National Health Accounts Research Articles

Tracking total spending on tuberculosis by source and function in 135 low-income and middle-income countries, 2000–17: a financial modelling study

SummaryBackgroundEstimates of government spending and development assistance for tuberculosis exist, but less is known about out-of-pocket and prepaid private spending. We aimed to provide comprehensive estimates of total spending on tuberculosis in low-income and middle-income countries for 2000–17.MethodsWe extracted data on tuberculosis spending, unit costs, and health-care use from the WHO global tuberculosis database, Global Fund proposals and reports, National Health Accounts, the WHO-Choosing Interventions that are Cost-Effective project database, and the Institute for Health Metrics and Evaluation Development Assistance for Health Database. We extracted data from at least one of these sources for all 135 low-income and middle-income countries using the World Bank 2019 definitions. We estimated tuberculosis spending by source and function for notified (officially reported) and non-notified tuberculosis cases separately and combined, using spatiotemporal Gaussian process regression to fill in for missing data and estimate uncertainty. We aggregated estimates of government, out-of-pocket, prepaid private, and development assistance spending on tuberculosis to estimate total spending in 2019 US$.FindingsTotal spending on tuberculosis in 135 low-income and middle-income countries increased annually by 3·9% (95% CI 3·0 to 4·6), from $5·7 billion (5·2 to 6·5) in 2000 to $10·9 billion (10·3 to 11·8) in 2017. Government spending increased annually by 5·1% (4·4 to 5·7) between 2000 and 2017, and reached $6·9 billion (6·5 to 7·5) or 63·5% (59·2 to 66·8) of all tuberculosis spending in 2017. Of government spending, $5·8 billion (5·6 to 6·1) was spent on notified cases. Out-of-pocket spending decreased annually by 0·8% (−2·9 to 1·3), from $2·4 billion (1·9 to 3·1) in 2000 to $2·1 billion (1·6 to 2·7) in 2017. Development assistance for country-specific spending on tuberculosis increased from $54·6 million in 2000 to $1·1 billion in 2017. Administrative costs and development assistance for global projects related to tuberculosis care increased from $85·3 million in 2000 to $576·2 million in 2017. 30 high tuberculosis burden countries of low and middle income accounted for 73·7% (71·8–75·8) of tuberculosis spending in 2017.InterpretationDespite substantial increases since 2000, funding for tuberculosis is still far short of global financing targets and out-of-pocket spending remains high in resource-constrained countries, posing a barrier to patient's access to care and treatment adherence. Of the 30 countries with a high-burden of tuberculosis, just over half were primarily funded by government, while others, especially lower-middle-income and low-income countries, were still primarily dependent on development assistance for tuberculosis or out-of-pocket health spending.FundingBill & Melinda Gates Foundation.

Equity of health-care financing: a progressivity analysis for Egypt

Purpose This paper aims to evaluate the progressivity of health-care financing in Egypt by assessing all five financing sources individually and then combining them to analyze the equity of the whole financing system. Design/methodology/approach Lorenz dominance analysis and Kakwani progressivity index were applied on data from 2010/2011 Household Income, Expenditure, and Consumption Survey and the National Health Accounts 2011 using Stata to evaluate the progressivity of each source of health-care finance and the financing system overall. Findings The data show that Egypt’s health-care system, which is largely financed by out-of-pocket (OOP) payments, is slightly regressive, with an overall Kakwani index of −0.079. The overall regressive effect was the result of three regressive sources (OOP payments, an earmarked cigarette tax and direct taxes), one proportional finance source (social health insurance) and two slightly progressive sources (indirect taxes and private health insurance). This shows that the burden of financing health care falls more on the poor. These results signal the need for reform of health-care financing in Egypt to reduce dependence on OOP payments to achieve more equitable financing. Originality/value The paper seeks to augment the literature on health-care financing in Egypt by calculating specific progressivity estimates for all five sources of financing the Egyptian health-care system and analyzing the overall equity of this financing system. It will, therefore, provide a benchmark for monitoring the equity of finance in the Egyptian health-care system in future studies and allow one to assess the impact of implemented financing reforms in the future on the level of progressivity of health system financing.

