Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health National Health Accounts and its policy use in Ethiopia World Public Health Congress, Addis Ababa, April 24, /9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health 1.Country profile 2.Health financing in Ethiopia 3.NHA in Ethiopia 4.Major NHA findings (from four NHA rounds) 5.NHA policy use 6.Conclusion Outline 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health General Country Profile 9 regional states and two city admins Over 82 million population 1.1 million sq. km. Map of Ethiopia 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health Health financing in Ethiopia Health was/is generally under financed Ethiopia recognized the need for clear financing policy and developed/approved the HCF strategy in 1998 Overall, health financing evidence was lacking NHA has been critical in generating health financing evidence since /9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health Health financing in Ethiopia (3): The spider web flow of funds… 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health NHA in Ethiopia Ethiopia conducted four NHA –First round in 2000 based on 1995/96 spending General NHA only –Second round in 2003 based on1999/00 spending General NHA only –Third round in 2007 based on 2004/05 spending General NHA Child health and reproductive health subaccounts 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health NHA in Ethiopia (2) Fourth round in 2010 based on 2007/08 –General NHA –HIV/AIDS subaccount –Child health subaccount –Reproductive health subaccount –Malaria subaccount –TB subaccount –Health information system (HIS) subaccount All rounds of NHA financed by USAID through the HSFR Bilateral project 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health NHA in Ethiopia (3): Data Collection Methodology (Fourth NHA) Primary Sources: For the first three rounds 1-3 household income, consumption and expenditure /HHICES/ data was used. General HH survey: A total of over 10,000 households surveyed by a local consultant using a survey tool developed and used in other countries and contextualized to the Ethiopian situation. Targeted HIV/AIDS survey (sample of PLWHA): About 4,000 PLWHA were interviewed on their health service utilization. Institutional surveys: Donors, local and international NGOs, private and parastatal employers, and insurance enterprises; Secondary sources: All relevant documents (published and unpublished) were collected by the NHA team from all sources; Audited government account (MOFED). 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health NHA in Ethiopia (3): INSTITUTIONAL SURVEYS: (Fourth NHA) Donors (Bilateral and Multilateral): Census of 31 donors. Twenty five partners (81%) filled in and returned the questionnaire. NGOs (International and Local): Census of 251 NGOs (95 international and 156 local NGOs. 86 (about 90%) and 138 (88%) of international and local NGOs respectively filled in and returned the questionnaires. Employers (Parastatals and private employers): 214 private enterprises (employers) 15% of the total 2,915 private sector employees. 30 public enterprises/parastatals 30% of 108 public enterprise/employers. Ethiopian Air Lines, Ethiopian Electric Power Corporation, Ethiopian Telecommunication Corporation & Commercial Bank of Ethiopia were also covered in the study. A total of 198 (about 80%) of the 248 employers filled-in and returned the questionnaires. Insurance: All 10 were surveyed and completed the questionnaire (1 public, 9 private). 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health Source of Finance2004/052007/08Change Government145,501,590(28%)248,527,277(21%)71% Households160,042,854(30%)441,064,781(37%)176% Rest of the world192,293,175(37%)466,628,078(39%)143% Public enterprises13,796,059(3%)16,235,732(1.37%)18% Private employers6,129,755(1%)12,978,643(1.09%)112% Local NGOs and other private funds3,966,145(1%)3,786,513(0.54%)-5% Total521,729, ,189,221, % NHA findings: Comparison between 3 rd and 4 th NHA Financing sources (in US$). 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health NHA Findings Overall spending in health is increasing overtime Total health spending: Birr 11, 123, 022,113 Billion (USD1.2 Billion) in 2007/ % increase from 2004/05. Per capita health expenditure estimated to be USD 16.1(increased from USD 7.1 in 2004/05) 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health NHA findings: Source of health financing in 2007/08 (Fourth NHA) 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health NHA Findings: Trends in Per Capita Health Expenditure in USD 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health Policy use of NHA The last four NHA round evidences used: As input for FMOH and partners evaluation of subsequent health sector development programs (HSDP) Input for designing HSDP including HSDP-IV; Generate evidence on health sector spending in HSDP priority areas; NHA evidence is used in policy dialogue and negotiation with health sector development partners 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health Policy use of NHA (2) Used in health financing reforms initiation and implementation: To convince law makers and finance that health is not adequately financed, and government budget allocation for health is increasing overtime Enabled ratification of HCF reform legal frameworks and guiding implementation of the reforms including revenue retention and use at health facility level Systematizing fee waiver system The evidence also revealed the burden on households: The showed the need for risk pooling and financial protection : CBHI under piloting and legal framework put in place for SHI, and will start very soon 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health Conclusion Ethiopia substantially benefited from conducting subsequent rounds of NHA NHA evidence was useful for initiation and implementation of the various financing reforms Recognized the usefulness of the evidence, Ethiopia needs to speed-up institutionalization of NHA 2/9/2014

Health Sector Financing Reform Project Federal Democratic Republic of Ethiopia Ministry of Health Thank You 2/9/2014