National Health Accounts in Serbia Lund, 6-7 July, 2007 Dr Milena Gajic-Stevanovic

Background Statistics Serbia population: 7,5 million, Health System financed by compulsory health insurance based on 12,3% payroll taxes via Health Insurance Fund, Problems of reduced financial basis in Health care system (2 million employed financing 7 million insured), Providers are mostly public and contracted by HIF. Private sector is not part of public financing

Money flow in Serbian health system Republic. Budget MoD Military HC providers Republican Budget MoJ Prison Health providers MoE MoF oJ MoSA MoH Health education HIF MHIF Public HC providers Pension Fund Military personnel General population Regional Budgets Municipal Budgets Private HC providers Enterprise HC Enterprises Budget allocation Contributions Taxes, tolls Intergovernmental money transfers Refunds, compensations Public current health expenditures Private current health expenditures Public health-related expenditures HIF sub account

Establishment of NHA in Serbia Objective: To increase transparency of financial resources allocation by National health accounts in order to determine and compare Nation’s overall health spending patterns. Aim: To provide policy makers with internationally comparable indicators, analysis and recommendations based on the information received and processed. Material and methods: Data are obtained from Public expenditure Reviews, Administrative data, Household Budget Surveys, Provider Surveys, and linked applying the rules of “A System of Health Accounts (SHA)” Version 1.0.

Establishment of NHA in Serbia In Republic of Serbia NHA represents a part of the Government Health sector reform strategy Work on NHA started in January 2005. Work was divided on Phase I and Phase II Purpose of Phase I: - to produce a first set of NHA - 3 tables - to determine overall health spending patterns - to provide recommendations to policy makers based on first results

Establishment of NHA in Serbia Purpose of Phase II: More detailed information on private sector, labour account, cost of illness account All of that was accomplished as well as : OECD Guide for the use of NHA translated -NHA enters the government financial plans in 2006 with projections for 2007,2008 -Six workshops were organized with 200 participants -Presentation of NHA in Budapest HE Conference -Adjusted reporting data from providers -Media popularization and connection with private sector

First task- to find data sources Second task- setting up the system of cooperation and coordination of all relevant sides The Ministry of Finance- Tax office,(HF2.5) Budget and Treasury The Ministry of Health (HP.5,HP.6,HC.6,HC.7,HC.R.1) The Ministry of Labor, Employment and Social Affairs (HP.2,HC.3,) Ministry of Justice Ministry of Education (HC.R.2) Ministry of Defense Ministry of International Economic Relations (HF.3.1) Ministry of Science (HC.R.3) Health Insurance Fund- Public expenditure reviews Public Health Institute Republican Statistical Office Chamber of Health Institutes - Public expenditure reviews Drug agency (HP.4, HC.5) Agency for Environment Protection (HC.R.5) Retirement Fund (HC.R.6)

Data Sources (continued) Households out of pocket spending for Public sector are calculated from health institutions data and HIF data on co-payment Households purchases of pharmaceuticals are obtained from retail trade data from drug agency Household out of pocket spending for Private sector providers are calculated from Statistical surveys : Complex annual report – is based on annual financial reports and provides data on income end expenditure of health care providers; Survey on private entities – is based on data from Tax Office with data on income of private providers; Household budget survey – provides data on household’s expenditure for physicians, dentists, medical aids, hospitals, Spas

Results:Financing structure 2003 Who pays and how much?

Financing structure 2004

Financing structure 2005

Money allocated to providers Who provides goods? Table 2A. Current health expenditure allocated the health providers (% ) Current costs in Serbia in %     2003 2004 2005 Hospitals HP.1 (42,32) (46,94) (44,56) Nursing and residential care HP.2 (0,30) (0,31) (0,2) Ambulatory care HP.3 (18,39) (19,45) (19,82) Retail sale and other providers of medical goods HP.4 (26,01) (24,00) (27,51) Public health institutes HP.5 (2,56) (1,18) (1,86) Health administration and insurance HP.6 (7,08) (4,93) (4,04) Other industries Occupat.health and households HP.7 (3,25) (3,13) (2,05) Rest of the world HP.9 0,06) (0,06) (0,05) Total current health costs  100