The differential impact of economic recessions on health systems in middle-income settings: a comparative case study of unequal states in Brazil

IntroductionAlthough economic crises are common in low/middle-income countries (LMICs), the evidence of their impact on health systems is still scant. We conducted a comparative case study of Maranhão and São...

Inequality in dental expenditures among Iranian households: A cross-sectional survey using the National Health Accounts

Recently, inequality in dental care has become increasingly popular in both developed and developing countries as a matter of health policy. Thus, the aims of this study were examining inequality in dental care expenditures and assessing the effects of insurance coverage and other variables on these services. In this cross-sectional and descriptive-analytical study, we used secondary data of the National Health Accounts that has been conducted in 2008 in Iran. The sample size was 17,239 households in all over the country. All analyses were performed by Stata software using Mann-Whitney test and logistic regression. P < 0.05 was considered statistically significant. To determine inequality in dental services, the concentration index (CI) was used. CI for total dental expenditures was 0.315 and for orthodontics was 0.6. Findings showed that out-of-pocket expenditure for dental care was progressive and there was a significant relationship between total dental expenditure with residence areas (odds ratio [OR] =1.3; P > 0.001), complementary insurance coverage (OR = 1.3; P > 0.001), family size (OR = 1.46; P > 0.001), and income (OR = 1.3; P > 0.001). Dental expenditures were progressive in Iran, and the rich have paid more share for these services. It seems that implementing insurance programs, changes in the financing of dental care, development of insurance basic benefits package, supporting programs for the poor, adopting educational policies, and promoting oral health for vulnerable people can have an effective role in decreasing inequality in using dental services.

Pattern of Healthcare Expenditure in India

The objective of the paper is to analyze accessing the healthcare system for the poor in India and the pattern of healthcare expenditure on health sector in India. The analysis reveals that levels of public spending on healthcare in India are amongst the lowest in the world. It can be suggested relevant measures to improve the role of government in providing world-class health facilities to the needy at an affordable price including health insurance schemes and increased budgetary allocation at both national and state government levels. The government hospital has some problems like poor physical or healthcare facilities, ineffective leadership and medical supplies faculty of staffing procedure. The aforesaid problems do not exist in private hospitals. Therefore, the present study carried out to assess the healthcare expenditure of government and private hospitals in India. Finally, the study suggests that an initiative along the role of government is requested to secure the health demands of poor as health care costs are growing over time. The study is based on secondary data collected from Economic Survey, National Health Accounts, RBI Database, World Bank Database, Ministry of Health and Family Welfare. The pattern and trend in time series data are conducted using growth rates, line graphs, least-square methods and macroeconomic linkages with GDP are analyzed by using coefficient of Correlation, Granger Causality test, vector autoregression(VAR), Dicky fuller Test (Stationarity), Mean difference test(t-test) and Descriptive Statics. Therefore, in light of the above, this paper looks at the pattern of health expenditure on health sector in India through a legal perspective.

Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy.

Cambodia’s healthcare system has seen significant improvements in the last two decades. Despite this, access to quality care remains problematic, particularly for poor rural Cambodians. The government has committed to universal health coverage (UHC) and is reforming the health financing system to align with this goal. The extent to which the reforms have impacted the poor is not always clear. Using a system-wide approach, this study assesses how benefits from healthcare spending are distributed across socioeconomic groups in Cambodia. Benefit incidence analysis was employed to assess the distribution of benefits from health spending. Primary data on the use of health services and the costs associated with it were collected through a nationally representative cross-sectional survey of 5000 households. Secondary data from the 2012–14 Cambodia National Health Accounts and other official documents were used to estimate the unit costs of services. The results indicate that benefits from health spending at the primary care level in the public sector are distributed in favour of the poor, with about 32% of health centre benefits going to the poorest population quintile. Public hospital outpatient benefits are quite evenly distributed across all wealth quintiles, although the concentration index of −0.058 suggests a moderately pro-poor distribution. Benefits for public hospital inpatient care are substantially pro-poor. The private sector was significantly skewed towards the richest quintile. Relative to health need, the distribution of total benefits in the public sector is pro-poor while the private sector is relatively pro-rich. Looking across the entire health system, health financing in Cambodia appears to benefit the poor more than the rich but a significant proportion of spending remains in the private sector which is largely pro-rich. There is the need for some government regulation of the private sector if Cambodia is to achieve its UHC goals.

