NATIONAL HEALTH ACCOUNTS

Transcription

1 NATIONAL HEALTH ACCOUNTS Financial year 2002, 2003 and 2004 REPUBLIC OF THE GAMBIA DEPARTMENT OF STATE FOR HEALTH & SOCIAL WELFARE THE QUADRANGLE BANJUL, THE GAMBIA NOVEMBER

2 Table of Contents Table of Contents List of Tables List of Figures Abbreviations and Acronyms Foreword Acknowledgements Executive Summary Page (i) (ii) (iii) (iv) (v) (vi) (vii) Chapter 1: Chapter 2: Chapter 3: Chapter 4: Chapter 5: Chapter 6: Chapter 7: References Annexes Matrix I Introduction Background Methods and Sources of Data Main NHA Findings Recommendations Conclusion Further Analysis of Current Health Financing System [End of each chapter] Matrix II Matrix III 2

3 List of Tables Page Table 1: Table 2: Table 3.1 Number of various types of health facilities in The Gambia Distribution of health workers in ECOWAS countries Breakdown of the categories 3

4 List of Figures Page Figure 2.1: ECOWAS Member States in 2006 (Population in Million) Figure 2.2: Figure 2.3a: Adult literacy rate and combined enrolment ratios for primary, Secondary and tertiary schools in ECOWAS Value added by Type of economic activity millions of Dalasis Figure 2.3b: Value added by type of economic activity in 1999/2000 Figure 2.3c: Value added by type of economic activity in 2004/2005 Figure 2.4: Life expectancy at birth among ECOWAS countries in 2004 Figure 2.5: Under-5 mortality rate (per 1000LB) for ECOWAS countries in 2004 Figure 2.6: Adult mortality rate per 1000 among ECOWAS countries Figure 2.7: Maternal Mortality Ratio per live births (in year 200) Figure 2.8: Figure 3.1: Figure 4.1a: Figure 4.1b: Stillbirth rate and neonatal mortality rates per 1000 in ECOWAS How NHA Presents Financing Flows and Links to Health Policy Decisions Total Health Expenditure by Sources Per capita total health expenditure for ECOWAS countries (US$) Figure 4.2a: Health financing by source in The Gambia (year 2002) Figure 4.2b: Health financing by source in The Gambia (year 2003) Figure 4.2c: Health financing by source in The Gambia (year 2004) Figure 4.2d: Figure 4E: Figure 4F: Figure 4g: Figure 4.2I: Figure 4.2h: Per capita government expenditure on health in ECOWAS Government Expenditure on health as % of total government Expenditure Private expenditure on health as % of total expenditure on health in ECOWAS Out-of-pocket spending as % of private expenditure on health in ECOWAS Private prepaid plans as a % of private expenditure on health in ECOWAS External resources for health as a % of total expenditure on 4

5 health Figure 4.3: Percentage of total health expenditure by financing agents Appendix Table: General NHA Summary Statistics (2002, 2003, 2004) 5

6 Abbreviations and Acronyms NHA National Health Accounts NGO Non-Governmental Organisation DOSH Department of State for Health & Social Welfare DOSFEA ` Department of state for finance and Economic Affairs DOSFA Department of State for Foreign Affairs DOSI Department of State for Interior DOSE Department of State for Education DOSD Department of State for Defence LGA Local Government Authorty GBoS Gambia Bureau of Statistics UNDP United Nation Development Programme GDP Gross Domestic Product HDI Human Development Index WHO World Health Organisation OOPs Out-of pocket payments THE Total Health Expenditure TGHE Total Government Health Expenditure TPHE Total Private Health Expenditure GGHE General Government Health Expenditure CMH Commission for Macro Economics and Health CRP Cost Recovery Programme DRF Drug Revolving Fund BI Bamako Initiative FA Fianancing Agent P Providers F Functions FS Financing Sources 6

7 Foreword National Health Account provides information to guide health policy design especially the health financing policy. This report is the first to be completed for The Gambia. Objective of NHA Study in The Gambia The objectives of The Gambia NHA are: To trace the sources of health expenditure in The Gambia; To determine total health expenditure by financing agents and providers; To examine the distribution of funds by functions e.g. prevention and curative services; and To trace the channels of distribution of funds by inputs (line items), e.g. personnel remunerations, medicines. The inaugural NHA study was the first step towards The Gambia s aspiration of institutionalizing NHA to facilitate DOSH stewardship of the national health system. The study succeeded in addressing three of its four objectives: (i) to estimate the total health expenditure from public, private and donor sources; (ii) to determine the total health expenditure by financing agents; and (iii) to approximate the distribution of funds by various public health functions. Due to dearth of disaggregated information, it was not possible to estimate the amounts of funds spent on various health system inputs. The NHA evidence contained in this document constitutes a strong basis for developing a comprehensive health financing policy and a health financing strategic plan using the Sector Wide Approach (Common Basket Funding) and mapping out how the Government plans to realize the vision of universal coverage of health services and universal protection from potentially catastrophic and impoverishing health care expenditures in the long-term. In order to facilitate the monitoring and evaluation of such policy documents once developed, it is important to institutionalize national health accounts. The latter will require boosting of the capacities in the Directorate of Planning and Information. An attempt was made to analyse the Cost Recovery Program using selected Bamako Initiative Operated health centres. It is the strong believe that these information should provide sufficient information for the reform of the health services management in The Gambia. Dr. Malick Njie Secretary of State for Health and Social Welfare November

8 Acknowledgement The Department of State for Health and Social Welfare wishes to acknowledge the immense support provided by the World Health Organization ( principal financier), and the Fight Against Social and Economic Exclusion Project of UNDP for the financing of the study. Beyond the financial support WHO provided technical support from the Regional Office in the analysis and report writing. We wish to thank the various contributors to the data; public, private, NGO and donor community for their strong cooperation and support. The Department acknowledges the strong coordination role of the Directorate of Planning and Information, and supported by the National Health Account Technical Team in the development of this report. 8

9 Executive Summary Definition of NHA National Health Accounts (NHA) is a tool for health sector management and policy development that measures total public (all relevant sectors), private (including households, enterprises, NGOs) and donor (rest-of-the-world) health expenditures. It tracks all expenditure flows from the sources of funds to financing agents, service providers, public health functions and inputs. Objective of NHA Study in The Gambia The objectives of The Gambia NHA are: To trace the sources of health expenditure inthe Gambia; To determine total health expenditure by financing agents and providers; To examine the distribution of funds by functions e.g. prevention and curative services; and To trace the channels of distribution of funds by inputs (line items), e.g. personnel remunerations, medicines. Dimensions of The Gambia NHA Study According to the WHO guide to producing NHA [WHO 2003], international experience in the development and use of health accounts suggests a number of useful dimensions. a) Financing sources: Institutions or entities that provide funds used in the health system by financing agents. In The Gambia the financing sources consist of the Government (DOSFEA), Local Government Area (LGA), parastatals, private employers, households and donors (rest-of-the-world). b) Financing agents: Institutions or entities that channel funds provided by financing sources and use those funds to pay for, or purchase, the activities inside the health accounts boundary (i.e. all activities whose primary purpose is to promote, restore or maintain health). In The Gambia the financing agents include: DoSH, DoSE, DoSD, DoSI, DOSFA, LGA, NAS, NaNA, Parastatals, private insurance, households, NGOs, and private firms. The sum of the funds channelled through all the financing agents should be equal to the total amount of money provided by the financing sources. c) Providers: Entities that receive money in exchange for or in anticipation of producing the activities inside the health accounts boundary. Examples of providers in The Gambia include: Teaching hospital, general hospitals, private hospitals/clinics, Government Health Centres (Basic Health Services), NGO health centres, pharmacies, opticians, pharmaceutical companies, administration of public health, provision of public health services, other (private insurance), all other providers of health administration, insurance firms, research institutions, education and training institutions, NGO health related activities, and rest of the 9

10 4world. Ideally, the sum of the funds received by all the providers should be equal to the total amount of money provided by the financing agents. d) Functions: Services of curative care, services of rehabilitative care, ancillary services to medical care, medical goods dispensed to out-patients, prevention and public health services, health administration and health insurance, and health related functions. The latter includes: capital formation of health care provider institutions, maintenance service management, education and training of health personnel, research and development in health, traditional medicine development, and provision of overseas treatment. e) Resource/input costs: The factors or inputs used by providers or financing agents to produce the goods and services consumed or the activities conducted in the health system. In The Gambia resource/input cost categories would include: personnel (remuneration, employers contribution employees insurance, other conditions); goods and services (travel and subsistence expenses, drugs and medical supplies, material supplies, transport, utilities, maintenance, property rental and related charges; education and training (research and development, nutritional surveillance, water and sanitation, other services and expenses); subsidies and other current transfers (membership fees and subscription, government organization, individuals and non profit, public and departmental enterprise); and development expenditure (furniture and office equipment; vehicles, operational equipment, machinery). Beneficiaries: The people who receive those health goods and services or benefit from those activities (beneficiaries can be categorized in many different ways, including their age and sex, their socio-economic status, their health status, and their location). NHA matrices used to track flow of health expenditures Each of the NHA tables displays some facet of health expenditure cross-tabulated by two of the dimensions mentioned below and these include: a) Health expenditure by financing source and type of financing agent (FS x FA). This table highlights resource mobilization patterns in the health system. It addresses the question where does the money come from by showing the financing sources that contribute to each financing agent. It also shows how prominent a role each source plays in the financing of each financing agent and in the total spending overall. b) Health expenditure by the type of financing agent and type of provider (FA x P). This table describes how funds are distributed across different types of providers, e.g., what share of total spending goes to referral and district hospitals relative to hospitals, clinics, health posts, outreach stations. c) Health expenditure by provider and type of function (P x F). This table shows how expenditures on different health functions are channelled through the various types of providers. It provides useful perspective on the contribution of different 10

11 types of providers to the total spending on specific types of services, e.g. public health programmes vis-à-vis secondary and tertiary curative care. d) Health expenditure by type of financing agent and type of function (FA x F). This table shows who finances what types of services in the health system. It can also highlight the relative emphasis of public and private financing agents with respect to the various public health functions. Health expenditure data sources To determine household expenditure on health for this exercise, two sources were utilized. In view of the high cost involved in conducting large scale household surveys, it was decided to largely utilize data from the 2003 Integrated Household Survey (IHS) to arrive at estimates of household expenditure on health and also to conduct a small scale household survey in 2006 to address issues of health seeking behaviour which were largely not covered by the IHS. For the other health expenditure sources, the lists of organisations (employers, donors, NGOs, health care providers) were obtained from various registration sources including the Registrar General s Department, The Gambia Chamber of Commerce, NGO Affairs Agency, DoSFA and The Gambia Bureau of Statistics. All identified organisations were included in the survey. Except for the house hold survey which was done by GBoS, the rest of the data collection was done by Account Technicians provided by the Directorate of National Treasury. The NHA Technical Committee provided the supervision of the data collection. Main Findings of the NHA Study The total health expenditure (THE) was approximately D1,185,223,103 in 2002; D1,395,958,522 in 2003; and D1,682,323,673 in The THE as a percentage of GDP in The Gambia was 16.1% in 2002, 13.9% in 2003 and 14.9% in The per capita total health expenditure was D895 in 2002, D1026 in 2003 and D1203 in Figures 4.1C, 4.1D and 4.1E show the contribution of government/public, households, private employers and donors to the total health expenditure in the The Gambia during years 2002, 2003, and

