, Fiscal Year 20012/13 to 2015/ / / / /16 SN Ratio Indicator 1 Total Health Expenditure (THE) as % of Gross Domestic Product (GDP) , , , ,216 2 Current Health Expenditure (CHE) as % Gross Domestic Product (GDP) , , , , General Government Health Expenditures as % of GDP HF.1+ HF HK , , , , General Government Health Expenditures as % of General Government Expenditure (GGE) HF.1+ HF HK , , , , General Government Health Expenditures as % of THE HF.1+ HF HK , , , ,391 4 Current Government Health Expenditures as % Current Health Expenditure HF.1+ HF , ,056 5 Government Health Expenditure (excluding insurance) as % of CHE HF , , Central Government Expenditure as % Current Health Expenditure HF , Local Government Schemes as % Current Health Expenditures HF Voluntary Healthcare Payment Schemes % Current Health Expenditure HF (OOP + Prepayment for SHI + Prepayment for Private Insurance) as % of THE FS.6.1+ FS.3.1+ FS , , , , Out-of-Pocket Spending as % GDP HF , , , , Out-of-Pocket Spending as % THE HF , , , , Out-of-Pocket Spending as % Current Health Expenditure HF , , , ,706 9 Non-Profit Institutions Serving Households Schemes as % Current Health Expenditure HF Enterprises Health Exp. as % Current Health Expenditure HF Domestic General Government Funds for Health as % Current Health Expenditure FS ix

22 Classification code Ratio Value Per Capita Numerator Ratio Value Per Capita Numerator Ratio Value Per Capita Numerator Ratio Value Per Capita Numerator 2012/ / / /16 SN Ratio Indicator 11.2 Domestic General Government Funds for Health as % of General Government Expenditure (GGE) FS External Funds for Health as % THE FS.2+FS External Funds for Health as % Current Health Expenditure FS.2+FS Total Pharmaceutical Expenditure as % Current Health Expenditure HC HC , , , , Non-allopathic medicines expenditure as % Current Health Expenditure HC HC Expenditure on Inpatient care as % Current Health Expenditure HC Expenditure on Outpatient care as % Current Health Expenditure HC Expenditure on Preventive care as % Current Health Expenditure HC Expenditure on Hospitals as % Current Health Expenditure HP Expenditure on Hospitals - Government as % Current Health Expenditure HP HP HP Expenditure on Hospitals - Private as % Current Health Expenditure HP HP HP Expenditure on Ambulatory Health care centers as % Current Health Expenditure HP Expenditure on Pharmacies as % Current Health Expenditure HP , , , , Expenditure on Infectious and parasitic diseases as % of Current Health Expenditure DIS Expenditure on NCDs as % of Current Health Expenditure DIS , ,328 x

23 1.1 Context and Background 1. Introduction National Health Accounts is designed to track the health expenditure in systematic, comprehensive, and consistent manner through estimating the expenditures incurred for consumption of health care services and goods in a country for a reference year (OECD et. al. 2011). Health Accounts captures all the health care expenditures regardless of how or by whom the services or goods are funded, purchased and provided. It gives a wide-range understanding of health care financing system and the multi-sectorial contribution to the health care. NHA also facilitates monitoring and review of the health financing system and financial protection over time. Development and practice of the NHA provide evidence to help policymakers, non-governmental stakeholders, and managers to make better decisions in their efforts to improve the health system. Government and others can use NHA in several ways, and it is equally helpful in analyzing equity and efficiency in the health system. The production of NHA in Nepal was initiated back in the year 2000, which was the first official effort by Ministry of Health and Population (MoHP). Since then four rounds of NHA exercises have been conducted to the date. The first Nepal National Health Accounts (NNHA) report was published in the year 2006, that covered the fiscal year from 2000/01 to 2002/03 (Prasai et. al. 2006). The second round of NNHA was produced in the year 2009 that included the fiscal year from 2003/04 to 2005/06 (HEFU, 2009). Likewise, the third round that covered the fiscal year from 2006/07 to 2008/09 was produced in the year 2012 (Shrestha BR. et al. 2012). The first three rounds of NNHA were produced on the framework which was compatible with the OECD System of Health Accounts standards. The overall structure of OECD compatible framework follows the three-dimensional classification of expenditure basically by source, function, and provider (OECD, 2000). The fourth round, which was published in the year 2016 and included the fiscal year from 2009/10 to 2011/12, was the first NNHA based on System of Health Accounts 2011 (SHA 2011) framework. The fifth round of NNHA, which covered the fiscal year from 2012/13 to 2015/16, is the continuation of NNHA production based on SHA 2011 framework. Necessary adjustments of some variables and addition of disease accounts had been done in this round. 1.2 Objectives of Fifth Round of Nepal National Health Accounts This round of NNHA was conducted between March 2017 and May The primary objective was to track the flow and level of spending by various entities such as government, households, external donors, national and international NGOs, private sectors, employers, insurance providers etc. in the country s health system and how the funding was used to deliver the health services and goods to the people. Further, it helps to provide a benchmark to assist the production of the consistent and comparable database for the NHA in Nepal and internationally standardized cross-country comparisons. The purpose was to understand country s health financing landscape and mechanism for evidence-based policy making. The aim is to create the demand and use NHA to answer the key policy questions and inform policy decision for health financing reforms. An important agenda of this exercise was institutionalization 1 and regularization of NHA production in Nepal. The key questions that this round of NNHA intended to answer includes: Who was funding the healthcare spending in Nepal and how much did they contribute? How were the healthcare funds managed and distributed? Who managed the health care funds in Nepal? Who used the funds to deliver the healthcare services and how was the fund distributed at different levels of the health system of Nepal s? What inputs were used to deliver the overall healthcare services? What kinds of healthcare services and goods were purchased with the healthcare funds? 1 NHA institutionalization can be done through i) creating demand for NHA and its regular use; ii). production, data management and quality assurance; iii) dissemination of data and findings; and iv) translation of data into policy recommendations with the clear objective to inform national policy makers (OECD et.al. 2011). 1

24 Which diseases and health conditions Nepal spent on? What was the share of household out-of-pocket spending and its component in the health care spending in Nepal? 1.3 Methodology This round of NNHA estimates was based on the six-dimension classification of System of Health Accounts (SHA) 2011 Framework to ensure consistency in methodology and data reporting. SHA 2011 tracks all the healthcare spending in a given country over a defined period regardless of the entity or institution that financed and managed that spending (OECD et. al. 2011). It is a globally standardized process for systematic description and reporting of financial flows related to the health care in a defined territory and is comparable across countries, regions and between different periods. Accounting Framework of SHA 2011 uses a tri-axial recording of each transaction related to the value of health care goods and services provided and financed (Figure 1). It provides a systematic description of the financial flows according to three axes of the International Classifications for Health Accounts (ICHA) i.e. consumption, provision, and financing. Besides the classifications of health expenditure by financing agents, providers and functions, SHA 2011 includes additional classifications such as by financing and types of revenues of health financing and beneficiaries as illustrated in Figure 1. Figure 1: Tri-axial Accounting Framework of SHA 2011 (Source: OECD et.al. 2011) This approach ensures that the value of all health care goods and services consumed equals the value of health care goods and services provided and financed (OECD et.al. 2011). Unlikely to SHA 1.0 (OECD, 2000), SHA 2011 recommends keeping current healthcare expenditure (CHE) and capital formation (HK) separate and discourages the use of the aggregate total health expenditure as the basis of further classification of healthcare expenditure. SHA 2011 framework refers only to current health expenditure, and the capital formation is outside this framework. Thus, the distribution of health care expenditure of both the core and extended accounting framework was done based on the CHE and HK was separated beforehand the analysis Health Care Financing Schemes (HF): Health care financing refer to the components of a country s health financing system that channel revenues received, and use those funds to pay for, or purchase, the activities inside the health accounts boundary. Such as government programs, voluntary insurance, social health insurance, NPISHs etc. The extended framework includes; revenues of financing (FS), the institutional units for the revenues of financing (FS.RI) and financing agents (FA). The revenues of financing account the funds for the health financing received or collected through specific contribution mechanisms 2 Description of the disaggregated level of classifications under the core and extended accounting framework of NHA in context of Nepal are provided in the Annex B: NHA Classifications section of this report. 2

25 such as; direct foreign financial transfers; voluntary prepayment from employers; transfers from the ministry of finance to other governmental agencies etc. The financing agents denote institutional units that manage health financing such as MoHP, commercial insurance companies, national and international organizations etc Health Care Providers (HP) Health care providers are the entities for or in anticipation of producing activities inside the health accounts boundary such as; hospitals, clinics, health centers, pharmacies. The extended framework includes factors of provision (FP) i.e. the types of inputs used in producing the goods and services or activities conducted within the health accounts boundary such as; salaries and wages, utilities, rent, materials, and services used Health Care Functions (HC) Health care functions denote the types of goods and services provided and activities performed inside the health accounts boundary. Such as curative care, information, education, and counseling programs, medical goods such as pharmaceuticals and other supplies, governance and financing health system administration. The extended framework includes health care expenditures by beneficiary characteristics related to the diseases and health conditions, age, gender and socio-economic groups. The diseases and health conditions refer to the characteristics of those who receive the health care goods and services or benefited from the activities, are disaggregated based on disease classification. The age, gender, the socioeconomic groups refer to the benefit from the activities disaggregated based on age, gender, and socioeconomic group Capital Formation (HK) Capital formation accounts the types of investments made in the health sector during the accounting period and, are used for more than a year in the production of health services; such as infrastructure, machinery, and equipment, formal training, research and development related items. 1.4 Data Collection, use of HAPT and HAAT for Analysis and Validation The health expenditure data was collected from various primary and secondary sources and were reviewed for completeness and comprehensiveness. Where necessary, weights were applied for the estimation of national level health care expenditures 3. Health Accounts Production Tool (HAPT 4 ) and Health Accounts Analysis Tool (HAAT) were used for data mapping, validation, and analysis. The issues of double counting and data gaps in various sections were addressed. Mapping of each health care expenditure item was done by using HAPT based on the SHA 2011 classification. Allocation ratios for the disaggregated values required for the SHA 2011 classification were derived in advance through available health service utilization and costing information, and applied to split the aggregated expenditures. NHA matrices were derived to describe the flow of funds from sources to (FS X HF), to providers (HF X HP), to functions (HF X HC) and providers to functions (HP X HC). Likewise, the flow of funds from financing sources to financing agents (FS X FA), financing agents to providers (FA X HP), financing agents to health functions (FA X HC), and financing agents to the diseases (FA X DIS) were also created. Health Accounts Analysis Tool (HAAT) was used for deriving the cross tables 5 and the four years time series data. 3 Details of data sources, collection and estimation are given in Chapter 4 of this report. 4 HAPT is the standard tool for health accounts production with a well-defined methodology for entire estimation process. It is efficient in managing large data and simultaneously ensuring the data quality by checking for double counting and errors in classification codes, provides consistent estimates and keeping track of multiple expenditure data files. 5 The cross tables are provided in the Annex A. 3

26 in Billion NPR Percentage 2. General Health Accounts Results This chapter presents the general health accounts results. The current health expenditure and the capital formation are presented separately. 2.1 Current Health Expenditure (CHE) Current health expenditure includes all forms of expenditures made for purchasing or producing the health services and goods consumed by the residents within a year. It includes the expenditures made by various entities such as government, enterprises, households, NPISHs and rest of the world entities in purchasing or producing health care services. For example, the expenditure made by households to receive the health care services, medical goods and purchasing health insurance. Current health expenditure also includes the cost of health care services and goods provided to households free of charge by the government, employers and NPISH entities. Figure 2 shows the current health expenditures for providing the health care services to the Nepalese residents in current prices and their shares in GDP. The estimated CHE in this NNHA period were NPR billion (5.3% of GDP), NPR billion (5.8% of GDP), NPR billion (6.2% of GDP), and NPR billion (6.3% of GDP), in the years 2012/13, 2013/14, 2014/15 and 2015/16 respectively. CHE was the major proportion of overall health expenditures. (Figure 2) Figure 2: CHE and HK in Current Price and CHE and HK as a Percentage of GDP (2009/10 to 2015/16) / / / / / / /16 - Fiscal Year HK (in Bilion NPR) CHE (in Bilion NPR) CHE as % of GDP HK as % of GDP (GDP Source: Economic Survey 2015/16, MoF) 2.2 Capital Formation (HK): The capital formation includes every kind of capital investments made in the health sector to produce health services, such as infrastructure, medical equipment, machinery, intellectual properties etc. where the value of investment extended beyond a calendar year. The amount invested for capital formation in Nepal s health sector were estimated at NPR 7.80 billion (0.5% of GDP), NPR 6.13 billion (0.3% of GDP), NPR 6.53 billion (0.3% of GDP), NPR 9.70 billion (0.4% of GDP), in the years 2012/13, 2013/14, 2014/15 and 2015/16 respectively. Slightly more than half of the total capital investment was made in the residential and non-residential buildings such as health facilities, stores etc. followed by unspecified fixed capital formation. Besides, 8.6% of the total capital expenditure was made on the other structures than the buildings acquired. Similarly, 7.9% was invested in the machinery and medical equipment in the year 2015/16 (Figure 3). The capital expenditure reflected in this section is mainly from the government sources. The higher value in the FY 2015/16 was due to post earthquake reconstruction works. Details of each level of the disaggregated expenditures under capital formation category from the year 2012/13 to 2015/16 are provided in Table 15 of the General Health Accounts Tables section of this report. 4

27 (in Billion NPR) Figure 3: Breakdown of Capital Expenditure 2015/16 Land, 0.1% Changes in Inventories, 0.8% Intellectual property Products, 0.9% Unspecified Gross Fixed Capital Formation, 29.0% Residential and Non-residential Buildings, 52.7% Machinery and Equipment, 7.9% Other Structures, 8.6% 2.3 Total Health Expenditure (THE) Total health expenditure is aggregate of the current health expenditure and capital formation. Though SHA 2011 does not suggest aggregating and obtaining THE, it is presented primarily to compare with former total health expenditure as adopted by SHA 1.0. The total estimated amount spent in terms of current price, for the health care purpose were NPR billion (USD 1.12 billion), NPR billion (USD 1.22 billion), NPR billion (USD 1.40 billion) and NPR billion (USD 1.43 billion) in the years 20012/13, 2013/14, 2014/15 and 2015/16 respectively. In the last ten years period, THE has increased sharply (almost 5 times) in terms of current market prices but has almost just doubled in constant prices (from NPR 28.7 billion to NPR 54 billion) when expressed in terms of the base year 2000/01 prices (Figure 4). GDP deflator (health) was taken from National Accounts (CBS, 2017). (USD Exchange Rate Source: Nepal Rastra Bank, See details: Table 1.a in General Health Accounts Results Table Section) Figure 4: Trend of Total Health Expenditure in Current and Constant Prices In Billion (NPR) Current Price In Billion (NPR) Constant Price Fiscal Year Total Health Expenditure as a Percentage of Gross Domestic Product (GDP) Total health expenditure as a percentage of the gross domestic product shows the level of health system expenditure within a country relative to the economic development status of that country (McIntyre D., Kutzin J., 2016). In this NNHA period, the share of total health expenditure in the gross domestic products of Nepal has increased steadily from 5.5% in the year 2011/12 to 6.7% in the year 2015/16 (Figure 5). Prior to the FY 2011/12, THE to GDP ratio remained between 5.0% and 5.4%, except for 2003/04, when it had touched 5.7%. One of the reasons for the jump in THE/GDP ratio in 2014/15 and 2015/16 can be due to higher health care expenditures during post April 2015 earthquake and lower GDP values. 5

28 s in NPR Percentage Figure 5: Trend of THE as a Percentage of GDP Fiscal Year (GDP Source: National Accounts of Nepal, 2017/18, CBS) Per Capita Total Health Expenditure Per capita total health expenditure in current price has been increasing substantially in the last ten years. In this NNHA period, it has increased from NPR 3504 (USD 40) in 2012/13 to NPR 5216 (USD 49) in 2015/16 (Figure 6). (USD Exchange Rate Source: Nepal Rastra Bank, See details: Table 1.a in General Health Accounts Results Table Section) Figure 6: Trend of Per Capita THE in Current and Constant Prices (NPR) 6,000 5,000 Per Capita THE (NPR) Current Price Per Capita THE (NPR) Constant Price 4,217 4,851 5,216 4,000 3,504 3,000 2,000 1, ,011 1, ,244 1,910 1,617 1,236 1,301 1,344 1,363 1,164 1,133 1,109 1,096 1,102 1,138 1,252 2,617 2,921 1,380 1,371 1,573 1,593 1,718 1,863 Fiscal Year 2.4 General Government Health Expenditure (GGHE) General government health expenditure is overall expenditure in the health sector by the central and local governments including Ministry of Health and Population (MoHP), other ministries and government entities. It is the contribution of government to the current health expenditure and capital formation in heath sector. The revenues for the government are principally the domestic sources and funding from the foreign entities. The general government health expenditure represents the expenditures by the government on health from all its financing sources and it is presented as a proxy to represent former government s health expenditure as adopted by SHA 1.0. The MoHP is responsible for most of the government s health expenditures in the country. In this NNHA period, estimated GGHE were NPR billion, NPR billion, NPR billion and NPR billion in the years 20012/13, 2013/14, 2014/15 and 2015/16 respectively. One-third of total government health expenditure was spent on the curative services followed by preventive and promotive services (24.7%) and capital formation (24.1%) in the year 2015/16, whereas the expenditure on medical goods was least (1.0%) in the year 2015/16. Governance and health system administration and financing drew about 7.0% of the GGHE in the year 2015/16 (Figure 7). 6

29 Percentage in Billion (NPR) Figure 7: Breakdown of GGHE % 10.5% 3.1% 26.5% 3.8% 28.5% % 12.8% 4.1% 26.3% 2.6% 34.8% 24.1% 18.5% 9.5% 11.2% 7.0% 4.9% 27.6% 24.7% 0.8% 1.0% 36.1% 33.8% 2012/ / / /16 Fiscal Year Curative Care Medical Goods Preventive Care Gov., & Health System and Financing Other Health Care Services Capital Formation GGHE General Government Health Expenditure as a Percentage of General Government Expenditure (GGE) The government spends on health and other sectors in the country from its resources. The major sources for the government s expenditure are domestic revenues. Transfers from the foreign governments and entities also contribute in the government revenue. The share of general government health expenditure out of the general government expenditure indicates the government priority on funding for the health relative to other public expenditures (McIntyre D., Kutzin J., 2016). In this NNHA period, the proportion of government health expenditure in general government expenditure has slightly declined (8.2% in 2015/16), where the expenditures were made from both the domestic and external sources. This is still well under the Abuja declaration target of at least 15% of general government expenditure allocated to health to improve health sector. Likewise, the general government health expenditure as a percentage of general government expenditure made only from the domestic government sources (GGHE-D) in this NNHA period has almost been constant (5.3% in 2015/16). Donors funding through government channel has decreased in recent years. (Figure 8) Figure 8: Trend of General Government Health Expenditure as a Percentage of General Government Expenditure GGHE as % of GGE GGHE-D as % of GGE / / / / / / /16 Fiscal Year (GGE Source: Economic Survey 2015/16, MoF) 7

30 Percentage Percentage Domestic General Government Health Expenditure as a Percentage of General Government Expenditure in South-East Asian Countries In the context of general government health expenditure from domestic sources, Nepal falls below the mean average among the South-East Asian countries, but is close to the median expenditure ratio (Figure 9). Figure 9: GGHE as a Percentage of General Government Expenditure in South-East Asian Countries GGHE-D as % of GGE Countries (Source: GHED WHO, 2018) Domestic General Government Health Expenditure as a Percentage of Gross Domestic Products and General Government Expenditure The general government expenditure as a share of gross domestic products (GDP) shows the current financial capacity of the government, and is a contextual factor over which the health sector has limited influence. The general government expenditure on health as a share of general government expenditure is an indicator of the government s priority given to funding the health care relative to other public expenditures (McIntyre D., Kutzin J., 2016). In this NNHA period, the general government expenditure as a percentage of GDP was in the increasing trend while in the same period; only a small change was observed in domestic general government health expenditure as a percentage of general government expenditure (Figure 10). Figure 10: Trend of GGE as a Percentage of GDP and GGHE-D as a Percentage of GHE GGE as % of GDP GGHE-D as % of GGE Fiscal year (GDP and GGE Source: Economic Survey 2015/16, MoF) General Government Health Expenditure as a Percentage of Current Health Expenditure (CHE) The government spending on health mainly includes the expenditure from the government domestic sources, which is central (major) and local governments tax funds, and the external funds from foreign sources in the form of grants and loans. These funds for spending on health comprise mandatory 8

31 PPP (Int$) prepayment for the health system that flows through the government accounts in the category of general government expenditure on health. Such prepayment funds that play a significant role in reducing private OOP expenditure on health, has slightly fallen in this NNHA period (from 22.7% in 2012/13 to 21.6% in 2015/16). The external funding for health expenditure (EXT-G) through government accounts has sharply declined (from 6.3% in 2012/13 to 3.1% in 2015/16). While in the same period the government health expenditure from domestic sources (GGHE-D) has increased from 16.3% in 2012/13 to 18.6% in 2015/16. (Figure 11) Figure 11: General Government Health Expenditure as a Percentage of Current Health Expenditure Per Capita Domestic Government Health Expenditure (GGHE-D) and Domestic Private Health Expenditure (PVT-D) in Purchasing Power Parity (International $) Per capita government health expenditure in purchasing power parity (Int $) is a strong predictor of the extent to which the health system dependent on the private health expenditure from domestic sources (PVT-D). Since it is assessed as a level rather than a percentage thus, it provides insight into the level of government spending on health. This absolute measure reflects more the level of spending relative to the price/cost of internationally driven inputs (McIntyre D., Kutzin J., 2016). In the last ten-year period, the contribution of government and private per capita health expenditure (in Purchasing Power Parity) out of total per capita health expenditure from the domestic sources has almost been constant with an average proportion of 20:80 (Figure 12). The lower proportion of government per capita health expenditure (in Purchasing Power Parity) indicates that the major part of expenditure on health was being drawn from the domestic private sources. The private out-of-pocket spending is discussed further in the respective sections of this report. Figure 12: Per Capita Government and Private Health Expenditure from Domestic Sources in Purchasing Power Parity ($International) Fiscal Year GGHE-D Per Capita in PPP Int$ PVT-D Per Capita in PPP Int$ (Source: data from GHED WHO, 2018) 9

32 2.5 Revenues of Health Care Financing Schemes (FS): Who was funding health care spending in Nepal and how much did they contribute? Revenues of health care financing (financing sources) describe the revenue sources for each financing scheme. Households OOP payment while seeking health care services and goods was the major source of funding the health system, where more than half (55.4%) of all funds were coming from households in the year 2015/16. Detail analysis of households OOP spending is provided in the household OOP section of this report. The government through central and local government revenues funded 18.6% of CHE, followed by NPISH (12.0%). Direct fund transfer from foreign sources was 8.6% while multilateral and bilateral organizations contributed around 5.0% of total CHE. Corporations further contributed about 2.3% in the health care spending which was mainly through the cash benefits for medical services and insurance premiums paid on behalf of their employees, as well as the health programs conducted by such entities. (Figure 13) Figure 13: CHE Distribution by Revenues of Health Care Financing Schemes 2015/16 Direct Multilateral Financial Transfers, 1.4% Direct Bilateral Financial Transfers, 3.6% Other Direct Foreign Financial Transfers, 3.6% Direct Foreign Aid in Kind, 0.05% Transfers from Government Domestic Revenue (allocated to health purposes), 18.6% Other Revenues from NPISH n.e.c., 12.0% Other Revenues from Corporations n.e.c., 1.9 % Other Revenues from Households n.e.c., 55.4 Transfers Distributed by Government from Foreign Origin, 3.1% Voluntary Prepayment from Employers, 0.4% Under this classification category, transfers from the governments of foreign origins declined from 6.4% of CHE in 2012/13 to 3.1% of CHE in 2015/16, while in the same period, direct foreign transfers increased from 5.5% of CHE to 8.6% of CHE. Transfers from the government domestic revenues also increased slightly. The voluntary prepayments and the other domestic revenues was almost flat in this NNHA period (Figure 14). The details of each level of disaggregated expenditures under this classification category from the year 2012/13 to 2015/16 are provided in Table 2 of the General Health Accounts Tables section of this report. Figure 14: Trend of CHE Distribution by Revenues of Health Care Financing Source from 2012/13 to 2015/ % 68.6% 68.6% 69.3% 17.2% 18.6% 16.3% 16.6% 6.4% 5.1% 5.4% 3.1% 0.6% 0.5% 0.4% 0.4% 9.2% 8.3% 5.5% 8.6% Transfers from government domestic revenue (allocated to health purposes) Transfers distributed by government from foreign origin Voluntary prepayment Other domestic revenues n.e.c. 2012/ / / /16 Direct foreign transfers 10