EFFICIENCY, EQUITY, AND EFFECTIVENESS OF MALARIA FUNDING IN UGANDA: MAKING THE CASE FOR REFORMING PUBLIC FINANCING FOR HEALTH

Decreasing external funding for malaria requires high burden countries such as Uganda to increase domestic public financing to control and eliminate malaria. The aim of this study was to examine how the Government of Uganda, in collaboration with development partners and private sources of funding, has directed public resources in the recent past to help address the malaria burden. Data search and collection included national, regional and global reports and global data-bases. Government reports including National Development Plans, national health accounts (NHAs), national demographic health surveys, and other reports such as the Uganda Medicines Price Monitor, were included in the review. The findings indicate that government funding for malaria is limited (10% of total budget for malaria programming). Households (67%) are the main source of funds which makes malaria control in Uganda unsustainable. Public allocations are also inefficient with only 30% of funds allocated for preventive services contrary to global and national malaria control priorities. Evidence of inequity in the implementation of malaria programming are closely linked to poverty and ownership of preventive materials such as ITNs. Poor regions also report high malaria case incidence. Unavailability of anti-malarials is reported in lower level facilities serving mainly the poor. Overall progress in improving key malaria indicators is poor. There is also no correlation between expenditure on malaria and availability of ITNs (R 2 =0.6631). In conclusion, public financing for primary services such as malaria require reforms to strengthen health sector performance in terms of sustainability, efficiency, effectiveness and equity.

Reaching Universal Health Coverage by 2035: Is Cameroon on Track?

Access to health care is a fundamental human right, which places a legal obligation on states to ensure access to quality, timely, acceptable, and affordable health care for its citizens. However, many states struggle to meet this basic right for their citizens given that every year about 100 million people are pushed into poverty, while 150 million people suffer financial catastrophe due to out of pocket payments for health. In Cameroon, studies have shown that about 64% of households cannot access healthcare, because they perceive the cost of care to be high. In 2012, the National Health Accounts (NHA) estimated that about 70% of the Total Health Expenditure (THE) for the country was borne by households. Compared to its peers, the contribution of Cameroonian households is the third highest in Sub-Saharan Africa, where the average is 34%. To remedy this situation, Cameroon has initiated reflections aimed at establishing a universal health coverage (UHC) scheme for its population. This paper therefore aimed at providing a synthesis of Cameroon's progress and assessing if the country is on track to achieving UHC by 2035.

Tracking spending on malaria by source in 106 countries, 2000–16: an economic modelling study

SummaryBackgroundSustaining achievements in malaria control and making progress toward malaria elimination requires coordinated funding. We estimated domestic malaria spending by source in 106 countries that were malaria-endemic in 2000–16 or became malaria-free after 2000.MethodsWe collected 36 038 datapoints reporting government, out-of-pocket (OOP), and prepaid private malaria spending, as well as malaria treatment-seeking, costs of patient care, and drug prices. We estimated government spending on patient care for malaria, which was added to government spending by national malaria control programmes. For OOP malaria spending, we used data reported in National Health Accounts and estimated OOP spending on treatment. Spatiotemporal Gaussian process regression was used to ensure estimates were complete and comparable across time and to generate uncertainty.FindingsIn 2016, US$4·3 billion (95% uncertainty interval [UI] 4·2–4·4) was spent on malaria worldwide, an 8·5% (95% UI 8·1–8·9) per year increase over spending in 2000. Since 2000, OOP spending increased 3·8% (3·3–4·2) per year, amounting to $556 million (487–634) or 13·0% (11·6–14·5) of all malaria spending in 2016. Governments spent $1·2 billion (1·1–1·3) or 28·2% (27·1–29·3) of all malaria spending in 2016, increasing 4·0% annually since 2000. The source of malaria spending varied depending on whether countries were in the malaria control or elimination stage.InterpretationTracking global malaria spending provides insight into how far the world is from reaching the malaria funding target of $6·6 billion annually by 2020. Because most countries with a high burden of malaria are low income or lower-middle income, mobilising additional government resources for malaria might be challenging.FundingThe Bill & Melinda Gates Foundation.