12 Figure 4.1C: Health financing by source in Gambia (year 2002) Government/ public 18% Private employer 0% Donors 70% Household OOPs 12% Figure 4.1D: Health financing by source in Gambia (Year 2003) Government/ public 22% Private employer 0% Donors 67% Household 11% 12

13 Figure 4.1E: Health financing by source in Gambia (year 2004) Government/ public 24% Private employer 1% Donors 66% Household OOPs 9% During the three years over 66% of the total health funding came from donors (international health development partners). The Government of The Gambia contribution grew from 18% in 2002 to 24% of the total health expenditure in The households, through direct out-of-pocket payments to health care providers, contributed 12% in 2002, 11% in 2003 and 9% in 2004 to the total health expenditure. Key Recommendations 1) NHA should be institutionalised to ensure that it can be conducted on a regular and sustained basis. 2) NHA Advisory/Steering Committee (NHASC) should be maintain and the membership of the The Gambia NHA Technical Working Group should be expanded to include representatives of all relevant Government Departments (e.g. DoSFEA, DOSE, DOSI, DoSFA, LGA) and organs (e.g. NAS, NaNA), plus a representative of the health development partner group in the country. 3) There is need to plan for undertaking the second NHA exercise covering 2005, 2006 and 2007, and thereafter make a decision on the frequency of subsequent NHA studies. 4) DoSH should consider developing a comprehensive health financing policy and health financing strategic plan with a roadmap of how the Government plans to realize the vision of universal coverage of health services and universal protection from potentially catastrophic and impoverishing health care expenditures in the long-term. In the process of developing the national financing policy, it may be informative to refer to the WHO regional strategy for health financing for inspiration. 13

14 The following important findings should support the development of the health Financing policy: Government current per capita health expenditure is below $35 as recommended by WHO. The financing policy should advocate for government increase expenditure on health. Currently Social Security contribution to health is insignificant. The policy should therefore advocate for increase Social security contribution to health expenditure. The out- of-pocket expenditure as a propotion of total private health expenditure is over 95%. The health financing policy should advocate for the development of a national social insurance frame work including health financing safety nets for the poor. Donor contribution to the total health expenditure is over 65%. For effective coordination of this input the health financing policy should advocate for basket funding system. Conclusion This is the first National Health Accounts Study in The Gambia and its findings are important for better understanding of The Gambia health system financing. The evidence contained in this report will inform health decision-making, including policy and plan development. In addition, the results of the study will help government identify better policy instruments to re-orient the way health- finances are to be distributed in The Gambia, and will hopefully enable policy makers to better understand the flow of resources in the health system. Furthermore, the results could be used to negotiate with multilateral and bilateral agencies for additional funding for the health sector. Lastly, we hope that the NHA evidence will also be of use to non-governmental and private health stakeholders. 14

15 Chapter 1: Introduction 1.1 What is National Health Accounts? The scarcity of resources is increasingly forcing countries in the African Region to take stock of national health resources, review allocation patterns, review how equitably they are distributed, assess the efficiency of existing resource use, and evaluate health financing options [1]. Countries for a long-time have relied on Public Expenditure Reviews (PER). Unfortunately, PER enables countries to know only the monies invested into health by the government, and not the total investment made by all the stakeholders, e.g. all relevant government sectors, households, private firms, and donors. Thus, at best PER is a partial expenditure analysis. Instead, a number of countries in the Region have employed the National Health Accounts (NHA) tool to take stock of the national health resource investment, to support health system governance and decision-making. National Health Accounts (NHA) is a tool for health sector management and policy development that measures total public (all relevant sectors), private (including households, enterprises, NGOs) and donor (rest-of-the-world) health expenditures. NHA consists of a set of tables presenting various aspects of a nation s health expenditure. Its distinguishing features include [2:p.2]: A rigorous classification of the types and purposes of all expenditures and of all the actors in the health system; A complete accounting of all spending for health, regardless of the origin, destination, or object of the expenditure; A rigorous approach to collecting, cataloguing, and estimating all those flows of money related to health expenditure; and A structure intended for ongoing analysis (as opposed to a one-time study). In principle, NHA tracks all expenditure flows from the sources of funds to financing agents, service providers, public health functions and inputs. It seeks to answer questions such as [2]: Who pays and how much is paid for health services? How are resources mobilized and managed for the health system? Who provides health goods and services, and what magnitudes of resources do they use? How are health care funds distributed across the different services (e.g. prevention, treatment, care, rehabilitation), interventions and activities that the health system produces? How are the health funds distributed across the different inputs (e.g. human resources for health, pharmaceuticals and non-pharmaceutical supplies, equipment, buildings, vehicles, maintenance)? Who benefits from health care expenditure (e.g. by income groups, age/sex, geographical regions, diseases or health conditions)? NHA is an indispensable input in Department of State for Health & Social Welfare (DOHSW) stewardship of a performing health system. It empowers policy-makers (decision-makers) to effectively execute the stewardship functions of generation of financial intelligence, formulating sound strategic policy framework (national health policy, national strategic health development plan, comprehensive health financing policy 15

16 and plan), monitoring programme implementation, ensuring a fit between policy objectives and available resources, and ensuring accountability in use of all health sector resources [3]. According to Berman and Cooper [1:p.vii], NHA are a powerful tool that can be used to improve the capacity of decision-makers to identify health sector problems and opportunities for change and to develop and monitor reform strategies. NHA can provide some of the important information need for strengthening health system performance of its functions of stewardship, health financing, input (or resource) creation and services provision, and ultimately, the achievement of health system goals of health improvement (or maintenance), responsiveness to people s non-medical expectations and fair financial contributions [3,4]. 1.2 Development of The Gambia NHA The Government of The Gambia faces a situation in which it is expected to finance a growing double-burden of communicable and non-communicable diseases, rationalize health service delivery, regulate the quality, improve equity in health care delivery and meet the growing demand for better health care. National Health Accounts was designed to provide a comprehensive description of the flow of resources from the source to the ultimate use. This is the first time that the NHA tool has been used by the DOHSW in The Gambia. In November 2005, the DOHSW constituted a NHA Technical Working Group (TWG) comprising of the DOHSW, The Gambia Bureau of Statistics (GBoS), Office of the Directorate of Treasury, Local Consultant, and Head Department of Economist University of The Gambia to undertake a comprehensive NHA study for the years 2002, 2003 and In addition, the DOHSW constituted a NHA Advisory/Steering Committee to oversee the work of the TWG. The study was coordinated by the Directorate of Planning and Information, with the support of WHO and UNDP FASE Project. The launching of the NHA was done by Permanent Secretary Department of State for Health and Social Welfare on behalf of the Vice President. 1.3 Objectives of The Gambia's NHA Study The overall objective of this first NHA study was to establish the total health financing in The Gambia with a view to gather evidence that would inform policy and strategic plan. The specific objectives were to: To trace the sources of health expenditure in The Gambia; To determine total health expenditure by financing agents and providers; To examine the distribution of funds by functions e.g. prevention and curative services; and To trace the channels of distribution of funds by inputs (line items), e.g. personnel remunerations, medicines. 16

17 1.4 Organisation of the remaining chapters This report presents the analysis of the first of The Gambia s NHA study for the fiscal years 2002, 2003 and Chapter two briefly describes the geography, demography, socio-economic attributes and the health system in The Gambia. Chapter three describes the NHA methodology, data sources and limitations of the current NHA exercise. Chapter 4 reports the NHA findings. Chapter 5 presents the recommendations. Chapter 6 concludes the report. References 1. Berman P, Cooper DM: National health accounts: Software manual. Ver Boston: Harvard School of Public Health; World Health Organization: Guide to producing national health accounts: with special applications for low-income and middle-income countries. Geneva; World Health Organization: The world health report 2000 health systems: improving performance. Geneva; Murray CJL, Frenk J: A framework for assessing the performance of health systems. Bulletin of the World Health Organization. 2000, 78(6):

18 CHAPTER 2: BACKGROUND 2.1 Geographic and Demographic overview The Republic of The Gambia is located on the West Africa coast and extends about 400 km inland, with a population density of 128 persons per square kilometre. The width of the country varies from 24 to 28 kilometers and has a land area of 10,689 square kilometres. It is bordered on the North, South and East by the Republic of Senegal and on the West by the Atlantic Ocean. The country has a tropical climate characterized by two seasons, rainy season June-October and dry season November-May. Demographic characteristics According to the Demographic profile 2003, the population is estimated at 1.36 million and by the year 2011 it is estimated to reach 1.79 million, with annual growth rate of 2.74 % (The Gambia 2003 Census). About 60% of the population live in the rural area; and women constitute 51% of the total population. The crude birth rate is 46 per 1000 population while the total fertility rate is 5.4 births per woman. The high fertility level has resulted in a very youthful population structure. According to the 2003 Census, nearly 44% of the population is below 15 years and 19% between the ages 15 to 24. Average life expectancy at birth is 64 years overall. The Gambia is one of the 15 ECOWAS member states. In 2004 the ECOWAS had a total population of million people [WHR2006]. The total population of The Gambia was 1.48 million, i.e. 0.6% of the ECOWAS population (See Figure 2.1). The population aged 60 years and above increased from 5.2% in 1994 to 5.9% in The Gambia had an annual population growth rate of 3.2%, which was equal to that of Benin and Togo. The total fertility rate (TFR) decreased from 5.5 in 1994 to 4.6 in 2004; it was lower than the average ECOWAS TFR of 5.7. The Gambia s dependency ratio declined from 84 to 79 per 100 persons; which was lower than the average for ECOWAS of 96 per 100 [WHR2006]. 18

19 Figure 2.1: Population for ECOWAS in 2004 ('000) Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Thousands of people 2.2 Socio-economic overview Education Figure 2.2 presents the adult literacy rate (%) and combined gross enrolment ratio for ECOWAS countries in

20 Figure 2.2a: Adult literacy rate (% ages 15 and above) in ECOWAS Sierra Leone Niger Burkina Faso Mali Guinea-Bissau Côte d Ivoire Benin Guinea Senegal Gambia Nigeria Togo Ghana Cape Verde Percentage Adultliteracyrate2002 Adultliteracyrate2003 Adultliteracyrate2004 The Gambia had an adult literacy rate of 37.8.%. Those statistics were lower than the average ECOWAS adult literacy rate of 42% [UNDP HDR2006]. Figure 2.2b presents the gross enrolment ratio for primary, secondary and tertiary schools in ECOWAS. In 2004 The Gambia had the fifth highest gross enrolment ratio, after Cape Verde, Nigeria, Sierra Leone and Togo. 20