33 There are institutional units of the economy from which the revenues are directly generated for the healthcare financing (FS.RI). These institutional arrangements of the financing sources generate the resources. In the year 2015/16, the major institutions for generating the fund were households (55.4%) followed by government (18.6%), international NGOs (7.8%) and private donors (4.6%). Among the multilateral and bilateral organizations USAID (2.4%), GAVI (1.9%), DFID (1.5%), UNICEF (1.4%) and WHO (0.9%) were the major donors (Figure 15). Figure 15: CHE Distribution by Institutional Units Providing Funds to Financing Schemes 2015/16 GEFMAT General, 0.1% WHO, 0.9% WFP, 0.2% UNICEF, 1.4% UNFPA, 0.4% Global Fund, 0.1% GAVI, 1.9% Other and Unspecified bilateral donors, 0.9% United States (USAID), 2.4% United Kingdom, 1.5% Other and Unspecified multilaterial donors, 0.5% Japan, 0.1% Germany, 0.4% Australia, 0.1% NPISH, 0.5% Pool Fund, 0.2% Private donors, 4.6% Government, 18.6% Households, 55.4% International NGO, 7.8% Unspecified rest of the world, 0.1% Corporations, 2.3% A similar pattern of current health expenditures under this classification category was found from the corporations and the NPISH. But the revenue from the households declined in this NNHA period (from 63.5% of CHE in 2012/13 to 55.4% of CHE in 2015/16) and more revenue was generated from rest of the world entities (Figure 16). The details of each level of disaggregated expenditures under this classification category from the year 2012/13 to 2015/16 are provided in Table 3 of the General Health Accounts Tables section of this report. Figure 16: Trend of CHE Distribution by Institutional Units Providing Funds to Financing Schemes from 2012/13 to 2015/ % 59.4% 60.0% 55.4% 17.2% 18.6% 19.5% 20.5% 23.2% 16.3% 16.7% 16.8% 2.7% 2.6% 2.6% 2.3% 0.7% 0.6% 0.7% 0.5% Government Corporations Households NPISH Rest of the world 2012/ / / /16 11

34 2.6 Health Care Financing Schemes (HF): How were the healthcare funds managed and distributed? Health care financing are structural arrangements through which health care services and goods are paid for and obtained by the people. The expenditure through prepayment such as government, voluntary pre-payments from NGOs, rest of the world financing and enterprises were 21.7%, 12.1%, 8.6% and 1.9% of CHE respectively, whereas the household OOP direct payment was 55.4% of CHE in the year 2015/16 (Figure 17). The household direct OOP payment was predominantly the largest health care financing scheme as compared to all the pre-payment together which was much higher than estimated value of 15-20% as suggested by WHO (Xu et. al., 2010) for the financial protection while seeking health care. Since, over half of the healthcare expenditure was through direct payment for health with no risk pooling mechanism, there was lower risk pooling in the health system. The smaller the risk pool, the greater will be financial burden among households while seeking health care services. Figure 17: CHE Distribution by Health Care Financing Schemes 2015/16 Rest of the World Financing Schemes (nonresident), 8.6% Central Government Schemes, 21.3% State/Regional/Local Government Schemes, 0.4% Household Out-of-Pocket Payment, 55.4% NPISH Financing Schemes (including development agencies), 12.1% Enterprise Financing Schemes, 1.9% Under this classification category, CHE through the voluntary prepayment scheme was increasing while the households OOP expenditure was declining. The CHE through the rest of the world financing was increased from 5.5% in the year 2012/13 to 8.6% in the year 2015/16 (Figure 18). The details of each level of disaggregated expenditures under this classification category from the year 2012/13 to 2015/16 are provided in Table 4 of the General Health Accounts Tables section of this report. Figure 18: Trend of CHE Distribution by Health Care Financing Schemes from 2012/13 to 2015/ % 60.0% 59.4% 55.4% 22.7% 22.6% 21.7% 21.6% 14.3% 8.3% 9.1% 9.6% 5.5% 8.3% 9.2% 8.6% Government and compulsory contributory health care financing Voluntary health care payment Household out-of-pocket payment 2012/ / / /16 Rest of the world financing (non-resident) 12

35 2.7 Health Care Financing Agents (FA): Who managed the healthcare funds in Nepal? A health care financing agent is an institutional unit involved in the management of one or more financing scheme(s). Figure 19 illustrates the current health expenditure by financing agents. Households which are the agents of their own spending were the principal agent of health sector expenditure by managing 55.4% of CHE in the year 2015/16. Households were followed by the government entities, where MoHP alone managed 17.4% of CHE and rest of the government funds were managed by other ministries and public units (3.9% of CHE). NPISH pooled and managed 12.0% of CHE while the international organizations that represent donor agencies, pooled and administered their own funds directly without transferring to government and other entities was around 8.6% of CHE. Corporations and commercial insurance companies accounted for smaller spending (1.6% and 0.7% of CHE respectively). Figure 19: CHE Distribution by Health Care Financing Agents 2015/16 International Organisations 8.6% Ministry of Health 17.4% Other Ministries and Public Units (belonging to Central Government) 3.9% Commercial Insurance Companies 0.7% Households 55.4% NPISH 12.0% Corporations (Other than Insurance Corporations) 1.6% A similar pattern of current expenditures under the health care financing agents was observed in the years 2012/13 to 2015/16 as shown in Figure 20, except NPISH whose contribution in total CHE increased drastically in 2014/15 and 2015/16 due to higher role of NPISH during the earthquake reconstruction year. Households expenditure was in decreasing trend. In the year 2015/16 total households expenditures declined also in the absolute term. The details of each level of disaggregated expenditures under this classification category from the year 2012/13 to 2015/16 are provided in Table 5 of the General Health Accounts Tables section of this report. Figure 20: Trend of CHE Distribution by Health Care Financing Agents from 2012/13 to 2015/ % 59.4% 60.0% 55.4% 22.7% 21.7% 22.7% 21.8% 0.5% 0.7% 0.6% 0.5% 5.5% 6.9% 2.1% 2.1% 2.1% 1.6% 0.6% 12.0% 5.5% 14.1% 9.2% 8.6% General government Insurance corporations Corporations (Other than insurance corporations) Non-profit institutions serving households Households Rest of the world 2012/ / / /16 13

36 2.8 Health Care Providers (HP): Who used the funds to deliver the healthcare services and how was the fund distributed at different levels of the health system of Nepal? Health care providers are the organizations and actors involved in the provision of healthcare services and goods. Figure 21 demonstrates the breakdown of spending by the health care providers. It revealed that the majority (34.8% of CHE) of spending incurred at the pharmacies and providers of medical goods and appliances. Public health facilities spending was predominantly higher (12.2% of CHE) at the primary care level which comprised of health posts (HP) and primary health care centers (PHCCs). Among the hospitals, the CHE at public hospitals was 6.6%. The providers of preventive care, which are usually the public facilities of all levels, drew 13.6% of CHE. Major spending on preventive care occurs at the public facilities mainly through national programs. The private hospital s spending was 8.5% of CHE. Likewise, spending by private clinics (medical and dental) was around 1.4% of CHE, where the associated ancillary care expenditures were separated and classified into providers of ancillary care that drew around 6.0% of CHE. Around 2.0% spent for the foreign health care providers. Providers of health care system administration and financing drew around 5.1% of CHE in the year 2015/16. Figure 21: CHE Distribution by Health Care Providers 2015/16 Unspecified Health Care Providers, 4.4% National/Central/Specialized Hospitals, 4.5% Regional/Zonal/District and Public General Hospitals, 2.1% Private General/Specialised Hospitals, 8.5% Rest of the World, 1.9% Other General Hospitals, 3.0% Rest of Economy, 0.5% Other Specialised Hospitals, 0.9% Providers of Health Care System Admin. & Financing, 5.1% Providers of Preventive Care, 13.6 Unspecified Hospitals, 0.6% Residential Long-term Care Facilities, 0.2% Pharmacies and Providers of Durable Medical Goods/Appliances, 34.8 Providers of Ancillary Services, 6.0% Medical Practices, 0.8% Dental Practice, 0.6% Ambulatory Health Centres (HP/PHC) 12.2% A trend of current expenditures under health care providers in the years 2012/13 to 2015/16 is shown in the Figure 22. While expenditures on the providers of medicines and medical goods, and ambulatory health care were declining, those on hospitals and preventive care were in the increasing trend. The details of each level of disaggregated expenditures under this classification category from the year 2012/13 to 2015/16 are provided in Table 6 of the General Health Accounts Tables section of this report. Figure 22: Trend of CHE Distribution by Health Care Providers from 2012/13 to 2015/ % 40.1% 37.8% 34.8% 19.7% 19.4% 17.4% 12.8% 0.5% 0.1% 0.2% 0.2% 13.1% 12.7% 8.2% 8.1% 5.5% 6.0% 1.0% 0.7% 19.5% 15.9% 16.0% 14.9% 6.7% 6.3% 4.1% 5.1% 1.2% 0.1% 0.2% 1.1% 1.9% 0.1% 0.1% 1.1% Hospitals Residential long-term care facilities Providers of ambulatory health care Providers of ancillary services Retailers and Other providers of medical goods Providers of preventive care Providers of health care system administration and financing Rest of economy Rest of the world 2012/ / / /16 14

37 2.9 Factors of Health Care Provision (FP): What inputs were used to deliver the overall healthcare services? Factors of health care provision are the valued inputs used in the process of production and delivery of health care services. In the year 2015/16, the highest expenditure under factors of health care provision was incurred on the pharmaceuticals and medical goods (38.1% of CHE) followed by the health care services (31.2% of CHE), whereas on non-health care services was 4.7% of CHE. Wages and salaries paid for the health care services drew around 13.8% of CHE. The other items of spending on inputs was 2.8% of CHE while the expenditure on health care goods and materials used, and the health care services that could not be classified elsewhere were 1.0% and 1.6% of CHE respectively in 2015/16 (Figure 23). Figure 23: CHE Distribution by Factors of Health Care Provision 2015/16 Materials and Services Used, 1.6% Other Items of Spending on Inputs, 2.8% Unspecified Factors of Health Care Provision, 0.6% Non-health Care Services, 4.7% Other Health Care Goods, 1.0% Wages and Salaries, 13.8% Social Contributions, 0.9% All Other Costs Related to Employees, 0.7% Pharmaceuticals, 38.1% Health Care Services, 31.2 % Self-employed Professional Remuneration, 0.5% Laboratory & Imaging Services, 4.1% A similar pattern of current expenditures under the factors of healthcare provision was observed in the years 2012/13 to 2015/16, shown in Figure 24. The details of each level of disaggregated expenditures under this classification category from the year 2012/13 to 2015/16 are provided in Table 7 of the General Health Accounts Tables section of this report. Figure 24: Trend of CHE Distribution by Factors of Health Care Provision from 2012/13 to 2015/ % 82.2% 81.0% 80.7% 15.1% 15.3% 14.2% 16.1% 0.8% 0.7% 0.5% 0.5% 1.0% 1.2% 1.8% 2.8% Compensation of employees Self-employed professional remuneration Materials and services used Other items of spending on inputs 2012/ / / /16 15

38 2.10 Health Care Functions (HC): What kinds of healthcare services and goods were purchased with the healthcare funds? The health care functions refer to the health purpose of activities and determine health care goods and services consumed by the final users. Figure 25 shows the CHE distribution by health care functions in the year 2015/16. An analysis of expenditure on the health care fucntions at the various level of health care services shows that large proportion (35.0%) of current expenditure was made for the medicines and medical goods. Around one-third of the CHE incurred for the curative care, where the majority (12.4%) spending went to the outpatient care followed by inpatient care (11.5%). Around 4.8% of CHE could not be specified based on the outpatient and inpatient care. The overall current spending on the ancillary care was around 6.2% which includes the spending on laboratory services (3.5%), imaging services (0.8%), and patient transportation (1.8%). The rehabilitative care drew minimal (0.2%) current spending. Governance, and health system and financing administration drew around 4.9% of CHE. A large proportion (18.0%) of CHE incurred for the preventive care including the associated administrative expenditures. Preventive care services basically include expenditures incurred on the national programs (excluding curative care) on disease control, epidemiological surveillance, safe motherhood, child health, health promotion and information, education, and communication etc. Figure 25: CHE Distribution by Health Care Functions 2015/16 Other health care services not elsewhere classified, 3.4% General inpatient curative care, 7.7% Specialised inpatient curative care, 3.8% Governance, and health system and financing administration, 4.9% Dental outpatient curative care, 0.6% Therapeutic appliances and Other medical goods, 0.4% Preventive care, 18.0% General outpatient curative care, 12.4% Specialised outpatient curative care, 2.1% Unspecified outpatient curative care, 0.7% Other medical nondurable goods, 0.7% Over-the-counter medicines, 17.8% Unspecified curative care, 4.8% Rehabilitative care, 0.2% Prescribed medicines, 16.6% Laboratory services, 3.4% Patient transportation, 1.8% Imaging services, 0.8% The pattern of current expenditures under the health care functions during the years 2012/13 to 2015/16 is shown in the Figure 26. While the spending on curative care and preventive care increased, the expenditure on the medical goods (not specified by function) declined in this NNHA period. The details of each level of disaggregated expenditures under this classification category from the year 2012/13 to 2015/16 are provided in Table 8 of the General Health Accounts Tables section of this report. Figure 26: Trend of CHE Distribution by Health Care Functions from 2012/13 to 2015/ % 29.0% 28.6% 27.1% 23.7% 41.4% 38.6% 35.5% 18.0% 16.3% 16.5% 15.7% 0.5% 0.2% 0.2% 0.2% 5.4% 5.9% 5.5% 5.9% 6.6% 5.7% 4.5% 4.9% 4.2% 3.0% 4.1% 4.4% Curative care Rehabilitative care Ancillary services (non-specified by function) Medical goods (non-specified by function) Preventive care 2012/ / / /16 Governance, and health system and financing administration Other health care services not elsewhere classified 16

39 2.11 Diseases/Health Conditions (DIS): Which diseases and health conditions Nepal spent on? Figure 27 illustrates the CHE distribution by diseases/health conditions. In the year 2015/16, around 62.3% of the CHE under the diseases/health conditions category could be classified. It revealed that the majority (26.7% of CHE) incurred for the non-communicable diseases (NCDs), whereas infectious and parasitic diseases drew around 20.5% of CHE followed by reproductive health (6.4% of CHE). Spending incurred for nutritional deficiencies and injuries were 6.3% and 2.5% of CHE respectively. The non-disease specific spending which basically represents administrative support for the health sector and other expenditure was 3.5% of CHE. Such expenditures could not be allocated for a disease or health condition due to lack of disaggregated utilization and costing information. Due to lack of disaggregated disease costing and utilization data, around one-third of CHE could not be classified to the spending related to a disease or health condition which is represented by diseases/health conditions not elsewhere classified. Diseases/health conditions n.e.c. also represents other and unspecified diseases. Figure 27: CHE Distribution by Diseases/Health Conditions 2015/16 Infectious and Parasitic Diseases, 20.5% Other & Unspecified Diseases/Conditions, 34.1% Diseases/Health Conditions Specified, 62.3% Reproductive Health, 6.4% Noncommunicable Diseases, 26.7% Non-Disease Specific, 3.5% Nutritional Deficiencies, 6.3% Injuries, 2.5% Figure 28 illustrates further disaggregation of each category of diseases/health conditions expenditure that could be classified. In the year 2015/16, around NPR billion was spent on the NCDs where the major (12.4%) spending was made for the diseases of the digestive system. Likewise, a large proportion, of funds was drawn by the mental and behavioral disorders and neurological conditions (10.4%) and cardiovascular diseases (7.6%). The expenditures on sense organ diseases, oral diseases and neoplasm were 5.1%, 1.8% and 2.7% of CHE respectively in the year 2015/16. Around 1.2% of CHE was made on the respiratory diseases and 0.9% on the endocrine and metabolic disorders. A further level of disaggregation could not be done for the major proportion (56.3%) of expenditure made on NCDs. Next to the expenditure on NCDs, are the infectious and parasitic diseases on which NPR billion was spent, followed by reproductive health that basically includes maternal and perinatal conditions and family planning (NPR 9.09 billion), and nutritional deficiencies (NPR 8.84 billion). In the infectious diseases category, the majority (26.7%) spending incurred for the respiratory infections followed by diarrheal diseases (11.1%), and HIV/AIDS and other STDs (9.1%). The expenditure made on Vaccine Preventable Diseases (VPDs) was 7.9% of CHE followed by Neglected Tropical Diseases (2.5%), Tuberculosis (1.3%), while minimal (0.4%) fund was spent on the Malaria. Like the NCDs, a further level of disaggregation could not be done for the major proportion (41.0%) of expenditure made on infectious and parasitic diseases. The expenditure made on the injuries was NPR 3.48 billion. (Figure 28) 17

40 in Billion NPR Figure 28: CHE Distribution by Diseases/Health Conditions 2015/ Other Noncommunicable Diseases; 56.3% Other Infectious & Parasitic Diseases; 41.0% VPDs; 7.9% NTDs; 2.5% Diarrheal Diseases; 11.1% 9.09 Oral Diseases; 1.8% Sense Organ Disorders; 5.1% Diseases of the Genito-Urinary System; 1.5% Diseases of the Digestive; 12.4% 8.84 Respiratory Infections; 26.7% Malaria; 0.4% Tuberculosis (TB); 1.3% HIV/AIDS & STDs; 9.1% Other RH Conditions; 48.3% Contraceptive Mgnt; 19.3% Perinatal Conditions; 5.2% Maternal Conditions; 27.2% Respiratory Diseases; 1.2% Mental & Behavioral Disorders, and Neurological Conditions; 10.4% Cardiovascular Diseases; 7.6% Endocrine and Metabolic Disorders; 0.9% Neoplasms; 2.7% 3.48 Infectious and parasitic diseases Reproductive health Noncommunicable diseases Nutritional deficiencies Injuries Diseases/health conditions The burden of disease data from the Global Health Data Exchange of the Institute for Health Matrices and Evaluation (IHME, 2018), measured based on disability-adjusted life years per 100,000 suggests that the burden of NCDs in Nepal has grown up in the last fifteen years. Whereas, the burden of infectious and parasitic diseases has either declined or been constant in the same period (Figure 29). The diseases/health conditions wise expenditure distribution also demonstrates that more fund was flowing towards the NCDs, though the considerable amount was being spent on the communicable diseases. Figure 29: Diseases Burden Ranking, Both Sexes, 2001 and 2016 (Source: IHME, 2018) 18

41 Percentage Distribution of Diseases/Health Conditions Expenditures by Level of Care Figure 30 illustrates the expenditures made on the categories of diseases and health conditions at various levels of both the public and non-public health facilities. More than half of all the expenditures made on the infectious and parasitic diseases were at the primary level health facilities which is formed by PHCC and HPs, while one-fourth were at national and central hospitals. Minimal expenditure was made at the specialized hospitals. More than two-thirds of the expenditure made on the nutritional deficiencies were at the primary care level and around one-third were at the secondary, national and central level hospitals, while very few (0.6%) at specialized hospitals. As much as 42.7% of the expenditures made on the NCDs were at the public primary health care centers and the private clinics. Almost equal proportions of the expenditures on NCDs cases were made at the secondary level hospitals (24.3%) and national/central hospitals (23.5%), remaining 9.6% were at the specialized hospitals. An expenditure made on the injuries cases was maximum (56.3%) in the national and central hospitals followed by secondary level hospitals (30.6%), while minimal expenditures were made at the primary and specialized level of care. The majority (43.5%) of the expenditure made on reproductive health (maternal, perinatal, family planning etc.) were at the secondary level which is formed by regional/zonal/district public hospitals and private general hospitals, while 34.7% were at national and central hospitals. Around 9.1% of expenditures on reproductive health were made at the specialized hospitals, mainly the maternal hospitals. Figure 30: Distribution of Diseases/Health Conditions Expenditures by Level of Care 2015/ Infectious & Parasitic Diseases Reproductive Health Nutritional Deficiencies Noncommunicable Diseases Injuries Unspecified Diseases/Conditions Primary Secondary National/Central Specialised Distribution of Diseases/Health Conditions Expenditures by Sex and Age An analysis of the diseases/health conditions expenditure based on the sex of the patients revealed that the expenditures made on the infectious and parasitic diseases was almost in equal proportion among males and females, while in the case of NCDs, more (57.1%) expenditure was made on females than males. In the injury cases, more (56.9%) of expenditure was made on the males. 97.1% of all the expenditure made on the reproductive health was predominantly for the females, which was mostly for the maternal and perinatal conditions and family planning. The expenditure made on nutritional deficiencies was also higher (61.4%) among females. (Figure 31.a) Figure 31.b shows the diseases/health conditions expenditures based on two categories of the age groups; under-five years, and five and more than five years. The expenditures on the infectious and parasitic diseases, NCDs and injuries were made largely (82.5%, 89.9%, and 89.9% respectively) to the age group of five and more than five years. The major expenditure on the reproductive health incurred among the age group of more than five years. Minimal (10.1%) expenditure incurred for the reproductive health among the under-five age group which basically related to the child delivery and neonatal care. In the case of nutritional deficiencies, the major portion (70.1%) of funds spent for the under-five age group. The 19

42 details of each level of disaggregated expenditures under this classification category in the years 2014/15 and 2015/16 are provided in the Tables 9, 10, 11 and 12 of the General Health Accounts Tables section of this report. Figure 31.a Diseases/health conditions Wise Distribution by Sex 2015/16 Figure 31.b Diseases/health conditions Expenditures Distribution by Age 2015/16 Infectious & Parasitic Dis Infectious & Parasitic Dis Non-communicable Dis Non-communicable Dis Reproductive Health Reproductive Health Nutritional Deficiencies Nutritional Deficiencies Injuries Injuries Unspecified Dis Unspecified Dis % 50% 100% Female Male 0% 50% 100% < 5 years old 5 years old Share of Financing Schemes on the Diseases/Health Conditions Expenditures Figure 32 demonstrates the diseases/health conditions expenditure by financing. In the infectious and parasitic diseases, major (54.8%) spending was made through the households OOP payments, while around 30.5% spent through the government. Minimal (7.2%) expenditure was made in the form of voluntary healthcare payments, which was mostly from the NPISH and enterprises, and the rest of the world entities. In the context of spending on the NCDs, the household OOP expenditure was dominating over other with 62.8% of total expenditure on NCDs, followed by government share of 28.0%. While small proportion was spent through the voluntary payment and negligible (0.2%) was from the rest of the world entities. The majority (two-thirds) of expenditure on injuries was made from households followed by the voluntary payment (19.4%) and government (8.4%). Voluntary payment share on the expenditure of reproductive health was largest (37.8%) which was mostly from the NPISHs, followed by the household OOP expenditure. Rest of the world entities shared 17.6% of total expenditure on the reproductive health, followed by the government (14.3%). The major proportion of the fund for the nutritional deficiencies was through the government and the foreign entities which were 38.8% and 33.9% respectively. (Figure 32) Figure 32: Disease wise Expenditure Distribution by Financing Schemes 2015/16 Infectious and Parasitic Diseases Noncommunicable Diseases Reproductive Health Nutritional Deficiencies Injuries Unspecified Dis Percentage Government Voluntary Health Care Payment Household OOP Rest of the World 20