The cost of implementing Vietnam's national plan of action for nutrition for 2017-2020.

BackgroundThere is an urgent need to carry out a costing exercise of the National Plan of Action for Nutrition (NPAN) 2017–2020 since the costing of nutrition-sensitive interventions was not entirely integrated and proved difficult to track the different sectors' contributions to the nutrition program.ObjectiveTo estimate the required budget for the activities of the NPAN in 2017–2020.MethodsA standard ingredients approach activity-based costing was employed from the provider perspective.ResultsThe budget amount required for the NPAN activities in 2017, 2018, 2019 and 2020 would be US$ million 269.0; 310.5; 350.2 and 378.1, respectively. State budgets (especially from Ministry of Health) would be the main funding source for the NPAN. The budget required for implementing nutrition-sensitive interventions would be the largest share (more than 90%) while less than 10% are required for nutrition-specific interventions. The four interventions requiring the largest budget proportion (in 2020) included 1) Micronutrient supplementation (28.3%); 2) Breastfeeding & complementary feeding (21.9%); 3) Treatment of severe acute malnutrition (15.6%); and 4) Disease prevention and management (13.4%).ConclusionsBased on the data from Vietnam National Health account and the data on GDP of Vietnam, the total required budget for the Vietnam NPAN 2017 (USD millions 5,082) as shares of the State budget for health, total State (Government) budget, and GDP would be 5.29%, 0.49% and 0.14%, respectively. From the estimation, Vietnam represents the nutrition strategy which prioritized on nutrition-sensitive actions, similar to most of the SUN Movement member countries.

Funding and services needed to achieve universal health coverage: applications of global, regional, and national estimates of utilisation of outpatient visits and inpatient admissions from 1990 to 2016, and unit costs from 1995 to 2016

SummaryBackgroundTo inform plans to achieve universal health coverage (UHC), we estimated utilisation and unit cost of outpatient visits and inpatient admissions, did a decomposition analysis of utilisation, and estimated additional services and funds needed to meet a UHC standard for utilisation.MethodsWe collated 1175 country-years of outpatient data on utilisation from 130 countries and 2068 country-years of inpatient data from 128 countries. We did meta-regression analyses of annual visits and admissions per capita by sex, age, location, and year with DisMod-MR, a Bayesian meta-regression tool. We decomposed changes in total number of services from 1990 to 2016. We used data from 795 National Health Accounts to estimate shares of outpatient and inpatient services in total health expenditure by location and year and estimated unit costs as expenditure divided by utilisation. We identified standards of utilisation per disability-adjusted life-year and estimated additional services and funds needed.FindingsIn 2016, the global age-standardised outpatient utilisation rate was 5·42 visits (95% uncertainty interval [UI] 4·88–5·99) per capita and the inpatient utilisation rate was 0·10 admissions (0·09–0·11) per capita. Globally, 39·35 billion (95% UI 35·38–43·58) visits and 0·71 billion (0·65–0·77) admissions were provided in 2016. Of the 58·65% increase in visits since 1990, population growth accounted for 42·95%, population ageing for 8·09%, and higher utilisation rates for 7·63%; results for the 67·96% increase in admissions were 44·33% from population growth, 9·99% from population ageing, and 13·55% from increases in utilisation rates. 2016 unit cost estimates (in 2017 international dollars [I$]) ranged from I$2 to I$478 for visits and from I$87 to I$22 543 for admissions. The annual cost of 8·20 billion (6·24–9·95) additional visits and 0·28 billion (0·25–0·30) admissions in low-income and lower-middle income countries in 2016 was I$503·12 billion (404·35–605·98) or US$158·10 billion (126·58–189·67).InterpretationUHC plans can be based on utilisation and unit costs of current health systems and guided by standards of utilisation of outpatient visits and inpatient admissions that achieve the highest coverage of personal health services at the lowest cost.FundingBill & Melinda Gates Foundation.