21 Figure 2.2b: Gross enrolment ratio for primary, secondary and tertiary schools in ECOWAS Sierra Leone Niger Burkina Faso Mali Guinea-Bissau Côte d Ivoire Benin Guinea Senegal Gambia Nigeria Togo Ghana Cape Verde Percentage Combinedgrossenrolment2002 Combinedgrossenrolment2004 Combinedgrossenrolment Human Development Index The UNDP human development index is an indicator of human development that combines life expectancy, education and Gross Domestic Product (GDP) indices. UNDP use these indices to classify countries either as high human development (with an HDI ranging from 1.00 to 0.801); medium human development (with an HDI ranging from to 0.505); and low human development (with an HDI of and less). Figure 2.3 presents the 2002, 2003 and 2004 HDI for the ECOWAS. Only Cape Verde and Ghana had medium human development. All the other thirteen ECOWAS countries are low human development countries. 21

22 Figure 2.3: Human Development Index for ECOWAS (2004) Sierra Leone Niger Burkina Faso Mali Guinea-Bissau Côte d Ivoire Benin Guinea Senegal Gambia Nigeria Togo Ghana Cape Verde Human development index HDI2002 HDI2003 HDI2004 Thus, The Gambia is also classified as a low human development country. In 2004 the country had fourth highest HDI, after Togo (HDI=0.479), Ghana (HDI=0.532) and Cape Verde (HDI=0.722). The Gambia s HDI of was slightly higher than the average HDI for ECOWAS of and the global average HDI for low human development countries was [UNDP HDR2006] Economy The real gross domestic product for The Gambia in 1980 was $213 million. By 2004 it had more than doubled ($484 million). Between 2000 and 2004 the country experienced a real GDP growth rate of 3.2%, which was mainly attributed to growth in the industry (7.2% between ) and service sectors value added (5.9% between ). Over the same period the agricultural sector experienced a small growth in value added of 0.2% [World Bank, 2006]. 22

23 Figure 2.3: Gambia Agriculture-, industry-, and service value added ($millions) Year2004 Year2003 Year Value added ($ millions) Agriculture Industry Service In 1980 and 2004 the real GDP per capita was $327 [World Bank, 2006]. Figure 2.4 shows that the real GDP per capita for The Gambia was higher than those of Burkina Faso, Ghana, Guinea-Bissau, Liberia, Mali, Niger, Sierra Leone, and Togo. However, per capita GDP being an average measure, hides the inequalities in GDP distribution among the population. For example, the Gini Coefficient for The Gambia was 50.2 in 2004 [World Bank 2006]. 23

24 Figure 2.5: Life expectancy at birth for ECOWAS (2004) Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin NATIONAL HEALTH ACCOUNTS Life expectancy in years Sierra Leone Guinea-Bissau Burkina Faso Figure 2.4: Real GDP Per Capita ($) in ECOWAS Togo Senegal Nigeria Niger Mali Liberia Guinea Ghana Gambia Côte d Ivoire Cape Verde Benin Dollars per person GDPPC2002 GDPPC2003 GDPPC Health Profile Figure 2.5 presents the life expectancy at birth among ECOWAS in The 2004 life expectancy of The Gambia (57 years) was equal to that of Ghana. It was the second highest among the ECOWAS after that of Cape Verde (70 years). The life expectancy in The Gambia was 7 years higher than the average life expectancy for ECOWAS, which was 50 years. In The Gambia, the life expectancy for males was 55 years and females was 59 years. Figure 2.6 presents the probability of dying (per 1000 live births) below the age of 5 years (i.e. under-5 mortality rate) for the ECOWAS. The under-5 mortality rate (for both sexes) in The Gambia was 122 per 1000, which was second lowest in ECOWAS, after Cape Verde. The Gambia under-5 mortality rate for males (129 per 1000) was higher than that of females (115 per 1000). The under-5 mortality rate in The Gambia was lower than the average for ECOWAS of 178 per 1000 (male=183/1000 and female=168/1000). 24

25 Figure 2.6: ECOWAS under five mortality per 1000 live births (2004) Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Deaths per 1000 live births Figure 2.7 shows the probability of dying per 1000 between ages 15 and 60 years (adult mortality rate) for ECOWAS.. The adult mortality rate for The Gambia was 304 per 1000, which was lower than that of all the other ECOWAS, except for Cape Verde. The average adult mortality rate for ECOWAS was 410 per 1000 and the median was 441 per The Gambia adult male mortality rate was 344 per 1000 and that for females was 263 per

26 Figure 2.7: Adult mortality rate in 2004 Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Deaths per 1000 Male adult mortality rate Female adult mortality rate Figure 2.8 presents the maternal mortality ratio (per 100,000 live births) for the ECOWAS countries in year The maternal mortality ratio for The Gambia of 540 per 100,000 live births was the second lowest among the ECOWAS, i.e. after Cape Verde. It was far much lower than the average MMR for ECOWAS of 905/100,000 (and median of 800/100000). 26

27 Figure 2.8: Maternal mortality ratio in ECOWAS Niger Sierra Leone Mali Burkina Faso Guinea-Bissau Chad Côte d'ivoire Benin Guinea Nigeria Senegal Gambia Togo Ghana Cape Verde Maternal deaths per 100,000 live births Reported MMR2004 Adjusted MMR2000 The Gambia has an Infant Mortality Rate of 75/1000 live births(2003 census), 60% of which is attributable to malaria, diarrhoeal diseases and acute respiratory tract infections. The main causes of mortality in infants (0-12 months) are neonatal sepsis, premature deliveries, malaria, respiratory infections, diarrhoeal diseases and malnutrition. For child mortality, main causes are: malaria, pneumonia, malnutrition, and diarrhoeal diseases (HMIS). The Maternal Mortality 27

28 Ratio is estimated at 730/ live births, the majority of which are due to sepsis, haemorrhage and eclampsia. About 40% of total outpatient consultation in 1999 was due to malaria, while diarrhoeal diseases and acute respiratory tract infections constitute about 25%. The HIV prevalence rate is 1.1% for HIV1 and 0.6% for HIV2 (sentinel surveillance 2005). Tuberculosis remains a disease of public health importance in The Gambia. Through intensified case finding, the proportion of smear positive cases identified has increased from 56% in 2004 to 66.7% in There has been an increase in national coverage for fully immunized children to a present level of 79.6 % for under 1 year and 84.9% for the under 2 year (2004 EPI cluster survey). Malnutrition continues to be a major public health problem in The Gambia. The MICS 2006 indicated 19% stunting, 6.8% wasting and 17% underweight. Diabetes Mellitus is estimated to affect about 1% of the population while a study found that about 16% of urban women are obesed compare to only 1% of rural women. 2.4 Health System Overview A health system includes all activities whose primary purpose is to promote, restore or maintain individual s physical, mental and social well-being [11]. Thus, health system activities include health promotion, disease prevention, treatment, rehabilitation and nursing/care (including community and home-based care). According to WHO [12], a health system performs the functions of stewardship (oversight), health financing, creating resources/inputs (including human resources for health) for producing health, and delivering (providing) personal and non-personal services with a view to improving responsiveness to people s non-medical expectations, ensuring fair financial contribution to health systems and ultimately improving health status Stewardship The WHO Report 2000 broadly defines stewardship as the careful and responsible management of well-being of the population. Health stewardship focuses on the role of country s government, through its health ministry, in taking responsibility for the health and well-being of the population, and guiding the health system as a whole, in order to achieve its goals. The domains of stewardship include: generating and using intelligence/evidence; providing vision and direction for the health system through formulation of strategic policy framework; ensuring tools for implementation: powers, incentives, and sanctions; building coalitions/building partnerships; ensuring fit between policy objectives and organizational structure and culture; and ensuring accountability. 28

29 In order to exercise its stewardship role, The Government of the Republic of The Gambia developed the National Health Policy Framework [2001]; to guide health development of her population. The National Health Policy focuses on improving access to basic health care and health system strengthening Provision of Health Services According to the World Health Report 2000, this function of health system refers to combination of inputs within a production process (e.g. hospital, clinic, public health programme) that leads to the delivery of personal health services (consumed directly by the individual, whether preventive, diagnostic, therapeutic or rehabilitative) and nonpersonal health services, i.e. actions applied either collectivities (e.g. national vaccination campaigns, mass health education) or to the non-human components of the environment (e.g. basic sanitation, water, air-pollution control). The Republic of The Gambia responds to the aforementioned health situation through an extensive network of public and private health facilities (hospitals, health centres, clinics, health posts) and traditional healers in the 6 health regions of the country. Table 1 indicates the number of various types of health facilities existed in the country in Table 1: Distribution of Health Facilities by type and region in The Gambia (2006) Regions Public Health Facilities Private/NGO Health Facilities Hospitals Major Health Centre Minor Health Hospitals Health Centres (District Hospitals) Centres Western North Bank West North Bank East Lower River Central River Upper River KMC BCC Total Source: DOHSW [HMIS 2006] Table 1 shows the distribution of health facilities in The Gambia by region and type. 29

30 The Public Health Facilities are government owned. The rest are NGOs, Private sector and communities owned and managed. Public sector Village Health Services (Community Health Posts) The lowest level for health service provision is the community health post. This provides the very basic minimum health package to the village. The service providers are the Village Health Workers with very minimal training and Traditional Birth Attendants with limited additional training. The village health provider provides treatment for noncomplicated malaria, diarrhoea, minor injuries, worm infestation and stomach pain. He charges D0.75 for children and D2.00 for adults. The village health services are complemented by the Reproductive and Child Health (RCH) monitoring visits from the health centres. The RCH package includes: antenatal care, child immunization, weight monitoring and limited treatment for sick children. Minor Health Centre The minor health centre is the unit for the delivery of basic health services. The national standard is 15,000 population for a minor health centre. The minor health centre is meant to provide up to 70 percent of the Basic Health Care Package needs of the population. The minor health centre coverage for the rural community is not above 65 per cent, for the Greater Banjul Area it is below 15 percent. Major Health Centres (District Hospitals) The major health centres have a bed capacity of about 100. They serve as the referral health facilities for minor health centres for such services like, obstetric emergencies, essential surgical services, and further medical care. Major health centres also serve as blood transfusion points for the area. The national standard is 200,000 population for a major health centre and coverage is about 100 percent. General Hospital The general hospitals are the regional referral points. They have bigger bed capacities of up to 250 beds and are to provide additional services not available at the regional hospital level. Teaching and Specialist Hospital This is the most advanced referral health facility in The Gambia. Conditions that cannot be handled at this health facility have to be referred overseas, the nearest being in Senegal. 30