43 Percentage 2.12 Out-of-Pocket Spending: What was the share of household out-of-pocket spending and its component in the health care spending in Nepal? Household OOP expenditure is a direct payment for health care services and goods made by the users at the time of the use of health services including cost-sharing and informal payments, both in cash and kind from the household s primary income or savings. There is no involvement of third-party for the payment. OOP results in the direct burden of medical costs that households bear at the time of using the health care services. In this NNHA period, the estimated household s OOP spending were NPR 57,342 million, NPR 68,041 million, NPR 78,740 million and NPR 78,427 million in the years 2012/13, 2013/14, 2014/15 and 2015/16 respectively. For further details of OOP expenditure is provided in the Table 13 and 14 of General Health Accounts Tables section of this report. Likewise, per capita OOP spending estimated in this NNHA period were NPR 2,049 (USD 23.4), NPR 2402 (USD 24.5), NPR 2748 (USD 27.7) and NPR 2706 (USD 25.5) in the years 2012/13, 2013/14, 2014/15 and 2015/16 respectively. Figure 33 demonstrates the share of OOP spending in the total current health expenditure along with the trends of current health expenditures through other. In this NNHA period the OOP spending has declined. The estimated OOP was 55.4% of CHE in the year 2015/16 6. Figure 33: Trend of OOP Spending as Compared to Other Financing Schemes Ratios as Percentage of CHE (2009/10 to 2015/16) / / / / / / /16 Fiscal Year Government Enterprise Financing Schemes Rest of the World NPISH Household Out-of-Pocket Payment The OOP share in the current health expenditure was dominating the expenditures under all the health care, thus OOP direct payment continued to be the major fund in the health system of Nepal. The prepayment, that can manage payments in more predictable and affordable pattern, are very low as compared to the OOP direct payments OOP Spending as a Percentage of Current Health Expenditure in South-East Asian Countries The cross-countries comparison of OOP spending as a share of current health expenditure in South-East Asian countries revealed that OOP in Nepal was very high in the region as compared to the WHO recommended level of 15-20% of CHE (Xu et.al, 2010). (Figure 34) 6 In the year 2015/16, overall household consumption was declined in absolute terms (Annual Household Survey, CBS). GDP growth rate also slowed down in the same period. In 2015/16, it was observed that the expenditure in health from the voluntary payments from the NPISHs and foreign entities increased sharply. 21

44 Million NPR Percentage Figure 34: Trend of OOP as a Percentage of CHE in South-East Asian Countries (2015) Countries Source: WHO GHED, OOP Spending by Health Care Functions: What health care services and goods were households purchasing OOP? Households spent OOP mostly on the medicines, medical goods, curative services and diagnostics. Twothirds of OOP spending was made on medicines and medical goods, while curative care drew around one-fourth of total OOP expenditure in the year 2015/16. It was revealed that 10.6% of OOP was spent for the ancillary services such as medical laboratory and imaging services for diagnostic purpose and patient transportation (Figure 35). Figure 35: Household OOP Spending by Types of Services and Goods 78,740 78,427 68,041 57, % 67.3% 64.3% 63.4% 9.2% 19.4% 9.0% 23.6% 9.0% 10.6% 26.7% 26.1% 2012/ / / /16 Curative Care Fiscal Year Medical Goods (Non-specified by Function) Ancillary Services (non-specified by function) Total OOP (in Milions) OOP by Health Care Provider: Where did households made OOP payments for health care services? The breakdown of the household OOP spending by providers indicates that majority (62.6%) of OOP payment for health care was made to the retailers and other providers of medicines and medical products in the year 2015/16. Next to the providers of medicines and medical goods, 19.0% of OOP spending was incurred at hospitals where the majority (16.0%) occurred at private hospitals. The OOP expenditure at the private hospitals was more than two-thirds of all the hospital OOP expenditures. The OOP spending on the ancillary care was 10.6% of total OOP which constituted expenditures made on the providers of the medical laboratory, imaging, and patient transportation. The OOP expenditure made on receiving 22

45 in Million NPR medical services from the providers of foreign origin was 5.3%. While the OOP expenditure made on the providers of ambulatory care was 2.5% in the year 2015/16. (Figure 36) Figure 36: Household OOP Spending by Types of Providers 78,740 78,427 68, % 5.3% 57, % 6.2% 63.4% 62.6% 66.3% 70.4% 9.2% 2.2% 12.0% 9.0% 2.6% 17.3% 9.0% 10.6% 2.8% 2.5% 21.1% 19.0% 2012/ / / /16 Fiscal Year Rest of the World and Others Providers of Ancillary Services Hospitals Retailers and Other Providers of Medical Goods Providers of Ambulatory Health Care Total OOP (in Milions) OOP by Diseases/Health Conditions: On which diseases/health conditions did households spent OOP? Figure 37 illustrates the household OOP spending on the diseases/health conditions categories. It was found that out of the 59.7% of total OOP spending on the diseases/health categories that could be classified, as much as half of it was spent on the NCDs. Likewise, the households spent around 19.8% of total OOP spending on diseases categories for the infectious and parasitic diseases. Least amount of OOP was spent on the reproductive health (3.5%) and nutritional deficiencies (2.4%). Injuries also drew minimal (3.2%) OOP spending. Figure 37: Household OOP Spending by Diseases/Health Conditions 2015/16 Unspecified Diseases/Conditio ns, 40.3 Infectious and Parasitic Diseases, 19.8 Reproductive Health, 3.5 Nutritional Deficiencies, 2.4 Noncommunicable Diseases, 30.8 Injuries,

46 Percentage Percentage Percentage Percentage Household Spending Analysis by Income Quintile: Is household OOP spending for the health care results in poor financial protection and pushing them into poverty? OOP spending for the health care in Nepal is high; hence it is likely that the people are vulnerable towards the catastrophic expenditure with lower financial protection. Catastrophic expenditure is defined as the OOP payments for health exceeding either 10% or 25% of total household consumptions (at 10% or 25% threshold). To identify if OOP spending for the health care resulted in the catastrophic expenditure, an analysis of the health care spending as a share of total household consumption from the annual household survey (AHS) was conducted. (Hui Wang et. al., 2018) The findings show that almost 10.7% of entire population spent 10% of their total household expenditure on health. Further distribution of this large expenditure among the households of various wealth quintiles revealed that the richer two quintiles have faced higher burden by spending 11.8% and 14.5% of their household resources on health (Figure 38.a). Though households facing catastrophic expenditure were comparatively lower among the poorest two economic quintiles, it can be due to lower affordability and financial barriers that prevents them from accessing health care. The incidence of catastrophic expenditure was slightly higher (not statistically different considering the standard error) in the urban than in the rural areas (Figure 38.a). At the 25% threshold, around 2.4% of total households experienced catastrophic health expenditure. A similar pattern of distribution of high catastrophic expenditure was experienced at 25% threshold among the economic quintiles and in the urban and rural areas categories (Figure 38.b). Figure 38.a Incidence of Catastrophic Household OOP on Health (Threshold = 10%) 2014/15 Figure 38.b Incidence of Catastrophic Household OOP on Health (Threshold = 25%) 2014/ Large OOP payment for the health care also results into impoverishment; i.e. potentially push people below poverty lines. The poverty line is the estimated minimum level of income needed for a household to secure their basic needs of life, that vary across countries and depends upon the income level. Thus, absolute poverty lines (in international dollars) are commonly used for global comparison purposes, currently set at $1.90 and $3.10 per day per capita (2011 purchasing power parities, PPPs). 1.7% of the households fell below the poverty line of $1.90 and 3.4% below the poverty line of $3.10 per day per capita due to their spending on health. These are newly classified poor and do not include those who already are below poverty line. At the poverty line of $1.90, the households in the poorest quintiles were more vulnerable towards impoverishment, while at the poverty line of $3.10 the households in the middle economic quintiles were highly (15.5%) impoverished. The poorer economic quintiles were already below the poverty line. Irrespective of the poverty lines, households in the urban areas were more impoverished than rural areas (Figure 39.a and 39.b). It was also found that nationally, OOP spending on pharmaceuticals was higher irrespective of economic quintiles. Figure 39.a Percentage of Population Impoverished due to OOP Spending (at 1.90 Int. $) 2014/15 Figure 39.b Percentage of Population Impoverished due to OOP Spending (at 3.10 Int. $) 2014/

47 3. Data Sources and Estimation In this round of NNHA, health expenditure data collection was mostly done from secondary sources such as central government, NGOs, HMIS, and Annual Household Survey etc. The required health expenditure data from few entities such as donor agencies, international NGOs, local governments, private insurance companies, and employers were collected from the primary sources through surveys. The health expenditure data obtained from the secondary sources and surveys were utilized for the health expenditures estimation. The sources and details of the NHA data collection, collation, and process of estimation of the national level health expenditure are discussed in this chapter. In this round of NNHA, few methodological refinements were made in the estimation process. In due course, various challenges were encountered and those which could not be considered in this round were recorded as limitations. Besides, recommendations on few sections for future rounds of NNHA are made based on the overall experience. 3.1 Government Most of government s expenditure on health is made by central government, while the local governments had minimal health expenditure. The government health expenditure data was collected mainly from secondary sources. To estimate the local government health expenditure for the required level of disaggregation, primary sources were considered Central Government The health expenditure data of the central government entities mainly Ministry of Health and Population (MoHP) and other ministries including central government bodies such as the office of president, office of parliament etc. was collected from Ministry of Finance (MoF) budget details the Red Book. All the actual expenditures of MoHP and health-related expenditures of other ministries and government bodies were taken and fiscal year wise dataset was prepared with both the aggregated and disaggregated values. Public Health Facility Survey (NHEA, 2014), MoHP plan and budget details, Financial Controller General's Office (FCGO) expenditure details and Transaction Accounting and Budget Control System (TABUCS) of MoHP were used to derive the ratios for the distribution of the aggregated government expenditure to the disaggregated level compatible to SHA 2011 classification. Inpatient (IP) and Outpatient (OP) expenditure ratios by the providers were imported from Public Health Facility Survey (PHFS) 2014 and applied to classify inpatients and outpatients expenditures where required, particularly incurred at the public health facilities. The disaggregated expenditure ratios for the national health programs such as Tuberculosis, HIV/AIDS, integrated women/child health, curative and preventive care programs expenditure ratio were derived from MoHP plan and budget details, and the TABUCS. The Social Health Security Development Committee (SHSDC) program expenditure was collected from TABUCS, which was reflected under MoHP expenditure, where the source was internal transfers and grants. Capital expenditures were separated from the recurrent expenditures and classified according to the SHA 2011 classification Local Government Local government bodies such as District Development Committees (DDCs), Municipalities and Village Development Committees (VDCs) spend on the health services and programs at the local level. A survey was conducted to collect the total and health expenditures through local government bodies. Standard data collection tool was developed and data was collected from local government bodies. Local government bodies receive funds from the Ministry of Federal Affairs and Local Development (MoFALD) through internal transfers and grants, and responsible for various local level activities. They also raise funds at the local level. District-wise total expenditure by local government bodies were collected from MoFALD that includes all kinds of expenditures from local government bodies, including health services. The ratio of the financial source of local bodies by MoFALD and local revenue was derived based on the data collected from the survey. The objective was to understand the expenditure pattern of the local government bodies in the health sector and use the pattern to derive ratios of the health expenditures from the local government bodies out of their total expenditures. Where required, necessary information was also taken from the local bodies survey conducted for the previous round of NNHA. The ratios so 25

48 derived were applied to estimate the health expenditures from district-wise total expenditures obtained from MoFALD and ultimately the national estimates. Further disaggregated level health expenditure ratios were derived from the survey and applied to aggregated district-wise local government bodies health expenditures and obtained the required level of disaggregation based on SHA Bilateral and Multilateral Donors / External Development Partners (EDPs) The donor agencies or external development partners (EDPs) working in the health sector of Nepal spend mainly through the government which is reflected in the Red Book of MoF. Additionally, EDPs make considerable expenses through the direct funds such as grants made to the international/ national NGOs for health programs/projects, funding to the MoHP and other ministries and even through selfimplementation. A major part of the data related to health expenditure from EDPs was collected from the Red Book while a survey was conducted to collect their expenditures on health through direct funds. Data collection tool for the bilateral and multilateral donors was developed and adapted to collect the EDPs expenditure data in the health sector made through other organizations and self-implementation. The tool was developed based on SHA classification category through the consultations with the data providers and necessary adjustments were done. The purpose was to collect the information on the source of funding, total health expenditures related to both the directly implemented programs and through other agencies, administrative expenditures and staff medical benefits. In the tool, the provision was also made for the health expenditures of the EDPs categorized into the specific diseases and health conditions. Data providers were oriented and trained on the tool before the data collection. The finalized tool was circulated to all the donor agencies through and regular follow-up was done. Technical support was also provided during the data collection process. Every effort was made to avoid the double counting of the expenditures reported in the tool and reflected in the Red Book of MoF. 3.3 Non-Government Organizations (NGOs) Many international and national NGOs are working in the health sector of Nepal. NGOs have various sources of funding, such as multilateral and bilateral donors, foundations, governments, personal donations, charities etc. and conducts health programs/projects directly or in coordination and collaboration with government. Different approaches were made to collect the health expenditure data from the national and international NGOs International Non-Government Organizations (INGOs) INGOs spend in the health sector usually by self-implementing the programs/projects, through other organizations such as NGOs and direct funding to the MoHP and other ministries. The list of total international NGOs working in the health sector of Nepal was made based on the report of Association of International NGOs mapping exercise (AIN, 2016). A similar approach that was made for the data collection from the donor agencies was adopted to collect the health expenditure data from the international NGOs. Every effort was made to avoid the double counting of the INGOs health expenditures National Non-Government Organizations (NGOs) Mapping of national NGOs working in the health sector of Nepal was done before data collection. List of health-related NGOs was prepared from the Social Welfare Council (SWC) which is the government regulatory body for the NGOs in Nepal. All the national and international NGOs working in every sector are channeled through SWC when the financial resources are generated from the foreign sources. Total amount received by the NGOs from the foreign sources such as donations, charities, direct funding from the foreign organization, personal sources etc. are reported to the SWC. NGOs require approval from SWC for the implementation of their program/project and must report both programmatic and financial progress. Total approved budget details of NGOs for the health programs were collected from SWC. In the case where there were combined budgets of health programs with other sectors such as education, agriculture etc. health budget was separated based on equal proportions to the other components. Likewise, total program/project budget was split into yearly budget based on the project starting year and the total number of years which was within the time frame of this round of NNHA. 26

49 National NGOs health expenditure survey which was conducted for the previous round of NNHA was used to derive the ratio of actual expenditure out of the budget of the NGOs. The difference in the budget and expenditure was obtained, which was further utilized for adjusting the NGOs budget to estimate the total NGOs expenditures. The derived ratio was applied to estimate the national NGOs health expenditures of this round from the NGOs approved budget data obtained from SWC. Besides, the health expenditure of the international NGOs and EDPs that was made through the national NGOs (obtained from the survey of EDPs and INGOs) were also considered for recent information. Further disaggregated level of expenditures weights was derived from the NGOs expenditure pattern obtained from the NGOs survey conducted for the previous round of NNHA, and were used to distribute the total NGOs expenditure in this round. The health expenditures of the NGOs were categorized into the specific diseases/health conditions based on the information from the SWC records. Every effort was made to avoid the double counting of the NGOs expenditures estimated from SWC and reported from the donors, INGOs, and government. 3.4 Employers There are usually two types of employers, public enterprises such as state-owned enterprises, autonomous bodies; and the private companies. Such entities usually have two categories of health expenditures i.e. general health expenditures such as health camps, medicines and financial support for health programs and health facilities etc. and the medical or health benefits provided to their employees. The data collection and estimation of employer s health expenditure was done from both the primary and secondary sources State Owned Enterprises (SOEs) and Autonomous Bodies Health Expenditures from the state-owned enterprises and autonomous bodies were collected through surveys. List of all the SOEs and autonomous bodies and their total employee s number was prepared from secondary sources. Sampling was done according to the number of employees of both types of organizations. SOEs and autonomous bodies of the similar sector and of various employees sizes were considered for sampling. The data related to the number of employees, medical/health benefits provided to the employees and other general health expenditures were primarily collected from such organizations. The medical/health benefits and the number of employees were taken from the similar sector of sampled organizations to generate per employee disaggregated expenditure weights. The weights of other general health expenditures were derived from SOEs and autonomous bodies of similar sector. The total number of employees of SOEs and autonomous bodies was obtained from secondary sources. The derived per employee expenditure weights were applied to estimate the medical/health benefits expenditure of a total number of employees of all the SOEs and autonomous bodies respectively. The derived weights of general health expenditures from similar sector SOEs and autonomous bodies were applied to estimate total general health expenditures of such organizations. The total expenditure on medical/health benefits to the employees and other categories of health expenditures of each sector were added to obtain the total health expenditure from SOEs and autonomous bodies. Lump sum cash benefits and in-kind services provided to the employees were classified as n.e.c. The insurance premium paid on behalf of the employees was cross-checked with the private insurance company and social health insurance data to avoid double count of the premium amounts Private Companies Private companies have health expenditures usually in the health services as social contribution and the medical benefits provided to the employees. The weights for both kinds of health expenditures were derived from the private companies survey conducted for the previous round of NNHA. A list of total private companies was prepared from secondary sources. The numbers of private companies that have health expenditures out of the total companies were estimated based on the private companies health expenditure survey conducted for the previous round of NNHA. The average health expenditure per private company from the survey was taken as weight and applied to estimate total private company health expenditure excluding the staff medical benefits in this round. The disaggregated health expenditures ratios by functions and providers were derived from SOEs health expenditures. 27

50 A total number of employees for this round of NNHA period were obtained from the annual household expenditure survey (AHS, CBS). Out of the total number of employees, those who received medical benefits and the average medical benefit per employee were derived from the private company s survey. The weights so obtained were applied to estimate the medical benefits of the total employees for this round of NNHA. The health expenditures and the employee medical benefits were aggregated to obtain total private company health expenditure. Lump sum cash benefits and in-kind services provided to the employees were classified as n.e.c. 3.5 Private Insurance Companies Private insurance company s expenditures on health are usually the reimbursement made for the medical expenses of their clients, administrative expenses and medical benefits to their employees. All the private insurance providers in the country were mapped and list of the companies providing health insurance was prepared. Sensitization workshop with private insurance company representatives and data providers was conducted to discuss the data collection tool, data availability and reporting. Data collection was done from all the companies providing health insurance. The number of policies and clients covered were checked for health insurance and avoided other kinds of insurances. The number of clients, claims and reimbursement made in total and by diseases/health conditions were collected. The medical/health benefits of the private insurance provider employees were also taken, considering private insurance companies as enterprises. 3.6 Households Households pay out of pocket for the health care services they need which is the major expenditure in the health sector. Household s expenditure on health was tracked through the annual household survey (AHS, CBS). Three years AHS data (2013/14, 2014/15 and 2015/16) could be obtained from the Central Bureau of Statistics (CBS). Since the 2012/13 AHS data was not available, national estimates of the households health expenditure for the year 2012/13 was done by using decreasing trend of the 2013/14, 2014/15 and 2015/16 AHS data. Both exponential and linear trend lines gave a good fit to the existing data, with linear having a slightly better fit so the value was derived using linear trend. The OOP expenditure data from AHS was available basically for the medical services (OP) and hospital services (IP), diagnostic services, dental services, and pharmaceuticals and other medical goods related expenditures. The disaggregated level of OP and IP expenditure data required based on SHA 2011 classification was not available in the AHS. The service utilization data obtained from the HMIS was used to derive the further disaggregated level of expenditure. For this purpose, total utilization was split into OP and IP of both the public and non-public health (all kinds of private) facilities where public health facilities were further categorized based on the level of care. To derive the ratios required to split the aggregated expenditures, the service utilization data was used, where visits and admissions for the new cases were considered. The unit costs of outpatient and inpatient at each level of facilities were determined from the public health facility survey (NHEA, 2014), SHSDC costing study and census of private hospitals of Nepal (CBS, 2013). The unit costs so determined were applied to the service utilization and expenditure weights were derived. The derived weights were used to disaggregate the total OP and IP services by providers and functions. The expenditure ratios derived from the various providers survey conducted for the previous round of NNHA was used to classify those which could not be disaggregated. The AHS data of medical products and goods, therapeutic appliances and equipment, traditional health services, health-related transportation services, medical equipment purchased and health services in abroad were used without the further level of disaggregation. For the estimation of the catastrophic expenditure on health and the impoverishment due to the spending in health, the proportion of the households expenditure on health as a share of total household consumption or income was calculated from the AHS 2014/15 data. The catastrophic household expenditures on health were identified using two thresholds; 10% and 25% of total household consumption or income. The households were categorized into five expenditure quintiles and two regions; rural and urban. Households spending on health, out of total household consumption or income was derived for each expenditure quintiles and regions to establish catastrophic spending on health. The 28

51 impoverishment due to spending on health was also derived from the 2014/15 AHS data (Hui Wang et.al 2018). 3.7 Diseases/Health Conditions SHA 2011 framework recommends using Global Burden of Disease (GBD) and ICD-10 classification for more disaggregated level diseases/health conditions wise classification. The ICD-10 classification was chosen for the level of details. The diseases/health conditions wise cases based on the ICD-10 was obtained from HMIS. The required grouping of similar inpatient morbidity cases to the respective diseases case was done based on WHO standard disease grouping (Eurostat/OECD/WHO, 2008) and classified according to the HAPT diseases (DIS) classification. The entire process of diseases/health conditions wise expenditure classification was performed in the following steps Utilization Data Outpatient visits of public health facilities were available by diseases, sex and level of facilities i.e. HPs, PHCCs, district hospitals (DH), zonal hospitals (ZH), regional hospitals (RH), national hospitals (NH) and specialized hospitals (SH) with ICD codes at a disaggregated level. The OP visits were clubbed into four levels of public health facilities; primary, secondary, national and specialized. Total male and female OP clients served were obtained from HMIS. In the specific condition to females (e.g. Tetanus Toxoid injections for mother) were kept under females and remaining all other OP visits were divided into the ratio for males and females. OP visits for the age of under five years were specified when the diseases/health conditions are specific for the children e.g. pediatric pneumonia, BCG etc. The preventive care related to the reproductive health, such as ANC and PNC, was also included in the OP of all levels of public health facilities. The total OP utilization in the non-public health facilities was available. IP visits to public health facilities were available by diseases/health conditions and sex only but not according to the health facilities level. Thus, to estimate IP visits by the level of public health facilities, the level/types of facility wise ratios were derived from Public Health Facility Survey (NHEA, 2014). All IP admissions were assumed to be taking place at secondary and tertiary facilities, except some admissions related to pregnancies that had taken places in the primary level facilities. In the context of non-public health facilities, only aggregated IP utilization was obtained. The diseases/health conditions wise distribution ratio reported by the private health insurance companies was used for distributing the aggregated IP utilization in non-public health facilities. The disaggregated level diseases/health conditions were grouped and re-grouped for similar conditions based on the ICD codes according to the WHO guideline (Eurostat/OECD/WHO, 2008). The disease groups were linked to DIS classification based on SHA The level of disease distribution was decided based on the availability of utilization data, disease burden and relevance for policy Derivation of Cost Weights OP costing of the public health facilities i.e. HP, PHCC, DH, ZH, RH, NH and SH was taken from the PHFS (NHEA, 2014). The average OP cost of the non-public was estimated based on the private hospital's survey (CBS, 2013) and the PHFS. Disease/health condition wise average IP package costs per admission in the public facilities were taken from the SHSDC updated disease package costing information. The average package cost per IP admission in the non-public facilities and in the specialized facilities were also estimated from the PHFS (NHEA, 2014) and the census of private hospitals (CBS, 2013) Derivation of Expenditure Weights Diseases/health conditions wise expenditures weights were determined separately for the OP and IP. In the context of public facilities, total counts of diseases/health conditions OP and IP utilization of each type of facilities were listed. The OP and IP utilizations were multiplied with the derived OP and IP costs of each facilities type respectively. The facilities wise OP and IP expenditures so derived were added across the type of facilities respectively to get the expenditures by level of public health facilities i.e. for primary (PHC+HP), secondary (ZH+DH+RH), national (NH) and specialized (SH). OP expenditure weights were derived by multiplying the OP visits count with the derived OP cost weights at each level of care respectively. Primary, secondary, national and specialized levels of cares were added to obtain the total 29

