Dr. Shahram Yazdani National Health Account. Dr. Shahram Yazdani Definition National health accounts...

Dr. Shahram Yazdani

National Health Account

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Definition

National health accounts (NHA) constitute a systematic, comprehensive, and consistent monitoring of resource flows in a country’s health system.

They are a tool specifically designed to inform the health policy process, including policy design and implementation, policy dialogue, and the monitoring and evaluation of health care interventions.

They provide the evidence to help policy-makers, nongovernmental stakeholders, and managers to make better decisions in their efforts to improve health system performance.

Put simply, NHA are a set of tables in which are arrayed the various aspects of a nation's health expenditure.

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National health accounts and health system performance measurement

All nations have health systems, which have been described as “all the activities whose primary purpose is to promote, restore or maintain health”.

Whether arrived at by conscious creation or by evolution, health systems exist to produce some benefit for societies and their citizens.

A health system mobilizes and channels resources into institutions and uses them for individual or social consumption.

This consumption of goods and services produces a flow of benefits to the population, which results in some new level or stock of health.

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National health accounts as an input to stewardship

Experience in the countries that have developed and used health accounts has been that the accounts are very helpful in answering following questions: How are resources mobilized and managed for the

health system? Who pays and how much is paid for health care? Who provides goods and services, and what

resources do they use? How are health care funds distributed across the

different services, interventions and activities that the health system produces?

Who benefits from health care expenditure?

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Analytical dimensions of health expenditure

The tables that comprise a nation's health accounts represent different views of the same object - national expenditure on health.

Although the viewpoint of each table depends upon which dimensions of health expenditure are being observed, at least in theory the object itself remains unchanged by the shift in viewpoint.

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1. Financing sources: institutions or entities that provide the funds used in the system by financing agents;

2. Financing agents: institutions or entities that channel the funds provided by financing sources and use those funds to pay for, or purchase, the activities inside the health accounts boundary;

3. Providers: entities that receive money in exchange for or in anticipation of producing the activities inside the health accounts boundary;

4. Functions: the types of goods and services provided and activities performed within the health accounts boundary;

5. Resource costs: the factors or inputs used by providers or financing agents to produce the goods and services consumed or the activities conducted in the system;

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6. Demographic characteristics of beneficiaries: policy-relevant groupings of those receiving or affected by the goods and services consumed within the health accounts boundaries –– age, sex, race, urban or rural residence, ethnicity, and so on;

7. Socioeconomic status of beneficiaries: policy-relevant groupings of those receiving or affected by the goods and services consumed within the health accounts boundaries –– grouped along the lines of educational attainment, income, wealth, or occupation;

8. Health status of beneficiaries: policy-relevant groupings of those receiving or affected by the goods and services consumed within the health accounts boundaries –– groupings typically include condition or disease state, functional status, or type of intervention received;

9. Regions: sub-national groups of the entities involved in the financing or consumption of goods and services transacted within the health accounts boundaries.

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Classification schemes for health expenditure

A classification scheme should satisfy several criteria: It should represent an important, policy relevant

dimension, and should partition the dimension in policy relevant ways.

It should partition the dimension in a mutually exclusive and exhaustive way, so that each transaction of interest can be placed in one –– and only one –– category.

It should respect and reflect, to the extent possible, existing international standards and conventions.

It should be feasible to implement using the data available.

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The International Classification for Health Accounts

The International Classification for Health Accounts (ICHA) is a comprehensive classification system with three important NHA dimensions: financing agents, providers, and functions.

It was designed to be compatible with a number of existing classification schemes and practices in international economic statistics – most importantly, with the system of national accounts (SNA).

The ICHA classifications in the OECD system of health accounts (SHA) are accompanied by detailed definitions of each item in the scheme.

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The International Classification for Health Accounts The system of national accounts (SNA) is a broad structure

for national economic accounting, developed jointly by the Commission of the European Communities, the International Monetary Fund, the Organisation for Economic Co-operation and Development, the United Nations, and the World Bank.

The rules and structure of the SNA are contained in a manual called System of national accounts 1993, typically abbreviated SNA93.

The foreword to the SNA93 describes it as “a comprehensive, consistent, and flexible set of macroeconomic accounts intended to meet the needs of government and private sector analysts, policy makers, and decision takers”.

It provides the definitions that underlie such concepts as gross domestic product (GDP).

