A user guide for policy analysis based on Fiji National Health Accounts. Jennifer Price

Transcription

1 A user guide for policy analysis based on Fiji National Health Accounts. Jennifer Price Nossal Institute for Global Health University of Melbourne June, 2013

2 Introduction In 2013 Fiji will produce their fourth biennial set of National Health Accounts (NHA). The accumulated data covering the years offer a wealth of information for monitoring and evaluating health sector performance. However, NHA data are complex and require some specialised understanding of their relevance to Fiji Ministry of Health (FMoH) operations and strategic objectives to be used effectively. Most Ministry staff lack this training, hence the potential of NHA data has been underutilised. To improve this transition from raw data to health system analysis and stimulate regular use of NHA evidence based information, the data needs to be easily accessible and directly related to everyday policy concerns. Reducing the complicated data to a set of indicators aligned to FMoH policy priorities and presented in an accessible format will assist staff to use the data regularly with confidence and consistency. This paper contains two sets of NHA based policy guides, one developed from the NHA report and another for internal FMoH purposes. The first list, NHA Report Indicator Policy Guide, translates the list of indicators adopted by the NHA production committee (raw data) and suggests how they can be applied to policy analysis. This information could be available to the public. The second list, NHA Policy Analysis Guide, specifically links more detailed NHA data to the goals established in the FMoH Strategic Plan This guide is intended for internal FMoH research, analysis and report writing. The focus for both lists is policy analysis, with NHA data categorised to help read the health system more clearly. These indicator policy guides go beyond just repackaging NHA data. They attempt to integrate and align three Ministry of Health commitments: 1) evidence based policymaking, 2) health sector planning to strengthen the health system, and 3) improved public financial management and performance. Fiji s Government has committed significant resources to each of these components. Fiji is the first Pacific island country and one of a handful of developing countries to adopt the updated OECD-WHO System of Health Accounts methodology, providing more precise and detailed analysis of funding sources, distribution and health expenditure. FMoH has consistently produced detailed annual reports and five year strategic plans. The current strategic plan includes health system strengthening as one of three primary objectives. 3 In August 2010, Fiji joined other Pacific Islands Forum countries in adopting the World Bank Public Financial Management Performance Measurement Framework 4 that uses a comprehensive list of indicators to measure fiscal performance, thus committing Fiji to reviewing and improving their public management and performance. 5 6 The policy guides presented here use NHA data as the catalyst for further investigation of other existing research on Fiji s health system performance. Their purpose is to simplify rather than further complicate the information gathered from these various perspectives via an easy-to-use policy tool. 1

3 Methodology The policy guides have been developed through forensic reading of the OECD-WHO System of Health Accounts 2011, the FMoH Strategic Plan , the World Bank Public Financial Measurement Framework, and other related texts. Policy applicability was the guiding principle, however, the lists have been developed without consultation with ministry staff and would benefit from further discussion within the FMoH. They are intended as a first step only. NHA data are enhanced when combined with other health systems research. For instance, the links between NHA classifications and indicators in the Strategic Plan could be refined with more detailed information on health outcomes, program, policy and public health accounts held within the ministry. Aim Develop two sets of NHA based policy guides oriented to FMoH concerns which: Outcomes a) Align the NHA Report health financing indicators to FMoH policy issues, b) Utilise NHA data for internal Ministry of Health monitoring and evaluation of health sector performance in Fiji. Linking NHA indicators with FMoH policy analysis and strategic objectives will: Simplify complex data to a useable format Assist staff to understand and use NHA data regularly Standardise NHA data to avoid misuse Increase evidence based policy analysis within the FMoH Strengthen health sector planning and public management Expand the list of health financing indicators for future FMoH strategic plans Demonstrate NHA are useful, relevant and merit continued resources Identify critical gaps in the data which need further research and resources Goal To encourage consistent, shared and purposeful use of NHA data to improve evidence based policy analysis within the FMoH. 2

