Institutionalising Health Accounts in Brazil

7. Strengthening health accounts in Brazil: Institutionalisation, governance, and policy impact

Abstract

To have any policy impact, health accounts should be fully institutionalised, and its results widely disseminated. This chapter highlights how health accounts production in Brazil could be strengthened to fully unlock its potential. Based on best practice in OECD countries, it discusses how the governance of health accounts production could be organised as well as some technical aspects for the health accounts production process, with the aim to lay out a path for a full institutionalisation of health accounts in Brazil. It also gives examples of comprehensive dissemination strategies developed in OECD to maximise the impact of health accounts.

Health accounts serve as a vital tool for informing health policy, enabling evidence‑based decision-making, resource allocation, and system performance monitoring. However, to fully realise their potential, their production must be systematically institutionalised, and their results should be widely disseminated. In Brazil, building on existing efforts, further progress can be made by drawing on the experiences of other countries that have successfully strengthened their health accounts.

A well-established production of health accounts ensures consistency, comparability, and sustainability in analysis. It also facilitates integration with broader health and economic policy making. Equally important is the dissemination of health accounts to policy makers, researchers, and the public, fostering transparency and informed debate on health financing and expenditures.

Drawing on the experiences of around a dozen OECD countries, best practices and key lessons can be identified to guide Brazil’s efforts to strengthen its health accounts (OECD, 2025[1]). These insights highlight the importance of securing legal and institutional mandates, fostering inter-agency collaboration, investing in technical capacity, and developing user-friendly communication strategies. By incorporating these elements, Brazil can further enhance the effectiveness of its health accounts, ultimately contributing to more efficient and equitable healthcare policies.

7.1. Institutionalisation: Building a strong foundation

The 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. While there is no universal approach to institutionalising health accounts, the experiences from OECD countries highlight some best practices that can guide countries in tailoring their frameworks to fit their unique health systems, data landscapes, and administrative structures (OECD, 2025[1]). For Brazil, strengthening institutional arrangements and governance mechanisms will be key to ensuring the sustainability, reliability, and policy relevance of its health accounts.

7.1.1. Suitable governance and institutional arrangements

A well-structured governance framework is essential for ensuring the credibility and sustainability of health accounts. Different countries have adopted varying institutional models, each with advantages and trade‑offs.

One approach is to assign the responsibility for delivering health accounts to the Ministry of Health, ensuring that expenditure data are closely linked to health policy discussions. This can facilitate rapid responses to emerging policy needs and align health accounts with broader strategic objectives. However, ministries may lack the technical expertise, financial analytical capacity, or the cross-sectoral perspective required for comprehensive analysis.

The main alternative is for countries to entrust health accounts production to their National Statistical Institutes (NSIs), which typically offer strong technical expertise, methodological consistency, and long-term institutional stability. On the downside, NSIs may not be as closely connected to health policy makers, potentially limiting the direct use of health accounts in decision-making.

A further option is to institutionalise health accounts within independent health agencies or through multi‑institutional collaborations involving health ministries, statistical offices, and academic institutions. These hybrid models can leverage the strengths of different institutions, ensuring both technical rigor and policy relevance. However, they require well-defined co‑ordination mechanisms to avoid duplication of efforts and ensure accountability.

A key factor in ensuring the sustainability of health accounts is a legal or regulatory mandate for their production. In many countries, health accounts are legally required, providing a stable framework for funding, staffing, and data access. A legal basis or mandate can also facilitate co‑operation with data providers, such as insurers and healthcare providers. While some countries maintain robust health accounts production without formal legislation, strong institutional commitment remains essential for long-term success.

7.1.2. Robust and accessible data systems

The production of health accounts depends on integrating data from multiple sources, including government expenditure records, insurance claims, household surveys, and private sector reports. Establishing and maintaining strong relationships with data providers and stakeholders is critical to ensuring data completeness, accuracy, and timeliness.

