NHA-Pakistan-2021-22.pdf

Pakistan Bureau of Statistics National Health Accounts

Pakistan Bureau of Statistics National Health Accounts

ii

National Health Accounts-Pakistan 2021-22

Pakistan Bureau of Statistics National Health Accounts

iii Dr. Naeem uz Zafar Chief Statistician Pakistan Bureau of Statistics Planning, Development
& Special Initiatives Division, Islamabad Government of Pakistan

21-Statistics House, Mauve Area, G-9/1, Islamabad, Pakistan.

Tel:

+9251 9106515 E-mail: [email protected]
Website: www.pbs.gov.pk

Syed Ejaz Ali Shah Wasti Member, National Accounts Pakistan Bureau of Statistics Planning, Development
& Special Initiatives Division, Islamabad Government of Pakistan

21-Statistics House, Mauve Area, G-9/1, Islamabad, Pakistan.

Tel:

+9251 9106516 Website: www.pbs.gov.pk
E-mail: [email protected]

Pakistan Bureau of Statistics National Health Accounts

iv Foreword

This report presents the 9 th round of National Health Accounts (NHA) for Pakistan, compiled by the Pakistan Bureau of Statistics (PBS) with reference year 2021-22. The preceding 8th round was unveiled in September 2022, covering data for the fiscal year 2019-20. NHA is a framework to track a country’s health expenditures. It ensures comparability across countries and over time. NHA is designed to an- swer questions like ; (i) where do he alth re- sources come from (domestic versus external)? (ii) Who are the financing agents (government, insurance schemes, households, donors, NGOs)? (iii) What goods and services are pur- chased with these resources (curative, preven- tive, pharmaceuticals, etc.)? (iv) Where do these resources go (type of organization that provides health services)? NHA stand as a cornerstone of immense value, ensuring comparability across countries and over time. The meticulous moni- toring of health expenditures is indispensable for maintaining accountability to plans and budgets, facilitating effective prioritization and allocation of resources. Furthermore, NHA data assumes a pivotal role in evidence -based policymaking, providing essential guidance for decisions per- taining to health financing.
PBS has collected health expenditure data from all source agencies namely - Account- ant General Pakistan Revenues (AGPR) , its re- gional sub -offices, and Provincial Accountant Generals (AGs). Federal Sehat Sahulat Pro- gram (SSP) and KP SSP. Reimbursement of medical charges obtained from Controller Gen- eral of Accounts (CGA), Economic Affairs Divi- sion, Provincial Employees Social Security Insti- tutions, Military Accountant General, Military Lands & Cantonments Department, Ministry of Religious Affa irs, Zakat and Usher, Pakistan Bait-ul-Mal, and Provincial Finance Departments have provided the requisite data for this report
For the 9th round of NHA, Out-of-Pocket (OOP), health expenditure 2021-22 has been estimated by extrapolating the OOP health expenditures figures for the year 2018-19 (obtained from HIES 2018-19). Health expenditure of private health care providers has also been estimated by ex- trapolating forward the actual results of the cen- sus of big hospitals and survey of the rest of the providers conducted for the fiscal year 2009-10. Whereas, health expenditures of autonomous bodies and corporations under federal & provin- cial governments are estimated on the basis of
data obtained from the census of autonomous bodies and corporations conducted in 2011-12.
This report is anticipated to prove beneficial for researchers, policymakers, and other users seeking data on health financing. It aims to serve as a foundational resource, fostering evide nce- based planning and informing policies within the health sector of Pakistan. Suggestions for improvement of the report will be appreciated.

DR. NAEEM UZ ZAFAR Chief Statistician Pakistan Bureau of Statistics Islamabad, March, 2024

Pakistan Bureau of Statistics National Health Accounts

v Genesis of the Report

The compilation of the National Health Accounts -Pa- kistan report for 2021-22 owes to the persistent and tremendous efforts of the following staff of NHA sec- tion, Pakistan Bureau of Statistics.