4 NHA Report Indicator Policy Guide The list of indicators included in the NHA Report are a new initiative to highlight important issues and encourage better understanding and utilisation of the NHA data. The indicators condense the complex data to a series of snapshots of the health system. They have been selected based on policy priorities identified within the FMoH, critical factors affecting how well a health system performs and international conventions for reporting NHA. Although the indicators were not specifically included in previous reports, the same data is available in earlier reports to extend the trend lines to Background information for NHA based policy analysis Health systems are extraordinarily complex arrangements, influenced by a myriad of factors. Tracking the flow of money through the system is fundamental for health planning. NHA are the only means of tracking health expenditure in all sectors: public, private, external (donor), households, non-government and not-for-profit organisations. Essentially, there is one amount of money flowing through the system. Although that one amount of money remains constant, NHA allows the viewer to track the flow of money from a variety of perspectives depending on what the planner wants to know. The 24 NHA Report indicators cover the main NHA categories: Aggregate or general data on total current health expenditure - how much money was spent on health services that year Revenue schemes or in-flows from public, private and external sectors - where has the money came from Financing schemes for tracking financing arrangements - how is the money collected and channelled to pay for health care Providers of health services - which organisations or people provide health services Health Functions list the consumption of health services - what types of treatments, goods and services was the money spent on Factors of Provision list aggregated inputs needed to produce health services - broad categories of money spent to keep the organisation working Beneficiaries of health care goods and services - who benefits or receives the services provided Capital Formation expenditure - spending on long term investments used for more than one year Disease specific classification of health expenditure burden - Non-communicable diseases (NCDs) spending is prioritised for Fiji For those unfamiliar with NHA, Chapters 1 and 2 of the System of Health Accounts 2011 provides an easy to read and comprehensive introduction. One important note on methodology is the recent change from the earlier version of the System of Health Accounts (SHA) produced in 2000 to the revised edition published in Fiji is among the first few developing countries to apply the SHA2011 methodology, being used for the report. The revised methodology separates total expenditure 3

5 spent within the health system into two broad components, Total Current Health Expenditure (TCHE) and Capital Formation, which were previously grouped together. Simply put, TCHE includes all expenditure on goods and services bought and used within the one year, while Capital Formation includes money spent on longer-term investments used over several years, such as infrastructure, technology, research and development. To make comparisons easier with previous NHA accounts and other countries still using SHA2000, the NHA Report indicators include both forms, TCHE and TCHE+Capital. Identifying and working with the separate components gives a clearer and more accurate assessment of health expenditure. For instance, TCHE on regular items is not distorted by occasional injections of large amounts of money for infrastructure projects. As other counties gradually introduce SHA2011, keeping TCHE and Capital Formation separate will become the convention. NHA Indicator Policy Guide One year of NHA data includes many separate classifications that can be crossreferenced or triangulated to show relationships between different areas of the health system for that year. However, the strength and meaning of NHA data becomes more apparent when the data is collected over time (for Fiji, ) and for comparisons between countries. Table 1 below lists the indicators selected for the NHA Report , with suggestions for longer-term trends, policy relevance and complementary research to put NHA data into a broader policy context. Table 1 does not include details of specific policy decisions or situational analysis. It demonstrates how NHA data can be used to follow trends, highlight sudden fluctuations or gradual shifts in health expenditure that may need correction, and help monitor and evaluate whether policy is on the right track towards stated objectives. The aggregate figures (TCHE; TCHE plus capital formation; public, private and external revenue schemes; financing schemes) can be broken down for further analysis of more specific issues. For instance, the per cent of TCHE spent on a particular health function or provider. A ratio of spending within one category can also be instructive: e.g. the revenue from public, private and external sectors, or household contributions to prepaid insurance schemes versus user fees. The guides are designed to stimulate further investigation and policy analysis, not provide oversimplified answers to complex issues. Familiarity with using the NHA data will show it is flexible and responsive. The data can be shaped and reshaped depending on the question being asked, especially when it is combined with other information on the policy issue. NHA data are best used in a specific context with first hand knowledge about budgeting, policy and program initiatives, operational changes, private sector, and donor activity. Other evidence-based research, such as household and consumer surveys, health outcomes, academic and economic analysis, and budget audits, all help enrich the NHA data. Long-term trends, international comparisons and the policy context each inform a better understanding of how the health sector is performing. 4

