The study is based on secondary data from three Malawi National Health Accounts (NHA) reports [18
]. The first NHA exercise covered the Financial Year 1998/99; the second round included the Financial years 2002/2003, 2003/2004 and 2004/2005 and, in addition to the general NHA developed sub-accounts for three programme areas, namely HIV/AIDS, reproductive and child health programmes. The last one covered the Financial Year 2005/2006. Besides the general NHA, this also included sub-accounts for HIV/AIDS, malaria and tuberculosis. The focus of this study is on the general NHA. Implications of the NHA data are analysed in terms of their relevance to policy use within the framework of the various NHA entities.
Definition of terms and core health financing indicators
In order to have a clear understanding of the essence of the report, it is important to present the definition of the most commonly used terms in NHA as provided by the NHA Producers' Guide [7
i. Out-of-pocket payment: The direct outlays of households, including gratuities and payments in kind, made to health practitioners and suppliers of pharmaceuticals, therapeutic appliances and other goods and services whose primary intent is to contribute to the restoration or to the enhancement of the health status of individuals or population groups.
ii. Financing sources (FS): Institutions or entities that provide the funds used by the financing agents. They are the originators of the funds (e.g. Ministry of Finance, households, donors etc).
iii. Financing agents (HF): entities or institutions that channel funds provided from the financing sources and use those funds to pay for or purchase the activities inside the health accounts boundary. In the Malawian case, the financing agents included: Ministry of Health, National AIDS Commission, Other Ministries and Government Agencies (Ministries of Defense, Home Affairs, Education, Training Institutions, Regulatory Bodies-Nursing, Medical, Pharmacy and Poisonous Board etc), local authorities (Cities, Town and District Assemblies), private insurance enterprises (Medical Aid Society of Malawi), private households' out-of-pocket payment, non-governmental organizations (non-profit institutions), Christian Health Association of Malawi (CHAM), local non-governmental organizations, private firms and corporations, rest of the world (donors and international non-governmental organizations).
iv. Providers (HP): Entities that receive money in exchange for or in anticipation of producing the activities inside the health accounts boundary. They are the providers of health care services, e.g. hospitals, providers of ambulatory health care, pharmacies.
v. Health care functions (HC): The types of goods and services provided and activities performed within the health accounts boundary, e.g. curative care, services of rehabilitative care, prevention and public health services, health administration and health insurance, health-related functions (e.g. capital formation for health care provider institutions, education and Training of Health Personnel, research and development in health, environmental health and food, hygiene and drinking water control).
Overview of the NHA methodology
The three Malawi National Health Accounts (NHA) studies used the standard internationally agreed NHA methods contained guidelines for low-income and middle income countries published by World Health Organization, World Bank and the United States Agency for International Development [7
National health expenditure encompasses all expenditures for activities whose primary purpose is to restore, improve and maintain health for the nation and for individuals during a defined period of time [7
]. National health accounts (NHA) are a tool for systematic, comprehensive, and consistent monitoring of resource flows in a country's health system. Specifically, the NHA tracks the flow of health system resources from financing sources (i.e. entities that provide the funds), financing agents (entities that receive and use funds to pay for health activities), providers (entities that receive money to produce health activities), functions (types of goods and services provided) and health system inputs to beneficiaries [7
The total health expenditures consist of public funds, private funds and rest of the world funds. Public funds consist of mainly funds from central government revenue, regional and municipal government revenue and return on assets held by a public entity. The private funds compose of essentially employer funds, household funds and funds from non-profit institutions serving individuals. The rest of the world funds include bilateral grants, multilateral international grants and funds from funds contributed by institutions (including foundations) and individuals outside the country.
The commonly used national health accounts indicators include: levels of government and total per capita expenditure on health; total expenditure on health as a percentage of gross domestic product (GDP); general government expenditure on health as a percentage of total expenditure on health; private expenditure on health as a percentage of total expenditure on health; general government expenditure on health as a percentage of total government expenditure; external expenditure as a percentage of total expenditure on health; social security expenditure on health as a percentage of general government expenditure on health; out-of-pocket expenditure as a percentage of private expenditure on health; and private prepaid plans as a percentage of private expenditure on health. Sub-national health accounts entails producing those indicators by disease (e.g. HIV/AIDS, TB) or health programme (e.g. reproductive health, child health).
The three Malawian studies entailed populating with data the following four general (non-disease or program specific) NHA tables:
• Financing Sources (FS) × Financing Agents (HF);
• Financing Agents (HF) × Health Providers (HP);
• Financing Agents (HF) × Health Functions (HC); and
• Health Providers (HP) × Health Functions (HC).
However, the second and third studies in addition to the above mentioned general NHA tables they produced NHA sub-accounts of HIV/AIDS, Malaria and TB.
The three studies used both primary and secondary data for financial years 1998/99, 2002/2003-2004/2005 and 2005/2006 collected from institutions and a specialist survey of People Living with HIV and AIDS.