Dr. Bahrawar Jan
Deputy Director General National Health Accounts

Ms. Shazia Begum Director National Health Accounts

Mr. Ihsan-ul-Haq Chief Statistical Officer National Health Accounts

Mr. Muhammad Rafique Statistical Officer National Health Accounts

Mr. Asghar Ali Narejo Statistical Assistant (Graphic Designer) Data Dissemination & Support Services

Pakistan Bureau of Statistics National Health Accounts

vi Preface

National Health Accounts (NHA) is a framework for estimating the total health expenditures (both public and private) at the national level. NHA methodology actually tracks the flow of funds through the health sector by compiling the four selected dimensions namely, (i) Financing sources (ii) Financing agents (iii) Health care providers & (iv) Health care func- tions. NHA is a standard set of matrices, or tables, that presents various aspects of a nation’s health ex- penditures and deals with the questions like, (i) who is financing health care in Pakistan? (ii) how much do various financing agents spend? and (iii) on what type of services? This globally ac- cepted tool based upon the expenditure review approach, highlights the “financial and fiscal health” of national health systems in Pakistan. In its 9th round, NHA has developed three classi- fications namely - financing sources, financing agents, and health care providers by incorporat- ing estimated OOP health expenditures and pri- vate health care providers’ health expenditures. Secondary data on health expenditures col- lected from various source agencies like CGA, AGPR, provincial AGs, MAG, ML&C, ESSIs, Provincial Zakat & Usher Departments, Pakistan Bait ul Mal etc. have also been incorporated in this report. NHA is an important tool designed particularly to assist policy -makers in understanding their health systems and improving health system performance. NHA mainly deals with the estima- tion of total health expenditures by covering both the Public & Pri vate sector of a country. NHA methodology organizes and presents health spending information in a such explorative way that a layman can easily understand and inter- pret the NHA results . It allows policymakers to understand the use of resources in a health sys- tem to evaluate impact of health reforms on dif- ferent segments of society. NHA can certainly demonstrate significant impact on better policy making and in a major shift in health policy for better healthcare in Pakistan. I am thankful to all respondents who have ex- tended their support for providing data to PBS for this important assignment. NHA section is in- deed grateful to Ms. Rabia Awan, Deputy Direc- tor General, PSLM section for her support to in- sert the OOP health expenditure questionnaire in the HIES as a permanent section. Moreover, I also appreciate the diligent efforts of Dr. Bahrawar Jan, Deputy Director General, Ms. Shazia Begum, Director, Mr. Ihsan-ul-Haq, Chief Statistical Officer, Mr. Muhammad Rafique, Sta- tistical Officer for the timely compilation of NHA report 2021-22. I hope that this report will provide the basis for evidence-based policymaking and innovative re- search in the field of health financing services.

SYED EJAZ ALI SHAH WASTI Member, National Accounts Pakistan Bureau of Statistics Islamabad, March, 2024

Pakistan Bureau of Statistics National Health Accounts

vii Contents Executive Summary ..................................................................................................................... xiv