52 counts and total expenditures. Diseases/health conditions wise IP admissions expenditures were determined by multiplying the total IP utilization counts with the derived average package cost weights obtained from the SHSDC. Expenditure items across the diseases/health conditions codes were link to the agreed HAPT and DIS categories. For the non-public facilities, the total OP and IP utilizations were multiplied with the derived OP and IP costs weights. The diseases/health conditions wise expenditure weights for both OP and IP at each level of cares of public health facilities and non-public health facilities were derived Application of Expenditure Weights and Diseases/Health Conditions Wise Expenditure Distribution The derived diseases/health conditions wise expenditures weights were used in the relevant sections of health expenditures from various sectors to distribute the expenditures of the respective diseases. The amount transfer by MoHP to the primary, secondary, national and specialized care health facilities were distributed according to the derived expenditure weights. To distribute disease wise expenditure by functions, inpatient and outpatient expenditure weights were applied separately in all kind of public health facilities. It was considered that the visits to public facilities are financed by the government, thus the expenditures data for those were taken from the national programs of MoHP available in the Red Book. However, one may need to have additional OOP expenditures particularly for admissions, ancillary services and pharmaceuticals outside the facilities while seeking services in the public facilities. The extra OOP thus occurred at the public health facilities were distributed diseases/health conditions wise in the household expenditures. The amount transferred to the hospitals operated by other ministries such as defense ministry, home ministry, and general administration ministry etc. was distributed by applying the inpatient and outpatient diseases/health conditions wise expenditure weights of national hospitals separately. Government specific disease program (TB, HIV, Safe-motherhood etc.) expenditures were directly allocated to the respective diseases/health conditions. The health expenditure from other government bodies such as the office of the president, parliament, other ministries etc. were distributed by using similar disease/health conditions expenditure weights of the respective level of public health facilities. In the context of household expenditures, both the medical (OP) services and hospital (IP) services were distributed according to the diseases/health conditions wise expenditure weights derived from the private insurance company s reimbursement expenditures allocated to diseases/health conditions. In the meantime, it was found that the expenditure weights on the nutritional deficiencies and maternal conditions were higher in the private insurance company expenditure which was rare. Similarly, expenditures on pharmaceuticals and other medical goods and ancillary services such as laboratory and imaging expenditures were also distributed diseases/health conditions wise by using expenditure weights derived from the private insurance data. In the case of bilateral and multilateral organizations, disease/health conditions wise expenditures were extracted from the reported expenditures on disease conditions by such organizations and allocated directly to the respective diseases/health conditions. A similar approach was made for distributing the diseases/health conditions expenditures reported by international NGOs. For the national NGOs, the diseases/health conditions wise expenditure was obtained from the SWC data, which was directly allocated for diseases/health conditions. The private insurance companies diseases/health conditions wise expenditures were allocated based on the data provided by few insurance companies. 30

53 3.8 Refinements over the Previous NNHA In this round of NNHA, overall data collection and the estimation were revisited and where possible required refinements were done. Secondary sources of data were extensively used and cost-effective way of data collection was promoted simultaneously for the institutionalization of the data reporting for future rounds of NNHA. In this round of NNHA, for the first-time diseases/health conditions wise distribution of health expenditures was conducted. The data collection from EDPs and INGOs was done through consultations and workshops with the data providers before and during the data collection process. The objective, process, use of the health expenditure data and the data collection tool was extensively discussed among the data providers. Hence, the data providers were made aware of the entire process that helped in reporting the data effective. The EDPs and INGOs data was collected through , a cost-effective way of data collection required for the NHA institutionalization. Technical support and timely feedback on the reported data was provided for accurate reporting to enhance the level of precision of reported data. The health sector expenditures from all the national NGOs was estimated based on the individual NGOs expenditure from the NGOs budgets information collected from SWC. This is refinement over the previous process of estimation where the NGOs health expenditure weight obtained from the surveys and the derived weights were applied to the total number of NGOs for the national estimate of total health expenditures from NGOs. General health expenditures and the medical benefits provided to the employees were estimated separately in SOEs and autonomous bodies and later added to derive the overall health expenditures by such entities. Weights for the general health expenditures and employee benefits were derived and applied separately. The medical benefit to the employees was estimated based on the number of employees rather than the number of SoEs and autonomous bodies. In the case of private companies health expenditures, the medical benefits to employees were estimated based on the number of employees rather than the number of the companies. The health expenditures and the medical benefits provided to the employees was estimated separately and later aggregated to derive the total health expenditures from private companies. The data collection of the private insurance company was done in close coordination with Insurance Board of Nepal for timely and regular reporting of data without separate survey for insurance companies. A sensitization workshop was organized to the private insurance data providers to orient data collection tool and process for effective reporting of data. Besides, yearly reporting of data from private health insurance providers was ensured for the future rounds of NNHA. To distribute MoHP expenditure to the required level of disaggregation, the details of MoHP plan and budget and TABUCS were extensively referred. Since TABUCS have a greater level of MoHP expenditure details, hence the MoHP expenditures could be distributed more precisely. OP/IP distribution ratio was also reviewed according to utilization data from HMIS and cost ratios derived from the PHFS. The household OOP expenditure, in this round was tracked through the annual household survey. Annual Household Survey is the national representative survey that tracks the household expenditure on the overall consumption including health services. 31

54 3.9 Limitations in Estimations of this Round of NNHA In the data collection and estimation process, few challenges were experienced. The data and methodological issues were addressed to the maximum during the data collection and estimation. Despite every effort, there are still some limitations in this round of NNHA. Health expenditure data from few EDPs and INGOs that could not be collected potentially affected in the estimation of the total health expenditure in this round of NHA. Though efforts were made to extract the unreported expenditure data from those organizations from various sources, there was high probability of missing out few of them. Proper recording system of the reported financial progress of the NGOs was not available, so the total approved NGOs program budgets were taken for estimating the expenditures. In many cases, total budgets of the multi-year programs of NGOs of combined programs (health and other programs) were only available Hence, it was challenging to split the total budget on yearly basis and separating health program budget proportionately from combined programs. Besides, the health expenditures from the NGOs registered and generated funds locally for the health programs could not be captured in this round of NNHA. Data collection from SOEs and autonomous bodies of past four years was challenging due to availability of limited records of health expenditures in such organizations. Data from few autonomous bodies could not be collected which would have affected the estimation of health expenditures from autonomous bodies. Since there was no recent private company health expenditure related information available, this round of NNHA relied upon the private company health expenditure survey conducted for the previous round of NNHA to derive the weights of health expenditure and employee medical benefits of private companies. The reimbursement made to the clients according to the diseases/health conditions could be obtained from very limited private insurance companies. The weighted average value of those limited insurance companies was applied to distribute the overall insurance companies health expenditure to the diseases/health conditions categories. Thus, there was a chance of losing the opportunity to represent more insurance companies with different diseases/health conditions wise expenditure behaviors. In the classification of health care providers, the expenditure at private hospitals could not be categorized by profit and not-for-profit private hospitals due to lack of disaggregated data. To derive the disaggregate expenditures weights in few sections of local bodies health expenditure, a similar survey for the previous round of NNHA was used. The required level of disaggregated data related to ambulatory care at the non-public facilities and the ancillary services were not available in the Annual Household Survey. Likewise, Annual Household Survey only have total pharmaceuticals expenditure but no further categorical details were available. Thus, the survey conducted for the previous round of NNHA was used to derive weights for further disaggregation of the ancillary services and pharmaceuticals, also to estimate the ambulatory care expenditure at the non-public facilities. Due to unavailability of data related to the expenditure by selfemployed professional for private ambulatory care, self-employed professional remuneration could be captured only from the expenditure reported by employers/organizations under this heading. Due to unavailability of disaggregated data on inputs (salaries, medical goods etc.) made by government hospitals led to an underestimation of the expenditure on employee compensation and medical goods, thus there could be overestimation on health care services. The consumption of fix capital under factors of health care provision could not be estimated, as extracting the data on each facility and equipment along with the knowledge of their age to calculate the retirement function as suggested in SHA 2011 was quite complicated based on the available information. The tax paid for health care services could not be captured due to unavailability of the required data. The disease account could be done only for the years 2014/15 and 2015/16 due to unavailability of disease wise OP and IP utilization of the years 2012/13 and 2013/14. Only data on total IP admissions in the public facilities available, thus it was challenging to distribute the total IP utilization in the public facilities by their types and level. 32

55 Medicines and medical goods purchased out of the IP and OP packages, over the counter medicines, ancillary services such as laboratory and imaging expenditures, patient transportation, expenditures made in abroad treatments and traditional health care expenditure could not be distributed diseases/health conditions wise due to lack of information on such types of expenditures specific to disease categories. The diseases/health conditions wise allocation of IP expenditures was estimated based limited private insurance company s disease wise expenditure data. Thus, it limits the proper estimations of diseases/health conditions wise expenditures of the households OOP in absence of other private insurance companies diseases/health conditions data. The expenditure provided by bilateral, multilateral organizations, international and national NGOs that could not be allocated according to disease were allocated to either non-disease expenditures if the expenditure is related to administrative purpose and for those which could not be allocated according to diseases/health conditions were classified as other and unspecified diseases n.e.c. The health expenditure data provided by corporations/enterprises such as autonomous bodies, SOEs, private companies could not be categorized according to diseases and health conditions due to unavailability of diseases/health conditions wise health expenditures from such entities Recommendations for the Future NNHA Involving the data provider right from the initial phase of the NHA exercise needs to be continued, as it is an effective way of institutionalization of data collection. The process of health expenditure data collection from EDPs and INGOs adopted in this round of NNHA should be continued for the future rounds. Since, it is essential to collect data from all donor agencies and INGOs, hence further efforts should be made to ensure the data collection from all the EDPs and INGOs. Recent national NGOs and private company health expenditure surveys are desired for the recent information regarding the health expenditure pattern from these entities. In the sampling process of selection of SOEs and autonomous bodies, categorization of such entities based on the number of employees to determine the sample size yield better estimation than categorization based on the sector of their business. Thus, the sampling based on the employee size of SOEs and autonomous bodies should be continued in the future NNHA to improve the estimation of the health expenditures from such entities. Further coordination and collaboration should be done with the CBS to include the more disaggregated level of information on the household health expenditures in the AHS or Living Standard Surveys, especially by providers and diseases. Household health expenditure and utilization surveys on periodic basis are useful for the OOP expenditure estimation. Advocacy and close coordination should be continued to ensure the timely and regular availability of household expenditure data. Updated information on the disease costing is required for the future rounds of NNHA. It is recommended to identify the alternative sources of information related to the costing of diseases/health conditions. Public and private health facility survey are required at least every five years for the updated information and would be useful if taken up by the statistical bureau. Coordination and collaboration with the professional and regulatory bodies experienced to be highly effective in data collection from the respective organization. Hence, it is helpful to continue the approach made in the future rounds on NNHA. The annual production of NHA is crucial for supporting data-driven policy decisions, effective resource allocation, and financial planning. Institutionalization of health accounts emphasizes the annual production and routine use of health accounts is an integral and sustained part of health system governance (Cogswell and Dereje 2015). The institutionalization of the NNHA production which is the process of regular generation of the NHA data in a cost-effective way and awareness on the utilization of NHA findings, and their policy implications should be continued. 33

56 4. References Association of International NGOs in Nepal (AIN), (2016) Mapping of AIN Members Contributing to the Health Sector in Nepal, Kathmandu Nepal Central Bureau of Statistics (2017) Nepal National Account 2016/17, National Planning Commission Secretariat, Govt. of Kathmandu Nepal Nepal, Central Bureau of Statistics (2015) Annual Household Survey 2013/14 National Planning Commission Secretariat, Govt. of Nepal, Kathmandu Nepal Central Bureau of Statistics (2016) Annual Household Survey 2014/15, National Planning Commission Secretariat, Govt. of Nepal, Kathmandu Nepal Central Bureau of Statistics (2017) Annual Household Survey 2015/16, National Planning Commission Secretariat, Govt. of Nepal, Kathmandu Nepal Central Bureau of Statistics (2013) A report on Census of Private Hospitals in Nepal, Govt. of Nepal, Kathmandu Nepal Cogswell, H. and T. Dereje. (2015) Understanding Health Accounts: A Primer for Policymakers. Bethesda, MD: Health Finance and Governance Project, Abt. Associates. Department of Health Services (2014) Annual Report 2012/13, Ministry of Health, Govt. of Nepal, Kathmandu, Nepal Department of Health Services (2015) Annual Report 2013/14, Ministry of Health, Govt. of Nepal, Kathmandu, Nepal Department of Health Services (2016) Annual Report 2014/15, Ministry of Health, Govt. of Nepal, Kathmandu, Nepal Department of Health Services (2016) Annual Report 2015/16, Ministry of Health, Govt. of Nepal, Kathmandu, Nepal Eurostat/OECD/WHO (2008) International shortlist for hospital morbidity tabulation (ISHMT) URL: Accessed on November 2017 HEFU (2009) Nepal National Health Accounts Second round: 2003/4 to 2005/6. Kathmandu: Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal Hui Wang et al (2018) Financial protection analysis of eight countries in the South-East Asia Region: current status and policy response. Bulletin of the World Health Organization. Forthcoming Institute for Health Metrics and Evaluation (IHME), (2017). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington, Available from Accessed on March 2018 Ministry of Finance (2014) Budget Details for Fiscal Year (Red Book) 2012/13, Ministry of Finance, Govt. of Nepal, Kathmandu, Nepal Ministry of Finance (2015) Budget Details for Fiscal Year (Red Book) 2013/14, Ministry of Finance, Govt. of Nepal, Kathmandu, Nepal Ministry of Finance (2016) Budget Details for Fiscal Year (Red Book) 2014/15, Ministry of Finance, Govt. of Nepal, Kathmandu, Nepal Ministry of Finance (2017) Budget Details for Fiscal Year (Red Book) 2015/16, Ministry of Finance, Govt. of Nepal, Kathmandu, Nepal McIntyre D., Kutzin J. Health financing country diagnostic: a foundation for national strategy development. Geneva: World Health Organization; 2016 (Health Financing Guidance No. 1). License: CC BY-NC-SA 3.0 IGO. Ministry of Finance (2013) Budget Details for Fiscal Year (Red Book) 2012/13, Ministry of Finance, Govt. of Nepal, Kathmandu, Nepal Ministry of Finance (2014) Budget Details for Fiscal Year (Red Book) 2013/14, Ministry of Finance, Govt. of Nepal, Kathmandu, Nepal Ministry of Finance (2017) Economic Survey 2015/16, Govt. of Nepal, Kathmandu, Nepal Nepal Health Economics Association (2015) Public Health Facility Survey, Kathmandu Nepal OECD (2000) A System of Health Accounts. (Version 1.0) Paris: Organization for Economic Co-operation and Development OECD Eurostat WHO (2011), A System of Health Accounts, OECD Publishing Prasai, DP; Karki, D; Sharma, TM; Ganwali, D; Subedi, GR; Singh, AB (2006) Nepal National Health Accounts, Kathmandu: Ministry of Health and Population, Govt. of Nepal Shrestha, BR; Gauchan, Y; Gautam, GS; Baral, P (2012) Nepal National Health Accounts, 2006/ /09. Kathmandu: Economics and Financing Unit, Ministry of Health and Population, Govt. of Nepal Health World Health Organization (2018), Global Health Expenditure Database, Geneva, Switzerland URL: Accessed in March 2018 World Health Organization (2017) Methods and Data Sources for Global Monitoring of UHC Indicators of Financial Protection Coverage within the Sustainable Development Goals (Draft); Health Systems Governance and Financing, WHO, Geneva February 2017 Xu, Ke, Saksena P., Jowett M, Indikadahena C, Kutzin J, and. Evans, DB. (2010) Exploring the thresholds of health expenditure for protection against financial risk. World Health Report Background Paper, No. 19. Geneva: WHO. 34

57 General Health Accounts Results Tables to

58 Table 1a. Macro Data Fiscal Year Population 1 GDP 2 GGE 3 Health Expenditure (Million NPR) GGHE (Million (Million (Million NPR) NPR) NPR) Male Female Total Total Current Capital OOPs (Million NPR) Exchange Rate 4 (USD) GDP Deflator 2 (Health) 2000/01 11,563,921 11,587,502 23,151, ,519 65,095 5,695 21,953 19,588 2,365 13, /02 11,845,495 11,855,956 23,701, ,443 68,149 7,472 23,960 20,925 3,035 14, /03 12,126,262 12,123,734 24,249, ,231 67,170 6,969 24,913 21,899 3,015 15, /04 12,406,222 12,390,837 24,797, ,749 72,263 9,837 30,650 24,773 5,877 17, /05 12,685,375 12,657,263 25,342, ,412 81,069 11,461 32,960 26,563 6,397 17, /06 12,963,722 12,923,014 25,886, ,084 83,384 14,664 34,796 26,441 8,355 17, /07 13,240,233 13,187,166 26,427, , ,883 11,156 36,019 30,493 5,526 21, /08 13,515,938 13,450,643 26,966, , ,233 14,712 43,613 35,518 8,095 25, /09 13,790,836 13,713,444 27,504, , ,663 17,521 52,526 43,984 8,542 28, /10 13,604,083 14,285,257 27,889,340 1,192, ,973 19,057 62,580 59,216 3,364 33, /11 13,763,752 14,516,039 28,279,791 1,366, ,960 21,435 74,019 69,273 4,746 40, /12 13,935,068 14,740,640 28,675,708 1,527, ,851 24,607 83,756 78,724 5,032 44, /13 13,587,023 14,398,287 27,985,310 1,695, ,054 20,459 98,051 90,255 7,796 57, /14 13,744,396 14,578,845 28,323,241 1,964, ,226 25, , ,312 6,129 68, /15 13,903,373 14,752,909 28,656,282 2,120, ,251 28, , ,480 6,531 78, /16 14,063,302 14,919,469 28,982,771 2,248, ,548 30, , ,462 9,702 78, Source: 1. Population Census, Central Bureau of Statistics, 2. Nepal National Account 2018, Central Bureau of Statistics, 3. Economic Survey 2015/16, Ministry of Finance, 4. Nepal Rastra Bank 36

59 Table 1.b. Major Indicators from 2000/01 to 2015/16 ( in NPR) Fiscal Year Per Capita GDP Per Capita GGE Per Capita GGHE Per Capita THE Per Capita CHE Per Capita HK Per Capita OOP THE as % of GGE THE as% of GDP GGHE as % of GDP CHE as % of GDP HK as % of GDP 2000/01 19,071 2, /02 19,410 2, , /03 20,340 2, , /04 21,694 2, , /05 23,300 3, ,301 1, /06 25,290 3, ,344 1, /07 27,525 4, ,363 1, /08 30,171 4, ,617 1, /09 38,172 6, ,910 1, , /10 45,435 8, ,244 2, , /11 51,594 9, ,617 2, , /12 56,880 10, ,921 2, , /13 60,568 10, ,504 3, , /14 69,361 13, ,217 4, , /15 73,997 14,944 1,004 4,851 4, , /16 77,587 17,064 1,056 5,216 4, ,

60 Table 2. Distribution of CHE by Revenues of Health Care Financing Schemes (s in Million) 2012/ / / /16 FS Code Revenues of Health Care Financing Schemes (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % FS.1 Transfers from Government Domestic Revenue (Allocated to Health Purposes) 14, , , , FS.1.1 Internal Transfers and Grants 14, , , , FS.1.2 FS.1.4 FS.2 Transfers by Government on Behalf of Specific Groups Other Transfers from Government Domestic Revenue Transfers Distributed by Government from Foreign Origin < < < < , , , , FS.5 Voluntary Prepayment FS.5.2 Voluntary Prepayment from Employers FS.6 Other Domestic Revenues n.e.c. 64, , , , FS.6.1 Other Revenues from Households n.e.c. 57, , , , FS.6.2 Other Revenues from Corporations n.e.c. 1, , , , FS.6.3 Other Revenues from NPISH n.e.c. 5, , , , FS.7 Direct Foreign Transfers 4, , , , FS.7.1 Direct Foreign Financial Transfers 4, , , , FS Direct Bilateral Financial Transfers 1, , , , FS Direct Multilateral Financial Transfers 1, , , , FS Other Direct Foreign Financial Transfers 2, , , , FS.7.2 Direct Foreign Aid in Kind < <0.1 FS Direct Foreign Aid in Goods < <0.1 FS Direct Multilateral Aid in Goods < <0.1 Total 90, , , , , , , ,

61 Table 3. Distribution of CHE by Institutional Units Providing Revenues to Financing Schemes (s in Million) FS.RI Code Institutional Units Providing Revenues to Financing Schemes Amoun t (NPR) 2012/ / / /16 (USD) % (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % FS.RI.1.1 Government 14, , , , FS.RI.1.2 Corporations 2, , , , FS.RI.1.3 Households 57, , , , FS.RI.1.4 NPISH FS.RI.1.5 Rest of The World 15, , , , FS.RI Bilateral Donors 2, , , , FS.RI Australia < < < FS.RI Germany FS.RI Japan FS.RI Korea < FS.RI Netherlands < < < <0.1 FS.RI Norway < < < <0.1 FS.RI Switzerland < FS.RI United Kingdom , , , FS.RI United States (USAID) 1, , , , FS.RI nec Other and Unspecified Bilateral Donors < , FS.RI Multilateral Donors 3, , , , FS.RI ASDB FS.RI EU Institutions < FS.RI GAVI < <0.1 2,

62 FS.RI Code Institutional Units Providing Revenues to Financing Schemes Amoun t (NPR) 2012/ / / /16 (USD) % (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % FS.RI Global Fund < FS.RI IDA + IBRD (World Bank) < FS.RI UNAIDS < < < <0.1 FS.RI UNDP < FS.RI UNFPA FS.RI UNICEF , FS.RI WFP FS.RI SAARC < <0.1 < <0.1 FS.RI WHO , , FS.RI UNHABITAT < <0.1 FS.RI UNCDF < < FS.RI IDA General <0.1 < FS.RI GEFMAT General FS.RI nec Other and Unspecified Multi-lateral Donors FS.RI Pool Fund 3, , , FS.RI Private Donors 3, , , , FS.RI Pharmaceutical Companies < FS.RI nec Other and Unspecified Private Donors 3, , , , FS.RI International NGO 2, , , , FS.RI.1.5.nec Unspecified Rest of the World FS.RI.1.nec Unspecified Institutional Units Providing Revenues to Financing < < < Schemes Total 90, , , , , , , ,

63 Table 4. Distribution of CHE by Health Care Financing Schemes (s in Million) HF Code HF.1 Health Care Financing Schemes Government Schemes and Compulsory Contributory Health Care Financing Schemes Amoun t (NPR) 2012/ / / /16 (USD) % (NPR) (USD) % (NPR) (USD) % (NPR) (USD) 20, , , , HF.1.1 Government Schemes 20, , , , HF Central Government Schemes 20, , , , HF State/Regional/Local Government Schemes HF.1.2 Compulsory Contributory Health Insurance Schemes < < < <0.1 HF Social Health Insurance Schemes < < < <0.1 HF.2 Voluntary Health Care Payment Schemes 7, , , , HF.2.1 Voluntary Health Insurance Schemes HF.2.1.nec HF.2.2 HF HF.2.2.nec Unspecified Voluntary Health Insurance Schemes (N.E.C.) NPISH Financing Schemes (Including Development Agencies) NPISH Financing Schemes (Excluding HF.2.2.2) Unspecified NPISH Financing Schemes (N.E.C.) , , , , , , , , < HF.2.3 Enterprise Financing Schemes 1, , , , HF Enterprises (Except Health Care Providers) Financing Schemes 1, , , , HF.3 Household Out-Of-Pocket Payment 57, , , , HF.3.1 Out-Of-Pocket Excluding Cost-Sharing 57, , , , HF.4 Rest of The World Financing Schemes (Non-Resident) 4, , , , HF.4.2 Voluntary Schemes (Non-Resident) 4, , , , HF Other Schemes (Non-Resident) 4, , , , HF Philanthropy/International NGOs Schemes 2, , , , HF Foreign Development Agencies Schemes 2, , , , Total 90, , , , , , , , % 41

64 Table 5. Distribution of CHE by Health Care Financing Agents (s in Million) FA Code Health Care Financing Agents (NPR) 2012/ / / /16 (USD) % (NPR) FA.1 General Government 20, , , , FA.1.1 Central Government 20, , , , FA Ministry of Health 14, , , , FA Other Ministries and Public Units (Belonging to Central Government) (USD) % (NPR) (USD) % (NPR) (USD) 5, , , , FA Ministry of Education 1, , FA Ministry of General Administration < FA Ministry of Home Affairs FA Ministry of Defense FA Ministry of Agriculture Development FA Ministry of Federal Affairs and Local Development 1, , , FA Ministry of Commerce and Supply FA Ministry of Finance 2, , , , FA nec Other Ministries and Public Units (Belonging to Central Government) < < < FA.1.2 State/Regional/Local Government FA DDC < <0.1 FA VDC < < < <0.1 FA Municipality FA.1.3 Social Security Agency < < < <0.1 FA Social Health Insurance Agency < < < <0.1 FA.2 Insurance Corporations FA.2.1 Commercial Insurance Companies FA.3 FA.3.2 FA.4 Corporations (Other Than Insurance Corporations) (Part of HF.RI.1.2) Corporations (Other Than Providers of Health Services) Non-Profit Institutions Serving Households (NPISH) 1, , , , , , , , , , , FA.5 Households 57, , , , FA.6 Rest of The World 4, , , , FA.6.1 International Organizations 4, , , , FA.6.2 Foreign Governments FA.6.3 Other Foreign Entities , Total 90, , , , , , , , % 42