The data was collected by trained research assistants, supervised by multi-sectoral NHA Technical Team of representatives from the relevant government ministries, United Nations agencies (WHO, UNDP and UNAIDS) and USAID-funded Partners for Health Reformplus Project (PHRplus). The co-authors EK and FM were closely involved in the design, analysis and writing of the three studies; and EZA was WHO's consultant in two of the studies. The questionnaires were tailored for each of the following data sources.
Firstly, data was collected from all the public sector institutions providing and receiving health funds, and providing health care goods and services, including: Ministry of Health, Ministry of Finance, Ministry of Foreign Affaires, Ministry of Local Government, Municipalities/Local Authorities, National AIDS Commission, Ministry of Defense and Home Affairs, Ministry of Education, Ministry of Women, Child Welfare and Community Services, Ministry of Agriculture, Nurses and Midwives Council, Medical Council; Pharmacy, Medicines and Poisonous board, and School of Health Sciences. The response rate was 100% in the three studies. The key informant interviews with those data sources was complemented with secondary data collection from government budget books, consolidated annual appropriation accounts, audited accounts, expenditure print-outs and ledgers.
Secondly, since no database exists for all donor (both bilateral and multilateral) expenditures on health in Malawi, a special donor survey targeting all 19 donors involved in health was undertaken to capture donor contributions for health using a specially designed questionnaire. The response rate for the first study was not noted. However, the response rates for other studies were: 40% and 47% in the second and third studies respectively.
Thirdly, in order to estimate NGO spending on health, a list of all NGOs and implementing agencies working in the health sector and HIV/AIDS sub-sector was obtained from Action Aid International Malawi. The list was reviewed to identify NGOs which were still functional during the time of the survey, in order to avoid sampling non-functional NGOs and community-based organizations (CBOs). Key informant interviews were used to select a total of 120 NGOs/CBOs. The response rate was 60% in the second and 47% in the third study.
Fourthly, data on employer and employees premium contributions to the medical aid society of Malawi (MASM), the only non-profit health insurance organization in the country, was obtained using a specially designed questionnaire. The quantity and quality of the data provided by MASM were excellent.
Fifthly, employers and employees in Malawi contribute to health expenditures through provision of onsite health facilities; reimbursements to employees; employer/employee contribution to an outside health insurance scheme, in particular MASM; and in-house health insurance scheme. A list of all firms and corporations registered in Malawi was obtained from the Malawi Chamber of Commerce. Key informant interviews were held and a comprehensive list of all firms involved in health and HIV and AIDS financing and delivery was prepared. Research assistants with a questionnaire were sent to all those firms. The response rates were: 80%, 65% and 86% in the first, second and third studies respectively. The information collected was supplemented by that collected from MASM.
Sixthly, surveys of purposely selected providers by different levels of care, ownership and region were carried out by research assistants and the NHA Team. The questionnaires were designed and used to collect the relevant information on utilization of various services, in particular for HIV/AIDS, reproductive health and child health (children age 0-5 years) and expenditure figures by source of finance/financing agent and function.
Seventhly, in order to estimate household out-of-pocket spending, national Integrated Household Survey results for 2004/05 were used. This estimated that health care consumes 1.3% of total private consumption. The figures were then distributed to various providers and functions using the household health expenditure and utilization survey of 2000.
Lastly, a People Living with HIV/AIDS (PLWHA) survey was conducted targeting confirmed HIV positive persons in Malawi age 15 years and older at the time of the survey. The major types of information obtained included utilization of health care services, household assets and expenditures for inpatient and outpatient care. Location sampling was used to identify the target population. The locations identified for the survey were: (a) PLWHA receiving ARVs in health centres and hospitals; and PLWHA receiving PMTCT. A sample of 900 individuals throughout the country was selected. The response rates were 93% in the second and third studies. The first study did not have sub-national health accounts.
The data processing consisted of office editing of questionnaires, data cleaning (validation and consistency checks), data entry and analysis using Microsoft Excel software.
Limitations of the three Malawi NHA studies
Reliability of estimates
data sources often provided conflicting data and lots of time had to be spent crosschecking and in some cases making value judgments of the data.
Incompleteness of data
Despite the research assistants' and NHA Team's repeated attempts at data collection, the response rate from donors and NGOs was poor and other sources had to be used to estimate their spending.
Unavailability of essential data in national health management information system (HMIS)
HMIS database did not have essential data on outpatient visits and inpatient admissions data by disease and facility type. Essential indicators such as bed occupancy rates, average length of stay, bed turnover rates, utilization by age, gender, type of facility-central hospital, district hospital, health centres are not reported to HMIS. Also it did not contain data by private-for-profit health sector.
Serious problems encountered with provider surveys
Funding and health services delivery are integrated at the health facility level making it extremely difficult for providers to disaggregate expenditures by source, function (curative, rehabilitative, ancillary services etc.) and disease type, e.g. HIV/AIDS. Furthermore, most private for-profit facilities were unwilling to provide their expenditures and revenue data, perhaps fearing that the data would be used for taxation purposes. Data on reported cause of morbidity or care seeking, number of bed days, discharge etc. were available in patient registers, but also were in a very poor state.