1. Introduction .................................................................................................................................. 1 1.1 Scope, purpose and limits of health accounts ............................................................................ 3 1.2 Steps taken to develop NHA in Pakistan .................................................................................... 7
2. Results of NHA at National Level ............................................................................................... 9 2.1 Total health expenditure ........................................................................................................... 11 2.2 Financing sources ..................................................................................................................... 11 2.3 Financing agents....................................................................................................................... 14 2.3.1 Overview ................................................................................................................................ 14 Total Health Expenditure .............................................................................................................. 17 2.3.2 Civilian (territorial) government ............................................................................................. 18 2.3.3 Military health expenditures ............................................................................................... 19 2.3.4 Cantonment Boards ............................................................................................................... 19 2.3.5 Social Security ....................................................................................................................... 20 2.3.6 Zakat and Bait-ul-Mal ............................................................................................................ 20 2.3.7 Private Health Insurance ....................................................................................................... 21 2.3.8 Households OOP health expenditure .................................................................................... 22 2.3.9 Sehat Sahulat Programme .................................................................................................... 22 2.3.10Development Partners/Donors ............................................................................................. 24 2.3.11Local Non-Government Organizations ................................................................................. 24 2.4 Financing sources by financing agents .................................................................................... 26 2.5 Health Care Providers .............................................................................................................. 28 2.5.1 Definition and classification ................................................................................................... 28 2.5.2 Private health care providers expenditures: Extrapolation from 2009-10 to 2021-22. ......... 29 2.5.3 Health care providers: Overview of results ........................................................................... 29 2.5.4 Retailers of pharmaceuticals ................................................................................................. 32 2.6 Health care providers by financing agents ............................................................................... 33 2.7 NHA Indicators with regard to National Accounts 2021-22 ...................................................... 36
3. Provincial Health Accounts ...................................................................................................... 37 3.1 Health expenditure at provincial level ....................................................................................... 39
4. Out-of-Pocket Health Expenditure Survey .............................................................................. 47 4.1 Introduction ............................................................................................................................... 49 4.2 Questionnaire and method: ...................................................................................................... 50 4.3 Main findings of the survey for 2021-22 ................................................................................... 50
5. Census of Autonomous ............................................................................................................ 56 Bodies/Corporations .................................................................................................................... 56 5.1 Why this census? ...................................................................................................................... 58 5.2 Autonomous bodies/corporations and their kinds of expenditures .......................................... 58 5.3 Autonomous bodies/corporations and their type of health services ........................................ 59 5.4 Data sources ............................................................................................................................. 60 5.5 Main findings for federal autonomous bodies/corporations ..................................................... 62 5.6 Provincial autonomous bodies/corporations ............................................................................. 64

Pakistan Bureau of Statistics National Health Accounts

viii 5.7 Federal & provincial autonomous bodies/corporations’ expenditure: Extrapolation from

2011-12 to 2019-20. ................................................................................................................. 66 6. Classifications and International Guidelines .......................................................................... 68 6.1 Definitions and boundaries ....................................................................................................... 70 6.2 ICHA-Classification adapted for Pakistan ................................................................................ 71 6.3 Revision of the System of Health Accounts ............................................................................. 73 6.4 Charts of Accounts Classification for government finance ....................................................... 74 7. Health Care System in Pakistan ............................................................................................... 76 7.1 Public sector, territorial government, civilian part ..................................................................... 78 7.2 Military health care system, cantonment boards, autonomous bodies .................................... 79 7.3 Social protection in Pakistan .................................................................................................... 80 7.3.1 Employees social security institutions ................................................................................... 81 7.3.2 Zakat managed by government ............................................................................................. 82 7.3.3 Pakistan Bait-ul-Mal ............................................................................................................... 83 7.4 Private health care facilities ...................................................................................................... 84 7.5 Private health insurance ........................................................................................................... 84 7.6 Philanthropic / Non-Government Organizations ....................................................................... 84

