Financing of health services:

A district perspective

Annual Health Forum

BMICH

9-10th February 2007

Dr. Ravi P. Rannan-EliyaInstitute for Health Policy

http://www.ihp.lk/

Outline

Study TOR & Mandate Approach & Scope Challenges Methods Results Implications

Policy Future monitoring

Mandate and HPRA TOR

To record recurrent and capital investments for health by district

Measure relative donor contributions by district Measure categories of recurrent spending by district

Selected districts: Colombo, Badulla, Matale

Implicit goals To assess feasibility and relevance, and to pilot

monitoring of spending at district level

General Approach & Scope Health accounts approach used to develop district

estimates of financing flows and investments Sri Lanka Health Accounts

Standardised profile of all national health expenditures Provincial expenditure estimates already available For AHF, methods developed to disaggregate further to district

level, identifying new data sources where practical Scope

Study scope extended to all districts Data source

IHP SLHA Estimates - available for 1990-2005 Meets latest international and national standards Other extensions include costing by disease

Advantages of approach

IHP SLHA system already tracks expenditures on annual basis at provincial level (81% of total) Existing system already maintained on annual basis Needed only modifications to incorporate district tracking

and reporting Approach supports tracking in all districts with

minimal additional effort Provides systematic and standardised framework for

profiling and categorising sources of financing, uses and providers of cares

Provides consistent link to national spending estimates

Challenges in monitoring expenditures at district level Provinces - not districts - are the budget holding entities in

public sector & under Constitution Accountability for budgets is at provincial level Financial reporting systems not designed to track expenditures at

district level, and district level FIS weak Provincial accounting systems lack detail to enable tracking of

functional categories Donors

Most donors cannot easily report expenditures either at provincial or district level (exceptions - GFATM, WB, JICA)

Difficult to obtain cooperation/data from most donors Private sector

Most survey data sources not reliable at district level Generally not available on annual basis

Methods: Public sector

MoH Recurrent and capital Source: Treasury reports and data on

expenditures - actual (to 2005) Allocated to district/province by project Medical supplies tracked to district using MSD

records Allocable:

By district - 59%

Methods: Public sector

Provincial Departments of Health (PDOHs) Recurrent and capital Sources: Provincial financial statements Actuals only available to 2004 Allocated to districts using PDOH reports

5 out 9 provinces responded (WP, Uva, Sab, NCP, CP) . . . otherwise based on analysis of levels of hospital

infrastructure and population size Not possible to analyze categories of spending at district

level owing to lack of adequate data Allocable:

By district - 89%

Methods: Donors

Recurrent and capital Source: Survey of donors and analysis of

project documents Allocable:

By province/district - < 30%

Methods: Private sector

Private hospital investment MOH-IHP Census of Private Hospitals 2006 80% response rate

Plantation companies IHP Survey of Estate Hospitals 2006

Other private spending Central Bank and Census & Statistics Department

Household Expenditure Surveys IHP surveys of laboratories, ambulance companies, etc

Allocable: By district - 97%

Findings

National context

District focus

National health spending trends

1.81.5

1.71.4 1.5

1.7 1.7 1.61.8 1.8 1.8 1.8 1.7 1.6

2.0 2.0

1.9

2.0

1.9

1.9 1.91.9 1.9 1.9

1.9 2.0 2.0 2.1 2.2 2.3

2.3 2.2

3.7%3.5%

3.7%

3.3% 3.4%3.6% 3.6% 3.5%

3.7% 3.7% 3.8% 3.8% 3.9% 4.0%

4.3% 4.2%

-

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Pe

rce

nta

ge

of

GD

P (

%)

Public Expenditure (% GDP) Private Expenditure (% GDP) TEH as % GDP

IHP Sri Lanka Health Accounts 2006

How was health financed?

47%

Provincial Councils15%

MOH28%

2%1%5%

47%

Other 2%

MOH Provincial Councils Other Government Households

Employers Private Insurance Others

Out-of-pocket Government

2005Rs 99 billion4.2% of GDPUS$ 50 per

capita

IHP Sri Lanka Health Accounts 2006

What is being financed?