65 Table 6. Distribution of CHE by Health Care Providers (s in Million) 2012/ / / /16 HP Code Health Care Providers (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % HP.1 Hospitals 11, , , , HP.1.1 General Hospitals 7, , , , HP Public General Hospitals 3, , , , HP National/Central Hospitals 1, , , , HP Regional/Zonal Hospitals , , , HP District Level and Other Public General Hospitals 1, , , , HP Private (For-Profit) General Hospitals 3, , , , HP.1.1.nec Other General Hospitals , , HP.1.2 Mental Health Hospitals HP Public Mental Health Hospitals < < < <0.1 HP Private (For-Profit) Mental Health Hospitals HP.1.3 Specialized Hospitals (Other Than Mental Health Hospitals) 3, , , , HP Public Specialized Hospitals 1, , , , HP Private (For-Profit) Specialized Hospitals 1, , , , HP.1.3.nec Other Specialized Hospitals (Other Than Mental Health Hospitals) , HP.1.nec Unspecified Hospitals HP.2 Residential Long-Term Care Facilities HP.2.1 Long-Term Nursing Care Facilities <0.1 HP.2.9 Other Residential Long-Term Care Facilities HP.3 Providers of Ambulatory Health Care 11, , , , HP.3.1 Medical Practices , , , HP Offices of General Medical Practitioners HP Offices of Mental Medical Specialists HP.3.1.nec Unspecified Medical Practices < < < <0.1 HP.3.2 Dental Practice , HP.3.4 Ambulatory Health Care Centers 9, , , ,

66 2012/ / / /16 HP Code Health Care Providers (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % HP Family Planning Centers < < HP Ambulatory Mental Health and Substance Abuse Centers < < < <0.1 HP Non-Specialized Ambulatory Health Care Centers 8, , , , HP All Other Ambulatory Centers 1, , , , HP.3.nec Unspecified Providers of Ambulatory Health Care < < < <0.1 HP.4 Providers Of Ancillary Services 5, , , , HP.4.1 Providers of Patient Transportation And Emergency Rescue , , , HP.4.2 Medical and Diagnostic Laboratories 4, , , , HP.5 Retailers and Other Providers of Medical Goods 40, , , , HP.5.1 Pharmacies 39, , , , HP Allopathic Pharmacies/Dispensaries 38, , , , HP Non-Allopathic Pharmacies/Dispensaries HP.5.1.nec Other Pharmacies < < < <0.1 HP.5.2 Retail Sellers and Other Suppliers of Durable Medical Goods and Medical Appliances 1, , , , HP.6 Providers of Preventive Care 8, , , , HP.7 Providers of Health Care System Administration and Financing 3, , , , HP.7.1 Government Health Administration Agencies 2, , , , HP.7.2 Social Health Insurance Agencies < < < <0.1 HP.7.3 Private Health Insurance Administration Agencies HP.7.9 Other Administration Agencies 1, , HP.8 Rest of Economy 1, , , HP.8.2 All Other Industries as Secondary Providers of Health Care 1, , , HP.8.9 Other Industries < HP.9 Rest of The World 1, , , , HP.nec Unspecified Health Care Providers 6, , , , Total 90, , , , , , , ,

67 Table 7. Distribution of CHE by Factors of Health Care Provision (s in Million) FP Code Factors of Health Care Provision (NPR) 2012/ / / /16 Amoun t (USD) % FP.1 Compensation of Employees 12, , , , FP.1.1 Wages and Salaries 11, , , , FP.1.2 Social Contributions 1, , , , FP.1.3 All Other Costs Related to Employees FP.2 Self-Employed Professional Remuneration FP.3 Materials and Services Used 75, , , , , , FP.3.1 Health Care Services 24, , , , FP Laboratory & Imaging Services 4, , , , FP.3.1.nec Other Health Care Services 20, , , , FP.3.2 Health Care Goods 44, , , , FP Pharmaceuticals 43, , , , FP TB Drugs <0.1 FP Antimalarial Medicines FP Other Antimalarial Medicines FP Vaccines < <0.1 1, FP Contraceptives < FP nec Other Pharmaceuticals 42, , , , FP Other Health Care Goods 1, , , , FP nec Other and Unspecified Health Care Goods 1, , , , FP.3.3 Non-Health Care Services 2, , , , FP Training , FP Technical Assistance , , , FP Operational Research FP.3.3.nec Other Non-Health Care Services 1, , , , FP.3.4 Non-Health Care Goods < < <0.1 FP.3.nec Other Materials and Services Used 3, , , , FP.4 Consumption of Fixed Capital < < FP.5 Other Items of Spending on Inputs , , , FP.5.1 Taxes < < FP.5.2 Other Items of Spending , , , FP.nec Unspecified Factors of Health Care Provision (NPR) Amoun t (USD) Total 90, , , , , , , , % (NPR) (USD) % (NPR) (USD) % 45

68 Table 8. Distribution of CHE by Health Care Functions (s in Million) HC Code Health Care Functions (NPR) 2012/ / / /16 (USD) % HC.1 Curative Care 21, , , , HC.1.1 Inpatient Curative Care 6, , , , HC General Inpatient Curative Care 4, , , , HC Specialized Inpatient Curative Care 2, , , , HC.1.1.nec Unspecified Inpatient Curative Care < < < <0.1 HC.1.3 Outpatient Curative Care 11, , , , HC General Outpatient Curative Care 8, , , , HC Dental Outpatient Curative Care , HC Specialized Outpatient Curative Care 1, , , , HC.1.3.nec Unspecified Outpatient Curative Care HC.1.nec Unspecified Curative Care 3, , , , HC.2 Rehabilitative Care HC.2.3 Outpatient Rehabilitative Care < < < <0.1 HC.2.4 Home-Based Rehabilitative Care < < HC.2.nec Unspecified Rehabilitative Care HC.4 Ancillary Services (Non-Specified By Function) 5, , , , HC.4.1 Laboratory Services 3, , , , HC.4.2 Imaging Services 1, , , , HC.4.3 Patient Transportation , , , HC.4.nec Unspecified Ancillary Services < < <0.1 HC.5 Medical Goods (Non-Specified By Function) 42, , , , HC.5.1 Pharmaceuticals and Other Medical Non-Durable Goods 41, , , , HC Prescribed Medicines 23, , , , HC Allopathic Medicines 23, , , , HC Non-Allopathic Medicines HC Over-The-Counter Medicines 17, , , , HC Allopathic Medicine 17, , , , HC Non-Allopathic Medicine HC Other Medical Non-Durable Goods HC.5.2 Therapeutic Appliances and Other Medical Goods HC HC Other Orthopedic Appliances and Prosthetics (Excluding Glasses and Hearing Aids) All Other Medical Durables, Including Medical Technical Devices (NPR) (USD) % (NPR) (USD) % (NPR) (USD) < < HC.6 Preventive Care 14, , , , HC.6.1 Information, Education and Counseling (IEC) Programs 3, , , , HC Addictive Substances IEC Programs < < < <0.1 % 46

69 HC Code HC ne c Health Care Functions Other and Unspecified Addictive Substances IEC Programs (NPR) 2012/ / / /16 (USD) % (NPR) (USD) % (NPR) (USD) % (NPR) (USD) < < < <0.1 HC Nutrition IEC Programs <0.1 HC Safe Sex IEC Programs < < HC.6.1.nec Other and Unspecified IEC Programs 3, , , , HC.6.2 Immunization Programs <0.1 HC.6.3 Early Disease Detection Programs HC.6.4 Healthy Condition Monitoring Programs 4, , , , HC.6.5 Epidemiological Surveillance and Risk and Disease Control Programs 1, , , HC Planning & Management HC Monitoring & Evaluation (M&E) HC Procurement & Supply Management HC Interventions 1, <0.1 1, HC Syringe-Exchange Programs < HC Drug Substitution Programs < HC ne c Other and Unspecified Interventions 1, <0.1 1, HC.6.5.nec Unspecified Epidemiological Surveillance and Risk and Disease Control Programs < HC.6.6 Preparing for Disaster and Emergency Response Programs , HC.6.nec Unspecified Preventive Care 4, , , , HC.7 Governance, and Health System and Financing Administration 2, , , , HC.7.1 Governance and Health System Administration 2, , , , HC Planning & Management 1, , , , HC Monitoring & Evaluation (M&E) , HC Procurement & Supply Management <0.1 HC.7.1.nec Other Governance and Health System Administration , , , HC.7.2 Administration of Health Financing HC.7.nec HC.9 Unspecified Governance, and Health System and Financing Administration Other Health Care Services Not Elsewhere Classified , , , , Total 90, , , , , , , , % 47

70 Table 9. Distribution of Disease/Health Conditions Expenditures According to Age, 2014/15 (s in Million) Disease Code Classification of Diseases / Conditions NPR Age < 5 Years Old 5 Years Old USD Percent NPR USD Percent Other and Unspecified Age NPR USD Percent NPR Total USD Percent DIS.1 Infectious and Parasitic Diseases , , , DIS.1.1 HIV/AIDS and Other Sexually Transmitted Diseases (STDs) , , DIS.1.1.nec Unspecified HIV/AIDS and Other STDS , , DIS.1.2 Tuberculosis (TB) DIS.1.2.nec Unspecified Tuberculosis DIS.1.3 Malaria DIS.1.4 Respiratory Infections , , , DIS.1.5 Diarrheal Diseases , , , DIS.1.6 Neglected Tropical Diseases < < DIS.1.7 Vaccine Preventable Diseases DIS.1.nec Other and Unspecified Infectious and Parasitic Diseases , , , DIS.2 Reproductive Health , , DIS.2.1 Maternal Conditions , , DIS.2.2 Perinatal Conditions DIS.2.3 Contraceptive Management (Family Planning) DIS.2.nec Unspecified Reproductive Health Conditions , , DIS.3 Nutritional Deficiencies , , , DIS.4 Noncommunicable Diseases , , , DIS.4.1 Neoplasms , DIS.4.2 Endocrine and Metabolic Disorders DIS Diabetes

71 Disease Code DIS.4.2.nec Classification of Diseases / Conditions Other and Unspecified Endocrine and Metabolic Disorders NPR 23.8 Age < 5 Years Old 5 Years Old USD 0.2 Percent NPR USD Percent Other and Unspecified Age NPR USD Percent NPR Total USD Percent DIS.4.3 Cardiovascular Diseases , , , DIS Hypertensive Diseases DIS.4.3.nec Other and Unspecified Cardiovascular Diseases , , DIS.4.4 Mental & Behavioral Disorders, and Neurological Conditions , , , DIS Mental (Psychiatric) Disorders DIS Behavioral Disorders < DIS Neurological Conditions DIS.4.4.nec Unspecified Mental & Behavioral Disorders and Neurological Conditions , , DIS.4.5 Respiratory Diseases , , DIS.4.6 Diseases of the Digestive , , , DIS.4.7 Diseases of the Genito-Urinary System , , DIS.4.8 Sense Organ Disorders , , DIS.4.9 Oral Diseases , DIS.4.nec Other and Unspecified Non-Communicable Diseases , , , DIS.5 Injuries , , , DIS.6 Non-Disease Specific < <0.1 2, , DIS.nec Other and Unspecified Diseases/Conditions , , All DIS 3, , , , ,

72 Table 10. Distribution of Disease/Health Conditions Expenditures According to Sex, 2014/15 (s in Million) Disease Code Classification of Diseases / Conditions NPR Female USD Percent NPR Gender Male USD Percent Other and Unspecified Sex NPR USD Percent NPR Total USD Percent DIS.1 Infectious and Parasitic Diseases 4, , , , DIS.1.1 HIV/AIDS and Other Sexually Transmitted Diseases (STDs) , , DIS.1.1.nec Unspecified HIV/AIDS and Other STDS , , DIS.1.2 Tuberculosis (TB) DIS.1.2.nec Unspecified Tuberculosis DIS.1.3 Malaria DIS.1.4 Respiratory Infections 1, , , , DIS.1.5 Diarrheal Diseases , , DIS.1.6 Neglected Tropical Diseases < DIS.1.7 Vaccine Preventable Diseases DIS.1.nec Other and Unspecified Infectious and Parasitic Diseases 1, , , , DIS.2 Reproductive Health 14, , DIS.2.1 Maternal Conditions 10, , DIS.2.2 Perinatal Conditions < DIS.2.3 Contraceptive Management (Family Planning) < DIS.2.nec Unspecified Reproductive Health Conditions 3, , DIS.3 Nutritional Deficiencies , , DIS.4 Noncommunicable Diseases 5, , , , DIS.4.1 Neoplasms , DIS.4.2 Endocrine and Metabolic Disorders

73 Disease Code Classification of Diseases / Conditions NPR Female USD Percent NPR Gender Male USD Percent Other and Unspecified Sex NPR USD Percent NPR Total USD Percent DIS Diabetes DIS.4.2.nec Other and Unspecified Endocrine and Metabolic Disorders DIS.4.3 Cardiovascular Diseases , , DIS Hypertensive Diseases DIS.4.3.nec Other and Unspecified Cardiovascular Diseases , , DIS.4.4 Mental & Behavioral Disorders, and Neurological Conditions , , DIS Mental (Psychiatric) Disorders DIS Behavioral Disorders < DIS Neurological Conditions DIS.4.4.nec Unspecified Mental & Behavioral Disorders and Neurological Conditions , , DIS.4.5 Respiratory Diseases , , DIS.4.6 Diseases of the Digestive , , DIS.4.7 Diseases of the Genito-Urinary System , , DIS.4.8 Sense Organ Disorders , , DIS.4.9 Oral Diseases , DIS.4.nec Other and Unspecified Non-communicable Diseases 2, , , , DIS.5 Injuries 1, , , , DIS.6 Non-Disease Specific < <0.1 2, , DIS.nec Other and Unspecified Diseases/Conditions , , All DIS 27, , , , ,

74 Table 11. Distribution of Disease/Health Conditions Expenditures According to Age, 2015/16 (s in Million) Disease Code Classification of Diseases / Conditions NPR Age < 5 Years Old 5 Years Old USD Percent NPR USD Percent Other and Unspecified Age NPR USD Percent NPR Total USD Percent DIS.1 Infectious and Parasitic Diseases 1, , , , DIS.1.1 HIV/AIDS and Other Sexually Transmitted Diseases (STDs) , , DIS.1.1.nec Unspecified HIV/AIDS and Other STDS , , DIS.1.2 Tuberculosis (TB) DIS.1.2.nec Unspecified Tuberculosis DIS.1.3 Malaria DIS.1.4 Respiratory Infections , , , DIS.1.5 Diarrheal Diseases , , , DIS.1.6 Neglected Tropical Diseases < < DIS.1.7 Vaccine Preventable Diseases , , DIS.1.nec Other and Unspecified Infectious and Parasitic Diseases , , , DIS.2 Reproductive Health , , , DIS.2.1 Maternal Conditions , , DIS.2.2 Perinatal Conditions DIS.2.3 Contraceptive Management (Family Planning) , , DIS.2.nec Unspecified Reproductive Health Conditions , , , DIS.3 Nutritional Deficiencies 4, , , , DIS.4 Noncommunicable Diseases 1, , , , DIS.4.1 Neoplasms , DIS.4.2 Endocrine and Metabolic Disorders <

75 Disease Code Classification of Diseases / Conditions NPR Age < 5 Years Old 5 Years Old USD Percent NPR USD Percent Other and Unspecified Age NPR USD Percent NPR Total USD Percent DIS Diabetes <0.1 DIS.4.2.nec Other and Unspecified Endocrine and Metabolic Disorders < DIS.4.3 Cardiovascular Diseases , , , DIS Hypertensive Diseases DIS.4.3.nec Other and Unspecified Cardiovascular Diseases , , DIS.4.4 Mental & Behavioral Disorders, and Neurological Conditions , , , DIS Mental (Psychiatric) Disorders DIS Behavioral Disorders < < DIS Neurological Conditions DIS.4.4.nec Unspecified Mental & Behavioral Disorders and Neurological Conditions , , DIS.4.5 Respiratory Diseases < DIS.4.6 Diseases of the Digestive , , , DIS.4.7 Diseases of the Genito-Urinary System < DIS.4.8 Sense Organ Disorders , DIS.4.9 Oral Diseases , DIS.4.nec Other and Unspecified Non-Communicable Diseases , , , DIS.5 Injuries , , , DIS.6 Non-Disease Specific , , DIS.nec Other and Unspecified Diseases/Conditions , , , All DIS 9, , , , ,

76 Table 12. Distribution of Disease/Health Conditions Expenditures According to Sex, 2015/16 (s in Million) Disease Code Classification of Diseases / Conditions NPR Female USD Percent NPR Gender Male USD Percent Other and Unspecified Sex NPR USD Percent NPR Total USD Percent DIS.1 Infectious and Parasitic Diseases 6, , , , DIS.1.1 HIV/AIDS and Other STDs , , DIS.1.1.nec Unspecified HIV/AIDS and Other STDS , , DIS.1.2 Tuberculosis (TB) DIS.1.2.nec Unspecified Tuberculosis DIS.1.3 Malaria DIS.1.4 Respiratory Infections 2, , , , DIS.1.5 Diarrheal Diseases , , DIS.1.6 Neglected Tropical Diseases < < DIS.1.7 Vaccine Preventable Diseases , , DIS.1.nec Other and Unspecified Infectious and Parasitic Diseases 2, , , , DIS.2 Reproductive Health 4, , , DIS.2.1 Maternal Conditions 2, , DIS.2.2 Perinatal Conditions DIS.2.3 Contraceptive Management (Family Planning) , , DIS.2.nec Unspecified Reproductive Health Conditions 1, , , DIS.3 Nutritional Deficiencies 1, , , DIS.4 Noncommunicable Diseases 8, , , , DIS.4.1 Neoplasms , DIS.4.2 Endocrine and Metabolic Disorders < DIS Diabetes <0.1 DIS.4.2.nec Other and Unspecified Endocrine and Metabolic Disorders <

77 Disease Code Classification of Diseases / Conditions NPR Female USD Percent NPR Gender Male USD Percent Other and Unspecified Sex NPR USD Percent NPR Total USD Percent DIS.4.3 Cardiovascular Diseases , , DIS Hypertensive Diseases DIS.4.3.nec Other and Unspecified Cardiovascular Diseases , , DIS.4.4 Mental & Behavioral Disorders, and Neurological Conditions , , DIS Mental (Psychiatric) Disorders DIS Behavioral Disorders DIS Neurological Conditions DIS.4.4.nec Unspecified Mental & Behavioral Disorders and Neurological Conditions , , DIS.4.5 Respiratory Diseases < DIS.4.6 Diseases of the Digestive 1, , , DIS.4.7 Diseases of the Genito-Urinary System < DIS.4.8 Sense Organ Disorders , DIS.4.9 Oral Diseases , DIS.4.nec Other and Unspecified Non-Communicable Diseases 3, , , , DIS.5 Injuries 1, , , DIS.6 Non-Disease Specific , , DIS.nec Other and Unspecified Diseases/Conditions 1, , , All DIS 24, , , , ,

78 Table 13. Distribution of OOP Expenditure by Health Care Functions (s in Million) OOP Distribution by Function Code Health Care Functions 2012/ / / /16 (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % HC.1 Curative Care 11, , , , HC.1.1 Inpatient Curative Care 5, , , , HC General Inpatient Curative Care 3, , , , HC Specialized Inpatient Curative Care 1, , , , HC.1.3 Outpatient Curative Care 3, , , , HC General Outpatient Curative Care 2, , , , HC Dental Outpatient Curative Care , HC Specialized Outpatient Curative Care , HC.1.nec Unspecified Curative Care 2, , , , HC.1+HC.2 Curative Care and Rehabilitative Care 11, , , , HC.1.1+HC.2. 1 Inpatient Curative and Rehabilitative Care 5, , , , HC.1.3+HC.2.3 Outpatient Curative and Rehabilitative Care 3, , , , HC.1.nec + HC.2.nec Other Curative and Rehabilitative Care 2, , , , HC.4 Ancillary Services (Non-Specified by Function) 5, , , , HC.4.1 Laboratory Services 3, , , , HC.4.2 Imaging Services 1, , , , HC.4.3 Patient Transportation , , , HC.5 Medical Goods (Non-Specified by Function) 40, , , , HC.5.1 Pharmaceuticals and Other Medical Non-Durable Goods 40, , , , HC Prescribed Medicines 22, , , , HC Allopathic Prescribed Medicines 22, , , , HC Over-the-Counter Medicines 17, , , , HC Allopathic Over-the-Counter Medicines 17, , , , HC Non-Allopathic Over-the-Counter Medicines HC Other Medical Non-Durable Goods HC.5.2 Therapeutic Appliances and Other Medical Goods HC All Other Medical Durables, Including Medical Technical Devices All HC 57, , , ,

79 Table 14. Distribution of OOP Expenditure by Health Care Providers (s in Million) OOP Distribution by Provider Code Health Care Providers 2012/ / / /16 (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % (NPR) (USD) % HP.1 Hospitals 6, , , , HP.1.1 General Hospitals 4, , , , HP Public General Hospitals 1, , , , HP National/Central Hospitals , HP Regional/Zonal Hospitals HP District Level & Other Public General Hospita HP Private (for Profit) General Hospitals 3, , , , HP.1.2 Mental Health Hospitals HP Public Mental Health Hospitals < < < <0.1 HP Private (for Profit) Mental Health Hospitals HP.1.3 Specialized Hospitals (Other than Mental Health Hospitals) 2, , , , HP Public Specialized Hospitals , , , HP Private (for Profit) Specialized Hospitals 1, , , , HP.3 Providers of Ambulatory Health Care 1, , , , HP.3.1 Medical Practices , , HP Offices of General Medical Practitioners HP Offices of Mental Medical Specialists HP.3.2 Dental Practice , HP.3.4 Ambulatory Health Care Centers < < < <0.1 HP Non-Specialized Ambulatory Health Care Centers < < < <0.1 HP.4 Providers of Ancillary Services 5, , , , HP.4.1 Providers of Patient Transportation and Emergency Rescue , , , HP.4.2 Medical and Diagnostic Laboratories 4, , , , HP.5 Retailers and Other Providers of Medical Goods 40, , , , HP.5.1 Pharmacies/Dispensaries 39, , , , HP Allopathic Pharmacies/Dispensaries 38, , , , HP Non- Allopathic Pharmacies Dispensaries HP.5.2 Retail Sellers and Other Suppliers of Durable Medical Goods and Medical 1, , , , Appliances HP.9 Rest of the World 1, , , , HP.nec Unspecified Health Care Providers 2, , , , All HP 57, , , ,

80 Table 15. Distribution of Capital Formation (s in Million) Code Description (NPR) Distribution of Capital Formation expenditure 2012/ / / /16 (USD) % HK.1 Gross capital formation 7, , , , HK.1.1 Gross fixed capital formation 4, , , , HK Infrastructure 3, , , , HK Residential and non-residential buildings 3, , , , HK Other structures HK Machinery and equipment 1, , , HK Medical equipment HK Transport equipment HK ICT equipment HK Machinery and equipment n.e.c , HK Intellectual property products HK Computer software and databases HK Intellectual property products n.e.c HK.1.2 Changes in inventories HK.1.nec Unspecified gross capital formation 2, , , , HK.2 Non-produced non-financial assets HK.2.1 Land HK.nec Unspecified gross fixed capital formation (NPR) ALL HK 7, , , , (USD) % (NPR) (USD) % (NPR) (USD) % 58

81 Annex A: Detailed NHA Cross-Tables to

82 HF.4 Rest of the world financing (nonresident) HF.3 HH OOPs HF.2 Voluntary health care payment HF.1 Government and compulsory contributory health care financing Internal transfers and grants Transfers by government on behalf of specific groups Other transfers from government domestic revenue Transfers distributed by government from foreign origin Voluntary prepayment from employers Other revenues from households n.e.c. Other revenues from corporations n.e.c. Other revenues from NPISH n.e.c. Direct bilateral financial transfers Direct multilateral financial transfers Other direct foreign financial transfers Annex A.1: Expenditures on Health Care by Health Care Financing Schemes and Revenues of Financing Scheme (2012/13) (HFXFS) Revenues of health care financing FS.1 Transfers from government domestic revenue (allocated to health purposes) FS.2 FS.5 Voluntary prepayment FS.6 Other domestic revenues n.e.c. FS FS FS All FS FS.1.1 FS.1.2 FS.1.4 FS.5.2 FS.6.1 FS.6.2 FS.6.3 Financing HF.1.1 Government HF.1.2 Compulsory contributory health insurance HF.2.1 Voluntary health insurance HF.2.2 NPISH financing (including development agencies) HF.2.3 Enterprise financing HF.3.1 HF.4.2 Voluntary (nonresident) HF Central government 14, , ,124 HF State/regional/local government HF Social health insurance HF.2.1.ne c HF HF.2.2.ne c HF HF HF Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Unspecified NPISH financing Enterprises (except health care providers) financing Out-of-pocket excluding costsharing Philanthropy/international NGOs Foreign development agencies , , , , , , ,664 1, ,690 2,29 7 2,297 All HF 14, , ,342 1,831 5,003 1,664 1,027 2,297 90,255 60

