Pakistan Bureau of Statistics National Health Accounts
7
1.2
Steps taken to develop NHA in Pakistan
The health system in Pakistan is multifarious. To understand the places and roles of different
actors, the health system has been reviewed and mapping has been done so that it can help in speci-
fying classifications and data collection.
Relevant literature on NHA and studies done specially focusing on the South Asian experiences
were reviewed because the health sector and data situation is very similar in those countries as in
Pakistan.
Prior to data collection, it is essential to assess which data is available at federal and Provincial
level. National Health Accounts section did the assessment regarding the data gaps, which determined
the availability and sources of data on:
•
Government entities including social insurance, military and cantonments etc.
•
Private health insurance
•
Autonomous bodies and firms and employers providing health care to their employ-
ees
•
Households out of pocket expenditures
•
Local and international non-governmental organizations
•
Donors/development partners
The data has been collected from the following sources
•
Federal government, provincial governments’ and district governments’ data from
respective Accountant General Pakistan Revenues (AGPR) and Accountant General
(AG) offices
•
Military health expenditures data from Military Accountant General (MAG) office
•
Cantonment boards health expenditures data from Military Lands and Cantonment
Department
•
Insurance companies (private health insurance) data from Securities and Exchange
Commission of Pakistan (SECP)
•
Donor’s health expenditures data from Economic Affairs Division (EAD) of Ministry
of Economic Affairs and Statistics
•
Autonomous Bodies/Corporations (ABs/C) health expenditures data obtained from
the Census of Autonomous bodies/Corporations
•
Households’ OOP health expenditure data obtained through a special survey (HIES)
•
Health expenditures by the private health care providers was estimated by a special
Private Health Care provider survey
•
Social security health expenditures data from Employees Social Security Institutions
(ESSI) and Ministry of Labour
•
Zakat and Bait-ul- Mal data from Ministry of Zakat & Ushr and Pakistan Bait-ul-Mal
(PBM)
All data obtained and analyzed is classified according to financing sources, financing agents
and health care providers. After that, the information was allocated to matrices to trace the original
sources. Errors, conflicts and missing data were resolved and then graphs and tables were prepared.
For the first round, only the matrix of financing sources by financing agents was developed. The second
and subsequent rounds include the matrix of health care providers by financing agent as well.
Workshops/conferences are part of the advocacy efforts needed to promote, communicate,
build demand, and to sell the NHA activity to all major Pakistani stakeholders (government and private)
and to the media. It is also meant to address health policy issues or questions that NHA can shed light
Pakistan Bureau of Statistics National Health Accounts
8 on. In this regard, PBS has conducted training courses on NHA and invited participants from all over the Pakistan and different stakeholders.
Pakistan Bureau of Statistics National Health Accounts
- Results of NHA at National Level
Pakistan Bureau of Statistics National Health Accounts
Pakistan Bureau of Statistics National Health Accounts
11 2.1 Total health expenditure
Total health expenditure is obtained by adding up the two aggregates of “current health
expenditure and capital health expenditure4 (often called development expenditure). While, current
health expenditure includes only direct health expenditures, and excludes health related expendi-
tures on training, research, environmental health etc. Therefore, expenditures on medical educa-
tion, health-related professional training & research are not included in the Total health expendi-
ture. This definitional framework is important, when it comes to cross country comparisons.
Total health expenditure in Pakistan in the FY 2021-22 is estimated at Rs. 1,962 billion.
This shows an increase of Rs. 496 billion over the FY 2019-20, which is a 33.8% increase in
nominal terms as it includes inflation of health care goods and services. It is pertinent to men-
tion here that 33.8% as shown at column 4 is the overall change for the time span of two years.
Table 3: Total Health Expenditures 2019-20 & 2021-22 by Financing Agents (Million Rs.)
