SPECIAL EXPERT ADVISORY WORKSHOP ON THE SYSTEM

OF HEALTH ACCOUNTS (SHA), OECD Paris

June 14-15, 2010

Charu C. Garg (cgarg@worldbank.org)

Human Development Network, World Bank

GSAP Structure

Section I: Introduction

• Need for NHA and NHA Institutionalization

• Goal and objectives

Section II: Defining and Measuring NHA Institutionalization

Section III: Framework for Institutionalization

Section IV: Roadmap

• Key Strategies for NHA Institutionalization (at National , and International

Levels)

• Scaling up investments to institutionalize NHA

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Need for NHA Institutionalization

• Benchmarking performance against historical and established

targets and goals

• Holding policymakers (national and international) accountable to

policy promises

• Assessing sustainability, and fiscal space

• Identifying existing gaps and projecting future needs

• More efficient, equitable, and needs driven resource allocation

Supporting institutionalization is cost-effective

• Why now?

• Several countries at the tipping point

• renewed emphasis on results and financing (RBF, IIFM, MDGs GHIs)

• we can ill-afford to spend scare resources without knowing where the

need is most pressing (financial crisis)

• Renewed interest from countries and DPs for better data

3

Assessment criteria

• Consistent production of

NHA data

• Consistent use of NHA data

• Adequate financial, human

and infrastructure capacity

to routinely produce and

use health accounts

• Use of health accounts

methodology

4

Institutionalized – all 4 criteria met

Almost institutionalized – 3 criteria met

Insufficient progress towards institutionalization –

1 or 2 criteria met

Not institutionalized – no criteria met

Where are we now ?

42 countries have

institutionalized

NHA and 127

countries have

produced at least

once.

2010: Where we

are now

2020: Where we

want to be

Goal and Objectives

Goal and Objectives

Goal: by 2020

1. At least 100 countries

have institutionalized

NHA

2. 3 out of 4 countries

produce NHA (or health

accounts) at least once.

Objectives:

• Develop strategies to

achieve above goal

• Build global consensus

around these strategies

• Obtain global commitment

to implement these

strategies

5

Defining NHA Institutionalization?

Routine government-mandated production and

utilization of a minimum set of “globally” agreed health

expenditure data using a standard HA framework

6

Suggested Indicators to Measure NHA Institutionalization

Key Elements Indicators

NHA is government

mandated

Law/regulation empowering entity and mandating production

• Identified home for NHA

• Government budget marked for NHA work

NHAs are a

regular/routine

activity

NHAs are conducted and data is reported annually

• Public data collected and compiled every year

• Private data collected at least once in 5 years and

estimated every year

NHA methodology

applied consistently

Data is consistent with:

• NHA boundary definition

• NHA classifications (for example, local

classifications are mapped to NHA classifications)

Minimum set of

“globally agreed

data produced”

• All global key indicators are reported

• At least one NHA table is available

Data is utilized and

disseminated

• NHA data is used for reporting health expenditures in

government documents

• Core data is available publicly on website

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Framework for Institutionalization

Assess constraints - along the seven key core dimensions

Identify Strategies to overcome the specific problem and cause

Map specific actions to different stakeholders - domestic and

international

Achieve key goals for institutionalization

Constraints Problems and their causes

Strategies to solve problems

Mapping Stakeholders –defining a role for

each

Goals

GSAP Objective #1:Develop strategies to achieve the goal-

100 countries to have institutionalized NHA by 2020

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Framework Derived from Key Constraints- Lessons from

Case Studies, Questionnaires, and Consultations

Environment Governance /

Legislation/ Coordination

Lack of mandate; perceived to be donor driven; lack of coordination

between key stakeholders

Resources Primarily Human and

Financial

Inadequately trained staff; low technical capacity; uncertain funding,

High cost due to reliance on external staff and one off surveys

Data Collection Problems of availability, access, and inconsistency between NHA data

needs and standard surveys and available data; not easily extractable;

few (if any) linkages with public expenditure management

Data Management Absence of long-term strategy to store, manage and use data; no

standard estimation methods,

Information

Products

Stress on extended NHA matrices; strategy not linked to incremental

process and policy needs; subaccounts missing key NHA data

Quality of Data

and Estimates

Problems of timeliness, frequency, consistency and comprehensiveness

in existing data; inconsistent methodology; poor validity checks.

Dissemination and

Use

Link to policy unclear; disconnect between producers of NHA and users;

weak dissemination strategy; statistical reporting in countries not

referring to indicators produced from NHA data 9

Mandate and ensure a long term commitment to produce and

use NHA

e.g. national decree or legislation

Ensure that adequate resources are available

firm financial commitment from the Ministry of Finance

Harmonize national efforts

NHA Steering Committee

Fund routine production and use of NHA

increased investments in data automation and electronic filing

systems

Introduce cost-reducing mechanisms

modifying national level household and budget surveys to include

more NHA category questions

Disseminate and share NHA data

Strategic Actions Required at the National Level

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Strategic Actions Required at the International Level

Commit long-term to NHA institutionalization

Fund routine production of NHA not one-off exercises

Introduce cost-reducing mechanisms

e-tools, regional database of consultants, surveys

Harmonize donor efforts

global consensus on a list of minimum indicators

with other GHIs

Build awareness of NHA use

South-South learning forums, integration and use with other

resource tracking and analytical health financing tools

Pass resolutions mandating NHA institutionalization

e.g. supported by global agencies including WHO, World Bank, IMF

Enforce conditionality for loans and grants

e.g. GFATM, GAVI

Regional Strategy –Knowledge sharing and support capacity building.