Enabling reproductive, maternal, neonatal and child health interventions: Time trends and driving factors of health expenditure in the successful story of Peru.

We compared expenditure trends for reproductive, maternal, neonatal and child health (RMNCH) with trends in RMNCH service coverage in Peru. We used National Health Accounts data to report on total health expenditure by source; the Countdown database for trends in external funding to RMNCH, and Ministry of Finance data for trends in domestic funding to RMNCH. We undertook over 170 interviews and group discussions to explore factors explaining expenditure trends. We describe trends in total health expenditure and RMNCH expenditure in constant 2012 US$ between 1995 and 2012. We estimated expenditure to coverage ratios. There was a substantial increase in domestic health expenditure over the period. However, domestic health expenditure as share of total government spending and GDP remained stable. Out-of-pocket health spending (OOPS) as a share of total health expenditure remained above 35%, and increased in real terms. Expenditure on reproductive health per woman of reproductive age varied from US$ 1.0 in 2002 to US$ 6.3 in 2012. Expenditure on maternal and neonatal health per pregnant woman increased from US$ 34 in 2000 to US$ 512 in 2012, and per capita expenditure on under-five children increased from US$ 5.6 in 2000 to US$ 148.6 in 2012. Increased expenditure on RMNCH reflects a greater political support for RMNCH, along with greater emphasis on social assistance, family planning, and health reforms targeting poor areas, and a recent emphasis on antipoverty and crosscutting equitable policies and programmes focused on nutrition and maternal and neonatal mortality. Increasing domestic RMNCH expenditure likely enabled Peru to achieve substantial health gains. Peru can provide useful lessons to other countries struggling to achieve sustained gains in RMNCH by relying on their own health financing.

Cold War Legacy in Public and Private Health Spending in Europe.

Cold War Era (1946–1991) was marked by the presence of two distinctively different economic systems, namely the free-market (The Western ones) and central-planned (The Eastern ones) economies. The main goal of this study refers to the exploration of development pathways of Public and Private Health Expenditure in all of the countries of the European WHO Region. Based on the availability of fully comparable data from the National Health Accounts system, we adopted the 1995–2014 time horizon. All countries were divided into two groups: those defined in 1989 as free market economies and those defined as centrally-planned economies. We observed six major health expenditures: Total Health Expenditure (% of GDP), Total Health Expenditure (PPP unit), General government expenditure on health (PPP), Private expenditure on health (PPP), Social security funds (PPP) and Out-of-pocket expenditure (PPP). All of the numerical values used refer exclusively to per capita health spending. In a time-window from the middle of the 1990s towards recent years, total health expenditure was rising fast in both groups of countries. Expenditure on health % of GDP in both group of countries increased over time with the increase in the Free-market economies seen to be more rapid. The steeper level of total expenditure on health for the Free-market as of 1989 market economies, is due mainly to a steep increase in both the government and private expenditure on health relative to spending by centrally-planned economies as of the same date, with the out-of-pocket expenditure and the social security funds in the same market economies category following the same steepness. Variety of governments were leading Eastern European countries into their transitional health care reforms. We may confirm clear presence of obvious divergent upward trends in total governmental and private health expenditures between these two groups of countries over the past two decades. The degree of challenge to the fiscal sustainability of these health systems will have to be judged for each single nation, in line with its own local circumstances and perspectives.

