Charu C. Garg Sr. Health Economist The World Bank Health, Nutrition and Population Human Development Network Hotel Palomar, Washington DC, October 20, 2010
NHA: A framework to Convert Raw Data into Actionable Information 2
NHA Provides Information for Making Health Financing Decisions Collection & pooling S our ce of Finance Financing source & agents Where does the money comes from? Purchasing P r oduction Health inputs and Providers What does the money get spent on? Distributing Consum ption Health functions & beneficiar ies W ho benefits and how much? Systematic, comprehensive, and consistent information on flow of funds in a country s health system 3
What is institutionalization of health accounts? A government-mandated process Routine production & routine use A minimum set of globally agreed health expenditure information Using a standard health accounting framework Why is it Important? Routine and standardized health expenditure data helps monitor resources and make evidenced based policy Builds capacity for routine production and use Saves money (can reduce annual costs of NHA production by 66%) 4
1.20 NHA Data Informs Policy and Helps Monitor Flows India s National Rural Health Mission Government Health Expenditure as Percent of GDP Before 1.20 After 1.00 1.00 % GDP 0.80 0.60 0.40 0.20 % GDP 0.80 0.60 0.40 Centre States Total (Centre & States) 0.00 0.20 1999-2000-2001-2002-2003-2004- 2000 01 02 03 04 05 0.00 2004-05 2005-06 2006-07 Source: Berman and Ahuja 2007, RBI Bulletin; Expenditure Budget, Government of India 5
NHA Data Helps to Monitor Health Spending for Public Health programs: Tanzania 42% 37% 32% 27% 22% 17% 12% 7% 2% -3% 29.0% 21.9% 20% 15.2% 14% 16% 0.6% 7% 10.7% 2% 42% HIV/AIDS TB Malaria RH CH Others 26% 2003 2006 6
Countries can Benchmark their Expenditure with Other Countries and also Link to Outcome Levels Correlation between health expenditure and outcomes (2003) Switzerland 80 75 Healthy Life Expectancy (number of years) 70 USA 65 60 55 50 45 40 DRC Botswana 35 Zimbabwe Liberia Burundi Angola Swaziland Lesotho 30 10 100 1,000 10,000 Log of Total Expenditure on Health (THE) per capita in international dollars 7
NHA Data Provides Information on Allocative Efficiency Total expenditures by disease and providers: Sri Lanka, 2005 Injuries Cardiovascular Hospitals Nervous system disorders Diabetes mellitus Malignant neoplasms Neonatal causes Ambulatory services Total pharmaceuticals Community and public health and Dental Maternal conditions Asthma Infectious and parasitic - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 Total expenditure by disease (Rupees million) Source: Rannan Eliya, 2009 8
NHA Data Tracks Resources for Health Insurance Programs and Household Health Spending: Colombia Large Mobilization of Resources 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Reduction of OOP 10% 8% 8% 44% 26% 23% 45% 40% 1993 2003 Other private OOP Payroll taxes Taxes Total Health Expenditure in SHI (million of Col Pesos of 2000) Changes in Composition of Health Expenditure 1993-2003 Sources: Colombian National Health Accounts. Graph Giedion, 2008. Barón G. Ministerio de la Protección Social, Bogotá 2007. Unidad de Gestion de la Demanda, 2008 9
Time Series NHA Data Helps to Make Projections : Thailand Expenditure Share in GDP of Financing Agencies - Long-term Trends 6.0 Rising share of workers insurance, social security and universal coverage 5.0 4.0 Private HH Universal Coverage Per cent 3.0 2.0 1.0 MoPH 0.0 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026 MoPH OthMin LocGovt StateEnterprise CSMBS SocSec UC WCF PrivIns TrafficIns ERBenefits PrivHH NonProfit RoW 10
NHA Data Used Widely for Informing Health Policy: WB Survey Results 11
Cost of Production of NHA is lower in countries where it is Institutionalized Costs of Production of NHA - World Bank Survey Results 12
The Global Strategic Action Plan (GSAP) helps in Assessing constraints to institutionalization and formulate strategies to overcome constraints. Defining and providing measures for institutionalization Shifting focus from episodic production and sporadic use to routine production and routine use of information Building capacity, processes, and institutions for sustained production and use by emphasizing incremental approach to Institutionalization Setting a global level target for the next 10 years and outlines a roadmap Suggesting strategies for countries and for regional and international agencies to work together with countries to achieve this target 13