In many countries, data acquisition is based on informal agreements with data holders. While this can provide flexibility, reliance on voluntary co‑operation may lead to inconsistencies over time. To mitigate this risk, some governments have established formal data-sharing agreements, particularly with private healthcare providers and insurers. These agreements help standardise reporting, improve data reliability, and ensure regular updates.

A good number of OECD countries have also established health accounts expert groups composed of specialists from government agencies, academia, and various independent organisations that are active in the area of healthcare. These groups provide technical guidance, advise on methodological improvements, support data interpretation and can also serve to ensure quality of health accounts results. Equally important, they help build trust among stakeholders and ensure that health accounts reflect the realities of the health system.

Beyond their technical role, expert groups can also contribute to enhancing transparency and legitimacy by facilitating peer reviews and feedback mechanisms. This process strengthens the credibility of health accounts, making them more likely to be used in policy discussions and public debates.

7.1.3. Clear technical processes and sufficient capacity

The technical process of producing health accounts varies across countries, shaped by differences in administrative structures, data availability, and institutional culture. However, best practices point to several key principles that support efficient and sustainable production:

• Clear operational procedures: A well-defined production cycle ensures that data collection, validation, processing, and analysis are carried out systematically. A structured timeline helps co‑ordinate efforts across institutions and prevents delays in publication.

• Standardisation with flexibility: While health accounts should follow established guidelines for consistency, they should also allow for continuous improvement. Regular reviews to update data sources, classifications, and methodologies are essential to increasing accuracy.

• Adequate capacity and infrastructure: A dedicated team with expertise across health economics, statistics, and data science is essential for producing high-quality health accounts. Additionally, investment in IT systems and data management tools can improve efficiency and reduce errors.

• Robust quality assurance: Implementing validation checks at every stage of the production process ensures data reliability. Peer reviews, external audits, and automated consistency checks further enhance accuracy.

• Comprehensive documentation: Recording methodological decisions, data sources, and calculation methods ensures continuity and institutional memory. This is particularly important for mitigating disruptions due to staff turnover or organisational changes.

Ultimately, the objective of institutionalising health accounts is to ensure their widespread use in shaping health policy. While health accounts teams may have limited direct influence over policy decisions, proactive engagement with key stakeholders – such as health ministry officials, parliamentarians, civil society representatives, health professional organisations, insurers, and healthcare providers – can significantly enhance their impact. By fostering dialogue and collaboration, these efforts can encourage greater policy uptake of health accounts data, ultimately generating demand for more detailed health expenditure analyses. This, in turn, strengthens a positive feedback loop, where increased use of health accounts drives further investment in their quality and relevance, reinforcing their role as a vital tool for evidence‑based decision-making in healthcare.

7.1.4. The path forward for Brazil: Institutionalising health accounts

With the production of its health accounts manual and the latest health expenditure estimates for year 2022, Brazil has made notable progress in developing health accounts. Building on the experience over the last decade and the renewed initiative, Brazil is in a favourable position to fully institutionalise the production of health accounts. Key developments point to strong potential for success, as the country moves toward a more structured and sustainable approach.

• One encouraging sign is the strong support from high-level policy makers within the Brazilian Government to produce and use this data on a regular basis. A health accounts workshop in June 2024 opened by the Secretary of Science, Technology, and Innovation of the Ministry of Health alongside the President of the Brazilian Institute of Geography and Statistics (IBGE), the President of the Brazil Hospital Services Company (EBERSH), and high-level presentation from the National Supplementary Health Agency (ANS) and the Pan-American Health Organisation (PAHO) demonstrated clear public sector commitment to the initiative. The event brought together a diverse group of stakeholders – including representatives from states, municipalities, the private health insurance agency, several federal ministries and academia indicating a broad, engaged interest in strengthening health accounts and a solid foundation for institutionalisation.

