1. Commonwealth Regional Health Community for East, Central and Southern Africa. 3 rd International NHA Conference, San Francisco, California 13-14 June 2003 Institutionalization of National Health Accounts in ECSA: Progress Report `Dr. Mark Bura Health Systems Development Coordinator. CRHCS.1

2. First version of this paper was presented at the 36 Conference of Commonwealth Regional Health Ministers Conference, Entebbe, Uganda, 18-22 November 2002 2

3. Historical Perspectives of NHA  NHA, a framework for measuring flow of funds in a health system has been practiced in the USA for over 30 years.  OECD countries use a framework known as a System of Health Accounts, SHA.  SHA uses a classification system know as International Classification for Health Accounts, ICHA, which has been adopted as a classification for NHA. 3

4. WHY NHA  In the past decade spending in health has became one of the major policy issues the world over  There is a strong recognisation at local and international level that data on health indicators, in particular spending on health services lack coherence.  There is a growing consensus at international level to use a standard for measuring health expenditures in order to allow inter and cross country comparability. 4

5. Inconsistent Estimates on Health Spending

6. Milestones in Institutionalisation of NHA in ECSA ONE Popularisation of NHA by WHO, Harvard School of Public Health from mid-nineties to date 6

7. TWO Ten ECSA Countries bold enough to undertake first NHA  Kenya, Uganda, Tanzania, Malawi, Zambia,  Mozambique, Zimbabwe, South Africa, Ethiopia and Rwanda undertook their first NHA between 1995-2000 7

8. THREE CRHCS/ECSA arrives on the NHA scene.  November 2000 : CRHCS established Health Care Financing Programme  March 2001: trained CHF Coordinator in NHA with USAID/REDSO support  April 2001 : ECSA/Health Care Financing Expert Committee met first time and drafted a HCF Strategic Plan in which NHA is included as major activity over 4 years. 8

9. Training of core Regional and national NHA promoters- VERMONT

10. FOUR NHA ECSA Network and Health Ministers Resolution to Institutionalise NHA.  April 2001: NHA ECSA Network coordination taken over by CRHCS  September 2001: First ECSA NHA Executive Sensitisation Workshop for Permanent Secretaries MoH and Directors held in Mombasa. They endorse NHA 10

11. FOUR CONT. NHA ECSA Network and Health Ministers Resolution to Institutionalise NHA. November 2001 : 34 th Regional Health Ministers Conference makes a resolution to Institutionalise 11

12. ECSA Regional Training Courses on NHA by CRHCS, WHO, SIDA, USAID/REDSO, PHRplus etc.

13. NHA Country and CRHCS Activities  November 2001: 1 st ECSA NHA Regional Training Workshop coordinated by CRHCS in collaboration with USAID/REDSO and PHR plus- took place in Lusaka Zambia.  November 2001: Mauritius NHA process launched with support of CRHCS in collaboration with USAID/REDSO and PHR. 13

14. NHA Country and CRHCS Activities cont.  August 2002: Seychelles invited CRHCS to launching of NHA process to date Seychelles has established an NHA steering and working committees 14

15. Partnership and collaboration is good for NHA

16. CRHC forges Collaboration with Partners and Donors  June 2002: A Joint Donor Meeting to mobilize resources for NHA in Sub-Saharan Africa took place in Nairobi–CRHCS played a major role in coordination and drafting the NHA Strategy in Africa.  November 2002: 2 nd ECSA NHA Regional Training Workshop was conducted by CRHCS and WHO in Mutare Zimbabwe. 16

17. ECSA Countries are moving fast with NHA Analysis. 2003:  Zimbabwe, Kenya, Uganda, Tanzania and Ethiopia are currently working on their 2 nd NHA analyses. 17

18. The Challenge of Training NHA analysis in ECSA  At this point in time NHA is a new concept in Sub-Saharan Africa and other developing countries in the World.  None of the Sub-Saharan countries has adequate expertise in NHA.  WHO, Harvard School of Public Health (Peter Berman and others) and PHRplus/Abt Associates are the main fountain of knowledge and skills in NHA currently  CRHCS and WHO AFRO feels confident to run and conduct NHA with just little technical support from partners and donors.18

19. The Challenge of Training NHA analysis in ECSA cont.  To date ECSA have collectively trained only about 110, one to two weeks workshop trainees. Of these trainees 95 are from 11 active CRHC member countries.  A one month training course could be a basic requirement for NHA analysis.  A two week further training might be required for focus on data collection and analysis –6-8 weeks course would be required to qualify as an NHA practitioner 19

20. NHA Training in ECSA KenyaUgandaTanzaniaMalawiZambiaMozambiqueZimbabweSwazilandLesothoMauritiusSeychellesTOTAL One-two week workshop attendances 1213178121012706295

21. Indicators: Institutionalization of NHA in ECSA- Country Activities KenyaUgandaTanzaniaMalawiZambiaMozambiqueZimbabweSwazilandLesothoMauritiusSeychelles Decision to start NHA YES ? ? ? Committee in place YES ? ? No of NHA committee meetings 833?83>8>4?62?

22. Indicators: Institutionalization of NHA in ECSA cont.-Country Activities KenyaUgandaTanzaniaETHIOPIAMalawiZambiaMozambiqueZimbabweSwazilandLesothoMauritiusSeychelles Resource Mobilisation YES ?? ??? Training: No attending 1-2 week workshops 12131781210127062 Status of 1 st NHA analysis DONE 03? Status of 2 nd NHA 03

23. NHA Financing and Collaboration in ECSA Collaborators USAIDPHRplusWHOSARA/AEDWB/WBISIDAEUDFIDDANIDACIDANORADFrenchCooperation Country based YES Technical resources +++++ Financial resources ++++++++++ +++++ Training resources +++++++++??? Joint meetings YES

24. Policy Impact of NHA use in ECSA  Though the results of 1 st NHA analysis in ECSA were received with mixed feeling, a few ECSA countries have already put to use the outcome.  Kenya has decided to undertake 2 nd NHA in order to come up with more realistic estimates especially on Household Expenditures  Tanzania used NHA results to reinforce coordination of external resources and increase its attention of the private sector.  Zambia confirmed the importance of the private sectors and efforts are made to integrate both sectors  Zambia is using NHA to improve allocate efficiency particularly allocating more resources to preventive services.24

25. Conclusions  NHA has been received by Policy makers in ECSA and there is a strong political will to use NHA as policy tool  Member States and Donors are building up efforts to institutionalize NHA  Despite a strong political will there is a challenging technical and resource gap  There is a window opportunity for both MS and Donors to leverage their efforts to institutionalize and sustain of NHA in ECSA. 25

26. Thank You