Best Practice in Institutionalising Health Accounts

Health accounts are a crucial tool to systematically monitor the financial resources that countries allocate to health and to inform evidence‑based policy making. Beyond tracking health spending along the three core dimensions around which the international standard framework “A System of Health Accounts 2011” is built (financing, provision and services), many countries are also interested in additional applications of health accounts such as examining health financing and spending at a subnational basis or breaking down health spending by age, gender and disease. In addition to producing health spending data applying the SHA 2011 concepts for the purpose of international comparisons, a number of countries also have national versions of health accounts to serve country-specific information needs.

While previous work has looked to some extent into how health accounts have been implemented by countries – analysing the manner in which initial health spending estimates are generated – the issue of how the production of health accounts has been permanently institutionalised in countries has received less attention.

An appropriate institutionalisation of health accounts is a vital step to ensure that data on health expenditure and financing of high quality are regularly produced. In this context, the governance of the production process, the technical aspects of the production process and the dissemination of the results including their use to inform policy making are crucial domains. This report teases out the best practices of institutionalising health accounts based on the experience in 13 OECD countries with a relatively long health accounts history.

Overall, a key message is that there is no “one size fits all” approach. Many factors related to characteristics of the health system, the health data information landscape or administrative cultures and rules play a role in determining how health accounts should be best institutionalised in a country.

Regarding the governance of health accounts, countries have several options when assigning the institution responsible for their production, and there are several trade‑offs attached to this choice. A number of countries place this stream of work within the Ministry of Health which has the advantage of being close to policy making, but ministries may lack the technical capacity or a broader economic perspective to do this work. The opposite is generally true for National Statistical Institutes. Other options such as institutionalisation of health accounts in independent health agencies or via other arrangements come with their own advantages and potential challenges.

A legal mandate for the production of health accounts (either explicitly or implicitly) exists in the majority of countries surveyed, and this can be an important lever to ensure the sustainable financing and resourcing needed to guarantee the continuity of the work. Having a legal basis for health accounts production can also help facilitate data acquisition and may reinforce engagement with other stakeholders. However, there are also examples where a sustained production of health accounts is possible without such a mandate.

Producing health accounts relies on combining data from many different data sources. Hence establishing and maintaining good relationships with the various data providers and other stakeholders is crucial. While in many cases, data acquisition is based on the “good will” of data holders and therefore remains rather informal, most countries also rely to some extent on more formalised arrangements with some key data producers.

Several countries have taken the decision to establish health accounts expert groups which typically draw on a broader range of experts from within and outside of the responsible authority. These groups can take on different roles such as advising on health accounts production, methodological questions and the dissemination of results but may also be able to provide a broader policy perspective of the health accounts work. Such a group can be a useful instrument to get additional “buy-in” from major stakeholders and can also potentially improve the quality of the accounts and add legitimacy to their results.

The technical process by which health accounts are produced differs widely across countries depending on many factors such as the methodology adopted to implement health accounts, the health data information landscape, data availability, but also administrative and cultural norms. That said, there are some communalities in best practice that can be discerned. First, there should be clear operational procedures in place that set out the annual production cycle with a division of responsibilities among health accounts team members and possible collaboration partners. This requires establishing a coherent production timeline from the initial acquisition of the various input data and their validation, the processing of data and the calculation of the health accounts, through to the final review of the results and analyses, and then publication as well as dissemination of the accounts and associated products.

Sufficient staff with the correct skill-mix and an adequate IT infrastructure to manage the country-specific data landscape are needed to accomplish this cycle. For a smooth regular production of health accounts, processes should be standardised as much as possible. That said, there should be an iterative stepwise approach that strives for continuous excellence. Reviewing and improving data sources, methods and processes for future production rounds based on past experience is a vital component in the institutionalisation of health accounts. Quality assurance at all steps in the production cycle is also key. Finally, comprehensive documentation of the different stages in the production process, the methodology used, and the various calculation steps is important to efficiently sustain the process and to maintain capacity quickly when faced with team changes.

Developing dissemination strategies to maximise impact of health accounts and their policy use is also a key component of a successful institutionalisation. Best practices suggest producing a suite of outputs for different users to maximise outreach and impact. This should range from media releases and accompanying data tables to raise awareness and communicate high-level results to a broad audience to more in-depth analyses, which also places health spending into a wider policy context. It is clear that the nature of these analyses needs to focus on topics of high relevance to the country to be able to contribute to policy debates. The organisation of high-level events for publication and discussion of health accounts results have proved to be an effective way to further raise awareness and increase the relevance of health accounts results.

Widespread use of health accounts to inform health policy is clearly an important ultimate objective of health accounts institutionalisation beyond the production itself. However, health accounts teams may have only limited influence on this aspect. But strategies to engage with staff in health ministries, parliamentarians, civil society representatives and the different stakeholders such as health professional organisations, insurers or health providers can contribute to an increased policy use which in turn can trigger demand for more detailed health expenditure analysis, reinforcing a positive feedback loop.

In all of this, it is critical that health accounts can be adapted to respond to changing (and growing) health spending information needs. The institutionalisation in countries needs to reflect this to maintain and potentially increase the policy relevance of health accounts data.