Introduction

Last year, a representative of the civil society organization Melcolians for Better Health confronted Melcolia’s Minister of Health at a town hall meeting, saying, “In the campaign, your government pledged to reduce out-of-pocket health expenditure, increase public expenditure for primary care, and reduce the imbalances in financial allocations for health care among our different provinces. Please tell us specifically how much household health expenditures have been reduced in the past two years. Has the recent reform reduced the gap of per capita health expenditure between the eastern and western provinces? Have your new policies increased resources for primary care?” The Minister was sure that her policies had met the campaign pledges but could not back this up with numbers, in particular, on out-of-pocket spending and expenditures on the various functions of the health system. She equivocated, mumbling something about having increased overall Ministry spending by 15 percent and bringing up the new African Development Bank loan of $17 million. Afterwards, she chided her advisor on financing: “I really need a better grasp of the numbers – to answer these citizen groups, but also so that I know what is happening and can shape the system to the President’s Vision for a New Melcolia.”

Financial resources are an essential input in the production of health care. As countries work to improve their citizens’ health, information on health sector financing is needed to appropriately allocate resources, identify inequities in the health system, analyze provider efficiency, and improve accountability on the use of resources. National Health Accounts (NHA)is an internationally recognized framework for measuring health expenditure – public, private, and donor – and the flow of funds through a country’s health system.

An integrated approach to conducting NHA produces financial information that is linked to other health-related information. It also requires NHA to be a country-led effort, putting ownership of the process within the government and therefore making it a part of government planning and budget cycles. Furthermore, it builds capacity at the local level by asking that level to first collect data and later to transform the resultant information into knowledge for action. Finally, an integrated approach makes information public so that it can be discussed among and used by different stakeholder groups.

The problem

Although NHA information now is widely available and used in developing countries, its full potential is not always recognized and relatively few countries have fully institutionalized the methodology.

For more than a decade, donor partners have provided technical assistance for conducting NHA in countries throughout the world. In some places, assistance has been extensive, with partners helping countries to conduct surveys of households, providers, and donors; elsewhere, the NHA undertaking has been more limited, with assistance provided only for the analysis of available information. In countries that have doneseveral “rounds” of NHA estimates, the value of the information is more appreciated and policymakers have used results in different ways. However, in many countries, NHA has been conducted as a stand-alone exercise of the Ministry of Health (MOH), with emphasis on collecting data and producing NHA tables, and results providing only a snapshot of health system financing. More closely linking NHA to other routine financial data collection and planning and budgeting processes could make NHA easier and less costly to prepare and result in deeper institutionalization. Further, making NHA findings accessible to a wide audience in both the public and private sectors would give it a greater constituency and enhance the ability of actors outside the MOH (for example, civil society organizations, local legislators, or regional authorities) to participate in policy debates armed with quantitative data and able to hold decision makers accountable for system performance.