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Achieving the Goal

Importance of indicators determining

success towards institutionalization

14

Greater utilization of NHA

data by governments

Government capacity to

produce and use NHAs

Government commitment

to produce and use NHAs

Development partners’

commitment and

conditionality

Utility to government

Government capacity to produce and use

Government commitment

Donor commitment

Governance and institutional

effectiveness

Resources

public investment

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Cost Estimates for achieving the goal

0

5

10

15

20

25

30

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

Millio

n U

S D

ollars

Contribution of participating countries

Development partner contribution (maximum) to the countries

Development partner support at regional level

Development partner support at global level

• Price tag is perceived high - Benefits (policy use) will outweigh costs

• Average cost of production decreases as countries move from stage

III or IV to stage I or II. (In latter less than $100K needed on average)

• If DP invest just $1 in every $1000 spent in Development Aid for

health, goal for GSAP will be achieved.

Work in Progress….preliminary results

WB consultant analysis for the project “Promoting institutionalization of NHA in countries, June 2010.

0

10000

20000

30000

40000

50000

60000

70000

80000

Stage I: already institutionalized (n=11)

Stage III & IV: insufficient progress towards

institutionalization (n=11)

Staff cost

Consultant cost

Office cost

IT cost

Travel cost

Training cost

Survey cost

Dissemination cost

Other costs

Y axis in USD

Phasing Matrix

Stage II: Almost

Institutionalized

Stage III

Moderate

stage—strong

governance

Stage IV

Insufficient

progress

weak governance

Stage V No experience

AFR Burkina Faso, Ethiopia, Kenya,

Malawi, Mali, Mozambique,

Namibia, Niger, Nigeria,

Rwanda, Uganda, Zambia

Botswana, Burundi,

Djibouti, Ghana, Liberia,

Madagascar, Mauritius,

Senegal, South Africa,

Tanzania, Togo,

Zimbabwe

Benin,

Congo, Gambia

Angola, Côte d'Ivoire**, Cameroon,

Cape Verde, Central African Republic,

Chad, Comoros, D R Congo**,

Equatorial Guinea, Eritrea, Gabon,

Guinea, Guinea-Bissau, Lesotho,

Mauritania, Sao Tome and Principe,

Sierra Leone, Somalia, Sudan**,

Swaziland

EAP Indonesia, Mongolia, Samoa Tonga Fiji, Micronesia,

Myanmar,

Palau, Papua New

Guinea,

Vanuatu

American Samoa, Cambodia, Cook

Islands, DPR of Korea, Kiribati, Lao

PDR, Marshall Islands, Nauru, Niue,

Solomon Islands, Timor-Leste, Tuvalu,

Singapore

ECA Estonia Albania, Bosnia-

Herzegovina

Latvia, Montenegro

Kazakhstan, Ukraine Andorra, Azerbaijan, Belarus, Croatia,

Kosovo, Macedonia, Malta, Moldova,

Monaco, San Marino, Tajikistan** ,

Turkmenistan, Uzbekistan

LAC

Bolivia, Brazil

Chile, Colombia, Ecuador,

El Salvador, Jamaica,

Nicaragua, Peru, Uruguay

Costa Rica, Dominican

Republic, Honduras,

Paraguay, Trinidad and

Tobago

Antigua and Barbuda,

Argentina, Bahamas,

Guyana, Haiti, Panama,

Suriname

Barbados, Belize, Cuba, Dominica,

Grenada, Saint Kitts and Nevis, Saint

Lucia, Saint Vincent and the

Grenadines, Venezuela

MNA Israel, Jordan, Lebanon, Morocco,

Tunisia

Algeria, Egypt Bahrain, Iran, Yemen Iraq, Kuwait, Libyan Arab Jamahiriya,

Oman, Qatar, Saudi Arabia, Syrian Arab

Republic, United Arab Emirates, West

Bank and Gaza

SAR Bangladesh, India, Sri Lanka Maldives, Nepal,

Pakistan

Afghanistan**, Bhutan, Brunei,

Seychelles **Currently in the process of producing NHA for the first time in 2010

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Next Steps

Objectives:

Develop strategies to achieve the goal

• Build global consensus around these strategies

• Obtain global commitment to implement these strategies

• Minimum 10-year commitment from countries and

development partners: to reach the tipping point

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Objective 2: Obtain Consensus and Commitment

Equal ownership of GSAP from all partners

• Support strategies leading to a completely demand driven

process

Share Knowledge

• Best Practices

• Estimation methods

• Surveys

• Tools

Provide Technical Support to build capacity

Advocate for financial commitments

Resolution on NHA institutionalization

Equal Partners in Action - “Coming together is a beginning.

Keeping together is progress. Working together is

success.” ….Henry Ford

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