83 HC. 5 Med ical good HC.5.1 s (non - spec Phar mac eutic al ified by func tion) HC.4 Ancillary services (nonspecified by function) HC.1+HC.2 Curative care and rehabilitative care HC.2 Rehabilitat ive care HC.1 Curative care HC.1.3 Outpatient curative care HC.1.1 Inpatient curative care Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Unspecified NPISH financing Enterprises (except health care providers) financing Out-of-pocket excluding costsharing Philanthropy/international NGOs Foreign development agencies Annex A.2: Expenditures on Health Care by Health Care Functions and Health Care Financing Schemes (2012/13) (HCXHF) Financing HF.1 Government and compulsory contributory health care financing HF.2 Voluntary health care payment HF.3 Househol d out-ofpocket payment HF.4 Rest of the world financing (nonresident) HF HF HF HF.2.1.nec HF HF.2.2.nec HF HF.3.1 HF HF All HF Health care functions HC General inpatient curative care , ,575 HC Specialized inpatient curative care 464 HC.1.1.nec Unspecified inpatient curative care ,188 0 HC General outpatient curative care 6, , ,303 HC Dental outpatient curative care HC Specialized outpatient curative care 551 HC.1.3.nec Unspecified outpatient curative care , HC.1.nec Unspecified curative care - 3, , HC.2.3 Outpatient rehabilitative care HC.2.nec Unspecified rehabilitative care HC.1.1+HC.2.1 HC.1.3+HC.2.3 HC.1.nec + HC.2.nec Inpatient curative and rehabilitative care Outpatient curative and rehabilitative care 1, , ,764 6, , ,230 Other curative and rehabilitative care , ,815 HC.4.1 Laboratory services , ,579 HC.4.2 Imaging services , ,088 HC.4.3 Patient transportation HC.4.nec Unspecified ancillary services HC Allopathic prescribed medicines 1, , ,285 61

84 HC.6.5 Epidemiological surveillance and risk and disease control programs HC.6 Preventive care HC.6.1 Information, education and counseling (IEC) programs HC.5.2 Therapeutic appliances and Other medical goods Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Unspecified NPISH financing Enterprises (except health care providers) financing Out-of-pocket excluding costsharing Philanthropy/international NGOs Foreign development agencies Financing HF.1 Government and compulsory contributory health care financing HF.2 Voluntary health care payment HF.3 Househol d out-ofpocket payment HF.4 Rest of the world financing (nonresident) All HF HF HF HF HF.2.1.nec HF HF.2.2.nec HF HF.3.1 HF HF Health care functions HC Allopathic over-the-counter medicines , ,086 HC Non-allopathic over-the-counter medicines HC Other medical non-durable goods HC All Other medical durables, including medical technical devices HC Addictive substances IEC programs HC Nutrition IEC programs HC Safe sex IEC programs HC.6.1.nec Other and unspecified IEC programs ,183 HC.6.2 Immunization programs HC.6.3 Early disease detection programs HC.6.4 Healthy condition monitoring programs 2, ,919 HC Planning & Management HC Monitoring & Evaluation (M&E) HC Procurement & supply management HC Syringe-exchange programs HC nec HC.6.5.nec Other and unspecified interventions Unspecified epidemiological surveillance and risk and disease control programs , ,

85 HC.7 Governance, and health system and financing administration HC.7.1 Governance and Health system administration Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Unspecified NPISH financing Enterprises (except health care providers) financing Out-of-pocket excluding costsharing Philanthropy/international NGOs Foreign development agencies Financing HF.1 Government and compulsory contributory health care financing HF.2 Voluntary health care payment HF.3 Househol d out-ofpocket payment HF.4 Rest of the world financing (nonresident) All HF HF HF HF HF.2.1.nec HF HF.2.2.nec HF HF.3.1 HF HF Health care functions HC.6.6 Preparing for disaster and emergency response programs HC.6.nec Unspecified preventive care 2, , ,088 HC Planning & Management ,100 HC Monitoring & Evaluation (M&E) HC Procurement & supply management HC.7.1.nec Other governance and Health system administration HC.7.nec Unspecified governance, and health system and financing administration HC.9 Other health care services not elsewhere classified 2, ,685 All HC 20, , ,831 57,342 2,297 2,690 90,255 63

86 HC. 9 HC.7 HC.6 HC.5 HC.4 HC.2 HC.1 General hospitals Mental health hospitals Specialized hospitals (Other than mental health hospitals) Unspecified hospitals Other residential long-term care facilities Medical practices Dental practice Ambulatory health care centers Unspecified providers of ambulatory health care Providers of patient transportation and emergency Medical and diagnostic laboratories Pharmacies/dispensaries Retail sellers and Other suppliers of durable medical goods and medical Government health administration agencies Social health insurance Private health insurance administration agencies Other administration agencies All Other industries as secondary providers of health Community health workers (or village health worker, community Rest of the world HP.1.1 HP.1.2 HP.1.3 HP.1.nec HP.2.9 HP.3.1 HP.3.2 HP.3.4 HP.3.nec HP.4.1 HP.4.2 HP.5.1 HP.5.2 Providers of preventive HP.7.1 HP.7.2 HP.7.3 HP.7.9 HP.8.2 HP.8.3 Unspecified health care providers Annex A.3: Expenditures on Health Care by Health Care Functions and Health Care Providers (2012/13) (HCXHP) Health care providers HP.1 HP.2 HP.3 HP.4 HP.5 HP.6 HP.7 HP.8 HP.9 HP.nec All HP Health care functions HC.1.1 Inpatient curative care 4, , ,764 HC.1.3 Outpatient curative care 3, , , ,227 HC.1.nec Unspecified curative care ,528 3,403 HC.2.3 Outpatient rehabilitative care HC.2.nec Unspecified rehabilitative care HC.4.1 Laboratory services 1 3,578 3,579 HC.4.2 Imaging services 1,088 1,088 HC.4.3 Patient transportation HC.4.nec Unspecified ancillary services 0 0 HC.5.1 Pharmaceuticals and Other medical non-durable goods , ,869 HC.5.2 Therapeutic appliances and Other medical goods HC.6.1 Information, education and counseling (IEC) programs , ,514 HC.6.2 Immunization programs HC.6.3 Early disease detection programs HC.6.4 Healthy condition monitoring programs 149 2,601 1, ,360 HC.6.5 Epidemiological surveillance and risk and disease control programs 1 9 1,915 1,925 HC.6.6 Preparing for disaster and emergency response programs HC.6.nec Unspecified preventive care 2 1,001 2, , ,538 HC.7.1 Governance and Health system administration 1, ,363 HC.7.nec Unspecified governance, and health system and financing administration Other health care services not elsewhere classified ,659 3,685 All HC 7, , , ,694 39,282 1,172 8,669 2, ,018 1, ,047 6,187 90,255 64

87 14,760 1, , , ,893 5,003 57,342 4,988 90,255 HF.4 Rest of the world HF.3 HH OOP HF.2 Voluntary health care payment HF.2.3 Enterpr ise financi ng scheme s HF.2.2 NPISH financing (including development HF.2.1 Voluntar y health insuranc e HF.1 Govt. & compulsory contributory health HF.1.2 Compulsor y contributor y health insurance HF.1.1 Gover nment Ministry of Health Ministry of Education Ministry of General Administration Ministry of Home Affairs Ministry of Defense Ministry of Agriculture Development Ministry of Federal Affairs and Local Ministry of Commerce and Supply Ministry of Finance Other ministries and public units (belonging to central government) District Development Committees Municipalities Village Development Committees Social Health Insurance Commercial insurance companies Corporations (Other than providers of health services) FA FA FA FA FA FA FA FA FA FA nec FA FA FA FA FA.2.1 FA.3.2 Non-profit institutions serving households (NPISH) International organisations Households FA.6.1 Annex A.4: Expenditures on Health Care by Health Care Financing Schemes and Health Care Financing Agents (2012/13) (HFXFA) Financing agents FA.1 General government FA.2 Insurance corporations FA.3 Corporation s) FA.4 FA.5 FA.6 Rest of the world All FA Financing HF Central government 14,71 5 1, , , ,124 HF Social health insurance HF.2.1.ne c Unspecified voluntary health insurance HF NPISH financing (excluding HF.2.2.2) , ,045 HF.2.2.ne c Unspecified NPISH financing HF Enterprises (except health care providers) financing , ,831 HF.3.1 Out-of-pocket excluding cost-sharing , ,342 HF Other (nonresident) HF HF Philanthropy/internatio nal NGOs Foreign development agencies ,297 2, ,690 2,690 All HF 65

88 HP.3 Providers of ambulatory health care HP.1 Hospitals Wages and salaries Social contributions All Other costs related to employees FP.1.1 FP.1.2 FP.1.3 Self-employed professional remuneration Laboratory & Imaging services Other health care services TB drugs Other antimalarial medicines Vaccines Other pharmaceuticals Other and unspecified health care goods Training Technical Assistance Operational research Other non-health care services Non-health care goods Other materials and services used FP FP.3.1.nec FP FP FP FP nec FP nec FP FP FP FP.3.3.nec FP.3.4 FP.3.nec Consumption of fixed capital Taxes Other items of spending Unspecified factors of health care provision FP.5.1 FP.5.2 Annex A.5: Expenditures on Health Care by Health Care Providers and Factors of Health Care Provision (2012/13) (HPXFP) Factors of health care provision FP.1 Compensation of employees F P. 2 FP.3 Materials and services used FP. 4 FP.5 Other items of spending on inputs FP.nec All FP Health care providers HP National/Central hospitals ,213 HP Public general hospitals HP HP Regional/Zonal hospitals District level and other public general hospitals ,246 HP n ec Other Public general hospitals HP Private (for profit) general hospitals HP.1.1.ne c Other General hospitals HP.1.2 Mental health hospitals HP HP Public mental health hospitals Private (for profit) mental health hospitals HP Public specialized hospitals HP.1.3 Specialized hospitals (Other than mental health hospitals) HP HP.1.3.ne c Private (for profit) specialized hospitals Other Specialized hospitals (Other than mental health hospitals) HP.1.nec Unspecified hospitals HP.2 Residential long-term care facilities HP.2.9 Other residential longterm care facilities HP.3.1 Medical practices HP HP Offices of general medical practitioners Offices of mental medical specialists

89 HP.5 Retailers and Other providers of medical goods HP.4 Providers of ancillary services Wages and salaries Social contributions All Other costs related to employees FP.1.1 FP.1.2 FP.1.3 Self-employed professional remuneration Laboratory & Imaging services Other health care services TB drugs Other antimalarial medicines Vaccines Other pharmaceuticals Other and unspecified health care goods Training Technical Assistance Operational research Other non-health care services Non-health care goods Other materials and services used FP FP.3.1.nec FP FP FP FP nec FP nec FP FP FP FP.3.3.nec FP.3.4 FP.3.nec Consumption of fixed capital Taxes Other items of spending Unspecified factors of health care provision FP.5.1 FP.5.2 Factors of health care provision FP.1 Compensation of employees F P. 2 FP.3 Materials and services used FP. 4 FP.5 Other items of spending on inputs FP.nec All FP Health care providers HP.3.1.ne c Unspecified medical practices HP.3.4 Ambulatory health care centers HP.3.2 Dental practice HP.3.nec HP.4.1 HP.4.2 HP.5.1 Pharmacies/dispensari es HP.5.2 HP HP HP HP HP HP HP.5.1.ne c Family planning centers Ambulatory mental health and substance abuse centers Non-specialized ambulatory health care centers All Other ambulatory centers Unspecified providers of ambulatory health care Providers of patient transportation and emergency rescue Medical and diagnostic laboratories Allopathic pharmacies/dispensari es Non- allopathic pharmacies dispensaries Other Pharmacies/dispensari es Retail sellers and Other suppliers of durable medical goods and medical appliances HP.6 Providers of preventive care 2, , , , , , , , , , , ,360 67

90 HP.8 Rest of the Nepalese economy HP.7 Providers of health care system administration and financing Wages and salaries Social contributions All Other costs related to employees FP.1.1 FP.1.2 FP.1.3 Self-employed professional remuneration Laboratory & Imaging services Other health care services TB drugs Other antimalarial medicines Vaccines Other pharmaceuticals Other and unspecified health care goods Training Technical Assistance Operational research Other non-health care services Non-health care goods Other materials and services used FP FP.3.1.nec FP FP FP FP nec FP nec FP FP FP FP.3.3.nec FP.3.4 FP.3.nec Consumption of fixed capital Taxes Other items of spending Unspecified factors of health care provision FP.5.1 FP.5.2 Factors of health care provision FP.1 Compensation of employees F P. 2 FP.3 Materials and services used FP. 4 FP.5 Other items of spending on inputs FP.nec All FP Health care providers HP.7.1 Government health administration agencies ,359 HP.7.2 Social health insurance agencies HP.7.3 HP.7.9 HP.8.2 Private health insurance administration agencies Other administration agencies All Other industries as secondary providers of health care , HP.9 Rest of the world ,047 HP.nec Unspecified health care providers , , ,187 All HP 11,197 1, ,637 20, ,35 8 1, , , ,255 68

91 Internal transfers and grants Transfers by government on behalf of specific groups Other transfers from government domestic revenue Transfers distributed by government from foreign origin Voluntary prepayment from employers Other revenues from households n.e.c. Other revenues from corporations n.e.c. Other revenues from NPISH n.e.c. Direct bilateral financial transfers Direct multilateral financial transfers Other direct foreign financial transfers Annex A.6: Expenditures on Health Care by Health Care Financing Schemes and Revenues of Financing Scheme (2013/14) (HFXFS) Revenues of health care financing FS.1 Transfers from government domestic revenue (allocated to health purposes) FS.2 FS.5 Voluntary prepayme nt FS.6 Other domestic revenues n.e.c. FS FS FS FS.1.1 FS.1.2 FS.1.4 FS.5.2 FS.6.1 FS.6.2 FS.6.3 All FS Financing HF.1 Government and compulsory contributory health care financing HF.2 Voluntary health care payment HF.3 Household out-ofpocket payment HF.4 Rest of the world financing (nonresident) HF.1.1 Government HF.1.2 Compulsory contributory health insurance HF.2.1 Voluntary health insurance HF.2.2 NPISH financing (including development agencies) HF.2.3 Enterprise financing HF Central government 18, HF State/regional/local government 6, , HF Social health insurance HF.2.1.ne c HF HF Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Enterprises (except health care providers) financing , , , ,406 68,04 HF.3.1 Out-of-pocket excluding cost-sharing ,041 1 Philanthropy/international NGOs HF.4.2 Voluntary HF ,180 3,180 (nonresident) HF ,166 1, ,200 Foreign development agencies All HF 19, , ,041 2,406 7,257 5,166 1,034 3, ,312 69

92 HC.4 Ancillary services (nonspecified by function) HC.1+HC.2 Curative care and rehabilitative care HC.2 Rehabilitative care HC.1 Curative care Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Enterprises (except health care providers) financing Out-of-pocket excluding cost-sharing Philanthropy/internation al NGOs Foreign development agencies Annex A.7: Expenditures on Health Care by Health Care Functions and Health Care Financing Schemes (2013/14) (HCXHF) Financing HF.1 Government and compulsory contributory health care financing HF.3 Household out-of-pocket payment HF.4 Rest of the world financing (non-resident) All HF HF HF HF HF.2.1.nec HF HF HF.3.1 HF HF Health care functions HC General inpatient curative care 1, , ,720 Specialized inpatient curative HC HC.1.1 Inpatient curative care care , ,074 HC.1.1.nec Unspecified inpatient curative care HC General outpatient curative care 7, , ,030 HC Dental outpatient curative care HC.1.3 Outpatient curative care Specialized outpatient curative HC care ,679 HC.1.3.nec Unspecified outpatient curative care HC.1.nec Unspecified curative care , , ,915 HC.2.3 Outpatient rehabilitative care HC.2.4 Home-based rehabilitative care HC.2.nec Unspecified rehabilitative care HC.1.1+HC.2.1 Inpatient curative and rehabilitative care 1, , ,849 HC.1.3+HC.2.3 Outpatient curative and rehabilitative care 8, , ,941 HC.1.4+HC.2.4 Home-based curative and rehabilitative care HC.1.nec + HC.2.nec Other curative and rehabilitative care , , ,099 HC.4.1 Laboratory services , ,031 HC.4.2 Imaging services , ,075 HC.4.3 Patient transportation , ,087 HC.4.nec Unspecified ancillary services

93 HC.6 Preventive care HC.5 Medical goods (non-specified by function) Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Enterprises (except health care providers) financing Out-of-pocket excluding cost-sharing Philanthropy/internation al NGOs Foreign development agencies Financing HF.1 Government and compulsory contributory health care financing HF.3 Household out-of-pocket payment HF.4 Rest of the world financing (non-resident) All HF HF HF HF HF.2.1.nec HF HF HF.3.1 HF HF Health care functions HC.5.1 Pharmaceuticals and Other medical nondurable goods HC Allopathic prescribed medicines , ,587 HC Overthe-counter medicines HC HC Allopathic over-the-counter medicines , ,369 Non allopathic over-the-counter medicines HC Other medical non-durable goods HC.5.2 Therapeutic appliances and Other medical goods HC.6.1 Information, education and counseling (IEC) programs HC HC nec All Other medical durables, including medical technical devices Other and unspecified addictive substances IEC programs HC Nutrition IEC programs HC Safe sex IEC programs HC.6.1.ne c Other and unspecified IEC programs , ,119 HC.6.2 Immunization programs HC.6.3 Early disease detection programs HC.6.4 Healthy condition monitoring programs 3, ,061 HC Planning & Management

94 HC.7 Governance, and health system and financing administration Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Enterprises (except health care providers) financing Out-of-pocket excluding cost-sharing Philanthropy/internation al NGOs Foreign development agencies Financing HF.1 Government and compulsory contributory health care financing HF.3 Household out-of-pocket payment HF.4 Rest of the world financing (non-resident) All HF HF HF HF HF.2.1.nec HF HF HF.3.1 HF HF Health care functions HC.6.5 Epidemiological surveillance and risk and disease control programs HC.6.6 HC.7.1 Governance and Health system administration HC Monitoring & Evaluation (M&E) HC Procurement & supply management HC Interventions HC.6.5.ne c Unspecified epidemiological surveillance and risk and disease control programs Preparing for disaster and emergency response programs HC.6.nec Unspecified preventive care 3, , ,926 HC.7.nec HC Planning & Management ,373 HC Monitoring & Evaluation (M&E) HC Procurement & supply management HC.7.1.ne c Other governance and Health system administration Unspecified governance, and health system and financing administration ,572 3, HC.9 Other health care services not elsewhere classified 3, ,055 All HC 25, ,344 2,406 68,041 3,180 6, ,312 72

95 HC.6 HC.5 HC.4 HC.2 HC.1 General hospitals Mental health hospitals Specialized hospitals (Other than mental health hospitals) Unspecified hospitals Other residential long-term care facilities Medical practices Dental practice Ambulatory health care centers Unspecified providers of ambulatory health care Providers of patient transportation Medical and diagnostic laboratories Pharmacies/dispensaries Retail sellers and Other suppliers of durable medical goods and medical appliances HP.1.1 HP.1.2 Providers of preventive care Government health administration agencies Social health insurance agencies Private health insurance administration agencies Other administration agencies All Other industries as secondary providers of Other industries n.e.c. Rest of the world HP.1.3 HP.1.nec HP.2.9 HP.3.1 HP.3.2 HP.3.4 HP.3.nec HP.4.1 HP.4.2 HP.5.1 HP.5.2 HP.7.1 HP.7.2 HP.7.3 HP.7.9 HP.8.2 HP.8.9 Unspecified health care providers Annex A.8: Expenditures on Health Care by Health Care Functions and Health Care Providers (2013/14) (HCXHP) HP.1 HP.2 HP.3 HP.4 HP.5 HP.6 HP.7 HP.8 HP.9 HP.nec All HP Health care providers Health care functions Nepalese Rupee (NPR), Million HC.1.1 HC.1.3 HC.1.nec HC.2.3 HC.2.4 HC.2.nec HC.4.1 Inpatient curative care Outpatient curative care Unspecified curative care Outpatient rehabilitative care Home-based rehabilitative care Unspecified rehabilitative care Laboratory services 7, , ,849 4, , , , , ,013 3, ,030 4,031 HC.4.2 Imaging services 1,075 1,075 HC.4.3 HC.4.nec HC.5.1 HC.5.2 HC.6.1 Patient transportation Unspecified ancillary services Pharmaceuticals and Other medical nondurable goods Therapeutic appliances and Other medical goods Information, education and counseling (IEC) 1 1,086 1, , , , ,369 73

96 HC.9 HC.7 General hospitals Mental health hospitals Specialized hospitals (Other than mental health hospitals) Unspecified hospitals Other residential long-term care facilities Medical practices Dental practice Ambulatory health care centers Unspecified providers of ambulatory health care Providers of patient transportation Medical and diagnostic laboratories Pharmacies/dispensaries Retail sellers and Other suppliers of durable medical goods and medical appliances HP.1.1 HP.1.2 Providers of preventive care Government health administration agencies Social health insurance agencies Private health insurance administration agencies Other administration agencies All Other industries as secondary providers of Other industries n.e.c. Rest of the world HP.1.3 HP.1.nec HP.2.9 HP.3.1 HP.3.2 HP.3.4 HP.3.nec HP.4.1 HP.4.2 HP.5.1 HP.5.2 HP.7.1 HP.7.2 HP.7.3 HP.7.9 HP.8.2 HP.8.9 Unspecified health care providers HP.1 HP.2 HP.3 HP.4 HP.5 HP.6 HP.7 HP.8 HP.9 HP.nec All HP Health care providers Health care functions Nepalese Rupee (NPR), Million HC.6.2 Immunization HC.6.3 HC.6.4 HC.6.5 HC.6.6 HC.6.nec Early disease detection Healthy condition monitoring Epidemiological surveillance and risk and disease control Preparing for disaster and emergency response Unspecified preventive care ,487 1,442 1,622 6, ,451 1, ,118 2, ,173 HC.7.1 HC.7.nec Governance and Health system administration Unspecified governance, and health system and financing administration Other health care services not elsewhere classified 5, , ,019 5,055 All HC 12, , , , ,086 5,151 44,117 1,272 10,340 5, ,046 1, ,243 7, ,312 74

97 HF.3 HH OOPs HF.2 Voluntary health care payment HF.1 Government and compulsory contributory health care financing Ministry of Health Ministry of Education Ministry of Gen. Admin. Ministry of Home Affairs Ministry of Defense Ministry of Agriculture Development Ministry of Federal Affairs and Local Development Ministry of Commerce and Supply Ministry of Finance Other ministries and public units (belonging to central government) District Development Committees Municipalities Village Development Committees Social Health Insurance Agency Commercial insurance companies Corporations (Other than providers of health services) FA FA FA FA FA FA FA FA FA FA nec FA FA FA FA FA.2.1 FA.3.2 Non-profit institutions serving International organizations Households Foreign governments Other foreign entities FA.6.1 FA.6.2 FA.6.3 FA.2 Insurance corporations FA.3 Corporations FA.4 FA.5 FA.6 Rest of the world Annex A.9: Expenditures on Health Care by Health Care Financing Schemes and Health Care Financing Agents (2013/14) (HFXFA) Financing agents FA.1 General Government All FA Financing HF.1.1 Government HF.1.2 Compulsory contributory health insurance HF.2.1 HF.2.1.nec HF.2.2 NPISH HF HF HF HF HF.2.3 Enterprise HF Voluntary (nonresident) HF.4 Rest of the world financing (nonresident) HF.4.2 HF.3.1 HF HF Central government State/regional/local government Social health insurance Voluntary health insurance Unspecified voluntary health insurance NPISH financing Enterprises financing Out-of-pocket excluding costsharing Philanthropy/internati onal NGOs Foreign development agencies 18,453 1, , , , , ,434 7, , , , , , , , ,200 All HF 18,541 1, , , , , , , ,312 75