6 Table 1: Fiji NHA Report, : Health financing indicators Policy Guide 7 General NHA Report Health Financing Indicators Total Current Health Expenditure (TCHE) TCHE+ capital Preventive Curative Health Expenditure Trends, Fiji TCHE TCHE + capital % TCHE curative % TCHE preventive % Capital: TCHE+capital Preventive spending $ Curative spending $ Capital spending $ NHA based data Policy Relevance TCHE growth Health 5% GDP % TCHE Preventive % TCHE Curative Preventive budget target Curative spending Capital spending % total Complementary Research % GDP to Health GDP growth National budget growth TCHE per capita TCHE+capital per capita Fiji Hospital Costing Study % GDP on Health: L- MIC av; Pacific; PICs; international Health functions Inpatient Long Term Care (LTC) Outpatient LTC Total LTC Pharmaceutical % TCHE on LTC % TCHE Inpatient LTC % TCHE Outpatient LTC Inpatient LTC spending Outpatient LTC spending Total expenditure LTC Inpatient:Outpatient ratio Pharmaceutical spending Facilities for LTC Treatment / support LTC % TCHE on LTC Per capita LTC Per capita LTC x age Per capita pharmaceuticals Health demographics LTC NCD, disability, age, injury Number patients LTC Untreated illness LTC Loss to GDP due to LTC HH expenditure survey: OOP pharmaceuticals Retail surveys pharma. Health facility surveys Financing schemes Providers Govt schemes Compulsory insurance Voluntary insurance Out of Pocket Health Hospital Ambulatory Govt Health expenditure % TCHE Private insurance % Private Expenditure from Private Insurance OOP per capita %TCHE Hospital care %TCHE Ambulatory care Hospital costs Ambulatory costs Govt incentives- insurance Ratio compulsory:voluntary Insurance contributions % TCHE from OOP OOP per capita - impact Hospital spending Hospital public/private Ambulatory spending Ambulatory public/private Ratio Hospital: Ambulatory Donor $ via Govt budget HH Expenditure survey: OOP to insurance vs user pays Insurance coverage rates Private Public Partnership Govt subsidies insured FMoH Annual report: Facilities opening/closing; hospital beds; finances Fiji Hospital Costing Study Consumer & facility surveys Revenue of schemes Factors of Provision External Public Private Human resources % TCHE Public % TCHE Private % TCHE External Public sector revenue Private sector revenue Donor sector revenue %TCHE Human resources HR spending Sector contributions TCHE TCHE revenue source ratio: Public/ Private/ Donor % Govt budget Health % Private budget insurance Donor spending Private sector spending % Donor $ via Govt budget Human resources Human resources per capita % Govt budget to Health Health $ vs other agencies Govt Health $ per capita Program priorities/not Donor Health $ per capita Which donors flow aid thru Govt budget? Programs receiving donor $ FMoH Annual reports: Staff, training, organisation Medical staff $ per capita Corporate Report - staffing Disease NCDs % TCHE NCDs NCD spending Beneficiaries Capital formation (CF) Injuries Age 65 + Public Private Hospital %TCHE injuries Injuries spending %TCHE Age 65+ Age 65+ spending CF x (TCHE+CF) - % Total % Total CF - Public % Total CF - Private % Total CF - Hospital Public capital formation $ Private capital formation$ Hospital capital formation NCD spending NCD spending per capita % TCHE injuries Injuries spending %TCHE Aged 65+ Aged 65+ spending Public Capital Formation Private Capital Form n Ratio Public: Private CF Providers receiving CF CF as % TCHE+CF Fiji, PIC NCD research: pop n health status, policy NCDs Economic cost/loss % Injuries to LTC Injuries - Economic cost/loss Survey injury demographics Aged 65+ care LTC / HH Surveys Aged 65+ care Program /provider mix CF Primary Health receiving CF % CF Donor contribution % Donor spending on CF 5