• The new Brazilian health accounts team composed of members of different institutions brings complementary expertise to the project. Led by project managers from the Department of Health Economics and Development (DESID) within the Ministry of Health, it also includes experts from the National Supplementary Health Agency (ANS)1 and the Brazilian Institute of Geography and Statistics (IBGE). The arrangement foresees that each agency is leading the estimates for one or more specific key financing schemes, whereas the Ministry of Health focuses on SUS and other public spending (HF1), the ANS on voluntary health insurance (HF21) and the IBGE on out-of-pocket spending (HF3), with the Ministry of Health also assuming the co‑ordination role. This type of arrangement is somewhat unusual compared to OECD countries, where the production of health accounts is generally concentrated within a single agency. However, it is not dissimilar to the situation in Korea, where several health and insurance agencies, under the leadership of a university professor collectively produce health accounts annually. In such an arrangement, the co‑operation between the different agencies should be formalised to ensure that each actor has clear and defined responsibilities.

• Many OECD countries that have successfully institutionalised health accounts have established expert groups to support the health accounts team in both the production and dissemination processes. These expert groups are considered a best practice, as they provide valuable advice on methodological and statistical issues related to health spending estimates, as well as on the policy implications of the results. They are often consulted prior to the release of new data, serving as an additional layer of “quality assurance”. The composition of these groups varies, with experts coming from diverse backgrounds within the health system.

  • In France, for example, the advisory group includes over 50 experts from various ministries, health agencies, professional associations, trade unions, patient groups, and academia.

  • Canada has two distinct expert bodies: one technical group, comprising statistical and data experts from federal and provincial agencies, and a political group that focuses on interpreting health accounts results within the broader health policy context, advising on dissemination strategies, and suggesting future areas of focus.

• Brazil should consider the formal establishment of such an advisory group, drawing from the success of the workshop held in June 2024, which brought together over 80 experts from various stakeholders, as well as already established partnerships. In forming such a group, it would be beneficial to ensure the inclusion of key stakeholders to foster a comprehensive and inclusive approach. This could include representatives from states and municipalities (via CONASS and CONASEMS), other federal ministries such as finance, health providers, health professionals, as well as researchers and research institutes. The primary focus of the group should be on improving the quality of health accounts but also ensuring that the results are placed within the broader context of Brazil’s health system. By doing so, the group would not only provide crucial expertise but also add legitimacy to this new area of work, reinforcing its importance for policy development.

• In many OECD countries, there is a legal mandate to regularly produce health accounts. This is true for member states of the European Union where there is a mandate based on European legislation. But even without such supra-national legislation, some countries embed their production in national legislation. In some other countries, such as Australia or Canada, there exists no explicit legal text requiring the annual production of health accounts, but a mandate can be derived implicitly through the mission statement of the agencies responsible for health accounts production. Hence, while not a prerequisite, a legal mandate to produce health accounts can support the successful institutionalisation of health accounts. Of course, such a mandate should go hand in hand with the necessary medium to long-term financial commitments and staffing decisions to ensure that a dedicated health accounts team can be permanently sustained.

• Finally, one lesson from Brazil’s previous pilot implementations of health accounts is that the methodology of how health accounts are set up, data sources used, and estimation techniques applied should be thoroughly documented. So far, this had been missing and is one of the challenges to migrate from a pilot implementation to a fully-fledged institutionalisation. Most OECD countries with a long history of health accounts production have established processes for the various production steps in place. Typically, these are documented in various files, and new staff can quickly build up knowledge to ensure a seamless health accounts production. However, in many OECD countries, there has been some continuity in the key members of the health accounts teams. With the re‑engagement in the health accounts work, Brazil has made a comprehensive documentation of the production process a priority, and – alongside the production of new health spending estimates – the health accounts team has drafted an internal handbook which should enable new staff to quickly understand the key health accounts concepts, classifications and categories, available data sources and estimation techniques. This is to be commended. While Costa Rica is currently engaged in a similar activity, most OECD countries do not have a such a “centralised inventory“ but rely on various different documents or files. Yet, in line with best practice, Brazil also considers publishing a methodological document to accompanying the release of new data. This adds legitimacy to the data and can also serve as a tool to potentially improve quality in the future. Mexico, for example, publishes annually a thorough health accounts quality report, also using a traffic light system to score their data sources (and data providers) on indicators such as timeliness, completeness, consistency with classifications, and validity of data (Gobierno de México, 2025[2]).