Table sample:National health expenditure by type of finansing agent and type of provider (FAxP) Providers ↓ Financing structure according to health care providers HF.1.1.1 Central government HF.1.1.2 State/ provincial government HF.1.1.3 Local/ municipal government HF.1.2 Social Security funds HF.2.3 Private house holds' out of-pocket payment. HF.3 Rest of the world HP.1 Hospitals 46,94 6,2 0,76 0,72 87,34 5,97 100 HP.2 Nursing and residential care facilities 0,31 HP.3 Providers of ambulatory health care 19,45 4,37 0,20 0,67 62,00 32,90 HP.4 Retail sale and other providers of medical goods 24,00 0,01 35,30 63,92 0,40 HP.5 Provision and administration of public health programmes 1,18 38,98 1,69 0,85 42,37 3,39 14,41 HP.6 General health administration and insurance 4,93 9,74 80,14 10,14 HP.7 All other industries 3,13 10,00 90,00 HP.9 Rest of the world 0,06 National health expenditure 4,74 0,42 0,49 67,92 25,59

finansing agent and by function (FAxF) Table sample:National health expenditure by type of finansing agent and by function (FAxF) Functions Financing Agents Total HF.1 General Government HF.2 Private Sector HF.3 Rest of the world HF.1 Territorial Government HF.1.2 Social Security funds HF.2.1 Private social insurance HF.2.2 Other private insurance HF.2.3 Private households' out-of-pocket payment HF.2.4 Non-profit institutions serving households HF.2.5 Private firms and corporations HF.1.1.1 Central government HF.1.1.2 Autonom region HF.1.1.3 Local/ municipal government HC.1 Services of curative care 45,07   55,82   54,20   44,26   29,58 14,41  39,68 HC.2 Services of rehabilitative care 0,49   0,26 0,76   0,48   1,08   0,82   0,62 HC.3 Services of long term nursing care 0,46 0,31   HC.4 Ancillary services 20,00 23,99 23,04 19,64 6,10 5,40 16,03 HC.5 Drugs and other med.goods 11,52 13,93 15,80 25,72 62,67 31,97 HC.6 Prevention 12,77 5,99 6,20 3,65 0,58 79,37 6,45 HC.7 Administration 10,15 5,79 60,00 4,93 100 100 

Table sample: National health expenditure by type of provider and by function (PxF) Health providers ↓ Financing structure according to health care providers HC.1 Services of curative care HC.2 Services of rehabilitative care HC.3 Services of long term nursing care HC.4 Ancillary services HC.5 Drugs and other med.goods out of hospital distibuted HC.6 Prevention and occupational health HC.7 Administration HP.1 Hospitals 46,94 59,99 0,47 25,08 14,46 100 HP.2 Nursing and residential heal.care fac 0,31 HP.3 Providers of ambulatory health care 19,45 58,09 2,02 21,47 7,65 10,78 HP.4 Retail sale andproviders of medical goods 24,00 HP.5 public health programmes 1,18 HP.6 Gene.health administration and insurance 4,93 HP.7 All other industries 3,13 HP.9 Rest of the world 0,06 63,59 1,64 26,03 8,75 0,83 National health expenditure 39,68 0,62 16,03 31,97 6,45

How are health care funds distributed across the different providers?

How are health care funds distributed across the different services?

2003

2004

Preliminary results for 2005

Discussion: The compilation of health accounts was in many ways useful Discussion: The compilation of health accounts was in many ways useful. For the first time private sector of providers and financers were observed. Conclusions and recommendations: Full access to the relevant information is indispensable. Data reporting might be biased by vested interests of stakeholders. It is therefore necessary to develop safeguards for reliable data delivery and analysis.

Plan for improving NHA The main issue to be addressed in the coming months is the institutionalization of the team and regular work on NHA. Institutionalization of NHA is an ongoing process in which NHA activities, structures, and values become an integral and sustainable part of Government operations. This complex process can take years and multiple estimates before it is fully integrated into country’s formal structure, but in order to ensure that NHA remains an effective policy tool in the future, institutionalization should be a goal from the initiation of NHA. Health information centre in PHI- Official health expenditure statistics Memorandum of understanding between RSO, PHI, CHI, MOH, HIF

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