Post on 28-Dec-2015
Institutionalization of National Health Accounts:A Global Strategic Action Plan (GSAP)
Charu C. Garg, Vaibhav Gupta, Rubama Ahmed, and Mahesh Shukla
Human Development Network, World Bank
GSAP Structure
Section I: Introduction • Need for NHA and NHA Institutionalization
Section II: Defining and Measuring NHA Institutionalization
Section III: Framework for Institutionalization
Section IV: Roadmap• Key Strategies for NHA Institutionalization (at Global and National Levels)
• Phasing Strategy
2
Goal: by 2020• At least 100 countries will have institutionalized NHA• 147 countries will have produced 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
GSAP presents a series of specific global, regional, and national level
strategies
Goal and Objectives
3
NHA is widely used to measure the financial status of the health system
NHA provides critical information:• resource gaps and advocacy• resource allocations, planning, and policy design• track health system performance
More countries are adopting the NHA framework Donor fatigue has become a pressing issue NHA is a global public good which will be under-produced if left
alone to the market Supporting institutionalization is cost-effective
Call for Action
4
What is NHA Institutionalization?
Routine government-mandated production and utilization of a minimum set of “globally” agreed health
expenditure data using a standard HA framework
5
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
6
First, countries have been assessed on four simple 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
Next, countries have been grouped under the following categories:
1. Institutionalized – all 4 criteria met
2. Almost institutionalized – 3 criteria met
3. Insufficient progress towards institutionalization – 1 or 2 criteria met
4. Not institutionalized – no criteria met
Measuring Institutionalization
7
Countries at Varying Stages of Institutionalization - 1
Institutionalized* Almost institutionalized
Insufficient progress
No progress
AFR Burkina Faso, Ethiopia, Kenya, Malawi, Mali, Mozambique, Namibia, Niger, Nigeria, Rwanda, Uganda, Zambia
Benin, Botswana, Burundi, Congo, Gambia, Ghana, Guyana, Liberia, Madagascar, Mauritius, Senegal, South Africa, Tanzania, Togo, Zimbabwe
Angola, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Côte d'Ivoire**, D R Congo**, Equatorial Guinea, Eritrea, Gabon, Guinea, Guinea-Bissau, Lesotho, Mauritania, Sao Tome and Principe, Sierra Leone, Somalia, Sudan** ,Swaziland
EAP Australia, China, Japan, Malaysia, New Zealand, Philippines, Republic of Korea, Thailand, Vietnam
Indonesia, Mongolia, Samoa
Fiji, Micronesia, Papua New Guinea, Palau, Tonga, Vanuatu
American Samoa, Cambodia, Cook Islands, DPR of Korea, Kiribati, Lao PDR, Marshall Islands, Nauru, Niue, Singapore, Solomon Islands, Timor-Leste, Tuvalu
ECA Armenia, Austria, Belgium, Bulgaria, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Hungary, Iceland, Ireland, Lithuania, Luxembourg, Netherlands, Norway, Poland, Portugal, Romania, Russian Federation, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom
Cyprus, Greece, Italy, Kyrgyzstan, Turkey, Ukraine
Albania, Bosnia and Herzegovina,Kazakhstan, Latvia, Republic of Montenegro
Andorra, Azerbaijan, Belarus, Croatia, Kosovo, Macedonia, Malta, Moldova, Monaco, San Marino, Tajikistan** ,Turkmenistan, Uzbekistan
8
Institutionalized* Almost institutionalized
Insufficient progress
No progress
LAC Guatemala, Mexico Bolivia, Brazil, Chile, Colombia, Ecuador, El Salvador, Jamaica, Nicaragua, Peru, Uruguay
Antigua and Barbuda, Argentina, Bahamas, Costa Rica, Dominican Republic, Haiti, Honduras, Panama, Paraguay, Suriname, Trinidad and Tobago
Barbados, Belize, Cuba, Dominica, Grenada, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Venezuela
MNA Israel, Jordan, Lebanon, Morocco, Tunisia
Algeria, Bahrain, Djibouti, Egypt, 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, Myanmar, Nepal, Pakistan
Afghanistan**, Bhutan, Brunei, Seychelles
*Canada and USA have also institutionalized**Currently in the process of producing NHA for the first time in 2010
Countries at Varying Stages of Institutionalization - 2
9
Framework for Institutionalization
By understanding why countries have been unable to institutionalize NHA (problems and their causes), seven core dimensions have been defined
Strategies and the specific actions that each stakeholder can take have been identified accordingly
Countries need to assess constraints, plan strategies, and implement the plan
GoalsConstraints
to achieving goals
Causes of problems
Strategies to solve
problems
Mapping Stakeholders –defining a role for
each
GSAP Objective #1:Develop strategies to achieve the goal- 100 countries to have institutionalized NHA by 2020
Both at global, regional,
and country level
10
Framework Derived from Key Constraints- Lessons from Case Studies, Questionnaires, and Consultations
EnvironmentGovernance / Legislation/ Coordination