7 Strategic Plan NHA indicators The FMoH Strategic Plan prioritises three Strategic Goals: 1. Community served by adequate local primary and preventive health services 2. Community access to quality clinical health care and rehabilitative services 3. Health system strengthening at all levels of FMoH The plan includes more than 140 indicators covering the three strategic goals. However, only one indicator relies directly on NHA data, for Health Expenditure to reach 5% of GDP. Most indicators are either health outcome targets or program deliverables. 8 NHA data can directly inform most objectives set out in the plan, for health outcomes, program objectives and health systems strengthening. Strategic Goal 1 and 2 are divided into seven Health Outcome categories: Reduce NCD burden, including reduced obesity and other risk factors. Reverse the spread of HIV/AIDS and control communicable diseases of public health importance. Improve family health and reduce maternal morbidity and mortality. Improve child health and reduce child morbidity and mortality. Improve adolescent health and reduce adolescent morbidity and mortality. Improve mental health care. Improve environmental health through safe water and sanitation. Strategic Goal 3 lists eight objectives that contribute to achieving Outcomes 1-7. Health care finance Health facility utilisation and assessment Health resource management Medicines and consumables management Public-private partnership Auxiliary services Health planning and infrastructure Monitoring and evaluation As with the indicators in the NHA Report, NHA classifications can be matched to the strategic goals set by the FMoH. The tables below assign relevant NHA data to the seven health outcomes for Strategic Goal 1 and 2, and health system objectives for Strategic Goal 3. To avoid confusion and duplication, the list of NHA classifications for each section refer very specifically to that policy area. Each section could be expanded to include aggregate or more general health expenditure figures that are relevant to all areas, such as TCHE or public-private-donor revenue, financing schemes and financing agents. These types of broad expenditure items have mostly been included under Strategic Goal 3, health system strengthening, particularly Health Care Finance, and Health Planning and Infrastructure. As before, policy analysis can focus on tracking NHA expenditure over the period or delve more deeply into the policy issue. For internal policy analysis, FMoH staff can access much more detailed NHA data than is available in the NHA 6

8 Report. This data, used with situational analysis, program information and public accounts, offers an opportunity for fine tuned analysis of public health expenditure. The NHA classifications in Tables 2, 3 and 4 are for policy analysis purposes but could be refined and used as supplementary indicators to the strategic plan. Table 2: NHA classifications for Strategic Goal 1, Fiji Health Strategic Plan : primary and preventive health care. Strategic Goal 1 Program area Health Outcomes matching NHA categories Policy relevant NHA classification NCDs Screening diabetes, HPV, cancer cervical, breast, prostate Community rehab Primary Health Care (PHC) Village Health Workers Long- term care (LTC) Preventive health lifestyle, smoking Tobacco control Dental health schools Reduce alcohol related injuries HC.2 Rehab Outpatient/day/home HC.3 LTC - Outpatient/day/home HC.6 Preventive expenditure HC.6.1 Information, education, counselling HC.6.4 Healthy condition monitoring HC.RI.3.4 Prevention NCDs HC.RI.3.5 Occupational health care HCR.1 Long- term care (social) HCR.1.2 Long- term social care, cash benefits HIV- CDs Preventive health HIV, STI Disease control and screening Typhoid, LF, GF TB, DF, leptospirosis Emergency, disaster, climate change HP.3 Ambulatory care HP Public health centres HP Nursing stations HP Village health workers HP.3.4 Ambulatory services HP Dialysis care centres HP.3.5 Providers of home health care services HP Prosthesis Unit HP.6 Providers of preventive care HP.6.1 Food Unit HP.6.5 National Diabetic Centre HP.6.9 Prevention and control NCDs HP.6.16 Tobacco control enforcement HP.6.20 Community Rehabilitation Assistants HP.6.28 Oncology / cancer HP.6.29 Typhoid prevention and control HP.6.31 National Food and Nutrition Centre HP.8.1 Household providers home health care HC.6 Total preventive expenditure HC.6.5 Epidemiological surveillance, risk and disease control HP.6.8 CDs Prevention and control HP.6.10 HIV Prevention and control HC.6.6 Disaster and emergency response HP.6.15 Leptospirosis control HP.6.17 Dengue prevention and control HC.RI.3.3 Prevention communicable diseases 7

