Download National Health Accounts and Measuring Efficiency

Measuring Health Systems
Performance and NHA:
Agenda for Health Services
Research and Evaluation
Akiko Maeda, Ph.D.
Lead Health Specialist
Europe and Central Asia Region
The World Bank
Introduction
NHA role in measuring health system
performance
 Challenges in measuring efficiency and
quality of health care
 Need for improved data collection and
evaluation tools
 Agenda for health services research &
evaluation & NHA in developing countries

Health Sector Resource Allocation &
Utilization Questions




How large is the sector?
What are its constituent parts?
What items currently dominates in
resource allocation?
Who pays for what, and what services
do they get for their payment?
Measuring Health Systems
Performance
Revenues
/Inputs
Health Services
Throughputs
Health
Outcomes
• Redistribution
(progressive?)
• Allocative
Efficiency
• Aggregate
• Administrative
Efficiency
• Microecon.
efficiency
• Risk-pooling/
Insurance
• Efficacy/
Effectiveness
NHA defines financial flows from
sources to service outputs
• Disease
specific
• Socioeconomic
factors
NHA Flow of Funds Analysis
SHA Coding
Sources of Funds
Financial Intermediaries
Uses of Funds:
- By Institutions
- By Functions
ICHAHF
ICHAHP
ICHAHC
Why Health Accounts?
 Health
accounts offer :
– Consistent and comprehensive definition of
health system taxonomy and boundaries, for
comparability
– Classification of resource inputs and
throughputs , by functional and
organizational categories
– A method for costing (valuation of) health
“transactions” for comparability, normative
evaluation
Measuring Health System
Performance

Outcome/Inputs = Cost-benefit, cost
effectiveness analysis, e.g., reduction in disease
incidence rate per $$

Outputs/Inputs – Efficiency measure based on
intermediate process indicators, e.g., cost per
hospitalization case

Outcome/Outputs = Effectiveness/ efficacy of
intervention, e.g., immunization rate and
reduction in disease incidence.
Challenges for improving the
relevance of NHA
NHA offers a consistent framework for
measurement, but does not offer normative
measures
 Difficult to evaluate performance based only on
aggregate expenditure data
 Need complementary indicators of efficiency
and quality: appropriateness of care,
productivity measures, and other benchmarks
 Poor quality and incomplete data at micro-level
(provider) limits usefulness of aggregate data

Measuring “Efficiency” of Health
System: Challenges
Major gap between aggregate macro-level data
GAP
....And microeconomic performance data
at provider and population level
Challenges in Comparing Health
System Performance
Variability in the organization of health care
delivery system
 Dynamically evolving technology: e.g.,
increasing use of day surgeries, decreasing acute
care hospitalization days
 Internal variability in performance among
providers and outcome among population groups
 Confounding factors: complex interactions
between socio-economic factors and health
outcomes

Example: Using NHA to evaluate
Estimating Allocative Efficiency
 NHA functional
categories: e.g., public
health programs, acute vs. chronic
inpatient care provides common
framework for defining products, but
needs to be adjusted for:
– Intensity, quality of care
– Population – demographic profile
– Evidence of clinical efficacy, costeffectiveness
The World Bank
What can we tell from these aggregate
expenditure data...?
Comparison of Health Spending by Functions as % Total
100%
80%
60%
40%
20%
0%
Czech Rep Denmark
1999
1999
Germany
1998
France
1999
Italy 1997
Croatia
2002
Others (Health Administration, Public Health, etc)
Therapeutic appliances
Pharmaceuticals & medical consumables
Outpatient, Ancillary & Home Health
Inpatient
Agenda for Research

Developing data collection and research
capacity in the following areas:
– Household consumption and expenditure
surveys, with improved designs on medical
services purchased directly or through
insurance
– Health care provider utilization surveys
– Improved quality of expenditure data at
provider level (case-mix, medical procedures)
Agenda for NHA in Developing Countries

Review of classification of services
– Need to review, adapt OECD SHA functional
and provider classifications to suit developing
country health systems

Health services research agenda:
– Developing affordable instruments for
collecting data at provider (private & public)
and population groups
Examples of Priority Topics for
Health System Research
Rational Use of Drugs
 Hospitalization – tracking changes in acute
and chronic care admission rates, length of
stay
 Administrative efficiency
 Public health programs – allocation on
prevention and population-based programs
versus personal/ clinical interventions

Agenda for Health System
Research

Recommendations:
– Focus greater attention on capacity building on
health services research and evaluation
– Introduce National Health Accounts within the
context of health services evaluation, not as a
stand-alone instrument
– With improved quality of data, it should
become more feasible to undertake meaningful
national and international comparisons
Agenda for Health System
Research
World Bank’s standard economic and sector
work focuses on Public Expenditure
Reviews (PER) and Household Surveys
(e.g., Living Standards Measurement
Surveys)
 Complementary capacity building should
focus on supporting provider surveys,
operational research on services

Measuring Health System
Performance – Instruments
Public
Expenditure
Reviews
Provider
Surveys
Household
Surveys
Health Systems
Performance
Evaluation
Administrative
Data
Quality & utilization
reviews, technology
assessment, demo. & epid.
analyses
Health System Performance
Evaluation 
Low-income countries
– Administrative data may be of limited value
– Limited data on private sector activities
– May need additional surveys to evaluate
performance

Middle Income Countries
– Improved capacity to collect performancebased data through regular operational and
regulatory systems
Health System Evaluation Process
Analysis of
Outputs, outcomes
and Expenditures
Utilization and
Quality Reviews
Provider level
Clinical and
epidemiological
outcomes
Population
groups
Contact:
Address:
Akiko Maeda
The World Bank H7-700
1818 H. St. N.W., Washington, D.C.
20433
USA
Telephone: +1 202 473 3793
Email:
[email protected]