Pakistan Bureau of Statistics National Health Accounts

ix List of Tables Table 1: Key health expenditure indicators, by SAARC countries, China & Iran for the FY 2018-19 ........................................................................................................................................................ xv Table 2: Limitations of NHA ............................................................................................................. 6 Table 3: Total Health Expenditures 2019-20 & 2021-22 by Financing Agents (Million Rs.) ......... 11 Table 4: Current and Development health expenditure by financing sources for 2019-20 & 2021-22
(Mllion Rs.)……………………………………………………………………………………………………… 12 Table 5: Total health expenditure by financing sources with % Change for 22019-20 & 2021-2213 Table 6: Current and development health expenditure by financing agents for 2019-20 & 2021-22 (Million Rs.) .................................................................................................................................... 14 Table 7: Total health expenditure by financing agents with % change for 2019-20 & 2021-22 .... 17 Table 8: Civilian Territorial Government Current Health Expenditures by function 2021-22 ........ 18 Table 9: Military health expenditures by organization 2021-22 (Million Rs.) ................................. 19 Table 10: Health expenditures of Cantonment Boards 2021-22 (Million Rs.) ............................... 19 Table 11: Employees Social Security Institutions Health Expenditures 2021-22 ......................... 20 Table 12: Zakat for Health Care by Program, 2021-22 ................................................................. 20 Table 13: Pakistan Bait ul Mal Individual Financial Assistance for Health 2021-22 ..................... 21 Table 14: Private Health Insurance 2013-14 to 2021-22 ............................................................... 21 Table 15: OOP health expenditures 2019-20 by province and component (Million Rs.)…………22 Table 16: Health expenditures paid through Sehat Sahulat Programme by Federal Government 2021-22 (Million Rs.) ...................................................................................................................... 23 Table 17: Health expenditures paid through Sehat Sahulat Programme by KP Government FY 2021-22 (Million Rs.)…..………………………………..………………………………………..………23 Table 18: Donors health expenditures 2021-22 (Million Rs.) ........................................................ 24 Table 19: Local Non-Government Organizations by type 2015-16 ............................................... 25 Table 20: Health expenditure of health related NGOs 2013-14 to 2021-22 .................................. 25 Table 21: Expenditures of private health care providers 2021-22................................................. 28 Table 22: Expenditures of private hospitals by kind of ownership 2021-22 .................................. 29 Table 23: Current health expenditures by healthcare providers 2021-22 ..................................... 31 Table 24: Purchases of pharmaceuticals in Pakistan 2021-22 (Million Rs.) ................................. 33 Table 25: Current & development health expenditures by provinces and financing agents 2021-22 (Million Rs.) .................................................................................................................................... 44 Table 26: Out of Pocket Health Expenditures in 2019-20 & 2021-22 by region (Million Rs.) ....... 50 Table 27: Out of Pocket health expenditure by type of health care 2021-22 in % ........................ 51 Table 28: Out of Pocket health expenditure by urban & rural 2021-22 in % ................................. 51 Table 29: Out of Pocket health expenditure by gender 2021-22 in % .......................................... 51 Table 30: OOP health expenditures of households 2021-22 by categoty & provinces in %........52 Table 31: Out of Pocket health expenditure in health providers by categories 2021-22 in % ..... 53 Table 32: OOP health expenditure on the type of health care providers accessed by the households 2021-22 ...................................................................................................................... 53 Table 33: OOP health expenditures 2021-22 by kind of accessed sector (private and public) and by province in % .................................................................................................................................. 54 Table 34: Health expenditures by kind of illnesses/incident and by province 2021-22 in % ........ 54 Pakistan Bureau of Statistics National Health Accounts

x Table 35: Federal autonomous bodies/corporations and their employees 2011-12 by Division .. 61 Table 36: Provincial autonomous bodies/corporations and their employees 2011-12 ................. 62 Table 37: Federal autonomous bodies/corporations 2011-12 by mechanism of health care provision ......................................................................................................................................... 62 Table 38: Expenditures of federal autonomous bodies/corporations on health via combination of reimbursement & health insurance 2011-12 (Million Rs.) ............................................................. 63 Table 39: Expenditures of federal autonomous bodies/corporations on health 2011-12 by mechanism ..................................................................................................................................... 64 Table 40: Expenditures of Provincial autonomous bodies/corporations on health via re-imbusment of medical chatges 2009-10 until 2011-12 (Million Rs.) ................................................................ 65 Table 41: Estimation of health expenditures of the non-responding autonomous bodies/corporations via re-imbusment method 2011-12 ............................................................... 66 Table 42: Expenditures of Provincial autonomous bodies/corporations on health by mechanism 2011-12 (Million Rs.) ...................................................................................................................... 67 Table 43: Federal & Provincial ABs/Cs Health Expenditures for the period 2009-10 to 2021-22 (Million Rs.) .................................................................................................................................... 67 Table 44: Public health facilities in Pakistan 2019 ........................................................................ 78