31 Considerable progress has been made in the areas of: EPI Coverage, expansion of health facilities and in recruitment of trained health personnel. Success has been registered in the implementation of the Baby Friendly Community Initiative and the Bamako Initiative. Also, relevant policy documents were developed including that of Nutrition, Drug, Malaria, Reproductive and Child Health, Human Resource for Health, Maintenance, Mental Health, HIV/AIDS, Health Management Information System, National Blood Transfusion, Information Technology, and others such as Traditional Medicine, National Health Laboratory, Health Research, are at various stages of development. Policy environment There is a pressing need to enhance the delivery of quality health services in order to reduce the high prevailing morbidity and mortality rates. The need to review the current health policy has been influenced by the following factors: To keep in pace with the Decentralization and Local Government Reforms which emphasizes an integrated management of government services, including health to the regions. The devolution of authority, responsibility and resources to the regions has to be directed by the policy. Proliferation of donor agencies each operating in their own way in the same health care system. There is therefore urgent need for better co-ordination of donor activities. The declining, though still high, incidence of infectious diseases and the emergence and re-emergence of non-communicable and communicable diseases needs intensification of efforts in our service delivery packages. Formulation of other sector policies impacting on the organization and the delivery of health services. The disparity in the demand and quality of services at different levels of health care. Experience from the implementation of certain health projects/programmes like PHC, BI and DRF to improve financing of health services Resource Generation Health systems include a diverse group of organizations that produce health services inputs, particularly human resources for health, medicines, physical facilities and equipment, and knowledge [12]. According to Murray and Frenk [17:p.727], this set of organizations encompasses universities and other educational institutions, research centres, and companies producing specific technologies such as pharmaceutical products, devices and equipment. 31

32 Human resources for health Table 2 presents a distribution of health workers in ECOWAS in ECOWAS had a total contingent of the following human resources for health: 45,426 physicians, 276,559 nurses, 3,014 midwives, 3,653 dentists, 10,727 pharmacists, 2,348 public and environmental health workers, 125,891 community health workers, 5,700 laboratory technicians, 11,981 Other health workers, and 29,464 Health management and support workers [WHR2006]. Out of those total human resources, 156 (0.34%) physicians, 1,719 (0.62%) nurses, 162 midwives (5.37%), 43 (1.18%) dentists, 14 (0.45%) pharmacists, 33 (1.41%) public and environmental health workers, 968 community health workers (0.77%), 99 (1.74%) laboratory technologist, 3 (0.03%) other health workers, and 391 (1.33%) health management and support workers were in the Republic of The Gambia. The densities of doctors and nurses per 1000 population were higher than those of most of the other ECOWAS. Table 2: Distribution of health workers in ECOWAS in 2004 Country Physicians Nurses Midwives Dentists Pharmacists Number Density per 1000 Number Density per 1000 Number Density per 1000 Number Density per 1000 Number Densit per 10 Benin Burkina Faso Cape Verde Côte d'ivoire The Gambia Ghana Guinea Guinea-Bissau Liberia Mali Niger Nigeria Senegal Sierra Leone Togo SOURCE: WHO [WHR2006]. Table 2: Continued Public and environmental health workers Community health workers Density per 1000 Number Lab technicians Density per 1000 Number Other health workers Density per 1000 Number Health manag and support w Country Number Density per 1000 Number Benin Burkina Faso Dens

33 Cape Verde Côte d'ivoire The Gambia Ghana Guinea Guinea- Bissau Liberia Mali Niger Nigeria Senegal Sierra Leone Togo Essential Medicines and Laboratory Services The Central Medical Stores (CMS) is the main source of pharmaceuticals and other medical supplies for the public sector. Its main depot was located at the Medical and Health Headquarters in Banjul. Until recently when a new complex was opened in Kotu in the Kanifing Municipal Area. It has distribution points in four out of the six regions. Procurement is usually done on an annual basis. A number of private pharmaceutical importers and wholesalers compliment the public provision. Laboratory services within the public health system are limited and some times the results are unreliable. More than 50% of public health facilities in the The Gambia are without laboratory services, whilst private sector and NGO provision of laboratory services are few. Although the private laboratories produce reliable results, the services are not affordable and accessible to a vast majority of The Gambians. The Gambia continues to depend on laboratories out side for a number of specialized investigations. 2.5 Health Financing Health financing has been defined as the raising or collection of revenue to pay for the operation of the health system [16]. It has three functions: revenue collection from various sources, pooling of funds and spreading of risks across larger population groups, and allocation or use of funds to purchase services from public and private providers of health care [12]. The objectives of health financing are to make funding available, ensure choice of cost-effective interventions, set appropriate financial incentives for providers, and ensure that all individuals have access to effective public health and personal health care [17]. In the Republic of The Gambia, there are various sources of health sector funding. Firstly, is government tax revenue, allocated by the Department of State for Finance and Economic Affairs to various financing agents, e.g. Departments of Health, Education, Defence, Interior and Foreign Affairs. Secondly, the households contribute to health funding through direct out-of-pocket payments (OOPs) for health goods and services. For the various charges see table 2 below. The OOPs do not go through any resource pooling 33

34 and risk-sharing mechanism. Thirdly, some employers provide medical cover for their employees, either through self-operated health clinics (e.g. GPA Clinic) or paying premiums into health insurance schemes. Fourthly, the international donors (e.g. bilateral and multi-lateral agencies, Global Fund for AIDS, Tuberculosis and Malaria, GAVI) also contribute to health funding in the country. To a lesser extent the Local Government Authorities also contribute to health financing. Chapter 4 provides more details regarding the amounts of money actually spent from the different sources. 34

35 Table 2 Public health services user fees Services Gambians Non-Gambians 0-6- Adult 0-5yrs 6-15yrs Adult 5yrs 15yrs Out-patient Hospital Out-patient Health Centre In-patient (per week) Hospital In-patient (per week) Health Centre Deliveries Hospital Deliveries Health Centre Minor Surgery Hospital Minor Surgery Health Centre Major Surgery Lab Services Category iv X-ray Dental MCH Clinic 5 75 Registration Mortuary

36 cold per day room References 1. Drug Revolving Fund Procedures Manual The Gambia Primary Health Care Programme 1980/85 3. Bamako Initiative Procedure Manual Health Services user fee revised list

37 CHAPTER 3: METHODS AND SOURCES OF DATA 3.1 NHA Conceptual Framework According to the WHO guide to producing NHA [WHO 2003], international experience in the development and use of health accounts suggests a number of useful dimensions. Financing sources: Institutions or entities that provide funds used in the health system by financing agents. These financing sources consist of the Government (DOSFEA), Local Government Areas (LGA), parastatals (Public enterprises), private employers, households and donors (rest-of-the-world). Financing agents: Institutions or entities that channel funds provided by financing sources and use those funds to pay for, or purchase, the activities inside the health accounts boundary (i.e. all activities whose primary purpose is to promote, restore or maintain health). These financing agents include: DoSH, DoSE, DoSD, DoSI, DOSFA, NAS, NaNA, Parastatals, private insurance, households, NGOs, and private firms. The sum of the funds channelled through all the financing agents should be equal to the total amount of money provided by the financing sources. Providers: Entities that receive money in exchange for or in anticipation of producing the activities inside the health accounts boundary. Examples of providers include: Teaching hospital, general hospitals, private hospitals/clinics, Government Health Centres (Basic Health Services), NGO health centres, pharmacies, opticians, pharmaceutical companies, administration of public health, provision of public health services, other (private insurance), all other providers of health administration, insurance firms, research institutions, education and training institutions, NGO health related activities, and rest of the world. Ideally, the sum of the funds received by all the providers should be equal to the total amount of money provided by the financing agents. Functions: Services of curative care, services of rehabilitative care, ancillary services to medical care, medical goods dispensed to out-patients, prevention and public health services, health administration and health insurance, and health related functions. The latter includes: capital formation of health care provider institutions, maintenance service management, education and training of health personnel, research and development in health, traditional medicine development, and provision of overseas treatment. Resource/input costs: The factors or inputs used by providers or financing agents to produce the goods and services consumed or the activities conducted in the health system. The resource/input cost categories would include: personnel (remuneration, employers contribution employees insurance, other conditions); goods and services (travel and subsistence expenses, drugs and medical supplies, material supplies, transport, utilities, maintenance, property rental and related charges; education and training (research and development, nutritional surveillance, water and sanitation, other services and expenses); 37

38 subsidies and other current transfers (membership fees and subscription, government organization, individuals and non profit, public and departmental enterprise); and development expenditure (furniture and office equipment; vehicles, operational equipment, machinery). Beneficiaries: The people who receive those health goods and services or benefit from those activities (beneficiaries can be categorized in many different ways, including their age and sex, their socio-economic status, their health status, and their location). Figure 3.1 shows how NHA tracks financial flows of health resources and its links to health policy issues and policy instruments. Figure 3.1 How NHA Presents Financing Flows and links to Health Policy Decisions Some Key Policy Issues Flow of Resources in Health Financing Some Key Health Policy Instruments How are resources mobilized? Who pays? Who finances? Under what scheme? How are resources managed? What is the financing structure? What pooling arrangements? What payment and purchasing arrangements? Who provides what services? Under what financing arrangements? With what inputs? Who benefits? Who receives what? How are resources distributed? Financing Sources Financing Agents Providers Inputs & Functions Resource mobilization/ financing strategies Pooling arrangements Cost recovery Regulation of payers Financial incentives Subsidies Resource allocation Regulation of providers Targeting Redistributive policies Outcome evaluation 38

39 Each of the NHA tables displays some facet of health expenditure cross-tabulated by two of the abovementioned dimensions. By convention, the origin of the funds dimension is shown as columns and the use dimension is shown as rows. Following this convention, each cell in the table show the amount of resources used for the row i of use from the column category j of origin ( spent by j on I ) as illustrated in Table 3.1 above. The three critical dimensions for accurate estimation of total health spending include health financing agents, providers, and functions. The NHA tables that cross-tabulate these dimensions include: Health expenditure by financing source and type of financing agent (FS x FA). This table highlights resource mobilization patterns in the health system. It addresses the question where does the money come from by showing the financing sources that contribute to each financing agent. It also shows how prominent a role each source plays in the financing of each financing agent and in the total spending overall. Health expenditure by the type of financing agent and type of provider (FA x P). This table describes how funds are distributed across different types of providers, e.g., what share of total spending goes to referral and district hospitals relative to primary/hospitals, clinics, health posts, outreach stations. Health expenditure by provider and type of function (P x F). This table shows how expenditures on different health functions are channelled through the various types of providers. It provides useful perspective on the contribution of different types of providers to the total spending on specific types of services, e.g. public health programmes vis-à-vis secondary and tertiary curative care. Health expenditure by type of financing agent and type of function (FA x F). This table shows who finances what types of services in the health system. It can also highlight the relative emphasis of public and private financing agents with respect to the various public health functions. Cost of resources used to produce health goods and services. This table illustrates the share of national health expenditure contributed by the value of labour, pharmaceutical supplies, equipment and buildings, etc. This table provides a basis for the analysis of the efficiency of production and resource use. Health expenditure by age and sex of the population. This table highlights the distribution of health goods and services among age/sex groups in the population, e.g. children, elderly, women of childbearing age. Health expenditure by socio-economic status of the population. This table can be used to answer the question Does the composition of financing one s health care vary with one s position in society? Using data from household income and expenditure surveys to aggregate the population into quintiles, health accounts may be used to assess how well specific payers target vulnerable groups and what share of the burden of spending is being borne by different groups. 39