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Not all countries use the SHA; some health accounts are built on the framework of the system of national accounts (SNA) and included in a satellite account, while others have a long-standing structure that varies in the degree of compatibility with either the SHA or the SNA.

Following the publication of the SHA manual in May 2000, however, a number of countries have begun to develop or modify their health accounts to bring them into alignment with the SHA standards.

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OECD Member countries are currently at different stages in implementing the SHA manual.

As of the summer 2002, 18 had a major SHA study completed or under way, 6 had begun preparations for such a study, 3 were considering implementation but had not yet allocated resources, and 3 had no plans for implementation.

Several countries were reporting regularly using the SHA framework; more often, the SHA implementation was still at an experimental stage and results had not yet been published.

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The attraction of the SHA framework for many non-OECD countries has been that, for the first time, it offers a means to compare both the level and structure of their health care spending with other countries in the same region, something that had not hitherto been possible for those countries outside the OECD.

Early drafts of the SHA manual were available to national health accounts (NHA) experts in the Asia-Pacific regions, and one of the first NHA systems based on the ICHA classification system was developed in the Hong Kong Special Administrative Region (SAR) of China.

The Republic of Korea has replaced its previous health accounting framework with the SHA, and Australia and Japan have developed the capability to display their accounts in SHA format as well as in their existing national frameworks.

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Sri Lanka, in establishing its first official NHA system, chose to base it on the SHA, and its first estimates for the period 1990–1999 were released in 2001.

Since then, the Hong Kong SAR of China, Samoa and Thailand have all released SHA-based NHA estimates.

By 2003, several other countries were also in various stages of establishing NHA systems based on SHA, including Bangladesh, Indonesia, Malaysia, Mongolia and Nepal.

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At this time, Estonia had published health accounts on a SHA basis and others in that geographical area were in the midst of preparing such estimates.

In the Americas, Bolivia, Chile, Colombia, Costa Rica, Ecuador, Guatemala, Honduras, Nicaragua, Panama, Paraguay, Trinidad and Tobago, Uruguay and others had begun work on health accounts incorporating parts of the SHA framework.

In the Eastern Mediterranean region, Algeria, the Islamic Republic of Iran, Morocco and Tunisia were among those doing likewise.

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Instituting the health accounts project

The cost of a health accounts project First-year costs have been in the range of US$ 50,000 to US$

75,000 Timeline for setting up health accounts

In most countries useful NHA can be assembled in 12–18 months with a team of 3–6 analysts working part-time.

Housing the health accounts project The location may be a government department, such as the

ministry of health, finance, statistics, or planning. Or it may be a specialized agency of government, such as a

national health inspectorate, national health economics research institute or national health statistics agency, or national health care financing body.

In some countries, the NHA project has been housed outside the government in a university or nongovernmental research institute.

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Setting the boundary of the national health accounts

OECD has proposed a boundary more specifically focused on health care services in the system of health accounts (SHA) manual:

“Activities of health care in a country comprises the sum of activities performed either by institutions or individuals pursuing, through the application of medical, paramedical, and nursing knowledge and technology, the goals of: Promoting health and preventing disease; Curing illness and reducing premature mortality; Caring for persons affected by chronic illness who require

nursing care; Caring for persons with health-related impairment, disability,

and handicaps who require nursing care; Providing and administering public health; Providing and administering health programs, health insurance

and other funding arrangements.”

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There is no clear line that distinguishes those activities that are “in” the health accounts sphere from those that are “out”.

This ambiguity goes back to the notion that virtually all activity affects health in some way, and it is reflected in the unclear border between the health system and the social services system.

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Type of activity Likely to be Unlikely to be health-related

Water supply and hygiene Surveillance of drinking-water

quality; construction of water

protection whose primary

purpose is to eliminate water

borne disease

Construction and maintenance activities of large urban water supply systems whose primary purpose is access to water for the urban population

Nutritional support activities Nutritional counseling and

supplementary feeding

program to reduce children’s

malnutrition

General school lunch

supplementary feeding programs

and general subsidies for food

prices, whose primary purposes is

income support or security

Education and training Medical education and in-service

training for paramedical workers

Secondary school education

received by future physicians

Or health workers

Research Medical research; health services

research to improve program

performance

Basic scientific research in biology and chemistry

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Establishing aggregate measures of national health expenditure

In its SHA manual, OECD has proposed three measures of health spending for use in international comparisons: Total expenditure on personal health care. This is the sum of

expenditures classified under categories HC.1 to HC.5 and covers spending for goods and services directed at the care of specific individuals (as distinct from collective health or public health services).