IHP Sri Lanka Health Accounts 2006

5%

5%

5%

0%

11%

Medical goods including outpatient

medicines

Outpatient care21%

Inpatient care28%

Inpatient care

Outpatient care

Preventive and publichealth

Distribution of medicalgoods

Ancillary services

Administration

Other

Capital investment

2005Rs 99 billion4.2% of GDPUS$ 50 per

capita

1,642

1,687

2,064

2,074

2,048

2,019

2,207

2,221

2,244

2,228

2,310

2,532

2,424

2,583

2,974

2,902

2,801

3,107

3,183

3,147

3,270 10,455

- 2,000 4,000 6,000 8,000 10,000

VavuniyaNuwara Eliya

KegalleBatticaloa

JaffnaRatnapura

BadullaAmpara

MoneragalaMatale

PolonnaruwaAnuradhapura

HambantotaMatara

KurunegalaKalutaraPuttalam

AVERAGEGalle

KandyGampahaColombo

Total expenditure per capita, 2004 (Rupees)

Total health spending by district (2004)

834

592

842

1,031

992

977

1,214

871

1,176

1,134

1,155

1,366

821

905

1,171

957

819

1,083

1,207

1,510

704

809

1,095

1,222

1,043

1,056

1,042

992

1,351

1,068

1,094

1,155

1,167

1,602

1,678

1,802

1,944

1,982

2,024

1,975

1,637

2,567

7,236

3,220

- 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000

Vavuniya

Nuwara Eliya

Kegalle

Batticaloa

Jaffna

Ratnapura

Badulla

Ampara

Moneragala

Matale

Polonnaruwa

Anuradhapura

Hambantota

Matara

Kurunegala

Kalutara

Puttalam

AVERAGE

Galle

Kandy

Gampaha

Colombo

Public and private expenditure per capita, 2004 (Rupees)

Total health spending by source by district (2004)

494880102128127135130135

180193204217

303307

355395404410427431

541705

9712,843

445

- 500 1,000 1,500 2,000 2,500 3,000

MataleNuwara EliyaHambantota

PuttalamVavuniya

MannarKillinochchiTrincomalee

MullaitivuMoneragala

PolonnaruwaAnuradhapura

KalutaraAmparaKegalle

GampahaAVERAGE

JaffnaMatara

KurunegalaRatnapuraBatticaloa

BadullaGalle

KandyColombo

MOH expenditures per capita, 2004 (Rupees)

MoH spending by district (2004)

311

312

502

466

461

484

486

487

483

487

505

507

599

514

642

713

696

656

710

928

965

1,145

1,048

- 500 1,000 1,500 2,000 2,500 3,000

Colombo

Gampaha

Kegalle

Galle

Matara

Vavuniya

Trincomalee

Jaffna

Batticaloa

Ampara

Kandy

Nuwara Eliya

AVERAGE

Ratnapura

Badulla

Kurunegala

Kalutara

Puttalam

Hambantota

Polonnaruwa

Moneragala

Matale

Anuradhapura

PDOH expenditures per capita, 2004 (Rupees)

Provincial DoH spending by district (2004)

56891111121519202025303135485775788697

149161168

207

103

- 500 1,000 1,500 2,000 2,500 3,000

ColomboGampaha

KurunegalaKandy

KalutaraRatnapura

Galle Kegalle

AnuradhapuraPuttalam

MataraMatale

Nuwara EliyaPolonnaruwa

BadullaJaffna

AVERAGEMoneragala

BatticaloaTrincomalee

AmparaHambantota

MullaitivuMannar

KillinochchiVavuniya

Donor expenditures per capita, 2005 (Rupees)

Donor spending by district (2005)

Capital investment trends, 1990-2005 (Rs billion)

-

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Public Private

IHP Sri Lanka Health Accounts 2006

Capital investment by district and source (2005)

4

2

3

12

1

4

4

5

22

26

3

21

21

13

58

4

26

-

4

8

3

15

15

17

20

2

-

24

13

27

39

10

66

349

- 50 100 150 200 250 300 350 400

Polonnaruwa

Kalutara

Nuwara Eliya

Badulla

Kegalle

Matale

Matara

Kurunegala

Anuradhapura

Hambantota

Kandy

Ratnapura

Gampaha

Puttalam

Moneragala

Galle

Colombo

Public and private capital investment per capita, 2005 (Rupees)

IHP Sri Lanka Health Accounts 2006

Issues Current regional patterns

Must take into account all sources (MoH, Provinces, Private sector)

Large variations exist Mostly due to capacity for private spending Most significant is between Colombo and other districts Likely lower overall spending in East and North due to lower

private spending Imbalances in MoH spending partially compensate for

imbalances in PDoH budgets Implications

MoH budget is most important tool for achieving equity in district spending

Private spending largest contributor to district inequality

Issues

Capital investment Private sector investment mostly in Colombo, and

significantly outweighing public investment Should government policies continue to provide

favoured tax status to BOI investments given its contribution to district inequalities?

Issues

Monitoring district spending in future Are districts the best level to focus monitoring on?

Budget and expenditure data complete at provincial level, but mostly missing at district level

Accountability is at provinces and not districts District financial reporting systems

Should provincial financial systems be improved? Possible model to emulate

Malaysia’s MoH treasury reporting system, which tracks all MoH spending down to individual facility

Who should be responsible for action? Malaysia is a federal state, but health is a central responsibility