40 Health expenditure by geographic region (e.g. districts). In the current study, it was possible to obtain expenditure data disaggregated by financing sources, agents, providers, and functions and resource costs. (See Annex Tables 3.1a, 3.1b, 3.1c,,3.1n). 3.2 Field Work Methodology The Gambia NHA study relied on primary and secondary data. A wide range of data and information was collated from various government publications and other sources. In addition, data was collected from the following sources: Government Departments: DoSFEA, DoSH, DoSE, DoSD, DoSI, DOSFA, LGA; National AIDS Secretariat (NAS); NaNA; Parastatals; Employers; Insurance; Non-Governmental Organisations (NGOs involved in health); Donors (both bilateral and multilateral); and Health care providers: Public, Private for-profit/ not-for-profit Facilities. To facilitate the data collection process a National Health Account sensitization workshop was held in September Potential NHA stakeholders were invited to a one day workshop where they were introduced to NHA, the usefulness of NHA and its relevance to The Gambia Sampling Approaches: Household health expenditure and utilization survey To determine household expenditure on health for this exercise, two sources were utilized. In view of the high cost involved in conducting large scale household surveys, it was decided to largely utilize data from the 2003 Integrated Household Survey (IHS) to arrive at estimates of household expenditure on health and also to conduct a small scale household survey in 2006 to address issues of health seeking behaviour which were largely not covered by the IHS. Integrated Household Survey (IHS) The primary sampling unit for the IHS were enumeration areas (EA) which were drawn from the 2003 Population and Housing Census demarcated EAs. For this survey 240 EAs were selected consisting of 4 sub-samples of 60 EAs surveyed at each quarter. A sample of 4800 households was drawn across all Local Government Areas LGA) with the probability of selecting a household in an LGA proportional to the size of the LGA, in terms of population. The sampling was done in two levels: enumeration areas (EAs) and households. EAs were stratified by rural-urban areas (12 strata + Banjul and Kanifing). 40

41 Training of field workers lasted a week during which both enumerators and supervisors were trained on how to complete the questionnaires. Since the questionnaires were in English and not translated to any of the local languages, it was decide to train, first, in English and later on attempt a translation of all the questions in the three major local languages (Mandinka, Fula and Wollof). As the majority of Gambians could not complete the questionnaires in English the translation exercise was aimed at ensuring a common understanding of the concepts in the questionnaires and a uniform translation of the questions. Enumerators despatched to the field during the data collection began with a household listing exercise. The listed households served as a sampling frame for the selection of households for the detail interviews. Households in protected areas were not surveyed (mostly military, police and prison camps etc.). Six teams made of 6 supervisors and 30 enumerators each were assigned to the different geographical locations. Each enumerator covered 40 households in two EAs by quarter. Among these 40 households, 20 households were selected (10 per EA) for whom the daily diaries were administered. In total the enumerators stayed 6 weeks in each EA. The data collection started in January 2003 and ended in May For the purpose of collecting data on household expenditure daily diaries were kept for the selected households by enumerators of the IHS. These diaries were used to keep records of household expenditure for a period of a month. The data presented in this report on household expenditure on health was derived from data compiled from these diaries. As is common to household surveys, particularly, income and expenditure surveys reporting is often prone to varying degrees of errors. A limitation identified with the IHS is the under-reporting of household expenditure attributed to respondent fatigue due to the long duration of the completion of the daily diaries. This under-reporting of expenditure might have affected the expenditure figure presented in this report. Another limitation related to the IHS data is the fact that since the survey was not specifically designed for the National Health Accounts, the data was not structured to fit in the NHA tables. For example, to determine how much of health expenditure went to out-patient services and how much to in-patient services, data on health seeking behaviour had to be used as a proxy to disaggregate expenditure on health. As health expenditure was also not disaggregated by service provider, data on health seeking behaviour had to be used to disaggregate expenditure. National Health Accounts (NHA) Household Health Expenditure and Utilization Survey, 2006 The Household Health Expenditure and Utilization Survey conducted in 2006 targeted 1000 households distributed across LGAs. Probability of selecting a household from each of the LGAs was proportional to the population size of the LGA. For the purpose of 41

42 selecting the sample EA the country was stratified into urban and rural. For the 38 enumeration areas selected for the survey 18 were in urban areas and the remaining 20 in rural areas. As was the case with the IHS the EAs in the 2003 Population and Housing Census were used as the sampling frame. The second stage of the sampling involved the selection of households for the detail interviews. Upon the updating of the households in the selected enumeration areas, enumerators selected households in each of the selected households. This selection process involved the use of random number table to avoid any bias in the selection. Enumerators were trained on the completion of the questionnaires for an initial period of 3 days. Following this training enumerators and supervisors were despatched to the field to pre-test the questionnaires for a day. The following day the teams returned to the training hall for a review of the completed questionnaires and also to share experiences of the pre-test. Supervisors who reviewed the completed questionnaires commented on them and identified errors and misconception. During mock interviewers in the course of the training, the questions were translated into the local languages to enhance interviewers understanding of the questionnaires. The questionnaires were designed to collect data on the following areas; Demographic characteristics Education Employment and remuneration of households in the last 12 months Health Status of members of the household in the last four weeks Smoking Habits Presence of chronic illness Health seeking behaviour In-patient admission in the last one year; reasons for admission and duration for admission Utilization of out-patient and other health related services in past four weeks Reasons for seeking health care: Type of the health provider/facility visited and reasons for the choice Cost of the services received Availability of prescribed drugs Perception on the quality of service received Time and cost of transportation to health provider Routine health expenses in the last four weeks Type of the health provider/facility admitted in and reasons for the choice Reasons for and cost of admission source of funds for the services received including drugs Travel time to health facility and cost of transportation (admissions) Perception of the quality of services at the inpatient facility Time and cost of transportation to inpatient health provider Mortality of household members in the last 12 months Did the deceased consume health services before he/she died? How much did the household spend on treatment for the deceased? 42

43 Access to health insurance HOUSING CONDITIONS Construction material (walls, floor and roof) Source of lighting Cooking facility and fuel Toilet facility Source of drinking water Tenure of accommodation of households Notwithstanding the array of topics covered in this survey, for the purpose of the NHA, data was compiled on selected areas which have been presented in this report. Topics included in this report mainly relate to health seeking behaviour. Further analysis of the results of this survey could be the subject of further research. Data Collection, Processing and Analysis For the data collection 4 teams, each consisting a supervisor and five enumerators, were constituted. Two officials one from the Central Statistics Department and one from DPI coordinated the data collection. The data collection lasted 20 days. Following the completion of the data collection a coding and editing exercise was undertaken after which using data was entered using the CSPro software. After the entry the data was cleaned of errors and the tables generated Sampling Frame for organizations survey Seventy-three (73) private firms (companies), 21 private/ngo health facilities, 37 NGOs, 17 donors and 4 insurance companies were identified for the survey. Table 3.1 shows the numbers and percentages of different organizations contacted and those that responded. In general the response was good. Table 3.1: Breakdown of data sources contacted and respondents Total number contacted Number of Responded Health Care Providers Public Private/NGO Sources Govt Department LGAs Donor NGO Insurance Percentage collected 43

44 Employer/Private firms Households (2006) Employer Survey The lists of companies and other employers obtained from Registrar General s Department, The Gambia Chamber of Commerce and were compared to determine the sample size and the cut off point (only organisations with more than (20) twenty employees). All identified were included in the survey. The data collection was done by Account Technicians provided by the Directorate of National Treasury. The NHA Technical Committee provided the supervision of the data collection. The employer survey instrument contained questions on: general information (firm name and ownership, principal activity, number of full-and part-time employees); whether the firm provided medical insurance in the year 2002 to 2004; number of employees covered by insurance; whether the insurance covered dependents; amount of premiums paid by the firm; amount employees contribute to private health insurance; types of health services covered by insurance; amount the firm reimbursed employees for medical expenses incurred; types of health care services (e.g. inpatient, outpatient, drugs) the firm reimbursed for; amount spent to reimburse for services purchased at private and public health care facilities; whether the firm provided on-site health services for employees; amount spent to provide on-site health services (e.g. expenditure on salaries, drugs and medical supplies, equipment etc); amount of subsidies the government or any other nongovernmental organization make in support of their health facilities; number of health care facilities owned by the firm and types of services provided; amounts of money employees pay for services and/or medication offered in these facilities; firm s annual expenditure on various public health sector services (See Employer questionnaires in the Annex section) Non-Governmental Organizations Survey The lists of NGOs was obtained from the Registrar General, NGO Affairs Agency of the Department of Local Government were used to determine the sample size and identified NGOs involved in health. The data collection was done by Account Technicians provided 44

45 by the Directorate of National Treasury. The NHA Technical Committee provided the supervision of the data collection. The non-governmental organization survey questionnaire gathered information on: NGO identity; types of health services or activities supported; amount of revenue obtained by the NGO from cost sharing/user fees, grants from government, and foreign assistance; types and market value of goods received in kind; organizations that the NGO provided with funds for health activities and the amounts in 2002 to 2004; and details on the amount spent on various health service functions (see NGO Questionnaires in Annex..) Development partners/ Donor survey The list of donors was provided by the Department of State for Foreign Affairs and all were contacted. The data collection was done by the NHA Technical Committee. The donor survey instrument contained items/questions on: identification information (name and type of donor and contacts); type of health care related activities provided/supported (financially and/or technically) and dollar value of that support; grants/loans to other institutions/organization(s) that provide health care or health related activities. Each donor was also asked to indicate the amount that it spent in the year 2002 to 2004 to support your health or health related activities within its own organization, e.g. for programme administration, inpatient care, outpatient care, rehabilitative care, drugs and medical supplies, public health administration of health services, administration of public health programmes, education and training of health personnel, research, IEC, and environmental health, among others (See Annex ). Lastly, the donor was asked to indicate the amount that his/her organization spent in the year 2002 to 2004 to support her activities (i.e. administration) in The Gambia as well as the amount spent on technical assistance not included in the earlier amounts, e.g. administration/programme support, technical assistance, in-kind support, etc (see Donor Questionnaires in Annex ) Insurance firms survey The list of insurance companies was obtained from Registrar General Department and all were contacted. The data collection was done by Account Technicians provided by the Directorate of National Treasury. The NHA Technical Committee provided the supervision of the data collection. The health insurance survey instrument had questions on: general information (e.g. type of insurance company); type of insurance policies (e.g. health insurance, life assurance, personal accident, car insurance, education insurance); whether health insurance is included as part of other insurance, total premiums and health expenses; organisation s total revenues (group/company, individual/family); whether the insurance company offered health insurance coverage for hospital inpatient care, out patient care, maternity 45