9 Maternal Child Adolescent Mental Environmental General Preventive health contraception, unplanned, pregnancy education Skilled health care Access Primary Health Care Screening anaemia pregnant women PHC - IMCI Preventive health healthy baby, child Vaccines School health programs Screening RHD, scabies, Vitamin A Reduce dental caries Preventive STI, SRH, adolescent health Screening anaemia Personnel trained mental health Mental health services in all divisions Safe water Safe sanitation Preventive health Primary health care HC.RI.2 Traditional, complementary, alternative med HC.RI.3.1 Maternal, child health, family planning, counselling HP.3.4 Ambulatory health care centres HP Family planning centres HP Traditional healers HP.6.18 Family health projects HP.6.35 Reproductive health program HC.6.2 Immunisation programs HC.RI.3.1 Maternal, child health, family planning, counselling HC.RI.3.2 School health services HP.6.22 Milk for malnourished children HP.6.23 Child health development HP.6.26 Oral Health Promotion HP.3.4 Ambulatory health care centres HP Mental health, substance abuse HP.6.21 Adolescent health programs HP.3.4 Ambulatory health care centres HP Mental health, substance abuse HP.6.14 Suicide prevention program HP.6.11 Control and protection of pollution HP.6.12 Control, safety, quality food, water HP.6.13 Environment, Planning, Management, HC.6 Total preventive expenditure HC.6.1 Information, education, counselling HC.6.3 Early disease detection HC.RI.2 Traditional, complementary, alternative med HCR.2 Health promotion multi- sectoral HP.6 Providers of preventive care HP.6.1 Food Unit HP.6.2 MoH public health programs HP.6.3 National Centre for Health Promotion HP.6.4 Health Promotion Council activities HP.6.6 Prevention and control NCDs and CDs HP.6.7 Health promotion activities HP.6.19 Public health projects HP.3 Ambulatory care HP Public health centres HP Nursing stations HP Village health workers HP.3.4 Ambulatory health care centres HP.8.1 Households as provider of health care 8

10 Table 3: NHA classifications for Strategic Goal 2, Fiji Health Strategic Plan : clinical and rehabilitative services. Strategic Goal 2 Program area NCDs Health Outcomes matching NHA categories Diabetes admissions, amputation Screening diabetes, CVD, hypertension ALOS foot sepsis < 15 days Laboratory services Radiology services Prostheses available Policy relevant NHA classification HC.2 Rehabilitative care HC.2.1- HC.2.4 Inpatient rehabilitative HC.2.1- HC.2.4 Rehab - In/outpatient/day/home based HC.3 Long- term health care HC.3.1 Inpatient long- term health care HC.4 Ancillary services HC.4.1 Laboratory services HC.4.2 Imaging services HC.5.2 Therapeutic appliances, medical goods HC Orthopaedic appliances, prosthetics HP.4.2 Medical and diagnostic laboratories HP Prosthesis Unit HIV- CDs Maternal Child Screening HIV at delivery, HIV in TB patients, syphilis, chlamydia Lab services quality, maintain stocks Emergency obstetrics 4 div. hosp. Screening high risk pregnancies Trained health workers Emergency neonate, paediatric units Ante/peri/postnatal checks Vaccine Hep B, rotavirus, pneumococcal Screening low birth weight, RHD Baby friendly facilities GBD.2.3 Diabetes mellitus HC.4 Ancillary services HC.4.1 Laboratory services HC.4.2 Imaging services HP.1.3 Specialised hospitals TB, leprosy HP.4.2 Medical and diagnostic laboratories GBD.1.18 Infectious and parasitic diseases HC.RI.2 Traditional, complementary, alternative med. HC.RI.2.1 TCAM inpatient HC.RI.3.1 Maternal child health, family planning HP Education and training (includes FSM and FSN separate to others) GBD.1.3 Maternal conditions HP.6.24 Baby Friendly Hospital Initiative GBD.1.4 Perinatal conditions GBD.1.5 Nutritional deficiencies Adolescent Screening repeat STI HP.6.21 Adolescent health programs Mental Personnel trained mental health Services all divisional hospitals HP.1 Hospitals HP.1.2 Mental health hospitals HP.3 Ambulatory care HP Private medical practices HP Offices of mental medical specialists GBD.2.5 Neuropsychiatric disorders 9

11 General Curative care HC.1 Curative care Inpatient/outpatient/day/home HC.1.1 Inpatient curative care HC.1.2 Day curative care HC.1.3 Outpatient curative care HC.1.4 Home based curative care HC.2 Rehabilitative care HC.RI.2 Traditional, complementary, alternative medicine HC.RI.2.1 Inpatient TCAM HP.1 Hospitals General, divisional, subdivisional, private, specialised hospitals HP.2 Residential LTC facilities public, private, other HP.3 Ambulatory care medical practices, specialists Global Burden of Disease GBD.1 Communicable, maternal, perinatal, nutritional GBD.2 Non- communicable conditions GBD.3 Injuries 10

