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What are National Health Accounts and why are they important?

What resource could you use to track a country’s health expenditure and compare it across countries over time?
Spreadsheets and graphs with one person holding a calculator, and another person writing
© The Nossal Institute for Global Health at the University of Melbourne.

The System of Health Accounts (SHA) is a standardised framework to track a country’s health expenditures. It ensures comparability across countries and over time. National Health Accounts (NHAs) are designed to answer the following questions:

  1. Where do health resources come from (domestic versus external)?
  2. Who are the financing agents (government, insurance schemes, households, donors, NGOs)?
  3. What goods and services are purchased with these resources (curative, preventive, pharmaceuticals, etc)?
  4. Where do these resources go (type of organisation that provides health services)?

NHAs are useful as they are one of the only sources of internationally comparable health expenditure data. Tracking health expenditures is useful for accountability to plans and budgets and to enable good resource prioritisation and allocation. NHA data is also very useful for evidence-based policy making and to guide health financing decisions.

Organisations working with government often need information such as that available from NHA to influence budget allocations and advocate for more funds for Universal Health Coverage (UHC).

They are one of the only sources of information that focus on actual expenditure in the health sector from all sources (government, private and external donors).

The table available to view under downloads below (see: Table 1: NHA indicators on health expenditure and sources of finance) gives an overview of key NHA indicators.

For a more complete list refer to WHO’s Global Health Expenditure Database. It is important to note that this is a composite database that WHO compiles, but countries might have other more detailed information.

Limitations and challenges

There are several challenges in producing timely and good quality NHAs and in using them for evidence-based policy making.

  1. Producing NHAs is a time consuming process where a large amount of data needs to be collected and analysed. Not only do all government expenditures on health need to be tracked but data from private sources and donors also needs to be collated. This requires both funding as well as technical capacity.
  2. Although international classification systems and manuals provide a framework, this framework needs to be contextualised to fit a country’s health system. Price et al (2016) have argued that these international manuals focus too much on the production of NHA data and do not provide practical and low-cost strategies on how to translate data into evidence for policy making. They provide an interesting case study of Fiji, where efforts have been made to integrate NHAs into national level policy making processes by embedding health finance indicators in planning documents, producing a country-specific user guide matching NHA classifications to priority policy areas, and encouraging collaborative policy research using NHAs.
  3. Data quality can be challenging in many contexts. Many assumptions have to be made during the aggregation and collation process which could compromise the final results if not done well. A recent systematic review on NHA data (Bui et al, 2015) found that for many countries, data for NHA reports is often incomplete and of questionable quality.

An unpublished case study conducted by Sine and Wisnu (2016) as part of the Knowledge Sector Initiative in Indonesia found that NHA use for policy making in Indonesia was constrained by all three issues identified. In general there was low awareness of the existence of NHAs amongst key policy makers and those that were aware had poor ownership and saw it as an externally driven process. The study also found low capacity to understand and analyse NHA outputs for policy making and do any form of secondary analysis on NHA data. There was also a perception of poor technical quality especially regarding the data used to produce NHAs. All these factors contributed to the lack of integration into policy making processes and therefore low use of NHAs to guide policy making.

These findings echo the broader challenges of making health policy and strategy more evidence-based: the difficulties and expense of collecting good quality data, conducting regular and rigorous analyses, and translating this into actionable recommendations which are taken up by policy makers and implementers.

If you have not done so previously, search online for the latest copy of your country’s national health accounts (if available), and read a summary.

  • Do you think it provides adequate information to guide policy makers?
  • Does it discuss the assumptions made in calculations?
  • Is there any discussion about data quality?

Reflect on how reliable and useful you think this report would be to policy makers.

McIntyre, D & Kutzin, J, 2016, Health financing country diagnostic: a foundation for national strategy development, (No. WHO/HIS/HGF/HFDiagnostics/16.1), World Health Organization.
Price, JA, Guinness, L, Irava, W, Khan, I, Asante, A & Wiseman, V, 2015, ‘How to do (or not to do)… translation of national health accounts data to evidence for policy making in a low resourced setting’, Health policy and planning, vol. 31, no. 4, pp. 472-481.
Sine, J & Dinna W, 2016, Health Policy Mapping: Case Study of National Health Accounts in Indonesia, Health Sector Policy Mapping study, Knowledge Sector Initiative, Australia – Indonesia Partnership program, 2016 (unpublished working paper).
© The Nossal Institute for Global Health at the University of Melbourne.
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