1. Expenditure tracking in health care National Health Accounts Tomas Roubal WHO, South Africa

2. Two messages What is the health accounts, and what information do they give? How NHAs can help us in accessing the value for money expenditures?

3. 1) System of Health Accounts Internationally recognized accounting system for health – Expenditures by provider, type of care and source of financing Updated version was published in 2011 – System of Health Accounts 2011 What is new is to measures spending per beneficiary groups – expenditure by disease and condition (including maternal health) – expenditure by age – also by region

4. International commitment WHO convened a meeting in Geneva in February 2014 to discuss the information needs and what NHAs may or may not respond Participants: – Countries (Tanzania, Burkina, ground, Liberia, Ghana, Thailand, Burundi, China) – Development partners (UNAIDS, GAVI, UNFPA, WHO, Global Fund, Gates, USAID, SIDA, World Bank, NIDI, CHAI, Abt, Futures, PEPFAR, OECD) Agreement that expenditure tracking are integrated through the System of Health Accounts

5. Data sources Data from the public sector – Ministry/department of health – Ministry of finance (e.g. other departments) – Healthcare providers (Hospitals, clinics, etc.) – District data (often must be collected in person because the details are lost at central level) – Social security insurance systems Data from the private sector – Private insurance, surveys on household expenditures, expenditures by companies, NGOs External resources – Mostly donor money

6. Description of the money flows Who pools resources How is the payment organized (voluntary/mandatory) Where do the money come Which providers receive the money What goes to administration, investment and care Who does provide services Who receives the care Which care has been provided (acute, rehabilitation, LTC, pharmaceuticals) To whom which services

7. Results – Total health expenditure as % GDP in 2012

8. Reforms are based on? Source: - WHO, NHA indicators

9. 2) Short history in South Africa 1990s – Health Expenditure Review – geographic disparities, disproportionate spending on hospital-based care in the public sector, and severe cost escalation in the private sector late 1990s – National Health Accounts (NHA) Project – evaluates reforms, reveals two eras of public health sector financing – data from 1998/99 indicate falling per capita financing of health care by government, a reversal of re-distribution trends between provinces and limited growth in PHC expenditure – decline in value for-money in the private sector, prior to the implementation of the Medical Schemes Act

10. NHA – macro view on expenditures Where is South Africa internationally – % GDP on health – % of public expenditures on health – Out of pocket payments How do provinces compare – Role of public and private financing – How much is spent on investment & administration What are the changes over time On which diseases are spending money

11. Benefits for South Africa Budget preparation for 2017-2019 on provincial and central level Support NDoH and provincial DoH in discussion on raising resources for health Evaluate expenditures of provinces on hospitals, clinics, primary care Private/public sector expenditure comparison Administrative costs of the health system on various levels (central, provincial, district) How much are people paying out-of-pocket in hospitals, clinics, pharmacies (in various provinces/districts)

12. Evaluation of reforms Monitor the impact of recently introduced resource re-allocation policies in time; Provide data to assist in the development of three- year rolling budgets for the public sector; Evaluate health sector efficiency; Are expenditures linked to burden of diseases; and Inform the development of new policies.

13. Answers on questions Who controls the resources and their flows – Public x private, central x provincial x provider Who is paid to provide health services – Primary care, hospitals, specialists, clinics Do we channel the money to care the population needs – Diseases, age/gender information, type of care Is our system efficient – Investments x administrative costs x health services

14. Thank you very much! roubalt@who.int