12 Table 4: NHA classifications for Strategic Goal 3, Fiji Health Strategic Plan : health system strengthening. Strategic Goal 3 Program area Health care Finance Facility Utilisation Human Resources Management Health Outcomes matching NHA categories Health Expenditure to 5% GDP Issues: Funding revenue schemes Budgeting - financing schemes HH expenditure OOP Risk protection Insurance, prepayments, co- payments, subsidies, OOP Equity source of funds (HH burden) Beneficiaries available, affordable, accessible External assistance - foreign transfers reliable Donor alignment, harmonisation Foreign transfers distributed through Govt ALOS 7 to 5 days Survey patient satisfaction Doctor and nurse ratio per 100,000 Policy relevant NHA classification Revenue schemes FS.1 Govt transfer domestic revenue (health) FS.2 Transfer distributed by Govt from foreign origin FS.3, FS.4, FS.5 Social insurance and prepayment FS.7 Direct foreign financial transfers FS Direct bilateral financial transfers FS Direct multilateral financial transfers FS Other direct foreign financial transfers FS.RI.1 Institutional units providing revenue FS.RI.1.1 FS.RI.1.5 Govt, Corp, HH, NPISH, foreign FS.RI.2 Total foreign revenue (FS.2 + FS.7) Financing schemes HF.1.1 Government schemes HF.1.2 Compulsory insurance schemes HF Fiji National Provident Fund HF.2.1 Voluntary insurance schemes HF.3 Household out- of- pocket payment (OOP) HF.3.1 OOP excluding cost sharing HF.3.2.1, HF OOP cost sharing with insurance Financing agents managing financing schemes HF.RI.1.1- HF.RI.1.5 Govt, Corp, HH, NPISH, foreign Factors of Provision FP.1 Compensation of employees wages and salaries, social contributions, other employee costs FP.2 Self- employed professional remuneration FP.3 Materials (goods) and services used FP.4 Consumption of fixed capital HC.7 Governance, health system, financing admin HC.7.2 Administration of health financing HC.1 Curative Inpatient/outpatient/day/home HC.1 Specialised/ general care HC.2 Rehab - Inpatient/outpatient/day/home HC.3 LTC - Inpatient/outpatient/day/home HC.RI.2 Traditional, complementary, alternative med HC.RI.3 Prevention, public health as per SHA1.0 HC.6 Preventive care HP.1 Hospitals HP.1.1 General hospitals HP HP Sub/Divisional hospitals, region HP Private hospitals HP.2 Residential long- term care HP.3 Ambulatory care HP Public health centres, by sub/division FP.1 Compensation of employees wages and salaries, social contributions, other employee costs FP.1.1 Wages and salaries HP Education and training (includes FSM and FSN separate to others) HKR.5 Education of health personnel 11

13 Medicines and Consumables Management Private Public Partnership Auxiliary Services Health Planning & Infrastructure Monitoring and Evaluation Access affordable, essential medicines Survey facility services Increased private providers in public sector Outsource non- technical services Health Policy Commission 75% public capital projects completed Planning and administration Capital formation Strengthen M&E framework HC.5 Medical goods (non- specified by function) HC.5.1 Pharmaceuticals, medical non- durable HC Prescribed medicines HC Over the counter medicines HC.RI.1 Total pharmaceuticals HP.5.1 Pharmacies Factors of Provision FP Pharmacies HKR.3 Public- private partnerships HP.1 Hospitals HP Private hospitals HP Public long- term nursing care HP Private long- term nursing care HP.3 Ambulatory care HP Private medical practices HP.4 Ancillary services HP.4.9 Other providers of ancillary service (not patient transport, laboratory and diagnostics) HC.4 Ancillary services HC.4.9 Other ancillary services HC.9 Other health care services not elsewhere classified HP.6.13 Environment, Planning, Management, Development control HP.7 Health care system administration HP.7.1 Govt health administration agencies HP Health Policy Unit HP.7.3 Private health insurance administration HP HP Private insurance companies HP.8.1 Households providers home health care Factors of Provision FP.1 Compensation of employees wages and salaries, social contributions, other employee costs FP.2 Self- employed professional remuneration FP.3 Materials (goods) and services used HC.7 Governance, health system, financing admin HC.7.2 Administration of health financing Capital formation HK.1 Gross capital formation HK.1.1 Gross fixed capital formation HK Infrastructure HK.1.3 Acquisitions less disposal of valuables HKF.2 Capital transfers HKR.1 Loans HKR.2 Accumulated savings HKR.3 Public private partnerships Capital formation HK Information Communications Technology HK Intellectual property products HK Computer software and databases HKR.4 Research and development in health Global Burden of Disease GBD.1 Communicable, maternal, perinatal, nutritional GBD.2 Non- communicable conditions GBD.3 Injuries 12

