1. BOTSWANA NATIONAL HEALTH ACCOUNTS (NHA) 2007/08-2009/10 PRESENTED BY: J.A. ALFRED HEALTH ECONOMIST MINISTRY OF HEALTH, BOTSWANA DATE: APRIL 24 th 2012 13 th PUBLIC HEALTH CONGRESS ADDIS ABABA, ETHOPIA 4/24/20121

2. OUTLINE Health Financing Structure in Botswana NHA in Botswana Objectives and policy questions addressed by the Botswana 2010 NHA Methods and Data Sources Findings of the NHA Study Policy implications Conclusion Next steps 4/24/20122

3. Introduction Health Financing Situation in Botswana Health financing is pluralistic- services financed through a mix of government, private & donor funding, with government being the major source of funds. Revenue Generation : mainly through general taxation, households direct OOP, employer premiums and co-payments for public and private insurance schemes, and donor funding through bilateral and multilateral agreements. Pooling & Purchasing: mainly done by the government (both at central and local levels), and public & private insurance schemes. Provision of Services: pluralistic- done by public, private, and private not-for-profit providers. 4/24/20123

4. NHA in Botswana First round of NHA in Botswana was produced in 2006 covering 2000/01- 2002/03 financial years and provided data in aggregated form. Since then, a wide range of changes that have serious implications on the countrys health financing structure were introduced (e.g. exemptions of vulnerable groups from payment of user fees, increased number of people on ART, increased donor support, e.t.c.). Increased need for up to date evidence on health financing to help GoB to make informed decisions on its investment in Health. Thus the need to conduct the 2 nd round of NHA covering the FY 2007/08- 2009/10. 2 nd round of NHA is more detailed –provides health expenditures by key health programs such as HIV and AIDS, Maternal and Child health. Both rounds of NHA were supported by development partners (1 st - NORAD financially & WHO technically, 2 nd – PEPFAR financially & USAID technically) 4/24/20124

5. Objectives of the Botswana 2010 NHA using data for 2007/08-2009/10 Document total expenditure on health in Botswana; Document distribution of total spending on health by financing sources, financing agents, health providers and functions; Document the distribution of health spending by disease/service category, e.g. HIV/AIDS; maternal and child health, TB etc. Document the distribution of funds by level of care in Botswana. Analyse the data with regard to efficiency, equity and sustainability. Examine the distribution of funds by inputs/line items e.g. salaries, drugs e.t.c. 4/24/20125

6. Methods and Data Sources Methodology was guided by definition of health expenditure. Health expenditure data was collected from a wide range of primary and secondary sources as follows; Government ministries; National AIDS Coordinating Agency (NACA); Health care providers: Private for-profit/Mission (not-for-profit) Facilities Insurance Schemes(Public and private); Representative Sample of Employers Non-Governmental Organizations (NGOs) involved in health; Donors (both bilateral and multilateral); Household health expenditure data was extracted from the 2009/10 Botswana Core Welfare indicator Survey, undertaken by Central Statistics Office (CSO) which had a Health Care Utilization and Expenditure Module. 4/24/20126

7. FINDINGS OF THE 2 nd NHA STUDY 4/24/20127

8. Who are the major sources of financing health care services and goods in Botswana? Are actual expenditures on health increasing over time? The government of Botswana is the major source of health funds, accounting for an average of 68% seconded by Private sources at an average of 21%t while donors contributed an average of 12% over the years under review. With this pattern of health spending Botswanas health systems can be regarded as one of the few sustainable in the WHO Africa region due to its low reliance on donor resources. As such, the country could continue with its activities in the event of sudden withdrawal of donor aid in the health system. There was a slight increase in health expenditure over time. 4/24/20128

9. Has the Abuja target been reached? Are the resources adequate for providing basic package of cost effective interventions Botswana has been spending well in excess of the Abuja target (spending at least 15% of the Government budget on health). In per capita terms, this translated to US$256.03, US$255.91 and US$302.80 in 2007/08, 2008/09 and 2009/10 respectively. This is well above the Commission for Macroeconomics and Health target(spending at least $34 per head) and the average of the Africa Region of US$76 per capita per annum. These figures imply that the country has more than adequate total health resources to fund a minimum package of cost effective interventions. 4/24/20129

10. How does Botswana fair in relation to other countries in the SADC Region and WHO Africa Region SADC Member Country THE%GDP, 2009 THE/Capita, 2009 (USD) General government spending on health as % of Total Government Expenditure, 2009 Angola 4.70%203.1811.30% Botswana 6.30%444.6617.80% Lesotho 8.20%70.058.2% Malawi 6.20%19.0712.0% Mauritius 5.60%377.58.0% Mozambique 6.20%27.0614.20% Namibia 6.00%257.9712.10% South Africa 8.50%485.439.30% Swaziland 6.30%155.789.30% United Republic of Tanzania 5.10%25.3118.10% Zambia 6.20%60.6115.70% Average SADC 4.80%163.69.10% Average WHO Africa Region 2007 6.20% 76 9.60% Botswana is one of the two countries in the SADC region that had met the Abuja target, it ranked second in the 13 SADC countries in terms of total spending on health per capita (Zimbabwe was excluded due to lack of comparable data). In terms of GDP spending on health, the country is also above the average of the SADC region of 4.8%. 4/24/201210