7.2. Dissemination: Maximising the impact

The OECD review (OECD, 2025[1]) points to the development of dissemination strategies to maximise impact of health accounts and their policy use as a key component of 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 place health spending into a wider policy context to engage with expert audiences including health ministries and decision-makers. 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.

Brazil has released results of their health accounts in the past (Ministério da Saúde, Fiocruz, 2018[3]; Brasil. Ministério da Saúde, 2022[4]), but these publications do not appear to have had the desired effect of raising awareness of the data among key stakeholders (as well as the general public), which would eventually lead to an increased policy use. These publications described the first results in allocating spending of SUS for the years 2010 to 2014 (Ministério da Saúde, Fiocruz, 2018[3]) and then expanded to overall health spending for the years 2015 to 2019 (Brasil. Ministério da Saúde, 2022[4]) based on SHA 2011 accounting standards. However, less focus was put on discussing these results in the context of an ongoing health policy debate in Brazil and providing an international perspective.

In that regard, Brazil could learn from dissemination strategies in a number of OECD countries. France, for example, has developed a very elaborate dissemination strategy to maximise the impact of health accounts in the country (Box 7.1). It combines the annual publication of a substantial report where the latest health spending trends are put into a wider health policy context with high-level discussions on ongoing policy issues. The timing of the release is closely aligned with the budget cycle to have maximum policy impact right before the start of parliamentary discussions of the health budget. Finally, the health accounts publication is presented and discussed at an annual meeting of the health accounts commission (a group comprised of over 50 health financing experts), typically in the presence of the minister responsible for health, which adds some weight to the perception of the importance of this work in the eyes of the public.

To spread the knowledge of health accounts in the academic community as well as to obtain additional legitimacy to the data and the methodologies applied, health accounts experts in Korea and the United States regularly publish health accounts results and analysis in peer-reviewed scientific journals (Jeong, 2011[5]; Martin et al., 2025[6]).

A number of countries including Australia and Canada have developed a range of products to disseminate health accounts results targeted at different users. These range from infographics and social media posts with key messages to detailed analysis for an audience of health policy or data experts.

Box 7.1. The annual launch of the Comptes de la santé in France

The Direction de la Recherche, des Études, de l’Évaluation et des Statistiques (DREES) of the Ministry of Health in France has long been responsible for health accounts production. The most recent expenditure data including a revised time series is generally published each September of the following year, alongside a very detailed analysis of the health spending data and placing it in the context of important ongoing policy discussions. The 2024 edition of the French health account publication ran to nearly 300 pages (DREES, 2024[7]).

The timing of the release is important, not only dictated by data availability but chosen to have a tangible impact on health policy discussions: notably, at the end of September, the Social Security Financing Bill (Projet de loi de financement de la sécurité sociale (PLFSS)) for the following year is adopted in the Council of Ministers before being discussed in parliament. The Comptes de la Santé annual report is predominantly based on the French-specific version of NHA and covers detailed analysis of the trends for each individual healthcare service and financing arrangement (both in current and constant prices). It also includes a substantial comparison of French health spending in an international context for which the SHA 2011 framework is used (the differences between the French NHA and the French SHA data are also explained at length in the report). Some methodological information on the health expenditure calculations is also covered in the annexes to the report. Finally, the publication always includes some pertinent and complementary health policy analysis which goes beyond health spending. In the 2024 edition, for example, their analysis explored the implications of a policy reform to reduce co-payments for specific medical goods and the evolution of the compensation for sick leave.