98 HP.3 Providers of ambulatory health care HP.3.4 Ambulatory health care centers HP.3.1 Medical practices HP.2 HP.1.3 Specialized hospitals (Other than mental health hospitals) HP.1 Hospitals HP.1.2 Mental health hospitals HP Public general hospitals Wages and salaries Social contributions All Other costs related to employees Self-employed professional Laboratory & Imaging services Other health care services TB drugs Antimalarial medicines Other antimalarial medicines Vaccines Other pharmaceuticals Other and unspecified health care goods Training Technical Assistance Operational research Other non-health care services Non-health care goods Other materials and services used Consumption of fixed capital Taxes Other items of spending FP.1.1 FP.1.2 FP.1.3 FP FP.3.1.nec FP FP FP FP FP nec FP nec FP FP FP FP.3.3.nec FP.3.4 FP.3.nec FP.5.1 FP.5.2 Unspecified factors of health care provision Annex A.10: Expenditures on Health Care by Health Care Providers and Factors of Health Care Provision (2013/14) (HPXFP) Factors of health care provision FP.1 Compensation of employees FP.2 FP.3 Health care service used FP.4 FP.5 Other items of spending on inputs FP.nec All FP Health care providers HP National/Central hospitals 1, ,992 HP Regional/Zonal hospitals HP District level and other public general hospitals , ,030 HP nec Other Public general hospitals HP Private (for profit) general hospitals , ,419 HP.1.1.nec Other General hospitals HP Public mental health hospitals HP Private (for profit) mental health hospitals HP Public specialized hospitals 1, ,588 HP HP.1.3.ne c Private (for profit) specialized hospitals Other Specialized hospitals (Other than mental health hospitals) , , HP.1.nec Unspecified hospitals HP.2.9 Other residential long-term care facilities HP Offices of general medical practitioners HP Offices of mental medical specialists HP.3.1.ne c Unspecified medical practices HP.3.2 Dental practice HP Family planning centers HP Ambulatory mental health and substance abuse centers HP Non-specialized ambulatory health care centers 5, ,847 76

99 HP.8 Rest of the Nepalese economy HP.7 Providers of health care system administration and financing HP.5 Retailers and Other providers of medical goods HP.5.1 Pharmacies/disp ensaries HP.4 Providers of ancillary services Wages and salaries Social contributions All Other costs related to employees Self-employed professional Laboratory & Imaging services Other health care services TB drugs Antimalarial medicines Other antimalarial medicines Vaccines Other pharmaceuticals Other and unspecified health care goods Training Technical Assistance Operational research Other non-health care services Non-health care goods Other materials and services used Consumption of fixed capital Taxes Other items of spending FP.1.1 FP.1.2 FP.1.3 FP FP.3.1.nec FP FP FP FP FP nec FP nec FP FP FP FP.3.3.nec FP.3.4 FP.3.nec FP.5.1 FP.5.2 Unspecified factors of health care provision Factors of health care provision FP.1 Compensation of employees FP.2 FP.3 Health care service used FP.4 FP.5 Other items of spending on inputs FP.nec All FP Health care providers HP All Other ambulatory centers , ,680 HP.3.nec HP.4.1 HP.4.2 HP HP Unspecified providers of ambulatory health care Providers of patient transportation and emergency rescue Medical and diagnostic laboratories Allopathic pharmacies/dispensaries Non- allopathic pharmacies dispensaries , , , , HP.5.1.nec Other Pharmacies/dispensaries HP.5.2 Retail sellers and Other suppliers of durable medical goods and medical appliances , ,272 HP.6 Providers of preventive care 3,298 1, , , , ,940 HP.7.1 Government health administration agencies , ,760 HP.7.2 HP.7.3 Social health insurance agencies Private health insurance administration agencies HP.7.9 Other administration agencies ,046 HP.9 HP.8.2 All Other industries as secondary providers of health care HP.8.9 Other industries n.e.c Rest of the world ,243 HP.nec Unspecified health care providers , , ,059 All HP 15,308 1, ,094 27, ,651 1,278 3,462 3, , , , ,312 77

100 HF.4 Rest of the world financing (non-resident) HF.3 Household out-ofpocket payment HF.1 Government and compulsory contributory health care financing Internal transfers and grants Transfers by government on behalf of specific groups Other transfers from government domestic revenue FS.1.1 FS.1.2 FS.1.4 Transfers distributed by government from foreign origin Voluntary prepayment from employers Other revenues from households n.e.c. Other revenues from corporations n.e.c. Other revenues from NPISH n.e.c. Direct bilateral financial transfers Direct multilateral financial transfers Other direct foreign financial transfers Direct foreign aid in goods Direct multilateral aid in goods FS.5.2 FS.6.1 FS.6.2 FS.6.3 FS FS FS FS FS Annex A.11: Expenditures on Health Care by Health Care Financing Schemes and Revenues of Financing Scheme (2014/15) (HFXFS) Revenues of health care financing FS.1 Transfers from government domestic revenue (allocated for health purposes) FS.2 FS.5 Voluntary prepayment FS.6 Other domestic revenues n.e.c. FS.7 Direct foreign transfers All FS Financing HF.1.1 Government HF HF Central government State/regional/local government 21, , , HF.1.2 Compulsory contributory health insurance HF Social health insurance HF.2.1 Voluntary health insurance HF.2.1.ne c Unspecified voluntary health insurance HF.2.2 NPISH financing HF NPISH financing (excluding HF.2.2.2) , ,244 HF.2.3 Enterprise financing HF Enterprises (except health care providers) financing , ,003 HF.3.1 Out-of-pocket excluding cost-sharing , ,740 HF Other (nonresident) ,766 1,681 3, ,284 HF.4.2 Voluntary (nonresident) HF HF Philanthropy/international NGOs Foreign development agencies , , ,766 1, ,574 All HF 21, , ,740 3,003 9,154 13,532 3,363 7, ,828 78

101 Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Enterprises (except health care providers) financing Out-of-pocket excluding cost-sharing Philanthropy/internati onal NGOs Foreign development agencies Annex A.12: Expenditures on Health Care by Health Care Functions and Health Care Financing Schemes (2014/15) (HCXHF) Financing HF.1 Government and compulsory contributory health care financing HF.2 Voluntary health care payment HF.3 Household out-ofpocket payment HF.4 Rest of the world financing (nonresident) All HF HF HF HF HF.2.1.nec HF HF HF.3.1 HF HF Health care functions HC.1 Curative care HC.2 Rehabilitative care HC.1+HC.2 Curative care and rehabilitative care HC.4 Ancillary services (nonspecified by function) HC.1.1 Inpatient curative care HC.1.3 Outpatient curative care HC.1.nec HC.2.3 HC.2.4 HC.2.nec HC.1.1+HC.2.1 HC.1.3+HC.2.3 HC.1.4+HC.2.4 HC.1.nec + HC.2.nec HC HC HC.1.1.nec HC HC HC HC.1.3.nec General inpatient curative care Specialized inpatient curative care Unspecified inpatient curative care General outpatient curative care Dental outpatient curative care Specialized outpatient curative care Unspecified outpatient curative care Unspecified curative care Outpatient rehabilitative care Home-based rehabilitative care Unspecified rehabilitative care Inpatient curative and rehabilitative care Outpatient curative and rehabilitative care Home-based curative and rehabilitative care Other curative and rehabilitative care 1, , , , , , , , , ,132 1, , , , , , , ,665 10, , , , , ,825 HC.4.1 Laboratory services , ,477 HC.4.2 Imaging services , ,080 HC.4.3 Patient transportation , ,556 HC.4.nec Unspecified ancillary services

102 Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Enterprises (except health care providers) financing Out-of-pocket excluding cost-sharing Philanthropy/internati onal NGOs Foreign development agencies Financing HF.1 Government and compulsory contributory health care financing HF.2 Voluntary health care payment HF.3 Household out-ofpocket payment HF.4 Rest of the world financing (nonresident) All HF HF HF HF HF.2.1.nec HF HF HF.3.1 HF HF Health care functions HC Prescribed medicines HC.5 Medical goods (nonspecified by function) HC.6 Preventive care HC Over-thecounter medicines HC.5.2 Therapeutic appliances and Other medical goods HC Addictive substances IEC programs HC HC.6.5 Epidemiological surveillance and risk and disease control programs HC Interventions HC HC HC HC HC HC nec Allopathic prescribed medicines Allopathic over-the-counter medicines Non allopathic over-thecounter medicines Other medical non-durable goods Other orthopedic appliances and prosthetics (excluding glasses and hearing aids) All Other medical durables, including medical technical devices Other and unspecified addictive substances IEC programs , , , , HC Nutrition IEC programs HC Safe sex IEC programs HC.6.1.nec Other and unspecified IEC programs , ,604 HC.6.2 Immunization programs HC.6.3 Early disease detection programs HC.6.4 Healthy condition monitoring programs 3, , ,839 HC Planning & Management HC Monitoring & Evaluation (M&E) HC Procurement & supply management HC Drug substitution programs HC nec Other and unspecified interventions HC.6.5.nec Unspecified epidemiological

103 Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Enterprises (except health care providers) financing Out-of-pocket excluding cost-sharing Philanthropy/internati onal NGOs Foreign development agencies Financing HF.1 Government and compulsory contributory health care financing HF.2 Voluntary health care payment HF.3 Household out-ofpocket payment HF.4 Rest of the world financing (nonresident) All HF HF HF HF HF.2.1.nec HF HF HF.3.1 HF HF Health care functions HC.7 Governance, and health system and financing administration HC.6.6 HC.6.nec HC.7.1 Governance and Health system administration HC.7.nec surveillance and risk and disease control programs Preparing for disaster and emergency response programs Unspecified preventive care 4, , ,030 HC Planning & Management 1, ,314 2,578 HC Monitoring & Evaluation (M&E) HC Procurement & supply management Other governance and HC.7.1.nec Health system ,562 4,977 administration HC.7.2 Administration of health financing Unspecified governance, and health system and financing administration HC.9 Other health care services not elsewhere classified 3, , ,547 All HC 28, ,244 3,003 78,740 3,710 8, ,480 81

104 HC.6 HC.5 HC.4 HC.2 HC.1 General hospitals Mental health hospitals Specialized hospitals (Other than mental Unspecified hospitals Other residential longterm care facilities Medical practices Dental practice Ambulatory health care centers Unspecified providers of ambulatory health Providers of patient transportation and emergency rescue Medical and diagnostic laboratories Pharmacies/dispensarie s Retail sellers and Other suppliers of durable medical goods HP.1.1 HP.1.2 HP.1.3 HP.1.nec HP.2.9 HP.3.1 HP.3.2 HP.3.4 HP.3.nec HP.4.1 HP.4.2 HP.5.1 HP.5.2 Providers of preventive care Government health administration agencies Social health insurance agencies Private health insurance Other administration agencies All Other industries as secondary providers of health care Community health workers (or village health worker, community health aide, Rest of the world Unspecified health care providers HP.7.1 HP.7.2 HP.7.3 HP.7.9 HP.8.2 HP.8.3 Annex A.13: Expenditures on Health Care by Health Care Functions and Health Care Providers (2014/15) (HCXHP) Health care providers HP.1 HP. 2 HP.3 HP.4 HP.5 HP.6 HP.7 HP.8 HP. 9 HP.nec All HP Health care functions HC.1.1 Inpatient curative care HC.1.3 Outpatient curative care 10, , ,665 5, , ,112 1,132 11, ,516 HC.1.nec Unspecified curative care 1, ,498 3,669 HC.2.3 Outpatient rehabilitative care HC.2.4 Home-based rehabilitative care HC.2.nec Unspecified rehabilitative care HC.4.1 Laboratory services 1 4,475 4,477 HC.4.2 Imaging services 1,080 1,080 HC.4.3 Patient transportation 1 1,555 1,556 HC.4.nec Unspecified ancillary services HC.5.1 Pharmaceuticals and Other medical nondurable goods , ,496 HC.5.2 Therapeutic appliances and Other medical goods HC.6.1 Information, education and counseling (IEC) , ,707 HC.6.2 Immunization

105 HC.9 HC.7 General hospitals Mental health hospitals Specialized hospitals (Other than mental Unspecified hospitals Other residential longterm care facilities Medical practices Dental practice Ambulatory health care centers Unspecified providers of ambulatory health Providers of patient transportation and emergency rescue Medical and diagnostic laboratories Pharmacies/dispensarie s Retail sellers and Other suppliers of durable medical goods HP.1.1 HP.1.2 HP.1.3 HP.1.nec HP.2.9 HP.3.1 HP.3.2 HP.3.4 HP.3.nec HP.4.1 HP.4.2 HP.5.1 HP.5.2 Providers of preventive care Government health administration agencies Social health insurance agencies Private health insurance Other administration agencies All Other industries as secondary providers of health care Community health workers (or village health worker, community health aide, Rest of the world Unspecified health care providers HP.7.1 HP.7.2 HP.7.3 HP.7.9 HP.8.2 HP.8.3 Health care providers HP.1 HP. 2 HP.3 HP.4 HP.5 HP.6 HP.7 HP.8 HP. 9 HP.nec All HP Health care functions HC.6.3 HC.6.4 Early disease detection Healthy condition monitoring , ,134 HC.6.5 HC.6.6 Epidemiological surveillance and risk and disease control Preparing for disaster and emergency response HC.6.nec HC.7.1 HC.7.2 HC.7.nec Unspecified preventive care Governance and Health system administration Administration of health financing Unspecified governance, and health system and financing adm. Other health care services not elsewhere classified , , ,783 7, , ,507 5,547 All HC 16, , ,138 1,132 12, ,555 5,699 48,637 1,438 12,927 7, , ,438 7, ,480 83

106 HF.4 Rest of the world financing (nonresident) HF.3 HH OOPs HF.2 Voluntary health care payment HF.1 Government and compulsory contributory health care Ministry of Health Ministry of Education Ministry of General Administration Ministry of Home Affairs Ministry of Defense Ministry of Agriculture Ministry of Federal Affairs and Local Development Ministry of Finance Other ministries and public units (belonging to central government) District Development Committees Municipalities Village Development Committees Social Health Insurance Agency Commercial insurance companies Corporations (Other than providers of health services) FA FA FA FA FA FA FA FA FA nec FA FA FA FA FA.2.1 FA.3.2 Non-profit institutions serving households (NPISH) Households International organizations FA.6.1 FA.2 Insurance corporati Annex A.14: Expenditures on Health Care by Health Care Financing Schemes and Health Care Financing Agents (2014/15) (HFXFA) Financing agents FA.1 General government FA.3 Corporations FA.4 FA.5 FA.6 Rest of the world All FA Financing HF.1.1 Government HF.1.2 Compulsory contributory health insurance HF.2.1 Voluntary health insurance HF HF HF HF.2.1.nec Central government State/regional/local government Social health insurance Unspecified voluntary health insurance 19, ,256 3, , HF.2.2 NPISH financing HF NPISH financing (excluding HF.2.2.2) , ,244 HF.2.3 Enterprise financing HF.3.1 HF Enterprises (except health care providers) financing Out-of-pocket excluding cost-sharing , , , ,740 HF Other (nonresident) HF HF Philanthropy/internatio nal NGOs Foreign development agencies ,710 3, ,511 8,511 All HF 19, ,256 3, ,790 9,154 78,740 12, ,480 84

107 HP.3 Providers of ambulatory health care HP.2 HP.1 Hospitals Wages and salaries Social contributions All Other costs related to employees FP.1.1 FP.1.2 FP.1.3 Self-employed professional remuneration Laboratory & Imaging services Other health care services TB drugs Other antimalarial medicines Vaccines Contraceptives Other pharmaceuticals Other and unspecified health care goods Training Technical Assistance Operational research Other non-health care services Non-health care goods Other materials and services used FP FP.3.1.nec FP FP FP FP FP nec FP nec FP FP FP FP.3.3.nec FP.3.4 FP.3.nec Consumption of fixed capital Taxes Other items of spending FP.5.1 FP.5.2 Unspecified factors of health care provision Annex A.15: Expenditures on Health Care by Health Care Providers and Factors of Health Care Provision (2014/15) (HPXFP) FP.1 Compensation of employees FP.2 FP.3 Materials and services used FP.4 FP.5 Other ( inputs) FP. ne c All FP Factors of health care provision Health care providers HP Public general hospitals HP National/Central hospitals 1, ,394 HP Regional/Zonal hospitals 1, ,251 HP District level and other public general hospitals , ,857 HP nec Other Public general hospitals HP Private (for profit) general hospitals , ,824 HP.1.2 Mental health HP.1.3 Specialized hospitals (Other than mental health hospitals) HP.3.1 Medical practices HP.1.1.nec Other General hospitals , ,687 HP Public mental health hospitals HP Private (for profit) mental health hospitals HP Public specialized hospitals 1, ,753 HP HP.1.3.nec Private (for profit) specialized hospitals Other Specialized hospitals (Other than mental health hospitals) , , HP.1.nec Unspecified hospitals HP.2.9 Other residential long-term care facilities HP Offices of general medical practitioners HP Offices of mental medical specialists HP.3.1.nec Unspecified medical practices HP.3.4 Ambulatory health care centers HP.3.2 Dental practice , ,132 HP.3.nec HP Family planning centers HP HP Ambulatory mental health and substance abuse centers Non-specialized ambulatory health care centers , ,886 HP All Other ambulatory centers ,459 Unspecified providers of ambulatory health care

108 19,222 1, ,591 37, ,597 1, , , , , ,48 0 HP.8 Rest of the Nepalese economy HP.7 Providers of health care system administration and financing HP.6 5,408 1, , , HP.5 Retailers and Other providers of medical goods HP.4 Ancillary services Wages and salaries Social contributions All Other costs related to employees FP.1.1 FP.1.2 FP.1.3 Self-employed professional remuneration Laboratory & Imaging services Other health care services TB drugs Other antimalarial medicines Vaccines Contraceptives Other pharmaceuticals Other and unspecified health care goods Training Technical Assistance Operational research Other non-health care services Non-health care goods Other materials and services used FP FP.3.1.nec FP FP FP FP FP nec FP nec FP FP FP FP.3.3.nec FP.3.4 FP.3.nec Consumption of fixed capital Taxes Other items of spending FP.5.1 FP.5.2 Unspecified factors of health care provision FP.1 Compensation of employees FP.2 FP.3 Materials and services used FP.4 FP.5 Other ( inputs) FP. ne c All FP Factors of health care provision Health care providers HP.4.1 Providers of patient transportation and emergency rescue , ,555 HP.4.2 Medical and diagnostic laboratories , ,619 HP.4.9 Other providers of ancillary services , ,080 HP.5.1 Pharmacies/d ispensaries HP.5.2 HP Allopathic pharmacies/dispensaries , ,836 HP HP.5.1.ne c Non-allopathic pharmacies dispensaries Other Pharmacies/dispensaries Retail sellers and Other suppliers of durable medical goods and medical appliances , ,438 Providers of preventive care 21,202 HP.7.1 Government health administration agencies , , ,742 HP.7.2 Social health insurance agencies HP.7.3 Private health insurance administration agencies HP.7.9 Other administration agencies HP.8.2 All Other industries as secondary providers of health care HP.9 Rest of the world ,438 HP.n ec Unspecified health care providers , , ,017 All HP 86

109 HF.4 Rest of the world financing (nonresident) HF.3 OOPs HF.2 Voluntary health care payment HF.1 Government and compulsory contributory health care financing Internal transfers and grants Transfers by government on behalf of specific groups Other transfers from government domestic revenue Transfers distributed by government from foreign origin Voluntary prepayment from employers Other revenues from households n.e.c. Other revenues from corporations n.e.c. Other revenues from NPISH n.e.c. Direct multilateral financial transfers Other direct foreign financial transfers Direct multilateral aid in goods Annex A.16: Expenditures on Health Care by Health Care Financing Schemes and Revenues of Financing Scheme (2015/16) (HFXFS) Revenues of health care financing FS.1 Transfers from government domestic revenue (allocated to health purposes) FS.2 FS.5 Voluntary prepayme nt FS.6 Other domestic revenues n.e.c. FS.7 Direct foreign transfers FS.1.1 FS.1.2 FS.1.4 FS.5.2 FS.6.1 FS.6.2 FS.6.3 FS FS FS All FS Financing HF.1.1 Government HF Central government 25, , ,080 HF State/regional/local government HF.1.2 HF Social health insurance HF.2.1 Voluntary health insurance HF.2.2 NPISH financing (including development agencies) HF.2.1.nec HF Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) , ,088 HF.2.3 Enterprise financing HF Enterprises (except health care providers) financing , ,631 HF.3.1 Out-of-pocket excluding cost-sharing , ,427 HF Other (nonresident) HF HF Philanthropy/international NGOs Foreign development agencies , , , ,127 All HF 26, , ,427 2,631 17,007 1,912 5, ,462 87

110 Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Enterprises (except health care providers) financing Out-of-pocket excluding cost-sharing Philanthropy/internati onal NGOs Foreign development agencies Annex A.17: Expenditures on Health Care by Health Care Functions and Health Care Financing Schemes (2015/16) (HCXHF) Financing HF.1 Government and compulsory contributory health care financing HF.2 Voluntary health care payment HF.3 Household out-of-pocket payment HF.4 Rest of the world financing (non-resident) HF HF HF HF.2.1.nec HF HF HF.3.1 HF HF All HF Health care functions HC.1 Curative care HC.2 Rehabilitative care HC.1+HC.2 Curative care and rehabilitative care HC.4 Ancillary services (nonspecified by function) HC.5 Medical goods (nonspecified by function) HC.1.1 Inpatient curative care HC.1.3 Outpatient curative care HC General inpatient curative care 1, , ,584 HC Specialized inpatient curative care , ,619 HC.1.1.nec Unspecified inpatient curative care HC General outpatient curative care 9, , ,159 HC Dental outpatient curative care HC Specialized outpatient curative care 1, ,426 HC.1.3.nec Unspecified outpatient curative care HC.1.nec Unspecified curative care , ,311 HC.2.3 Outpatient rehabilitative care HC.2.nec Unspecified rehabilitative care HC.1.1+HC.2.1 Inpatient curative and rehabilitative care 2, , ,259 HC.1.3+HC.2.3 Outpatient curative and rehabilitative care 11, , , ,437 HC.1.nec + HC.2.nec Other curative and rehabilitative care , ,621 HC Prescribed medicines HC Overthe-counter medicines HC.5.2 Therapeutic appliances and Other medical goods HC.4.1 Laboratory services , ,783 HC.4.2 Imaging services , ,067 HC.4.3 Patient transportation , ,528 HC.4.nec Unspecified ancillary services HC Allopathic prescribed medicines , ,558 HC Allopathic over-the-counter medicines , ,398 HC Non allopathic over-the-counter medicines HC Other medical non-durable goods HC HC Other orthopedic appliances and prosthetics (excluding glasses and hearing aids) All Other medical durables, including medical technical devices

111 Central government State/regional/local government Social health insurance Unspecified voluntary health insurance NPISH financing (excluding HF.2.2.2) Enterprises (except health care providers) financing Out-of-pocket excluding cost-sharing Philanthropy/internati onal NGOs Foreign development agencies Financing HF.1 Government and compulsory contributory health care financing HF.2 Voluntary health care payment HF.3 Household out-of-pocket payment HF.4 Rest of the world financing (non-resident) HF HF HF HF.2.1.nec HF HF HF.3.1 HF HF All HF Health care functions HC Addictive substances IEC programs HC nec Other and unspecified addictive substances IEC programs HC Nutrition IEC programs HC.6 Preventive care HC.6.1.nec Other and unspecified IEC programs , , ,832 HC.6.2 Immunization programs HC.6.3 Early disease detection programs HC.6.4 Healthy condition monitoring programs 5, ,664 1,505 8,492 HC.6.5 Epidemiological surveillance and risk and disease control programs HC Planning & Management HC Monitoring & Evaluation (M&E) HC Procurement & supply management HC.7 HC Interventions HC.6.5.nec HC.6.6 HC.7.1 Governance and Health system administration HC nec Other and unspecified interventions Unspecified epidemiological surveillance and risk and disease control programs Preparing for disaster and emergency response programs , , ,198 HC.6.nec Unspecified preventive care 2, , ,552 HC Planning & Management 1, ,216 3,766 HC Monitoring & Evaluation (M&E) 1, ,256 HC Procurement & supply management HC.7.1.nec Other governance and Health system administration ,063 HC.7.2 Administration of health financing HC.7.nec Unspecified governance, and health system and financing administration HC.9 Other health care services not elsewhere classified 3, , ,270 All HC 30, ,088 2,631 78,427 5,033 7, ,462 89