How much does the treatment of each major disease cost? A decomposition of Swiss National Health Accounts

In most countries, surprisingly little is known on how national healthcare spending is distributed across diseases. Single-disease cost-of-illness studies cover only a few of the diseases affecting a population and in some cases lead to untenably large estimates. The objective of this study was to decompose healthcare spending in 2011, according to Swiss National Health Accounts, into 21 collectively exhaustive and mutually exclusive major disease categories. Diseases were classified following the Global Burden of Disease Study. We first assigned the expenditures directly mapping from National Health Accounts to the 21 diseases. The remaining expenditures were assigned based on diagnostic codes and clues contained in a variety of microdata sources. Expenditures were dominated by non-communicable diseases with a share of 79.4%. Cardiovascular diseases stood out with 15.6% of total spending, followed by musculoskeletal disorders (13.4%), and mental and substance use disorders (10.6%). Neoplasms (6.0% of the total) ranked only sixth, although they are the leading cause of premature death in Switzerland. These results may be useful for the design of health policies, as they illustrate how healthcare spending is influenced by the epidemiological transition and increasing life expectancy. They also provide a plausibility check for single cost-of-illness studies. Our study may serve as a starting point for further research on the drivers of the constant growth of healthcare spending.

National Health Accounts: A Framework For Understanding Health Care Financing.

Over the course of the past century, the challenges facing the United States in its consumption of health care goods and services have not changed very much. What is being consumed, who is paying for it, and how much is affordable are questions that arise in every cycle of the debate-if they ever go dormant. National Health Accounts are one tool to use in the search for answers to these questions and to the challenges behind the questions. The accounts cannot (and do not pretend to) address every aspect of the debate, but they provide an important context. In this article I briefly review the history of the health accounts and discuss their strengths and weaknesses in the context of the present debate over spending.

The financing gaps framework: using need, potential spending and expected spending to allocate development assistance for health.

As growth in development assistance for health levels off, development assistance partners must make allocation decisions within tighter budget constraints. Furthermore, with the advent of comprehensive and comparable burden of disease and health financing estimates, empirical evidence can increasingly be used to direct funding to those most in need. In our ‘financing gaps framework’, we propose a new approach for harnessing information to make decisions about health aid. The framework was designed to be forward-looking, goal-oriented, versatile and customizable to a range of organizational contexts and health aims. Our framework brings together expected health spending, potential health spending and spending need, to orient financing decisions around international health targets. As an example of how the framework could be applied, we develop a case study, focused on global goals for child health. The case study harnesses data from the Global Burden of Disease 2013 Study, Financing Global Health 2015, the WHO Global Health Observatory and National Health Accounts. Funding flows are tied to progress toward the Sustainable Development Goal’s target for reductions in under-five mortality. The flexibility and comprehensiveness of our framework makes it adaptable for use by a diverse set of governments, donors, policymakers and other stakeholders. The framework can be adapted to short‐ or long‐run time frames, cross‐country or subnational scales, and to a number of specific health focus areas. Depending on donor preferences, the framework can be deployed to incentivize local investments in health, ensuring the long-term sustainability of health systems in low- and middle-income countries, while also furnishing international support for progress toward global health goals.

Analiza izvora finansiranja zdravstvenih sistema zemalja u sastavu bivše Jugoslavije

Objective. The aim of this study was to analyse health expenditure between 2011 and 2015 in the chosen countries by using National Health Account indicators, and comparing financial health indicators between these countries. The study explains the structure of health systems in the countries and their sources of funding by using System of Health Accounts methodology. Methods. A retrospective analysis of health financing indicators in Bosnia and Herzegovina, Montenegro, Macedonia, Slovenia, Serbia and Croatia has been carried out. The World Health Organization's Global Health Expenditure database and the Health for All database were used for the analysis, in accordance with the methodology of the System of Health Accounts SHA 2011 - Organization for Economic, Cooperation and Development, System of Health Account, Version SHA 2011. Results. The obtained results showed that Bosnia and Herzegovina and Serbia had the same level of current health expenditure of 9.4% of GDP on average, in the period 2010- 2015, while in Montenegro and Macedonia this share was significantly lower (6% and 6.1% of GDP). Bosnia and Herzegovina, Montenegro and Serbia recorded similar levels of per capita current health expenditure, while Macedonia had the lowest expenditure, and the highest was in Slovenia. Public sector health expenditure as a share of GDP was the highest in Bosnia and Herzegovina (6.7%), and the lowest in Montenegro. Private consumption is predominantly based on pocket consumption and the highest out-of-pocket expenditure as a share of GDP is in Serbia (3.9%), Bosnia and Herzegovina (2.8%) and the lowest is in Slovenia and Croatia (1.1%). Bosnia and Herzegovina and Montenegro had similar levels of out-ofpocket expenditure per capita, which range in value of 315 and 305 PPPs on average for the six observed years. The reasons for the differences in the results of public expenditure in the observed countries and the reasons that can lead to unsustainable health systems have been explained. Conclusion. The obtained results will help to better understand the structure of health care financing systems in Bosnia and Herzegovina, Montenegro and neighbouring countries, and the need to develop the National Health Account for better monitoring and comparison of the health expenditure and health systems between the countries.