Financing Agents
2019-20
2021-22
Change in %
1
2
3
4
Federal Government
86,918
229,512
164.1
Provincial Government
358,116
519,960
45.2
District/Tehsil Government
105,481
134,435
27.4
Social Security Funds
17,073
17,931
5.0
Autonomous Bodies/Corporation
16,655
19,607
17.7
Private health insurance
14,269
16,260
14.0
Private households' OOP payment
775,412
916,727
18.2
Local NGO’s
85,129
99,941
17.4
Official donor agencies
7,373
8,099
9.8
Total health expenditure
1,466,426
1,962,472
33.8
2.2
Financing sources
The health expenditures shown by financing sources include some functions which for certain analysis are needed under a separate heading. One requirement may be to have cur- rent and capital health expenditures separately as the capital expenditures (often called “de- velopment expenditures”) will have a positive impact on health of the country’s population in subsequent years. The health expenditures represented by different financing sources in Ta- ble 4 have further disaggregated into current and development expenditures where empirically the break up was possible. This break up was not possible for the ABs/C and private sector financing sources. The total of depicted development expenditures is Rs. 27,029 million. Table 4 shows the breakdown by financing sources up to the maximum level of disaggrega- tion. Up to the three digits the classification has been maintained according to the International Classification of Health Accounts, next levels of disaggregation are adopted according to the Pakistan specific situation and policy relevance.
4 It refers to the demand for capital goods by health care providers. It is a physical asset with a useful life of more than one year.
Pakistan Bureau of Statistics National Health Accounts
12 Table 4: Current and Development health expenditure by financing sources for 2019-20 & 2021-22 (million Rs.) Sources by FS Classification
2019-20
2021-22
%
Share
Current
Exp.
Develop-
ment Exp.
Total
Current
Exp.
Develop-
ment Exp.
Total
FS.1
Public Funds
504,495
62,675
567,170
876,485
27,029
903,514 46.0
FS.1.1
Government Funds
487,840
62,675
550,515
856,878
27,029
883,907 45.0
FS.1.1.1
Federal Government
73,246
13,672
86,918
219,982
9,530
229,512 11.7
FS.1.1.1.1
Ministry of Finance
73,246
13,672
86,918
219,982
9,530
229,512 11.7
FS.1.1.2
Provincial Government
311,023
47,093
358,116
504,351
15,609
519,960 26.5
FS.1.1.2.1
Punjab Finance Dept.
139,445
25,844
165,289
269,494
3,819
273,313 13.9
FS.1.1.2.2
Sindh Finance Dept.
111,793
7,032
118,825
111,310
1,667
112,977 5.8
FS.1.1.2.3
KP Finance Dept.
36,992
8,927
45,919
88,950
9,618
98,568 5.0
FS.1.1.2.4
Baluchistan Finance Dept.
22,793
5,290
28,083
34,597
505
35,102 1.8
FS.1.1.3
District/Tehsil Bodies
103,571
1,910
105,481
132,545
1,890
134,435 6.9
FS.1.1.3.1
District Government
102,546
1,570
104,116
131,345
1,829
133,174 6.8
FS.1.1.3.2
Cantonment Boards
1,025
340
1,365
1,200
61
1,261 0.1
FS.1.2
Autonomous
Bodies/Corporations
16,655
0
16,655
19,607
0
19,607 1.0
FS.1.2.1
Federal Govt.
15,308
0
15,308
18,021
0
18,021 0.9
FS.1.2.2
Provincial Govt.
1,347
0
1,347
1,586
0
1,586 0.1
FS.2
Private Funds
891,872
11
891,883
1,050,859
0
1,050,859 53.5
FS.2.1
Employer Funds
27,150
11
27,161
31,343
0
31,343 1.6
FS.2.2
Household Funds
779,593
0
935,843
919,575
0
919,575 46.9
FS.2.3
Local/National NGO’s
85,129
0
85,129
99,941
0
99,941 5.1
FS.3
Rest of the World Funds
7,373
0
7,373
8,099
0
8,099 0.4
FS.3.1
Official Donor Agencies
7,373
0
7,373
8,099
0
8,099 0.4
Total Health Expenditure
1,403,740
62,686 1,466,426
1,935,443
27,029
1,962,472
100.0
Financing sources have three major categories, namely public funds, private funds and
rest of the world funds. In case of public funds, at federal level the Ministry of Finance is the
source of funding which provides the money to civil government and military part. For provin-
cial government, the provincial finance departments provide the money. And in case of local
bodies / district government, there are district government and cantonment boards that spend
on health in their respective jurisdiction areas. The last category of the public funds is ABs/C
working under federal and provincial governments. They spend money on the health care of
their employees through reimbursements/insurance and own health care facilities.