11. How does Botswana fair in relation to other countries in the SADC Region, WHO Africa Region and Internationally? COUNTRY Total Health Expenditure Per Capita (US$) 2009 Infant mortality rate (%)- 2009 Maternal mortality ratio/100,000 live births(2009) Life Expectancy- 2009 Angola 203.189861052 Botswana 444.664319054.4 Lesotho 70.056153048 Malawi 19.076951047 Mauritius 377.5133673 Mozambique 27.069655049 Namibia 257.97341857 South Africa 485.433341054 Swaziland 155.785242049 United Republic of Tanzania 25.316879055 Zambiia60.615647048 Average WHO Africa Region 2008848590053 Average WHO Euro Region 20082169122775 Singapore15012.31481 United Kingdom32856880 USA7410261178 In establishing the relationship between health spending and health outcomes in the SADC Region, WHO Africa Region and around the globe, it is clear that much as Botswana spends more on health compared to Mauritius and Namibia in the SADC region, these two countries have better health outcomes than Botswana. This disparity could be attributed to the fact that health of an individual or population is a function of many variables (income, education, housing conditions, environment etc.) and the efficiency in which health systems in different countries convert inputs into outputs and ultimately into outcomes is different. 4/24/201211

12. Who are the major managers of health funds and how are their roles changing over time? The Ministry of Health (MOH), was the major financing agent, controlling an average of 43.6% of THE over the three years Medical aid schemes (i.e., private health insurance schemes) came second managing an average of 11.3% of THE. NACA came third controlling about 10.8%of THE. Household direct OOP payments averaged 4.2 % of THE. This is one of the lowest levels of direct household OOP spending in the WHO Africa region and in the world. With such a low OOP spending, it is unlikely that health care spending in Botswana is catastrophic. 4/24/201212

13. Who are the major managers of Private health funds and how are their roles changing over time? The majority of total private funds were managed by health insurance schemes. 4/24/201213

14. Which health providers receive the large share of health funds and is the situation changing over time? In overall, general hospitals receive the greatest proportion of THE, an average 53% in 2007/08-2009/10. Botswana has a hospital-based health system, with hospitals receiving the majority of resources Providers of prevention and public health programs receiving fewer resources at an average of 9% of THE. 4/24/201214

15. On what were health funds spent in Botswana? Over half of THE (59%) during the period under review was spent on services of curative care (outpatient (28%) and inpatient (31%). Prevention and public health services consumed only 9%, which is not in line with the primary health care principle adopted by the Botswana government. 4/24/201215

16. Policy implications Botswana has more than adequate total health resources to fund a minimum package of cost effective intervention and more resources funded and managed by public sector: GoB needs to seriously address efficiency and equity in resource allocation between levels of care, geographic area, functions etc. Government is the major sources of health funds through general tax revenues which is vulnerable to macroeconomic crisis: Government gets most of its revenue through international trade thus vulnerable to external shock. There is need to explore potential alternative financing mechanisms for health. Majority of donors funding off-government budget: Government and Donors need to consider adopting a Sector Wide Approach (SWAp) to encourage use of donors and NGO resources towards a common health sector plan and Monitoring and Evaluation. 4/24/201216

17. Policy implications Contd The majority of health resources consumed by hospitals and providers of general health administration: Government and all stakeholders need to seriously consider reallocation of health resources to primary health care facilities and services and in particular to providers of prevention and public health programmes. The majority of resources spent on curative health care services and general administration and capital formation with little spent on prevention and public health services: Strongly need to increase resources allocation to prevention and public health services. There is need to improve efficiency and equity in health resource spending. Resource allocation seem to follow infrastructure rather than health needs of the population: Need to develop a resource allocation formula so that it takes into account the relative health needs of the population of different groups weighted by other factors that affect service delivery. 4/24/201217

18. Policy implications Contd Institutionalise NHA methodology: Government through the Ministry of Health should embark on sensitizing the stakeholders on the relevance of NHA in health policy design, monitoring and evaluation of health services and programmes and embark on the process of institutionalizing NHA in Botswana. Need to conduct further financing studies: There is need to conduct further financing studies such as the benefit-incident analysis, studies on fiscal space, studies on productivity and effectiveness of services (at all levels including functionality of the referral system). 4/24/201218

19. Conclusion Findings reveal that NHA information is important to health systems, without which, there is little basis for designing new ways of financing health in Botswana or delivering health services to the Batswana population. Thus the Botswana NHA study results need to be used in any health financing policy design debates and be also used for monitoring and evaluation of the health system 4/24/201219

20. NHA institutionalisation; Holding SHA 2011 and NHA Production tool training for NHA TWG –to facilitate and simplify the process of the development of future NHAs Holding a NHA Policy communication workshop –to help understand the value of NHA in health policy design, monitoring and decision making and thus help to create demand for NHA. Identification of the home for NHA – The department of Health Policy Development, Monitoring and Evaluation. Completion of the feasibility study for the introduction of Social Health Insurance Scheme as an alternative health financing mechanism. 4/24/201220 Next Steps

21. Next steps contd Undertake costing of health services to guide resource allocation. Establishment of Health Partners Forum (a SWAp mechanism) in order to bring health partners together in funding health care services.. 4/24/201221

22. Thank you! 4/24/201222