Total current expenditure on health (TCHE). This measure is the sum of expenditures classified under categories HC.1 to HC.7. Thus, it includes the spending for personal health care defined above, plus spending for collective health services and for the operation of the system’s financing agents.

Total expenditure on health (THE). This aggregate includes TCHE plus capital formation by health care provider institutions (HC.R.1).

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Classifying entities in the health care system

Schemes from the ICHA (and from other sources) are introduced as ways to categorize the various actors in the health care system - financing agents, providers, financing sources, and beneficiaries - and the resources used to generate the goods and services provided.

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Classifying entities in the health care system

The categories in any classification scheme need to be mutually exclusive and exhaustive.

Mutual exclusivity means that each transaction (or other unit being analyzed) cannot go into more than one category.

Exhaustiveness means that each and every transaction can go into one category.

Together, they mean that each transaction goes into exactly one category.

These two characteristics of classification schemes are critical to the success of the health accounts. Schemes that are

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Classifying financing agents

The classification scheme for financing agents allows the accountant to categorize the institutions and entities that pay for or purchase health care.

Financing agents include institutions that pool health resources collected from different sources, as well as entities (such as households and firms) that pay directly for health care from their own resources.

Health accountants using the OECD system of health accounts (SHA) manual will note that this set of actors is called “sources of funding”.

The term “financing agent” emphasize the role of these actors as poolers and distributors of money; “financing sources” (described below) is a term used for the entities that provide money to financing agents to be pooled and distributed.

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National health accounts tables

NHA tables serve two purposes. One is to display estimates of national health expenditure in ways that resonate with decision-makers.

The tables described here - and others similar to them - can be linked to fundamental policy questions such as: How are resources for health and health care mobilized? Who

pays the money out, who provides the money to be paid, and how?

How are those resources organized and managed? What goods and services are provided and by whom? Who uses those goods and services?

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The structure of national health accounts tables

The dimensions of health expenditure they portray include: Financing sources: institutions or entities that provide the funds used

in the system by financing agents; Financing agents: institutions or entities that channel the funds

provided by financing sources and use those funds to pay for, or purchase, the activities inside the health accounts boundary;

Providers: entities that receive money in exchange for or in anticipation of producing the activities inside the health accounts boundary;

Functions: the types of goods and services provided and activities performed within the health accounts boundary;

Resource costs: the factors or inputs used by providers or financing agents to produce the goods and services consumed or the activities conducted in the system;

Beneficiaries: the people who receive those health goods and services or benefit from those activities (beneficiaries can be categorized in many different ways, including their age and sex, their socioeconomic status, their health status, and their location)

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Structure of a typical table in the set of tables comprising the national health accounts

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Structure of a typical table in the set of tables comprising the national health accounts

Experience in countries where health accounts have been created indicates that three of the dimensions listed are critical for accurate estimation of total health spending.

These are the dimensions of financing agents, providers, and functions. Consequently, the NHA tables that cross-tabulate these dimensions are

important tools in the creation of the aggregate totals or subtotals displayed in all of the tables discussed in this chapter. Health expenditure by type of financing agent and type of provider (FAxP); Health expenditure by type of provider and type of function (PxF); Health expenditure by type of financing agent and type of function (FAxF); Health expenditure by financing source and type of financing agent (FSxFA); Cost of resources used to produce health goods and services; Health expenditure by age and sex of the population; Health expenditure by socioeconomic status of the population; Health expenditure by health status of the population; Health expenditure by geographic region.

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National health expenditure by type of financing agent and type of provider (FAxP)

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National health expenditure by type of provider and by function (PxF)

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National health expenditure by type of financing agent and by function (FAxF)

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National health expenditure by type of financing source and type of financing agent (FSxFA)

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Personal health expenditure by type of financing agent and by age and sex of the population

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National health expenditure by type of financing agent and by per capita household expenditure quintile

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National health expenditure by type of financing agent and by disease group

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National health expenditure by type of financing agent and by region

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Data and national health accounts

Once the framework for a country’s health accounts has been established, the next task is to assemble a database with which to estimate the parts of that framework.