46 /antenatal care services, HIV/AIDs services, TB care services, evacuation to other country and treatment in public, private, mission, and/or own facility; number of subscribers to company/employer, group, and individual/family health insurance cover; a breakdown of the amount of payment/reimbursement made according to various health service providers; total revenue from own overall business in the period; own total expenditure on health from overall business for the period; and types of services contract out to hospitals/ nursing homes and medical expenses reimbursed (see Insurance Questionnaires in Annex ) Private practitioners The Technical Committee had to use their knowledge of the health system to identify the private practitioners as there was no up to date registration of these institutions. The data collection was done by Account Technicians provided by the Directorate of National Treasury. The NHA Technical Committee provided the supervision of the data collection The health provider survey questionnaires contained items on: provider identification (name, type and ownership); types and amounts of revenue for health care and related activities/functions from private insurance reimbursement, employer reimbursement, direct user fees, community funds (at public health centres and dispensaries only), individual contributions/premiums, employer/group contributions, volunteer labour, cash and in-kind grants from government, and foreign/ngo assistance-grants/donations/loans; amounts given to other organizations to provide health related services; amounts of money that the provider spent on various health care functions (see Private Questionnaires in Annex ) Government Departments/Parastatals Survey The NHA Technical Committee encountered no difficulty to identify the departments and parastatals as they were few. All the concerned departments and parastatals were contacted. The data collection was done by Account Technicians provided by the Directorate of National Treasury. The NHA Technical Committee provided the supervision of the data collection The respondents were asked to indicate the amount of revenue obtained by his/her institution in 2002, 2003 and 2004 from Cost Sharing Schemes/User fees, Transfers from Central Government (DoSFEA) in cash and kind, and Foreign assistance (loans, grants and donations). S/he was also asked to indicate the amount her/his institution spent on the following activities in year 2002 to 2004, namely: inpatient care services, outpatient care services, rehabilitative care services, drugs and medical supplies, public health, administration of health services, administration of public health programs, education and training of health personnel, research, IEC, environmental health. The questionnaire also asked for the actual expenditure on the following inputs (in the years 2002 to 2004) on personnel emoluments (remuneration, employer contribution to employees health insurance), goods and services (travel and subsistence expenses, drugs and medical supplies, material supplies, transport, utilities, maintenance, property rental 46

47 and related charges, property rental and development), education and training (research and development, nutritional surveillance, water and sanitation), subsidies and other current transfers (membership fees and subscription, government organization, individuals and non-profit, public and departmental enterprise), and development expenditure (furniture and office equipment, vehicles, operational equipment and machinery) (See Departments questionnaires Annex ). The Local Government Area survey instrument contained questions on: general information; amount of revenue obtained from general taxes (utility taxes), grants (cash and kind) from government, foreign assistance (loans, grants/donations); amount spent on the following activities Inpatient care services, Adopt and maintain hospital ward, Outpatient care services, Rehabilitative care services, Drugs and medical supplies, Public health administration and services, education and training of health personnel, research, IEC, and environmental health; amounts spent on acquisition of health inputs. The other departments included DoSFEA, DoSFA, DOSE, DOSD, and DOSI. The survey instrument for other Departments of State gathered general information; amount of revenue (from cost sharing schemes/user fees, transfers from DoSFEA, foreign assistance) obtained by the Department of State in year 2002 to 2004; amount the department spent on inpatient services, outpatient services, drugs and medical supplies, public health administration and health services, education and training of health personnel, research, IEC, and environmental information, among others; and actual expenditure on the inputs in the year 2002 to Data analysis After checking for completeness of the questionnaires filled by various organizations, the data were entered, cleaned and preliminary analysis done using Excel software. This data was then entered into dummy matrix tables and analyzed using Excel software. The matrices were built in accordance to the International Classification of NHA to facilitate international comparison, but customised to the local situation. NHA uses many matrix tables for analysis, but due to paucity of data, a decision was made to attempt completing only the following four main matrices: Financing Sources (FS) to Financing Agent (FA): (FS X FA) Financing Agent (FA) to Providers (P): (FA X P) Providers (P) to Inputs (RC): (P X RC) Financing Agents (FA) to Health Functions (HF): (HF X FA) 3.4 Limitations of the NHA study a) In the 2006 survey household sample size was very small b) Poor response from the Bilateral donors and private health care providers c) Expenditure data from some respondents was not in the NHA questionnaire format 47

48 d) The IHS questionnaire was not designed to fulfil NHA e) Pledged Funding support from other partners was never made available. f) NAS could only provide the 2004 data g) Complete expenditure on CISP (Italian Project) was not available h) Expenditure on utility and telecommunication for DOSH and RVTH were not available i) The health insurance data was available in aggregate form and from only one provider References 1. WHO NHA Generic questionnaires 2. Kenyan NHA questionnaires 3. Namibia NHA questionnaires 4. Guide to developing NHA (WHO, WB and USAID) 48

49 Dalasi NATIONAL HEALTH ACCOUNTS CHAPTER 4: MAIN NHA FINDINGS 4.1 Health Financing by Sources Total health expenditure and per capita total health expenditure Figure 4.1a provides total health expenditure (THE) by various sources, including the Department of State for Finance and Economic Affairs (DoSFEA), Local Government Authorities (LGA), Parastatal Funds, private employer funds, household funds, and the rest of the world (Donors). The total health expenditure (THE) was D1,185,223,103 in 2002; D1,395,958,522 in 2003; and D1,682,323,673 in Total expenditure on health as a percentage of GDP in The Gambia was 16.1% in 2002, 13.9% in 2003 and 14.9% in 2004 (see Appendix Table 1 and 3). 1 The per capita THE was derived by dividing THE for each year by respective population ( people in year 2002, people in year 2003 and people in year 2004) estimates from The Gambia Bureau of Statistics (GBS). That yielded a per capita THE of D895 in 2002, D1026 in 2003 and D1203 in Thus, there was 41.9% nominal growth in the per capita THE between years 2002 and Figure 4.1a: Health expenditure in Gambia by sources 1,200,000,000 1,000,000, ,000, ,000, ,000, ,000,000 - Donors Household Private employers Parastatals LGA DoSFEA. Sources of funds Year2002 Year2003 Year2004 Figure 4.1b shows the per capita THE for the 15 ECOWAS countries [WHR2006]. During the three years, per capita THE for The Gambia was higher than that of Guinea- Bissau, Liberia, Niger, Sierra Leone and Togo, but lower than that of the remaining ECOWAS countries. 1 The gross domestic product (GDP) in The Gambia was D7,364,000,000 in year 2002; D10,025,934,179 in 2003; and 12,042,000,000 in 2004 (DoSFEA, 2007). 49

50 Figure 4.1b: Per capita total health expenditure (THE) for ECOWAS countries Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Per capita THE (US$) Year2002 Year2003 Year Total health expenditure by source There are broadly four sources of health financing in the Gambia, namely: public/government, household out-of-pocket payments (OOPs), private employers and donors (rest of the world). This subsection provides a distribution THE by each of those sources. Figure 4.1C shows a breakdown of heath financing by source in The Gambia for year Out of the THE of D1,185,223,103 in 2002, 70.2% came from donors, 17.5% from government/public, 12.2% from household OOPs, and 0.1% from private employers. 50

51 Figure 4.1C: Health financing by source in Gambia (year 2002) Government/ public 18% Private employer 0% Donors 70% Household OOPs 12% Figure 4.1D presents an analysis of heath financing by source in The Gambia for year During that year THE was D1,395,958,522, of which 67.6% were from donors, 21.6% from government/public, 10.7% from household OOPs and 0.1% from private employers. Figure 4.1D: Health financing by source in Gambia (Year 2003) Government/ public 22% Private employer 0% Donors 67% Household 11% 51

52 Figure 4.1E shows an itemization of heath financing by source in The Gambia for year In 2004 THE was D1,682,323,673, of which 65.9% originated from donors, 24.6% from government/public, 9.2% from household OOPs, and 0.7% from private employer funds. Figure 4.1E: Health financing by source in Gambia (year 2004) Government/ public 24% Private employer 1% Donors 66% Household OOPs 9% It is clear that majority of health funds came from the rest of the world (donors). However, there is evidence that the donor and household funding as a percentage of THE decreased slightly between years 2002 and The funding from private employers remained fairly constant Government Health Expenditure on Health General government expenditure on health (GGHE) includes health expenditure at all levels (and ministries) of government, including the expenditure of public corporations. In the GGHE consists of funding from DoSFEA, LGA and parastatals. The total GGHE was D207,995,042.6 (18% of THE) in year 2002; D301,763,059 (22% of THE) in 2003; and D409,165, (24% of THE) in During the three years majority of GGHE came from DoSFEA (93%), parastatals (6%), and LGA (1%). Approximately 34.2%, 24.1% and 40.4% of the GGHE was from external loans in years 2002, 2003 and 2004 respectively. The per capita GGHE for The Gambia was D691 in 2002, D812 in 2003 and D975 in Figure 4.1F portrays the per capita government health expenditure on health in the ECOWAS. The WHO Commission for Macroeconomics and Health (CMH) recommended that governments should spend at least US$34 per person per year on 52

53 health. During the years under consideration, it was only Cape Verde who met the CMH recommendation. The per capita GGHE was less than US$10 in Cote D Ivoire, The Gambia, Guinea, Guinea-Bissau, Liberia, Niger, Nigeria, Sierra Leone and Togo. Figure 4.1F: Per capita government health expenditure on health in ECOWAS Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Per capita expenditure on health (US$) Year2002 Year2003 Year2004 The Gambian government expenditure on health as a percentage of total government expenditure was 11.47% in year 2002, 13.03% in 2003 and 10.86% in Figure 4.1G shows the GGHE as a percentage of total government expenditure. In the Abuja Declaration, Heads of States and Governments of the African Union set a target of allocating at least 15% of their annual budget to the improvement of the health sector (AU 2001). In 2004 Cote D Ivoire, Guinea, Guinea-Bissau, and Nigeria spent less than 5% of their total government expenditure on health. According to the World Health Report (WHO 2006) it was only Burkina Faso and Liberia that had met the Heads of State target as at the end of year This means the 13 ECOWAS countries that spent 53

54 less than 15% of their national budgets on health will need to take appropriate steps to honour the commitment made by their respective Heads of State. 4.1G: Government expenditure on health as % of total government expenditure Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Percent Year2002 Year2003 Year2004 Social security spending on health: National health accounts guidelines define social security schemes as social insurance schemes covering the community as a whole or large sections of the community that are imposed and controlled by government units. They generally involve compulsory contributions by employees or employers or both, and the terms on which benefits are paid to recipients are determined by government units. The schemes cover a wide variety of programmes, providing benefits in cash or in kind for old age, invalidity or death, survivors, sickness and maternity, work injury, unemployment, family allowance, health care, etc. There is usually no link between the amount of the contribution paid by an individual and the risk to which that individual is exposed [WHO 2003, p.302]. In The Gambia, Benin, Cote D Ivoire, Ghana, Liberia, Mali, Niger, Nigeria, and Sierra Leone social security did not contribute to the general government expenditure on health. 54

55 In the remaining six ECOWAS countries social security contributed to health spending. Social security spending on health constituted over 14% of GGEH in Cape Verde, Senegal and Togo. Figure 4.1H: Social security expenditure on health as % of general government expenditure on health Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Percent Year2002 Year2003 Year Private expenditure on health Private health financing includes spending by private insurance, private households outof-pocket payment (Oops), non-profit institutions (other than social insurance), and private firms and employers (WHO 2003). Private financing for health comes from personal out-of-pocket payments made directly to various providers (e.g. public health facilities, private practitioners, private pharmacists, and traditional healers), prepayments 55