The publication is released on the website of the Ministry of Health to align with the annual meeting of the health accounts commission (Commission des comptes de la santé). This meeting is a half-day event, frequently opened by the minister, and attended by members of the commission and invited experts (around 50‑80 people). In addition to presenting and discussing the findings of the last health accounts data, the agenda includes complementary items covering timely health policy topics (e.g. dental care, mental health, long-term care). The OECD regularly attends the annual Commission meetings providing an international perspective on some of the results and topics discussed.

7.2.1. Brazil’s health accounts: Key lessons for success

In summary, Brazil has a valuable opportunity to draw inspiration from OECD countries and take decisive steps to fully institutionalise the production of health accounts and develop a comprehensive dissemination strategy. This includes establishing a robust legal and financial foundation for the regular compilation of high-quality health accounts that respond to national needs and priorities. The goal should be to produce timely and relevant annual health accounts that are sustainably resourced and systematically embedded within Brazil’s health information infrastructure. Fortunately, Brazil is not starting from scratch – it can build on existing work and leverage its established partnerships with key stakeholders. One crucial step that remains is to formalise the process through a legal mandate, ensuring continuity and long-term capacity. Additionally, the development of a national handbook on the methodology used in Brazil is a valuable resource that can support consistency and ease the transition during changes in personnel or institutional roles.

Looking ahead, Brazil should also explore the development of a regional breakdown of health spending. This would greatly enhance the analytical power and policy relevance of the health accounts. Large OECD countries such as Australia, Canada and the United States have demonstrated the value of sub-national comparisons in informing policy and addressing regional disparities. In Brazil’s case, where socio-economic and health disparities across regions are even more pronounced, regional health accounts could play an essential role in guiding more equitable policy decisions. Notably, other Latin American countries like Chile and Mexico have also taken steps to publish regional health spending data, providing useful models for Brazil to consider.

Finally, to fully capitalise on the potential of health accounts, Brazil should develop a coherent dissemination strategy that links the release of new data with timely policy analysis. Aligning data outputs with national health policy priorities – and presenting them through high-level policy discussions led by senior health officials – can elevate the visibility and impact of health accounts. A well-crafted dissemination approach is essential not only to raise awareness but also to demonstrate the practical utility of the data, thereby fostering sustained demand and policy engagement. To be truly effective, health accounts must be designed and communicated in a way that resonates with Brazil’s specific policy landscape and stakeholder interests.

References

[4] Brasil. Ministério da Saúde (2022), Contas de saúde na perspectiva da contabilidade internacional : conta SHA para o Brasil, 2015 a 2019, Ipea, https://doi.org/10.38116/978-65-5635-028-8.

[7] DREES (2024), Les dépenses de santé en 2023 - Résultats des comptes de la santé, Direction de la recherche, des études, de l’évaluation et des statistiques, https://drees.solidarites-sante.gouv.fr/sites/default/files/2024-11/CNS24.pdf.

[2] Gobierno de México (2025), SICUENTAS - Gasto Público en Salud, http://www.dgis.salud.gob.mx/contenidos/basesdedatos/da_sicuentas_gobmx.html.

[5] Jeong, H. (2011), “Korea’s National Health Insurance—Lessons From The Past Three Decades”, Health Affairs, Vol. 30/1, pp. 136-144, https://doi.org/10.1377/hlthaff.2008.0816.

[6] Martin, A. et al. (2025), “National Health Expenditures In 2023: Faster Growth As Insurance Coverage And Utilization Increased”, Health Affairs, Vol. 44/1, https://doi.org/10.1377/hlthaff.2024.01375.

[3] Ministério da Saúde, Fiocruz (2018), Contas do SUS na perspectiva da contabilidade internacional: Brasil, 2010-2014, Ministério da Saúde; Fiocruz, https://bvsms.saude.gov.br/bvs/publicacoes/contas_SUS_perspectiva_contabilidade_internacional_2010_2014.pdf.

[1] OECD (2025), Best Practice in Institutionalising Health Accounts: Learning from Experiences in 13 OECD Countries, OECD Publishing, Paris, https://doi.org/10.1787/cf997130-en.

Note

← 1.  The ANS is also a federal agency.