NHA is Institutionalized in 41 countries Institutionalized Almost institutionalized Insufficient progress No prior experience No data available 130 countries have produced NHA at least once. Where we are now (2010) 130 41 14
GSAP Framework focuses on seven core dimensions Constraints to institutionalization: Environment and governance Human, Financial and Institutional Capacity Data Collection Data Management Information Products Data Quality Dissemination and Use Lack of mandate; perceived to be donor driven; lack of ownership; absence of coordination between key stakeholders Inadequately trained staff; low capacity; uncertain funding, High cost due to reliance on external staff and sporadic surveys Problems of availability, access, and inconsistency; not easily extractable; Few linkages with public expenditure management Absence of long-term strategy to store, manage and use data; no standard estimation methods Stress on extended NHA matrices; strategy not linked to incremental process and policy needs; Problems of timeliness, frequency, consistency and comprehensiveness in existing data; inconsistent methodology; poor validity checks Link to policy unclear; disconnect between producers and users; weak dissemination strategy; NHA data not linked to statistical reporting and other resource tracking mechanisms 15
GSAP Suggests Several Country Level Strategies Ensure long term commitment to produce and use NHA through a mandate Make Available of adequate resources To build capacity, institutions and processes Harmonize national efforts Establish an NHA Steering Committee with wide stakeholder participation Fund routine production and use of NHA and not episodic exercises Increase investments in data automation, electronic filing systems and policy tools Introduce incremental approach Introduce cost-reducing mechanisms Link with national level household surveys and existing institutionalized data collection systems Disseminate and share health expenditure information widely Follow a systematic process of needs assessment, planning, implementation, monitoring and evaluation of institutionalization effort 16
and Also Global and Regional Strategies Global Long-term financial and technical support for building capacity, institutions and processes Create Supply side incentives: By show-casing policy use, building country comparison data set, grant conditions. Support cost-reducing mechanisms: Training tools, Surveys and other e-tools Link with other RT initiatives Strengthen country ownership and encourage incremental approach to assess and implement plans. Harmonize efforts among DPs Regional Provide a platform for sharing experiences Act as hubs of best practices and repositories of knowledge Progress from technical discussions to more policy related ones Include policy makers and not just technical experts Revisit mode and scope of training Look for innovative funding e.g. by linking NHA to other health financing initiatives Promote country ownership of networks and improve accountability 17
GSAP has been developed through an extensive process of consultations Country Institutionalization Pilots (5) Burkina Faso, Colombia, Mali, Mongolia, Morocco Country Case Studies (10) Ethiopia, Georgia, Guatemala, Indonesia, Madagascar, Mongolia, Nicaragua, Philippines, Rwanda, Thailand Regional Consultations (4) South Asia, Latin America, Central Asia and Europe, Africa Regional NHA Network Studies(5) Global surveys (2) on costs of health accounting on use of health expenditure information Consultation with over 200 health accounting and health policy experts Development Partner Consultations 18
Our target is Where we are now (2010) 130 Where we strive to be (2020) 150 100 41 19
We gratefully acknowledge your support? Countries MoH, MoPL, Statistics, MoF, NGOs Regional NHA Networks, Regional Institutions and Regional Offices Multilateral Organizations The Global Fund, IMF, Inter-American Development Bank, OECD, WHO, World Bank Bilateral Development Partners AusAID, Bill & Melinda Gates Foundation, DANIDA, GTZ, Netherlands Development Cooperation, NORAD, SIDA, United States Agency for International Development Civil Society Organizations / Research Institutions. 20
The Global Strategic Action Plan (GSAP): A Framework for Institutionalization of National Health Accounts Comments and suggestions cgarg@worldbank.org mchawla@worldbank.org nhai@worldbank.org 21