A solid understanding of the characteristics and dependability of the underlying data is fundamental to the development of high-quality national health expenditure figures, and a considerable amount of time should be spent searching for, evaluating, and comparing sources of data to find those that best capture the transactions and flows of resources that occur in the health system.

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Creating a data plan

Three aspects of each data source should be considered when assembling the data used to build a country’s health accounts: The origin of the data, The reason for data collection, and The level of detail of the data.

Each of these has implications for likely data quality, appropriateness and sufficiency.

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The origin of the data has implications for their usefulness in NHA.

These characterizations are very general, so each data set should be evaluated on a case-by-case basis and re-evaluated periodically.

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The second attribute of a data source is the reason for which the data were collected.

The motivation has important implications not only for accuracy, but also for bias.

As with characterization by data origin, the strengths and weaknesses attributed to these categories of data are general and each data source must be evaluated on a case-by-case basis.

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Not only are data captured at different points in the flow of funds from source to final use, they also are kept at different levels of detail (granularity).

This aspect of the data is important because of its implications for data storage and for the volume of data to be analyzed: there are far more people to keep track of than there are providers, and even more events than there are people.

For example, in the United States Medicare insurance system, 485,000 physicians treated 28,700,000 people in 1999, providing 850,000,000 covered services.

In this case, maintaining records at the event level requires about 2000 times as much storage as keeping data at the provider level.

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What data are needed?

Government entities can fill any of the roles in the health accounting framework. They can be a source of funds, a financing agent, or a provider of care.

Often, an entity can fill more than one role at a time. Therefore, the data need to capture where government entities get their money from, to whom they give it, and whether they provide funding, reimbursement, or actual services (or some combination).

If the entity does more than simply fund other entities, then the data also need to capture the types of goods or services for which expenditures were made and the beneficiary populations for whom the expenditures were made.

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Employers also can fill any of the roles in the framework. They may pay taxes to social security funds and premiums to social insurance funds, they may reimburse employees for household spending, or they may provide services directly to employees and their dependants.

In a number of middle-income and low-income countries, employers also fund non-profit institutions.

The health accounts data need to capture the different types of outlays employers make, and what those outlays were for.

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Households pay taxes and insurance premiums, and also make out-of-pocket payments for medical services.

They may also receive money in the form of reimbursement for outlays they have made, and the data sources must be able to capture these flows of money as well.

To examine the distribution of spending among various subsets of the population, something will need to be known about the household — its income, for example, or its total spending on all goods and services during the year.

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Nongovernmental organizations and external organizations can be financing sources, financing agents, or providers of care.

As with government entities, it is important to know where their funds come from, to whom funds are given, and the types of goods and services provided or purchased on behalf of consumers.

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Insurance companies and insurance funds typically serve as financing agents, but in some countries they also operate their own facilities.

As with other actors, it is important to know where these insurers get their funds from, and how and to whom those funds are disbursed.

The nature of the insurance has to be understood –– is it government social security, private social insurance, or voluntary medical insurance purchased individually?

It is also important to know about the operations of the insurers: how much is spent on administration and how much is retained as surplus.

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For providers of care, it is important to know what kinds of services or goods they produce and who pays them to produce those services or goods.

Data that show to whom the services were provided and what was used to produce them tend to be rare, and health accountants who have access to such data are fortunate.

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For consumers of goods and services, information is needed about the social, demographic, economic, and health characteristics of beneficiaries of spending.

Knowledge of the level of spending by the beneficiary unit and of the types of insurance coverage available to it also matters greatly for good health accounts.

The frequency with which such data are produced will play a large role in the decision about how often to produce the tables showing the distribution of spending among these populations.

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Assessing the quality of a data source

The health accountant’s work involves more than simply gathering data, just as the profession of the entomologist is more than just catching bugs.

Like the entomologist, the health accountant pursues elusive and fragile subjects.

And like the entomologist, the health accountant must catalogue what has been captured, examine their characteristics, compare them with other known species, and eventually decide whether or not they are valuable additions to the collection.

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Assessing the quality of a data source

Deciding whether to use a data source is critical to the success of a NHA exercise.

Accuracy and comprehensiveness in health accounts are not simply a function of the quantity of data available in a country.

The most substantial contribution to error in published estimates is not the lack of data, but the uncritical use of available data, or the failure to consider all available sources.