56 to private insurance and indirect payments for health services by employers (firms) and local charitable groups. The total private health expenditure on health in The Gambia was D145,545,671 in year 2002; D150,610,801; and D165,222,560. Private spending constituted 12.3% of the THE in 2002, 10.8% in 2003 and 9.8% in The Gambia in These figures are far much lower than the estimates contained in the World Health Report Private expenditure on health as a percentage of THE has not changed much over the three years. This source consists of primarily Oops and private health insurance (prepaid plans). The per capita private health expenditure was D128.4 in year 2002, D145.5 in 2003 and D156.7 in Figure 4.2I shows private spending on health as a percentage of the total expenditure on health for ECOWAS countries. This figure was generated from the NHA estimated contained in the World Heath Report In that report the private health spending for the The Gambia appears to have been over estimated. 4.1I: Private expenditure on health as % of total expenditure on health in ECOWAS Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Percent Year2002 Year2003 Year These figures are far much lower than the estimates contained in the World Health Report

57 In 2002, out of a total private health expenditure in The Gambia of D , 99.46% came from household funds and 0.54% from private employers. In 2003 the private health expenditure on health was Dalasis 150,610, % from household funds and 0.82% from private employers. In 2004 the private health expenditure on health was Dalasis 165,222, % from household funds and 6.68% from private employers. Out-of-pocket payments (OOPs): In 2002 household OOPs constituted 99.46% of the private health expenditure; 99.18% in 2003; and 93.32% in It is evident that the households, through direct out-of-pocket expenditures at the point of service consumption, make a significant contribution to the private health expenditure in the The Gambia. Figure 4.2J shows OOPs on health as a percentage of private expenditure on health for ECOWAS countries. Except for Ghana, household OOPs accounted for over 80% of private health expenditure on health. 57

58 Figure 4.1J: Out-of-pocket expenditure as % of private health expenditure on health Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Percent Year2002 Year2003 Year2004 Private prepaid plans: Figure 4.1K presents private prepaid plans (which are voluntary in nature) as a percentage of private expenditure on health. Apparently, The Gambia, Guinea, Guinea-Bissau, Liberia and Sierra Leone health systems did not receive any funding from prepaid plans. Contrastingly, the private prepaid plans accounted for more than 10% of private expenditure on health in Cote D Ivoire and Niger. 58

59 4.1K: Private prepaid plans as % of private expenditure on health Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Percent Year2002 Year2003 Year2004 External financing: External resources for health consist of mainly of grants from multilateral and bilateral aid donors and international nongovernmental organisations (e.g. Global Fund for AIDS, Tuberculosis and Malaria). Donors made a contribution of Dalasis 831,682,389 to health in 2002 (70.2%); Dalasis 943,584,662 (67.6%) in 2003; and Dalasis 1,107,935,916 (65.9%) in Thus, donors are a majority contributor to the THE in The Gambia. Figure 4.1L shows external resources for health as a percentage of total expenditure on health. The figure has been generated from the World Health Report Once again it is clear that donor contribution to THE in The Gambia was significantly higher than reported in the World Health Report. Donors contribute more than 20% of THE in 8 (53%) ECOWAS countries. 59

60 Figure 4.1L: External resources for health as % of total expenditure on health Togo Sierra Leone Senegal Nigeria Niger Mali Liberia Guinea-Bissau Guinea Ghana Gambia Côte d'ivoire Cape Verde Burkina Faso Benin Percent Year2002 Year2003 Year Health Financing by Financing Agents There were four categories of financing agents, namely: government (public), private, and external. Figure 4.2a depicts the distribution of funds between public, private and external financing agents (see also Appendix Table 2). Clearly the public financing agents absorbed the majority of health financing over the three year period. It is also vivid that the funds going into the public health financing agents grew consistently over the period under consideration. The funding to the private financing agents grew by a small margin. 60

61 Dalasi NATIONAL HEALTH ACCOUNTS Figure 4.2a: Funds received by public, private & external financing agents 1,400,000,000 1,200,000,000 1,000,000, ,000, ,000, ,000, ,000,000 - Year2002 Year2003 Year2004 Public financing agents Private agents Rest of the world Public health financing agents The public financing agents consisted of DoSH, DoSE, DoSD, DoSI, DoSFA, LGA, National AIDS Secretariat, NaNA and parastatals. In 2002 the public financing agents received Dalasi 915,547,949.8; of which 96.03% went to DOSH, 0.13% to DOSE, 0.00% to DoSD, 0.05% to DoSI, 3.39% to DoSFA, 0.36% to LGA and 0.04% to NaNA (See Figure 4.2b). In 2003 the public financing agents received Dalasi 1,104,213,908.12; of which 96.70% to DoSH, 0.12% to DoSE, 0.00% to DoSD, 0.04% to DoSI, 2.81% to DoSFA, 0.30% to LGA and 0.03% to NaNA (See Figure 4.2c). 61

62 DoSD D11,659 (0.001%) Figure 4.2C: Gambia funding to public heath financing agents in year 2003 DoSE D1,269,939 (0.115%) DOSFA D31,072,626 (2.814%) LGA D3,282,207 (0.297%) DoSI D416,616 (0.038%) NaNA D355,470 (0.032%) DoSH, 1,067,805,392, (96.703%) In 2004 the public financing agents received Dalasi 1,362,716,725.87; of which 88.59% to DoSH, 0.16% to DoSE, 0.04% to DoSI, 2.81% to DoSFA, 0.32% to LGA, 8.55% to NAS, and 0.06% to NaNA (See Figure 4.2d).. 62

63 Figure 4.2D: Gambia funding to public health financing agents in year 2004 DoSE D2,114,524 (0.16%) DoSI D600,369 (0.04%) DOSFA LGA, D31,072,626 D4,392,987 (2.28%) (0.32%) NAS, D116,513,010 (8.55%) NaNA D805,591 (0.06%) DoSH D1,207,217,620 (88.59%) It is evident in Figures 4.2b to 4.2d that majority of health financing that went to the public health sector were spent by health service providers within the aegis of the Department of State for Health Private health financing agents The private financing agents included private insurance, household out-of-pocket payments, non-governmental organizations, and private firms. Figure 4.2E portrays The Gambia s funding to the private health financing agents in year Eighty-five percent of funds received by private health financing agents were administered by households; 7% by NGOs; 4% by private firms; and 4% by private insurance. 63

64 NGOs D12,374,104 (7%) Figure 4.2E: Gambia funding to private health financing agents in year 2002 Private firms D6,633,064 (4%) Private insurance D6,282,904 (4%) Households OOPs D144,756,897 (85%) Figure 4.2F presents The Gambia s funding to the private health financing agents in year Seventy-six percent of funds received by private health financing agents were administered by households; 15% by NGOs; 4% by private firms; and 5% by private insurance. 64

65 Figure 4.2F: Gambia funding to private health financing agents in year 2003 NGOs D30,440,599 (15%) Private firms D7,359,222 (4%) Private insurance D10,770,647 (5%) Households OOPs D149,379,099 (76%) Figure 4.2G presents The Gambia s funding to the private health financing agents in year Seventy percent of funds received by private health financing agents were administered by households; 18% by NGOs; 7% by private firms; and 5% by private insurance. 65

66 Figure 4.2G: Gambia funding to private health financing agents in year 2004 NGOs D39,632,840 (18%) Private firms D15,291,004 (7%) Private insurance D10,018,122 (5%) Households OOPs D154,184,453 (70%) Evidence contained in Figures 4.2E to 4.2G vividly shows that majority of the health funds received by private financing agents were used by households to purchase health services from various service providers in The Gambia External financing agent The external financing agent consisted of rest of the world (donors). Figure 4.2H presents the total funds received by the rest of the world entities operating within the The Gambia. The trend has not been consistent across the three year period. 66

67 Figure 4.2H: Funds received by rest of the world in Gambia Year2004, D100,480,528 Year2002, D99,628,184 Year2003, D93,795, Distribution of health funds from financing agents to providers Figure 4.3A presents the distribution of health funds from financing agents to health service providers in Out of the total health expenditure of D , approximately 53% was spent on provision and administration of public health programmes, 18% on hospitals, 18% on institutions providing health related services, 10% on health centres, and 1% on rest of the world (see also Appendix Table 4A). 67

68 Figure 4.3a: Distribution of funds from financing agents to providers in 2002 HP.8 Institutions providing health related services * 18% HP.7 All other industries 0% HP.9 Rest of the world 1% HP.1 Hospitals 18% HP.2 Health Centres 10% HP.6 General health administration and Insurance* 0.05% HP.5 Provision and administration of public health programs 53% HP.3 Providers of ambulatory health care 0% HP.4 Retail sale and other providers of medical goods 0.42% Figure 4.3B portrays the distribution of health funds from financing agents to health service providers in Out of the total health expenditure of D , approximately 48% was spent on provision and administration of public health programmes, 24% on hospitals, 16% on institutions providing health related services, 11% on health centres, and 1% on rest of the world (see also Appendix Table 4A). 68

69 Table 4.3b: Distribution of funds from financing agents to providers in 2003 HP.8 Institutions providing health related services * 16% HP.7 All other industries 0% HP.6 General health administration and insurance 0% HP.5 Provision and administration of public health programs 48% HP.9 Rest of the world 1% HP.1 Hospitals 24% HP.2 Health Centres 11% HP.3 Providers of ambulatory health care 0% HP.4 Retail sale and other providers of medical goods 0% Figure 4.3C depicts the distribution of health funds from financing agents to health service providers in Out of the total health expenditure of D , approximately 57% was spent on provision and administration of public health programmes, 21% on hospitals, 11% on institutions providing health related services, 10% on health centres, and 1% on rest of the world (see also Appendix Table 4A). 69

70 HP.7 All other industries 0% HP.6 General health administration and insurance 0% Figure 4.3C: Distribution of health funds from financing agents to providers in 2004 HP.8 Institutions providing health related services * 11% HP.5 Provision and administration of public health programs 57% HP.9 Rest of the world 1% HP.1 Hospitals 21% HP.2 Health Centres 10% HP.3 Providers of ambulatory health care 0% HP.4 Retail sale and other providers of medical goods 0% The above distribution of health funds to providers is quite encouraging. In most of the other African countries a critical mass of the THE goes to teaching and general hospitals. Whereas the preferred scenario is where most of the resources are invested in the public health programmes aimed at protecting majority of the population from the risk of illness. In The Gambian case, majority of the total health expenditure rationally goes to the administration and provision of public health services. 4.4 Distribution of funds from health service providers to health functions Figure 4.3D shows the flow of health funds from service providers to health functions in Out of the total health expenditure of D1,185, 223,103, approximately 38% was spent on prevention and public health services, 19% on health administration and health insurance, 18% on services of curative care, 18% on health related functions and 7% on medical goods dispensed to outpatients (see also Appendix Table 5A). 70

71 Figure 4.3D: Flow of health care funds from providers to functions in 2002 HCR Health Related Functions 18% HC.1 Services of curative care 18% HC.2 Services of rehabilitative care 0% HC.4 Ancillary services to medical care 0% HC.7 Health administration and health insurance 19% HC.6 Prevention and public health services 38% HC.5 Medical goods dispensed to outpatients 7% Figure 4.3E shows the flow of health funds from service providers to health functions in Out of the total health expenditure of D , approximately 44% was spent on prevention and public health services, 28% on services of curative care, 8% on health administration and health insurance, 15% on health related functions and 5% on medical goods dispensed to outpatients (see also Appendix Table 5B). 71