14 Suggested indicators for health system analysis The 140+ health performance indicators in the FMoH Strategic Plan are overwhelmingly concentrated around Strategic Goal 1 and 2, focusing on health outcomes and program targets. Strategic Goal 3, health system strengthening, has only 12 indicators; just one relies directly on NHA data, for health expenditure to reach 5% of GDP. NHA data provides a useful, existing set of measures to monitor health system performance that could be utilised more effectively. Besides tracking health expenditure from a variety of perspectives, NHA categories (functions, providers, revenue, financing schemes, etc.) can be cross-referenced for indicators. For example, information on the consumption of health services can be cross-referenced to providers, showing the pattern of use for particular services at what cost. Tracing out-of-pocket spending by finance classifications (insurance, costsharing or direct payment for service) indicates the level of risk protection and equity in finance, particularly which households are struggling to pay for health costs. NHA expenditure items can also be cross-referenced with non-expenditure items. For example, expenditure data on types of care combined with information on who is receiving the services (utilisation) can monitor access and equity. 9 The list of indicators presented below introduces some options for further policy analysis and perhaps for expanding the list of indicators for Strategic Goal 3. The System of Health Accounts 2011 does not include a specific list of indicators but refers to their purpose and offers suggestions and examples throughout the text, advising countries to apply the principles to their country circumstances. The list of indicators presented here are guided by the objectives of the FMoH Strategic Plan , the Fiji NHA classifications for the current round of production, and the PEFA indicators for public financial management and performance measures, 10 modified to suit health purposes. Health system indicators for consideration: Health finances Government and donor revenue out-turns compared to original budget. Aggregate expenditure out-turn, i.e. per cent of approved budget spent. Composition of expenditure out-turns compared to original approved budget. Relative expenditure on curative/primary/preventive, perhaps with ideal ratio. Public/ private partnerships by health function expenditure. Average per capita expenditure in each region by provider. Per cent of TCHE on compulsory and voluntary insurance, preferably by income quintile. Out-of-pocket expenditure, by function and/or providers, by income quintile. External funds distributed through government schemes, per cent of TCHE. Financial information provided by donors for budgeting and reporting on project and program aid. Facility utilisation Consumption of goods and services (functions) by region and providers. 13

15 Expenditure on NCDs by type of care, public/private mix: inpatient, day care, outpatient, home-based care, and long-term care. Rehabilitative inpatient, day, outpatient and home care by public/private provider and region. Long-term care inpatient, day, outpatient and home care by public/private provider and region. Maternal and child health, family planning and counselling by program area and provider (should include TCAM on maternity, if data is available). Revenue sources for preventive health expenditure by program area. Human resources Wages and salary expenditure as per cent of TCHE. Per cent of health budget allocation for wages and salary spent, by staff type. Effectiveness of payroll controls, target performance indicators. Medicines and consumables management Stock and monitoring of expenditure payment arrears. Public-Private partnership Public-private revenue contribution to TCHE. Public-private expenditure by provider and function. Public-private contribution to capital formation, by 3/4 digit NHA classification. Auxiliary services Availability of information on resources received by service delivery units. Ancillary expenditure by detailed function. Health planning and infrastructure Aggregate expenditure out-turn, i.e. per cent of approved budget spent. Composition of expenditure out-turns compared to original approved budget. Relative share of expenditure inpatient/ day/ outpatient/ home based care. Per cent of household income spent on health function, by income quintile. Per cent of health budget allocation for capital formation spent. Financial information provided by donors for budgeting and reporting on project and program aid. Transparency, competition and complaints mechanisms in procurement. Timeliness and regularity of accounts reconciliation. Monitoring and evaluation A monitoring and evaluation schedule be produced itemising production of essential health system data including NHA, household expenditure surveys and health outcomes. Policy analysis frameworks NHA measures expenditure across the spectrum of health sector goods and services organised to complement most research questions. Although indicators can be very useful, they can sometimes be deceptively simple, understating the complexity of the 14