Conversely, the most substantial contribution to high quality estimates is an understanding of which data to use, when to use them, how much to rely upon them, and how to adjust them.

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Quality of survey data

Survey data play a critical role in the estimation of national health expenditure.

Typically, they are the major source of information about household spending on health care (and may also provide significant amounts of information about other dimensions of the health accounts, such as provider and financing agent activities or disease prevalence).

Given the importance of the household sector, it is important to enter into use of survey data prudently, because misinterpretation of such data is probably the single most important cause of error in NHA.

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Quality of survey data

Roughly speaking, the quality of a survey as a data source is tied to three attributes. These attributes are Sampling error, Non-sampling error, and Sample frame bias.

Evaluation of a survey’s quality for health accounting purposes involves consideration of its survey design and possibly examination of specific subsets of data for purposes of data verification.

Thus, it is important to have access to the design and instruments used, as well as to the data sets themselves.

A survey whose instrument and design are not available for examination is greatly reduced in value unless some evaluation of its reliability can be made.

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Quality of non-survey data

Non-survey data come from a wide variety of sources.

Government budget data, government special reports (“white papers”), insurers’ administrative data, trade association annual reports, academic research, business case studies, are all examples of this type of information.

So too are qualitative research documents, focus group results, data from convenience samples and opportunistic data.

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Quality of non-survey data

As different as they all are, there is a common set of questions that can be asked to assess the quality of these sources for a country’s health accounts. How complete is the base upon which the source is

built? Does the data source or sponsor have an agenda to

push? How were the data assembled? How homogeneous are the entities about which the

source provides information?

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How complete is the base upon which the source is built?

Government budget data, at one extreme, probably capture all money appropriated for use by the government entity.

At the other extreme, anecdotal evidence may consist of an interview with a single respondent.

Clearly, the wider the net is cast the more likely it is to bring in a good representation of what is in the sea.

Unfortunately, there can be no rules of thumb to deem a source to be inclusive enough: practice and experience –– and the advice of others –– will lead to an intuitive “feel” for that aspect of data quality.

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Does the data source or sponsor have an agenda to push?

Very often, data are assembled or created to advance a particular argument or agenda.

It does not require that the sponsor or compiler of the data be deliberately deceptive in order for the data to be of poor quality; it is enough that compilers stop looking once they have found a piece of evidence to support their position.

Data that conveniently buttress one position or another in a political debate are not necessarily wrong, but their provenance and assembly should be studied very carefully before they are added to the stock of raw material from which the health accounts are built.

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How were the data assembled?

Was the collection process a rigorous one, or did the compilers accept all entries without question?

Did they actively look for pieces of data, or simply sweep up what was close at hand?

Is there evidence of an attempt to review the results critically, or simply to document and release the information?

Once again, there are no rules of thumb for assessing this aspect of a data source’s quality: personal experience and the advice of colleagues are the only guides.

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How homogeneous are the entities about which the source provides information?

This is somewhat akin to the confidence interval concept for survey data.

If there is reason to believe that all the entities in the universe resemble one another closely, then the rigor of the data collection process becomes less important.

Unfortunately, there is often no way to assess the homogeneity of the universe without some type of analysis, in which case the non-survey data would not be needed!

However, enough anecdotes and indirect evidence from other sources can help to develop a partial picture of the subject universe sufficient to make a tentative guess about its homogeneity.

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Choosing among alternative data sources

Congruence with boundaries and classification schemes. Which data source is better aligned with the definition of health care and with

the classification schedules being used to distinguish among flows of money? Do the labels used by the data sources capture the true nature of the activities or transactions recorded?

Congruence with time period. Which data source more closely fits the time period covered by the health

accounts? For example, is one source several years old? Or does one report fiscal year figures and the other calendar year figures? Does one source measure budgeted amounts and another measure actual expenditures?

Congruence with content. Which data source more closely conforms to the concepts being measured in

the accounts? For example, does one source measure stocks and another measure flows?

Congruence with monetary measure. Does one measure inflation-adjusted expenditures and the other nominal

expenditures? Congruence with geopolitical borders.

Do the various data sources cover the entire nation completely and without overlap?

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Thank You !

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Dr. Shahram Yazdani National Health Account. Dr. Shahram Yazdani Definition National health accounts...

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