72 Figure 4.3E: Flow of health funds from providers to functions in 2003 HC.7 Health administration and health insurance 8% HCR Health Related Functions HC.1 Services of curative care 28% 15% HC.2 Services of rehabilitative care 0% HC.4 Ancillary services to medical care 0% HC.6 Prevention and public health services 44% HC.5 Medical goods dispensed to out-patients 5% Figure 4.3F presents the flow of health funds from service providers to health functions in Out of the total health expenditure of D1,682,323,673, approximately 33% on health administration and health insurance, 29% was spent on prevention and public health services, 21% on services of curative care, 13% on health related functions, 3% on medical goods dispensed to outpatients, and 1% on ancillary services to medical care (see also Appendix Table 5C). 72

73 Figure 4.3F: Flow of health funds from providers to functions in 2004 HCR Health related functions 13% HC.1 Services of curative care 21% HC.2 Services of rehabilitative care 0% HC.4 Ancillary services to medical care 1% HC.7 Health administration and health insurance 33% HC.6 Prevention and public health services 29% HC.5 Medical goods dispensed to outpatients 3% 73

74 CHAPTER 5: RECOMMENDATIONS Based on the experience garnered in the process of undertaking this inaugural NHA exercise in The Gambia, the NHA Technical Working Group (NHATWG), would like to make the following recommendations: 1. NHA should be institutionalised to ensure that it can be conducted on a regular and sustained basis. According to NHA guidelines (WHO, 2003), institutionalization is an ongoing process in which NHA activities, structures, and values become an integral and sustainable part of the government operations. With institutionalization, a department or unit is designated to house and oversee the gathering, analysis, and reporting of health expenditure data in a routine and systematic manner, with full support of the government. The complex process can take years and multiple estimates before it is integrated fully into the country s formal structure, but in order to ensure that NHA remains an effective policy tool in the future, institutionalization should be a goal from initiation of NHA (see According to the NHA guidelines (WHO, 2003) institutionalization process entails four steps: a. Creating demand among policy makers for institutionalization; b. Determining a location where NHA will be housed; c. Establishing standards for data collection and analysis; d. Institutionalizing data reporting requirements for all stakeholders (public, private and development partners. In the process of institutionalizing NHA, it will be necessary to: (i) explore the possibility of integrating NHA data collection within the national health information management systems; (ii) reinforce the institutional and human capacities of the unit responsible for undertaking NHA; (iii) include questions on household out-pocket payments for health care in the national household survey data collection instruments routinely carried out by The Gambia Bureau of Statistics; (iv) continually involve GBoS in NHA activities 2. The existence of a NHA Advisory/Steering Committee (NHASC) has proven to be of value. The government may consider broadening the NHASC to include permanent secretaries (or directors) from relevant Departments of State. Once established, it would be necessary to organize a sensitization seminar for the NHASC members on the usefulness of NHA evidence in health decision-making (policy and plan development). The creation of NHASC may help to sensitize the policymakers on the need for undertaking regular NHA exercises and institutionalizing it. 3. In order to facilitate the process of institutionalizing data reporting, there might be need to expand the membership of The Gambia NHATWG to include representatives of all relevant Government Departments (e.g. DoSFEA, DOSE, DOSI, DoSD, DoSFA, LGA), plus a representative of the health development 74

75 partner group in the country. Once NHATWG membership has been expanded it would be necessary to organize a technical NHA workshop to ensure there is a common understanding of the NHA conceptual framework. 4. There is need to plan for undertaking the second NHA exercise covering 2005, 2006 and 2007 and to include HIV/AIDS, TB, Malaria expenditure reviews, and thereafter make a decision on the frequency of subsequent NHA studies. In process of those plans, it may be necessary to revise the existing data collection instruments for use among sources, financing agents, health care providers (plus functions and inputs). 5. The DoSH should consider developing a comprehensive health financing policy and health financing strategic plan with a roadmap of how the Government plans to realize the vision of universal coverage of health services and universal protection from potentially catastrophic and impoverishing health care expenditures in the long-term. In the process of developing the national financing policy, it may be informative to refer to the WHO regional strategy for health financing for inspiration. The following important findings should support the development of the health Financing policy: Government current per capita health expenditure is below $35 as recommended by WHO. The financing policy should advocate for government increase expenditure on health. Currently Social Security contribution to health is insignificant. The policy should therefore advocate for increase Social security contribution to health expenditure. The out- of-pocket expenditure as a propotion of total private health expenditure is over 95%. The health financing policy should advocate for the development of a national social insurance frame work including health financing safety nets for the poor. Donor contribution to the total health expenditure is over 65%. For effective coordination of this input the health financing policy should advocate for basket funding system. 6. There will be need to develop a Sector-Wide Approach (SWAp) for coordinating partners efforts in the implementation of the national health policy. In the course of designing the SWAp there will be need to make study visits to countries that have been successfully implementing it, e.g. Ghana and Uganda. 7. The will be need for further training for core member of the National Health Accounts Technical Working Group. 75

76 CHAPTER 6: CONCLUSION NATIONAL HEALTH ACCOUNTS The inaugural NHA study was the first step towards The Gambia s aspiration of institutionalizing NHA to facilitate DOSH stewardship of the national health system. The study succeeded in addressing three of its four objectives: (i) to estimate the total health expenditure from public, private and donor sources; (ii) to determine the total health expenditure by financing agents; and (iii) to approximate the distribution of funds by various public health functions. Due to dearth of disaggregated information, it was not possible to estimate the amounts of funds spent on various health system inputs. The total health expenditure (THE) was approximately D1,185,223,103 in 2002; D1,395,958,522 in 2003; and D1,682,323,673 in THE as a percentage of GDP in The Gambia was 16.1% in 2002, 13.9% in 2003 and 14.9% in The per capita total health expenditure was D895 in 2002, D1026 in 2003 and D1203 in During the three years over 66% of the total health funding came from donors (international health development partners). The Government of The Gambia contribution grew from 18% in 2002 to 24% of the total health expenditure in The households, through direct outof-pocket payments to health care providers, contributed 12% in 2002, 11% in 2003 and 9% in 2004 to the total health expenditure. The NHA evidence contained in this document constitutes a strong basis for developing a comprehensive health financing policy and a health financing strategic plan mapping out how the Government plans to realize the vision of universal coverage of health services and universal protection from potentially catastrophic and impoverishing health care expenditures in the long-term. In order to facilitate the monitoring and evaluation of such policy documents once developed, it is important to institutionalize national health accounts. The latter will require boosting of the capacities in the Directorate of Planning and Information. 76

77 Chapter 7: FURTHER ANALYSIS OF THE CURRENT HEALTH FINANCING SYTEM COST RECOVERY PROGRAM AND THE DRUG REVOLVING FUND In August 1988 as part of the Economic Recovery Program pursued by the Government of the Gambia, a Cost Recovery Program was implemented in the public health sector. User fees were introduced for the recovery of the cost of medical goods. These include pharmaceuticals, laboratory consumables, X ray consumables. User fees were introduced for some of the services too, and these services include: Attendance at birth, Admission and dental care and minor and major operations. The main objective of introducing these fees was to create a Drug Revolving Fund for the re-financing of the purchase of the medical goods and the management of the supply of the goods. The Cost Recovery Program was part of the National Health Development Project By the end of the Project, an evaluation was done on the Cost Recovery Program including the management of the Drug Revolving Fund. National cost recovery average was below 35 % with the major health centres and hospitals performing better than the minor health centres. Bamako Initiative Strategy (BI) was piloted in two health centres in The main objective of introducing BI was to strengthen both the Primary Health Care Program and the Cost Recovery Program. With very little study of the pilot phase, the strategy was hastily implemented in several other health centres. By 1996, BI was implemented in 12 health centres. A quantitative evaluation of the implementation of BI in health centres showed some increase in revenue generation over the pre-bi phase, about 44% recovery. But the report also indicated several challenges for sustainability. What were the differences between a BI and non-bi health centre? These are essentially managerial and include: Involvement of the catchment area community in the management of the health services provision Revenue generated at health centre is controlled by the health centre committee and not deposited in the national treasury or with the Drug Revolving Fund. But otherwise, the user fees system and charges were the same for both type of health centres. Some efforts were made to strengthen the implementation of the BI strategy and also to expand to other health centres during the Participatory Health Population and Nutrition Project ( ). COST RECOVERY TRENDS IN SELECTED PUBLIC HEALTH FACILITIES As the Cost Recovery Program (CRP) is still the main mechanism for financing health services to supplement Government budgetary commitments, it was found useful to review the performance of the CRP in few selected BI facilities. The BI facilities were 77

78 selected because it was easy to follow their actual deposits of internally generated revenue in their accounts at the banks. The public hospitals were also included as they also maintain their own accounts. Cash deposit trends in selected BI facilities KUNTAUR YEAR , YEAR , YEAR , YEAR , YEAR , YEAR , YEAR , KAUR YEAR , YEAR , YEAR , YEAR , YEAR ,

79 KEREWAN YEAR , YEAR , YEAR , YEAR , YEAR , NGAYEN SANJAL YEAR , YEAR , YEAR , YEAR , GUNJUR YEAR , YEAR , YEAR , YEAR , YEAR ,

80 SALIKENE YEAR , YEAR , YEAR , YEAR , YEAR , BURENG YEAR , YEAR , YEAR YEAR , YEAR , YEAR , YEAR

81 15, HEALTH CENTRES COST OF PHARMACEUTICALS AND OTHER MEDICAL SUPPLIES ISSUED AND TOTAL BANK DEPOSIT IN 2006 % RECOVERY HEALTH CENTRE PHARM ISSUED BANK DEPOSIT SOMA 793, , ILLIASA 183, , NGAYEN SANJAL 257, , KUNTAUR 485, , KAUR 539, , MEDINA BAFUL 223, , ESSAU 646, , KUNTAYA 224, , KWINELLA , BURENG , SALIKENE ,

82 The public hospitals were also assessed on the cost recovery of the medical goods. PUBLIC HOSPITALS YEAR RVTH PHARM & OTHER MED USER FEES ,350, ,179, ,500, ,909, ,217, ,643, % RECOVERY YEAR BANSANG HOSPITAL PHARM&OTHER MED USER FEES % RECOVERY ,195, , ,810, , ,720, ,

83 YEAR AFPRC HOSPITAL PHARM&OTHER MED USER FEES % RECOVERY ,199, , ,612, , ,720, , YEAR SJ HOSPITAL PHARM&OTHER MED USER FEES % RECOVERY 83

84 , , It is quite easy to state that the current user fees cannot sustain the re-ordering of the essential medical goods. Other than RVTH, none of the other hospitals seem to be recovering even 50% of the cost of medical goods. The situation is not better with the health centres, majority of which cannot recover beyond 10% of the cost of medical goods supplied to them. 84