Lack of mandate; perceived to be donor driven; lack of coordination between key stakeholders
ResourcesPrimarily 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
11
Strategic Actions Required at the Global 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 with resource tracking
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
14
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
15
Roadmap: Revisiting the Challenge100 countries institutionalized by 2020
2010: Where we are now
2020: Where we want to be
16
Achieving the Goal
Importance of indicators determining success towards institutionalization
Gov. health
investments
Financial resources
Governance and institutional
effectiveness
Donor commitment and
conditionality
Government commitment
Government capacity to produce and use NHAs
NHA utility to Government
17
Greater utilization of NHA data by governments
Government capacity to produce and use NHAs
Government commitment to produce and use NHAs
Dev. partners’ commitment and conditionality
Methods to Achieve the Results OutlinedIndependent variables Proxy Variables
NHA Utility to the Government Ordinal Policy use of NHA in the past
Government commitment to NHAs
Ordinal NHA production record
Government capacity to produce and use NHAs
Continuous WB country policy and institutional assessment score, 2008 and Bertelsmann Transformation Index 2010 (Management Index)
Development partner commitment and/or conditionality
Ordinal Past record
Overall governance and institutional effectiveness
Continuous WBI world governance indicators dataset 2008 (of all countries)
Government investments in health
Continuous General government expenditure on health as % of total government expenditure
Financial resources available to government for producing and using NHAs
Ordinal Country per capita income
•Logistic regression model to estimate the likelihood of country institutionalizing NHA
•Variables linked to determinants of institutionalization and measured by proxy measures
Country attributes• Political will , government commitment
• Capacity and resources to routinely produce and use
• Government investments in health
• Governance , institutional effectiveness
NHA attributes • Utility to country
• Relative advantage over existing tools and mechanisms
• Communicability and ease of use
Development partner attributes • Consistent, harmonized and long term
support
• Conditionality: implied or expressed
18
100 countries to have institutionalized NHA by 2020• 58 countries to institutionalize in 10 years (in addition to 42 already
institutionalized)• 20 more countries start producing NHAs (in addition to 127 countries with
production experience as of now)
Four cohorts of 106 countries enter institutionalization mode in 2011• 2011-16 Cohort. 38 countries at an advanced stage of institutionalization• 2011-17 Cohort. 24 countries with insufficient progress toward
institutionalization but with stronger NHA capacity• 2011-18 Cohort . 24 countries with insufficient progress toward
institutionalization but with weaker NHA capacity • 2011-20 Cohort. 20 (out of 67) countries with no previous experience of NHA
production
Phasing Support for Institutionalization
19
Cost Estimates and Risk Analysis
21
Cost Estimates• Price tag is perceived to be high• Required investment and resources are likely to depend on:
oFocus countriesoTypes of activities that will be fundedo Extent of support that countries need
Risk Analysis and Mitigation Strategies• Priorities of countries – change of administration, conflicts• Priorities of development partners change – competing priorities with
other development sectors and also within health sector
Work in Progress….
Next Steps
• Build global consensus around strategies discussed
• Obtain global commitment to implement strategies
• Minimum 10-year support from development
partners: requires strong commitment
22
Equal Partners in Action
Equal ownership of GSAP from all partners
Consensus on length and breadth of support
• financial, technical assistance, advisory
Agreement on focus countries
Timeline proposal (leading up to the global
consultation)
Common materials (PPTs, informational brochure)
23
“How-to Institutionalize” Manual
Objective: Guide countries on the necessary steps required to institutionalize in both an efficient and cost-effective manner
• Guidelines to be based on five country pilots and ten country case studies, past country experiences, and peer-reviewed literature on the topic
Primary Audience: Country officials, research and policy institutes, universities, external agencies supporting NHA institutionalization
Contents: Action steps and practical guidance notes; examples of good practice- pitfalls or failures; checklists; catalogue of learning resources; references; useful websites and tools
Next Steps: Draft the manual, present it to World Bank Internal Steering Committee and NHA Advisory Group ; followed by development partners and the wider audience
24
Work under consideration….