112 HC.6 HC.5 HC.4 HC.2 HC.1 General hospitals Mental health hospitals Specialized hospitals (Other than mental health hospitals) Unspecified hospitals Long-term nursing care facilities Other residential longterm care facilities Medical practices Dental practice Ambulatory health care centers Unspecified providers of ambulatory health care Providers of patient transportation and emergency rescue Medical and diagnostic laboratories Pharmacies Retail sellers and Other suppliers of durable medical goods and medical All HP HP.1.1 HP.1.2 HP.1.3 HP.1.nec HP.2.1 HP.2.9 HP.3.1 HP.3.2 HP.3.4 HP.3.nec HP.4.1 HP.4.2 HP.5.1 HP.5.2 Providers of preventive care Government health administration Social health insurance agencies Private health insurance Other administration agencies All Other industries as secondary providers Community health workers (or village health worker, Rest of the world HP.7.1 HP.7.2 HP.7.3 HP.7.9 HP.8.2 HP.8.3 Unspecified health care providers Annex A.18: Expenditures on Health Care by Health Care Functions and Health Care Providers (2015/16) (HCXHP) Health care providers HP.1 HP.2 HP.3 HP.4 HP.5 HP. 6 HP.7 HP.8 HP. 9 HP.nec Health care functions HC.1.1 Inpatient curative care HC.1.3 Outpatient curative care 8, , , , , , ,368 2, ,259 HC.1.ne c Unspecified curative care 4, ,428 6,739 HC.2.3 Outpatient rehabilitative care HC.2.ne c Unspecified rehabilitative care HC.4.1 Laboratory services 1 4,782 4,783 HC.4.2 Imaging services 1,067 1,067 HC.4.3 HC.4.ne c Patient transportation Unspecified ancillary services 1 2,527 2, HC.5.1 Pharmaceuticals and Other medical non-durable goods , ,685 HC.5.2 Therapeutic appliances and Other medical goods HC.6.1 Information, education and counseling (IEC) , ,847 HC.6.2 Immunization HC.6.3 Early disease detection

113 HC.9 HC.7 General hospitals Mental health hospitals Specialized hospitals (Other than mental health hospitals) Unspecified hospitals Long-term nursing care facilities Other residential longterm care facilities Medical practices Dental practice Ambulatory health care centers Unspecified providers of ambulatory health care Providers of patient transportation and emergency rescue Medical and diagnostic laboratories Pharmacies Retail sellers and Other suppliers of durable medical goods and medical All HP HP.1.1 HP.1.2 HP.1.3 HP.1.nec HP.2.1 HP.2.9 HP.3.1 HP.3.2 HP.3.4 HP.3.nec HP.4.1 HP.4.2 HP.5.1 HP.5.2 Providers of preventive care Government health administration Social health insurance agencies Private health insurance Other administration agencies All Other industries as secondary providers Community health workers (or village health worker, Rest of the world HP.7.1 HP.7.2 HP.7.3 HP.7.9 HP.8.2 HP.8.3 Unspecified health care providers Health care providers HP.1 HP.2 HP.3 HP.4 HP.5 HP. 6 HP.7 HP.8 HP. 9 HP.nec Health care functions HC.6.4 Healthy condition monitoring 39 4,962 3, ,849 HC.6.5 Epidemiological surveillance and risk and disease control programs ,374 2,393 HC.6.6 Preparing for disaster and emergency response programs 0 1,172 1,172 HC.6.ne c Unspecified preventive care , ,596 HC.7.1 Governance and Health system administration 5, ,241 HC.7.2 Administration of health financing HC.7.ne c Unspecified governance, and health system and financing administration Other health care services not elsewhere classified ,798 4,842 All HC 18, , , , ,527 5,929 47,819 1,434 19,293 6, ,733 6, ,462 91

114 HF.4 Rest of the world HF.3 HH OOPs HF.2 Voluntary health care payment HF.1 Government and compulsory contributory health care financing Ministry of Health Ministry of Education Ministry of General Administration Ministry of Home Affairs Ministry of Defense Ministry of Agriculture Development Ministry of Federal Affairs and Local Ministry of Commerce and Supply Ministry of Finance Other ministries and public units (belonging to central government) District Development Committees Municipalities Village Development Committees Social Health Insurance Commercial insurance companies Corporations (Other than providers of health services) FA FA FA FA FA FA FA FA FA FA nec FA FA FA FA FA.2.1 FA.3.2 Non-profit institutions serving households (NPISH) Households International organizations FA.6.1 Annex A.19: Expenditures on Health Care by Health Care Financing Schemes and Health Care Financing Agents (2015/16) (HFXFA) Financing agents FA.1 General government FA.2 Insurance corporation s FA.3 Corpor ations FA.4 FA. 5 FA.6 Rest of the world All FA Financing HF.1.1 Government HF HF Central government State/regional/local government 24, , HF.1.2 Compulsory contributory health insurance HF Social health insurance HF.2.1 Voluntary health insurance HF.2.1.nec Unspecified voluntary health insurance HF.2.2 NPISH financing HF NPISH financing (excluding HF.2.2.2) , ,088 HF.2.3 Enterprise financing HF Enterprises (except health care providers) financing , ,631 HF.3.1 Out-of-pocket excluding cost-sharing , ,427 HF Other (nonresident) HF HF Philanthropy/intern ational NGOs Foreign development agencies ,033 5, ,127 7,127 All HF 24, ,227 17,007 78,427 12, ,462 92

115 HP.3 Providers of ambulatory health care HP.2 Residential long-term care HP.1.3 Specialized hospitals (Other than mental HP.1 Hospitals HP.1.2 Mental health hospital s HP Public general hospitals Wages and salaries Social contributions All Other costs related to employees FP.1.1 FP.1.2 FP.1.3 Self-employed professional remuneration Laboratory & Imaging services Other health care services TB drugs Other antimalarial Vaccines Other pharmaceuticals Other and unspecified health Training Technical Assistance Operational research Other non-health care services Non-health care goods Other materials and services used FP FP.3.1.nec FP FP FP FP nec FP nec FP FP FP FP.3.3.nec FP.3.4 FP.3.nec Consumption of fixed capital Taxes Other items of spending FP.5.1 FP.5.2 Unspecified factors of health care provision Annex A.20: Expenditures on Health Care by Health Care Providers and Factors of Health Care Provision (2015/16) (HPXFP) FP.1 Compensation of employees FP.2 FP.3 Materials and services used FP.4 FP.5 Other (inputs) FP.nec All FP Factors of health care provision Health care providers HP National/Central hospitals 1, ,504 HP Regional/Zonal hospitals 1, ,196 HP District level and other public general hospitals , ,729 HP nec Other Public general hospitals HP Private (for profit) general hospitals , ,609 HP.1.1.nec Other General hospitals 1, , ,294 HP Public mental health hospitals HP Private (for profit) mental health hospitals Private (for profit) specialized HP , ,146 hospitals Other Specialized hospitals HP.1.3.ne (Other than mental health , ,258 c hospitals) HP.1.nec Unspecified hospitals HP.2.1 health hospitals)hp Public specialized hospitals 1, ,066 Long-term nursing care facilities HP.2.9 Other residential long-term care facilities HP.3.1 Medical practice s HP.3.4 Ambul atory HP HP HP.3.1.ne c Offices of general medical practitioners Offices of mental medical specialists Unspecified medical practices HP.3.2 Dental practice HP Family planning centers HP Ambulatory mental health and substance abuse centers

116 HP.8 Rest of economy HP.7 Providers of health care system adm. & financing HP.5 Retailers and Other providers of medical goods HP.4 Providers of ancillary services Wages and salaries Social contributions All Other costs related to employees FP.1.1 FP.1.2 FP.1.3 Self-employed professional remuneration Laboratory & Imaging services Other health care services TB drugs Other antimalarial Vaccines Other pharmaceuticals Other and unspecified health Training Technical Assistance Operational research Other non-health care services Non-health care goods Other materials and services used FP FP.3.1.nec FP FP FP FP nec FP nec FP FP FP FP.3.3.nec FP.3.4 FP.3.nec Consumption of fixed capital Taxes Other items of spending FP.5.1 FP.5.2 Unspecified factors of health care provision FP.1 Compensation of employees FP.2 FP.3 Materials and services used FP.4 FP.5 Other (inputs) FP.nec All FP Factors of health care provision Health care providers health care centers HP.5.1 Pharm acies HP.3.nec HP.4.1 HP.4.2 HP.4.9 HP Non-specialized ambulatory health care centers 6, ,241 HP All Other ambulatory centers , ,142 Unspecified providers of ambulatory health care Providers of patient transportation and emergency , ,527 rescue Medical and diagnostic laboratories , ,861 Other providers of ancillary services , ,067 HP Allopathic pharmacies/dispensaries , ,956 HP Non- allopathic pharmacies dispensaries HP.5.1.nec Other Pharmacies/dispensaries HP.5.2 Retail sellers and Other suppliers of durable medical goods and medical appliances , ,434 HP.6 Providers of preventive care 3,193 1, , ,097 3, , ,534 HP.7.1 Government health administration agencies 1, , , ,047 HP.7.2 Social health insurance agencies HP.7.3 Private health insurance administration agencies HP.7.9 Other administration agencies HP.8.2 All Other industries as secondary providers of health care HP.9 Rest of the world , ,733 HP.nec Unspecified health care providers , , ,225 All HP 19,468 1, ,789 44, ,097 52,673 1, , , , ,462 94

117 Annex B: NHA Classifications This section provides the details of the NHA classifications categories in the context of Nepal and the generic meaning adopted from the SHA manual. Further details can be obtained from A System of Health Accounts 2011 (OECD et.al. 2011). 5.1 Revenues of Health Care Financing Schemes (FS) Transfers from Government Domestic Revenue (Allocated to Health Purposes) (FS.1): These are the funds allocated from Nepal government s domestic revenues for health purposes. Transfer from government domestic revenue is mainly through internal transfers and grants (FS.1.1) Transfers Distributed by Government from Foreign Origin (FS.2): The abroad originated bilateral, multilateral and other types of foreign funding agencies transfers are distributed through the general government in Nepal. Voluntary Prepayment (FS.5): The revenue under this category is voluntary insurance premiums received from the insuree or other institutional units, mainly through the private insurance companies. Other Domestic Revenues n.e.c. (FS.6): This category includes domestic revenues of financing not included under FS.1 to FS.5 which usually includes the households OOP spending for health care. Direct Foreign Transfers (FS.7): These are the revenues that are granted by the foreign governments, international agencies or donations from foreign sources (agencies or individuals) that directly contribute to the funding of the domestic health financing. 5.2 Health Care Financing Schemes (HF) General Schemes and Compulsory Contributory Health Care Financing Schemes (HF.1): This category includes mainly Nepal Government and compulsory private insurance intended to ensure access to basic health care for the whole Nepalese society, a large part of it, or at least some vulnerable groups. Government Schemes (HF.1.1): This category includes Nepal Government where a separate budget is set for the program and a government unit (both central and local) has an overall responsibility to operate it, but it may also be managed by NPISH (INGOs, NGOs or CBOs) or by an enterprise. Compulsory Contributory Health Insurance Schemes (HF.1.2): In Nepal, compulsory contributory health insurance are managed through the compulsory private insurance (HF.1.2.2) mainly by non-government and private entities by making health insurance compulsory to their employees. Voluntary Health Care Payment Schemes (Other Than OOP) (HF.2): All kinds of domestic pre-paid health care financing under which the access to health services is at the discretion of private actors are included in this financing scheme. In Nepal, NPISHs and enterprises which finance their employees are major voluntary health care payment. NPISH Financing Schemes (HF.2.2): NPISH financing manage a considerable amount in Nepal and generally raises funds through donations from the public, governments (budget of the national government or foreign aid) or corporations. Enterprise Financing Schemes (HF.2.3): This category primarily includes arrangements where enterprises/companies directly provide or finance health services for their employees. Household Out-of-Pocket Payment (HF.3): It is a direct payment for services from the households primary income or savings where the payment is made by the user both in cash and in-kind at the time of the use of services. It also includes cost-sharing and informal payments and has two sub-categories i.e. OOP excluding cost-sharing (HF.3.1) and OOP cost-sharing (HF.3.2). Rest of the World Financing Schemes (HF.4): Rest of the world financing mainly includes two sub-categories; compulsory (non-residents) (HF.4.1) and Voluntary (non-resident) (HF.4.2). This comprises of financial arrangements involving institutional units or managed by 95

118 institutional units that are resident abroad, but who collect, pool, resources and purchase health care goods and services on behalf of residents, without transiting their funds through a resident scheme. 5.3 Health Care Financing Agents (FA) General Government (FA.1): These are non-market and non-profit institutions that are controlled and mainly financed by the government of Nepal units such as MoHP, DoHS, RHDs, DHOs, DDCs, other government entities and social/community insurance funds. Central Government (FA.1.1): All institutional units such as Ministry of Health (FA.1.1.1) and other ministries and public units belonging to the central government (FA.1.1.2) such as Ministry of Education, Ministry of General Administration, Ministry of Home Affairs, Ministry of Defense makes the central government. State/Regional/Local Government (FA.1.2): All institutional units at local level government entities such as regional, district and municipality/vdcs making up the local government which may have the primary responsibility for providing access to health care are included in this category. Insurance Corporations (FA.2): Insurance corporations may act as a financing agent for different types of insurance such as commercial insurance companies (FA.2.1) which offer voluntary health insurance in Nepal. Corporations (Other Than Insurance Corporations) (FA.3): This category of financing agents in Nepal includes health management and providers corporations such as hospitals and medical schools except for traditional health service providers (FS.3.1) and corporations other than providers of health services (FS.3.2) such as enterprises and corporate houses. Non-Profit Institutions Serving Households (FA.4): NPISH consist of non-profit institutions that provide financial assistance, goods or services to households for free or at prices that are not economically significant. Many NPISH are serving Nepalese communities and holds a significant part in the health financing in Nepal. Households (FA.5): A household is a group of persons who share the same living accommodation, who pool some, or all, of their income and wealth, and who consume certain types of goods and services collectively, mainly housing and food. Rest of the World (FA.6): This includes the institutional units that are based in foreign countries such as bilateral and multilateral agencies, foreign governments and financial intermediaries (insurance, NGOs, charities, and foundations). 5.4 Health Care Providers (HP) Hospitals (HP.1): Hospitals provide medical, diagnostic and treatment services primarily for inpatient and outpatient medical care and provide daycare. General Hospitals (HP.1.1): General hospitals primarily provide general diagnostic, inpatient and outpatient services, imaging and laboratory services. In Nepal, these include public hospitals such as district, zonal, regional and non-specialized national hospitals, including army and police hospitals. There are also private (for-profit) and private (not-for-profit) hospitals such as teaching and university hospitals, community and NGO run hospitals, other than specialized hospitals. Mental Health Hospitals (HP.1.2): These are hospitals that provide diagnostic and medical treatment and monitoring services to inpatients and outpatients who have the mental illness. Specialized Hospitals (Other Than Mental Health Hospitals) (HP.1.3): Specialized hospitals are primarily engaged in providing diagnostic and medical treatment including monitoring services to inpatients as well as outpatients with a specific type of diseases or medical conditions, other than mental health such as heart, maternity, kidney, orthopedic, child hospitals etc. Providers of Ambulatory Health Care (HP.3): This item includes providers that serve health care services directly to outpatients who do not require inpatient services. This includes both the offices of general medical practitioners and medical specialists also the delivery of home care services. In Nepal, ambulatory care services are provided by both public and private sectors such as PHCCs, HPs, clinics and individual providers. 96

119 Medical Practices (HP.3.1): This subcategory comprises both offices of general medical practitioners and offices of medical specialists (other than dental practice) who are primarily engaged in the independent practice of general or specialized medicine, including psychiatry, cardiology, osteopathy, homeopathy, surgery, and others. Dental Practices (HP.3.2): This subcategory comprises independent health practitioners who are primarily engaged in the independent practice of general or specialized dentistry or dental surgery. In Nepal, dental service practices are mainly done in the central, regional level hospitals, medical and dental schools and private dental clinics. Other Health Care Practitioners (HP.3.3): This subcategory comprises the group of paramedical and other independent health practitioners such as chiropractors, optometrists, psychotherapists, physical, occupational, and speech therapists and audiologist establishments who are primarily engaged in providing care to outpatients. In Nepal, such services are provided mainly by central/regional hospitals, medical schools hospitals, private hospitals and clinics. Ambulatory Health Care Centers (HP.3.4): These establishments generally treat patients who do not require inpatient treatment and service is provided by PHCCs and HPs in public sector. Providers of Ancillary Services (HP.4): They provide the specific ancillary type of services directly to outpatients under the supervision of health professionals such as providers of patient transportation and emergency rescue, medical and diagnostic laboratories, dental laboratories and other providers of ancillary services. Retailers and Other Providers of Medical Goods (HP.5): This item comprises specialized establishments whose primary activity is the retail sale of medical goods to the public for individual or household consumption or utilization. Pharmacies/ Dispensaries (HP.5.1): This subcategory comprises establishments that are primarily engaged in the retail sale of pharmaceuticals to the population for prescribed and non-prescribed medicines (including non-allopathic). Retailers and Other Suppliers of Durable Medical Goods and Medical Appliances (HP.5.2): This item comprises establishments that are primarily engaged in the retail sale of durable medical goods and medical appliances such as hearing aids, optical glasses, other vision products and prostheses to the public for individual or household use. Providers of Preventive Care (HP.6): This category comprises institutions that provide promotive, preventive and public health programs for specific groups of individuals or the population-at-large which are primarily provided by public sectors and NPISHs. Providers of Health Care System Administration and Financing (HP.7): It comprises establishments that are primarily engaged in the regulation of the activities of health care providers and in the overall administration of the health care sector particularly in the public sectors in Nepal. Government Health Administration Agencies (HP.7.1): This subcategory comprises government administration (excluding social security). In Nepal, these include MoHP and Department of Health Services including all it s the agencies/centers. Social Health Insurance Agencies (HP.7.2): These are the independent agencies that provide social health insurance. In Nepal, government supported Social Health Security Development Committee (Health Insurance Board) initiated and managing social insurance with an objective to expand the coverage nationally. Private Health Insurance Administration Agencies (HP.7.3): This subcategory comprises private insurance corporations that may manage more than one type of health insurance scheme at the same time. Such corporations and are very limited in Nepal. Other Administration Agencies (HP.7.9): This subcategory comprises NPISHs (other than social insurance) primarily NGOs, INGOs and other social services agencies in Nepal. Rest of the Nepalese Economy (HP.8): These are the national entities and individuals that provide health services such as personal home health services provided within households by family members, 97

120 community health service providers, and health services as secondary activities such as occupational health services provided within enterprises. The establishments that are outside the health care universe but are specialized in health-related activities such as housekeeping, laundry, shopping, meal preparation, help with financial activities also falls in this category etc. Households as Providers of Home Health Care (HP.8.1): The item under this category includes personal home health services provided within households by family members. All Other Industries as Secondary Providers of Health Care (HP.8.2): This subcategory includes organizations that predominantly offer health care as a secondary activity, e.g. occupational health care services provided within enterprises. In Nepal, such services are much limited. Other Industries n.e.c. (HP.8.9): This category comprises establishments that are outside the health care provider universe and do not provide health care goods but which are specialized in health-related activities such as housekeeping, laundry, shopping, preparation of meals, help with financial activities, etc. 5.5 Factors of Health Care Provision (FP) Compensation of Employees (FP.1): The compensation of employees refers to the total remuneration, in cash or in kind, paid to an employee in return for work performed and measures the remuneration of all persons employed by providers of health care irrespective of whether they are health professionals or not. Wages and Salaries (FP.1.1): These include the remuneration either as regular interval payments or as a pay for a piece of work to employees such as overtime or night work, bonuses, allowances, as well as the value of in-kind payments. Social Contributions (FP.1.2): These are payments by the employers on behalf of their employees to social insurance for their social benefits including pensions and other retirement benefits. All Other Costs Related to Employees (FP.1.3): This includes other benefits given to the employees such as accumulated leave pays, clothing to employees, traveling expenses employee refresher training etc. Self-Employed Professional Remuneration (FP.2): This category includes the remuneration of the independent health professional practice, the income of non-salaried self-employed professionals and complementary or additional income generated through the independent/private practice of salaried health personnel. This is commonly practiced in Nepal. Materials and Services Used (FP.3): This is the total value of goods and services used for the provision of health care production such as pharmaceuticals supplies for clinical laboratory examinations, stationeries, outsourced or external services purchased by the provider, rental of buildings and equipment, laboratory work, imaging and patient transportation etc. Health Care Services (FP.3.1): This includes the health care services purchased by a provider to complete the package of service, such as diagnosis and monitoring services and specialized care services, offered by the same provider. Health Care Goods (FP.3.2): This includes the expenditure on pharmaceuticals and other healthcare goods. Non-Health Care Services (FP.3.3): These are the general services used for health care production such as maintenance cost of buildings and equipment, staff training, operational research, rental of equipment and buildings, housing etc. Non-Health Care Goods (FP.3.4): These are the general goods used for health care productions such as hospital kitchen supplies, fuel, and tools used to operate vehicles, utilities like electricity and water etc. Consumption of Fixed Capital (FP.4): The consumption of fixed capital, in the accounting period, is the cost of the decline in the current value of the producer s stock of fixed assets such as buildings, equipment and vehicles because of physical deterioration, foreseen obsolescence or normal or accidental damage, but not through damage caused by war or natural disasters. The expenditure related to operation and maintenance cost of buildings and equipment, rent of land and buildings spaces and sales of fix assets were included in this category. 98

121 Other Items of Spending on Inputs (FP.5): This category includes all the financial costs, such as interest payments on loans, taxes etc. The major expenditure under this category was on other items of spending (FP.5.2) which includes all transactions related to spending items n.e.c. such as property expenses, fines and penalties, interest rates and costs for the use of loans, and non-life insurance premiums and claims. 5.6 Health Care Functions (HC) Curative care (HC.1): Curative care comprises healthcare contacts during which the principal intent is to relieve symptoms of illness or injury such as treatment of injury, the surgery performed diagnostic and therapeutic procedures and obstetric services. Inpatient Care (HC.1.1): It is a formal admission into a health care facility for treatment and/or care that is expected to constitute an overnight stay which includes expenditure on food, nursing care, and medical goods. Outpatient Curative Care (HC.1.3): This is medical and ancillary services delivered to a patient who is not formally admitted to a facility and does not stay overnight and refers to any care offered to a nonadmitted patient regardless of where it occurs. Rehabilitative Care (HC.2): Rehabilitation care includes consumption of services aimed at reaching, restoring and/or maintaining optimal physical, sensory, intellectual, psychological and social functional levels. Long-Term Care/Health (HC.3): Long-term care (health) which includes a range of medical and personal supportive or palliative care or service to the patients with a degree of long-term dependency is much limited in Nepal. Ancillary Services (Non-Specified by Function) (HC.4): These are the services whose purpose is related to diagnosis and monitoring diseases or health condition and includes laboratory services (HC.4.1), imaging services (HC.4.2) and patient transportation and emergency rescue (HC.4.3). Medical Goods (Non-Specified by Function) (HC.5): It includes medical goods directly purchased for preventive, curative, rehabilitative or long-term care purpose and consumed for inpatient, outpatient and day care and self-prescription. In Nepal, often the relatives or patient need to purchase medicines themselves even in the cases of inpatient and outpatient services. It is further categorized into pharmaceuticals and other medical non-durables (HC.5.1) and therapeutic appliances and other medical goods (HC.5.2). Pharmaceuticals and Other Non-Durable Goods (HC.5.1): Pharmaceutical products and non-durable medical goods are medicinal preparations, branded and generic medicines, drugs, patent medicines, serums and vaccines, and oral contraceptives intended for use in the diagnosis, cure, mitigation or treatment of disease. Therapeutic Appliances and Other Medical Goods (HC.5.2): This sub-category includes a wide range of medical durable goods, such as glasses and other vision products (HC.5.2.1), hearing aids (HC.5.2.2), other orthopedic appliances and prosthetics (excluding glasses and hearing aids) (HC.5.2.3) and all other medical durables including medical-technical devices (HC.5.2.9). Preventive Care (HC.6): This is an approach to improve the health through the control of some of its immediate determinants. In Nepal majority of expenditure in preventive care is done by the government through national public health programs or by NPISHs. Governance, and Health System and Financing Administration (HC.7): This category of services focuses on the health system rather than direct health care such as formulation and administration of government policy, the setting of standards and regulation, management of the fund collection and the administration, monitoring and evaluation etc. Other Health Care Services n.e.c. (HC.9): This category includes any other health care services not classified in HC.1 to HC.7. 99

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