FS.2 shows all the private entities which are providing funds for health care. FS.2 is
further categorized in employer funds and household funds. The household funds are net of
reimbursements from employers and insurance companies (claims) but include insurance pre-
miums. Employers are providing funds in three ways. They are contributing through occupancy
health care (which is neglected in NHA due to lack of data), through social security (managed
by ESSIs) or through health insurance of their employees (group insurance). However, insur-
ance figure here is a lump sum which also includes the premiums paid by individual house-
holds. Disaggregated data is not available, but according to expert’s opinion group insur-
ance/insurance through employer has the major share in insurance expenditures.
In Pakistan the insurance companies are not a source of financing. They are agents, instead,
and to a certain extent (premiums minus claims) they are provider of (administrative) health services as
well. Household funds mainly comprise of OOP health expenditures, Bait-ul-Mal and Zakat contributions
made by households. Zakat contains all bank accounts whether owned by private households or some
Pakistan Bureau of Statistics National Health Accounts
13 employers. But due to non-availability of disaggregated data it has fully been counted under household funds. FS.3 shows the rest of the world funds which comprises of donor agencies. Develop- ment partners are also spending on health; however, only their direct spending is included. The money, which has been granted to the government (budgetary aid) and which thus is in the budget is reflected in government spending. NHA has to compromise in this regard as to avoid the double counting of funds transferred from one source to another. Out of total health expenditures in Pakistan, 46% of health spending is funded by public sector. Out of total public sector health expenditures federal government is funding 26%, provincial government is fund- ing 58% and district government/ local bodies are funding 15%. Out of total federal govern- ment spending, 74% are for civil part of the government and the rest 26% is disbursed via
military setup. Out of 53.5% of the health expenditures funded through private sector, 87.2%
is OOP health expenditures by households. Table 5 gives an overview of total health expendi-
ture with percentage shares by financing sources for 2019-20 and 2021-22.
Table 5: Total health expenditure by financing sources with % Change for 2019-20 & 2021-2022
Sources by FS Classification
2019-20
2021-22
% Change
Total
(Million Rs.)
Total
(Million Rs.)
FS.1
Public Funds
567,170
903,514
59.3
FS.1.1
Government Funds
550,515
883,907
60.6
FS.1.1.1
Federal Government
86,918
229,512
164.1
FS.1.1.1.
1
Ministry of Finance
86,918
229,512
164.1
FS.1.1.2
Provincial Government
358,116
519,960
45.2
FS.1.1.2.
1
Punjab Finance Dept.
165,289
273,313
65.4
FS.1.1.2.
2
Sindh Finance Dept.
118,825
112,977
(4.9)
FS.1.1.2.
3
KP Finance Dept.
45,919
98,568
114.7
FS.1.1.2.
4
Baluchistan Finance Dept.
28,083
35,102
25.0
FS.1.1.3
District/ Tehsil Bodies
105,481
134,435
27.4
FS.1.1.3.
1
District Government
104,116
133,174
27.9
FS.1.1.3.
2
Cantonment Boards
1,365
1,261
(7.6)
FS.1.2
Autonomous Bodies/Corporations
16,655
19,607
17.7
FS.1.2.1
Federal Govt.
15,308
18,021
17.7
FS.1.2.2
Provincial Govt.
1,347
1,586
17.7
FS.2
Private Funds
891,883
1,050,859
17.8
FS.2.1
Employer Funds
27,161
31,343
15.4
FS.2.2
Household Funds
779,593
919,575
18.0
FS.2.3
Local/National NGO’s
85,129
99,941
17.4
FS.3
Rest of the World Funds
7,373
8,099
9.8
FS.3.1
Official Donor Agencies
7,373
8,099
9.8
Total Health Expenditure
1,466,426
1962,472
33.8