Health accounts are a vital tool to obtain comprehensive and internationally comparable data on health expenditure and financing, which is key information to assess the performance of health systems. After several pilot implementations over the past decade, Brazil is now committed to institutionalising the annual production of health accounts at a more granular level. This will unlock the potential of health accounts to better inform health policy decision making. This report reviews efforts to institutionalise health accounts in Brazil aligned with international standards. It analyses the comprehensiveness of reporting, the data sources used, and methodologies applied to estimate health spending. It also provides recommendations on how to best institutionalise the regular production of health accounts and disseminate the results for greater policy impact and suggests how the current work could be further expanded in the future. Finally, the report analyses the first health expenditure data for Brazil generated with this new methodology in comparison to health spending in OECD countries.
Institutionalising Health Accounts in Brazil
Abstract
Executive summary
The systematic monitoring of the financial resources dedicated to health is crucial in any health system performance assessment and nearly all OECD countries have institutionalised the annual production of national health accounts as a key instrument to track health spending. Brazil has a long history in producing health satellite accounts to measure the health sector’s contribution to the overall economy and has also piloted the implementation of national health accounts over the past decade to provide more focused and detailed insights into health expenditure and financing. Yet, while two significant reports have been published, these previous studies have not resulted in a full institutionalisation of health accounts in Brazil.
In 2023, the Ministry of Health of Brazil decided to re‑engage in this work with the intention of fully institutionalising the annual production of health accounts to unlock its analytical potential. The OECD Secretariat is supporting the ministry in this endeavour and -with this report- has reviewed the new initiative to institutionalise health accounts in Brazil to ensure that it is line with international standards. The report also provides recommendations on how to best institutionalise the regular production of health accounts and disseminate its results, and indicates how the current work could be possibly expanded in the future.
In terms of the overall assessment the OECD concludes that:
The proposed methodology used to calculate health spending in Brazil is sufficiently aligned with international standards and practices to ensure international comparability.
All key financing schemes have been identified and for each of these appropriate distribution keys have been generated to allow an allocation of health spending to the various health services.
In addition, it is found that the level of detail that Brazil is able to provide from a service perspective generally meets international reporting requirements and, in some cases, goes beyond what several OECD countries can currently report. However, some data gaps exist and – looking towards future health accounts production rounds – it is recommended that Brazil should continue to explore how they could be filled:
For some of the government financing schemes spending data could not be identified.
Some types of financing schemes albeit of lesser importance in Brazil are missing entirely.
Finally, regarding the estimation techniques utilised, while there is confidence in the overall methodology, in some cases it could warrant further review or refinement. Two important areas are noted:
The estimation methodology of overall out-of-pocket spending and the allocation to functional level.
The production of the distribution keys for spending by SUS appears to be methodologically sound in principle but there should be further investigation to assess the extent to which the underlying data source (SIGTAP) accurately reflects the prices for the various products and services, and update as required.
One essential component of the new initiative to institutionalise health accounts is to comprehensively document the production process, the data sources used, and the methodologies applied to derive health spending estimates. It is felt that the new health accounts manual, which the Brazilian health accounts team has drafted when producing new data for year 2022, is an important step towards a comprehensive documentation of this work. In general, the structure and content of the Brazilian manual is considered robust, providing the key methodological information for people who want to get a better understanding of how results are derived. In areas advising further improvements, there may be scope to provide additional detail on how high-level “control totals” and distribution keys are derived in practice, including some specific examples.
Putting the new health accounts results for 2022 into an international context reveals a number of important insights and specificities of the Brazilian health system:
With 45% in total health spending, the financing share of compulsory schemes in Brazil is much lower than in OECD countries (75%). At the same time, the role of voluntary health insurance (27% of total spending) is much more pronounced than in any OECD country. On average, this scheme accounts only around 5% of overall health spending across the OECD. The share of out-of-pocket spending in Brazil (27%) is above the OECD average (19%).
The share of health spending allocated to outpatient curative care is higher in Brazil than across the OECD, while the share of inpatient services is lower. The extensive use of laboratory and imaging services in Brazil (representing 6% of total health expenditure each) are contributing to the high outpatient share. Brazil dedicated around 19% of its financial resources to basic healthcare services, a proxy measure used to compare spending primary healthcare internationally. This was similar to the OECD average. Conversely, Brazil only dedicated 22% of overall health expenditure to inpatient care in hospitals. Moreover, the overall proportion of total health expenditure dedicated to health system administration in Brazil (6%) is above most other OECD countries, reflecting somewhat the known complexities of managing SUS but also the management costs of the large private health sector in the country.
When analysing financial coverage of healthcare costs in Brazil, one finding that stands out is the substantial difference in coverage across goods and services. While overall spending on generalist outpatient care is largely covered by compulsory schemes (85%), only around 10% of all pharmaceutical costs are covered by the public pursue. This can point to gaps in the SUS benefit basket but also to problems in effectively accessing items that are publicly covered.
A full institutionalisation of health accounts production is required to obtain this type of information on an annual basis. Based on best practices across OECD countries, a number of factors were identified that facilitate such an institutionalisation.
Establishing a dedicated national health accounts team with sufficient staff and the appropriate skill-mix and access to adequate IT infrastructure is vital.
Having a legal a mandate for the production of health accounts is not a requirement but can in some instances accelerate and ensure the regular and sustainable production of this data.
Developing and maintaining good relationships with data providers and stakeholders is crucial and the establishment of an expert group to advise on the methodology to produce health accounts and on the interpretation of results has proven to be useful in many OECD countries.
The technical production process should be standardised as much as possible and needs to be considered as an iterative process, driven by the desire to continuously improve the health accounts methodology by incorporating new data sources and information whenever available.
Quality assurance across all steps in the production process and results and a comprehensive documentation of methods is also important.
Many of these elements are already aligned in Brazil, and the country can also leverage the strong high-level support for this stream of work.
In order for health accounts results to more efficiently inform policy making, Brazil should strengthen its dissemination strategy and develop a dissemination plan, including a suite of outputs for different users to maximise outreach and impact. This should range from media releases and accompanying data tables for a broad audience to more in-depth analyses for informed users. The organisation of high-level events to support the dissemination of results and to put them in wider health policy context raises the profile of health accounts data and increases the likelihood that the data is actually used to inform policy making. The publication of metadata and methodological reports can add to the legitimacy of the work and can be a way to promote this work among the research community.
The publication of the Brazilian national health accounts manual and the dissemination of the new 2022 results are important milestones towards a full institutionalisation of health accounts in Brazil but there remains scope to go further. First, to increase the relevance and potential use of the results, there should be efforts to improve the timeliness of the estimates. Then there is more untapped potential of analysis for Brazil and efforts should be made to explore an expansion of the current health accounts implementation status. This includes an allocation of health spending to health providers, the identification of revenue sources of the various financing schemes and investigating the feasibility to break down health spending by regions or states.