Health accounts from past to present for a political arithmetic.

ABSTRACTThis report traces the progressive expansion of health accounts (HA) to measure national health expenditures, from the first attempts in 1926 by the American Medical Association to the present day. Milestones in the development of A System of Health Accounts (SHA) are covered, from the economic background to initial efforts by a few countries and organizations, to the need for a set of accounting standards for health care systems, and finally, to consolidation with SHA 2011. International organizations, such as the World Health Organization, Organization for Economic Cooperation and Development, Eurostat, the World Bank, and the United States Agency for International Development have been critical to expanding national HA exercises and ensuring that these are standardized, comparable, and become institutionalized.National efforts to track health expenditures have not only enriched collective results, but have become an important component of global leadership, informing policy the world over. More than 100 countries have created HA under the global standard and have gained a better understanding of health spending and financial flows. These results are key for monitoring progress toward national and global initiatives, such as the Sustainable Development Goals and Universal Health Coverage. Challenges remain to be tackled, among them institutionalization and quality of results. Social responsibility for improving data sources and expanding the generation and usability of health accounts are also needed.

Finansijska održivost u zdravstvenom sistemu

The main goal of each country's health policy is to achieve financial sustainability of the health system itself, as well as to provide greater accessibility to health services for the whole population. In achieving this goal, the countries of the European Union have also established in their health systems the National Health Accounts (NZR), which provide information on financial flows in health care at the national level and allow for international comparisons.

Crowding out of Government Health Spending: Evidence from Bangladesh

While public spending on health in developing countries has increasingly come from domestic sources, existing studies show that government spending has been crowded out by foreign aid in the health sector. However, current research has mostly focused on cross-country studies. Cross-country studies present results that cannot be generalized to an individual country. Some countries may not experience a displacement of government health spending when there is an inflow of aid, while others may respond to health assistance by reducing their own spending in health. It may be worthwhile to look at country-specific cases in order to investigate whether health assistance over time crowds out purely government expenditure in health. To that end, this paper studies the displacement effect of foreign aid in Bangladesh. We specifically assess if government health spending in Bangladesh has been crowded out by health aid channeled to the government during the period 1995-2008. We identify pure government health expenditure net of aid (GHES) and health aid disbursed to governments (DAHG) and evaluate if GHES is affected by changes in DAHG. We use data from National Health Accounts (NHA) of the World Health Organization (WHO) and from the Institute for Health Metrics and Evaluation (IHME). We utilize Ordinary Least Squares (OLS), Generalized Method of Moments (GMM) and the Three-Stage Least Squares method (3SLS) to measure the crowding-out effect of aid in Bangladesh. We further address the causal relationship between domestic health spending, health aid and gross domestic product in the framework of the simultaneous equations model. We find that a one percent increase in health aid displaces Bangladesh's government health spending by at least 0.15 percent and at most 0.30 percent according to our 3SLS estimates. Our OLS and GMM estimates suggest that that aid inflows into the public health sector causes government health spending to fall between 0.14 and 0.23 percent. The government appears to reduce its own spending in response to aid inflows in the public health sector. Past spending in the health sector does not determine current health spending – the government policy is that of maintaining a steady expenditure. Our findings suggest that health-related projects are highly substitutable against donor aid. It may be easier to cut spending in health and reallocate the money to other priority sectors. There is a possibility that such displacement along with volatility in donor funding may have negative effects on the allocation of resources. To reduce this crowding-out effect, there should be an alignment between donor aid policies and priority sectors that governments want to focus their spending on.