16 health system and the issues involved. Many factors are critical to using indicators meaningfully. For instance, a standard measure such as the average per capita expenditure in each region by provider will not account for economies of scale in population centres or the vastly different costs of providing different services in rural versus urban centres. 11 Sometimes a more comprehensive analysis is required. Two useful frameworks for converting NHA data into health systems policy analysis are the WHO six Building Blocks 12 and the World Bank-Harvard University five Flagship Control Knobs 13. The two frameworks can work together, one feeding into the other. The WHO six building blocks focus on the delivery of health care goods and services: service delivery, health workforce, information, medicines, financing and governance. The Harvard Flagship framework focuses on assessing health system performance and formulating a policy response using the control knobs : financing, payment, organisation and service delivery, regulation, persuasion and politics, ethics and values. One comprehensive approach to policy analysis is to analyse each of the WHO building blocks in turn, gathering the situational and empirical evidence to identify the pertinent issues, then consider possible policy responses for each issue using the control knobs. In May 2013, the AusAID funded Health Policy and Health Finance Knowledge Hub from the Nossal Institute for Global Health, University of Melbourne, sponsored a training week for the Policy Unit, FMoH in the Harvard method of policy analysis using the Control Knobs and Diagnostic Tree. Using this training, the NHA data combined with other available evidence will enable staff to analyse health sector performance considering: Policy influences existing program or policy conditions influencing performance Policy impact are current policies having the desired effect, identify issues Policy evaluation positive and negative factors influencing performance Policy response what policy response is needed? Conclusion NHA data are an immediate and accessible source of information for policy analysis. Regular use of NHA tables will identify information gaps and the need for more detailed research of NHA classifications, particularly of private sector and external contributions, and the principal characteristics of beneficiaries for specific policy areas. Disaggregating health expenditure according to age, gender, socioeconomic status, disease type, and region give a truer picture of health system performance. Social objectives in health, such as fairness, equity, and access to quality health services can be investigated, promoting better understanding for health planners and decision-makers working to achieve better health outcomes. This paper is a first attempt at matching the 500 or so NHA classifications to the 140 or so indicators identified as health priorities for Fiji. Inevitably, there will be faults and omissions that will hopefully stimulate discussion and useful solutions. 15

17 References 1 Fiji Government 2011 Ministry of Health Strategic Plan Accessed 3/5/13 2 OECD-WHO 2011 System of Health Accounts Accessed 3/5/13 3 Op cit. 4 World Bank 2011 Public Financial Management Performance Measurement Framework Public Expenditure and Financial Accountability Secretariat, Washington, USA. 5 Pacific Islands Forum 2010 A Public Financial Management Roadmap for Forum Island Countries (Draft presented and accepted by PIF, August 2010) Management_Roadmap_Report.pdf Accessed 3/5/13 6 Pacific Financial Technical Assistance Centre 2011 FY12 Indicative Advisory Mission Plan: By Country (Fiji) Accessed 3/5/13 7 A list of the unabbreviated NHA Report indicators is attached in Annex 1. 8 Fiji Government 2011 op cit., pp OECD-WHO 2011 System of Health Accounts 2011 pp World Bank 2011 Public Financial Management Performance Measurement Framework Public Expenditure and Financial Accountability Secretariat, Washington, USA Ibid pp WHO 2010 Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva, Switzerland Accessed 28/5/13 13 Naqelevuki, S., Price, J., Irava, W The Pacific Flagship Course on Health Systems Strengthening and Health Financing Nossal Institute for Global Health, Melbourne, Australia data/assets/pdf_file/0008/624545/2012_pacific_flagship_report. pdf Accessed 28/5/13 16