Pakistan Bureau of Statistics National Health Accounts
14 2.3 Financing agents
2.3.1 Overview In a well compiled NHA, the total health expenditures by financing sources must match the total health expenditures by financing agents and health care providers. All figures result in a total of Rs. 1,962 billion. They only differ in their breakdown. For the interlocking of finan- cial agents by sources see Section 2.2. The health expenditures break up into current and development expenditures for Pakistan by financing agents are shown in Table 6 up to the maximum level of disaggregation confined, however, to those codes of the classification for which data was available. The detailed classification for Pakistan has been discussed in Chap- ter 1. Up to the three digits level the classification has been maintained according to the Inter- national Classification of Health Accounts, next levels of disaggregation are adopted accord- ing to the Pakistan specific situation and policy relevance. Further explanation of each cate- gory is given in later sections. Financing agents also have public funds, private funds and rest of the world funds as the main categories. HF.1 denotes the general government and HF 1.1 shows the territorial government which is further disaggregated into federal government, pro- vincial government and district government/local bodies. HF 1.2 shows the social security funds which are managed through government. It is further broken down into (i) employee’s social security institutions (ESSI) which are working in all four provinces and (ii) Zakat funds which are collected from bank accounts, deposit receipts, saving certificates etc. and then partly spent by government on health-related activities. HF 1.3 shows the ABs/C which is fur- ther disaggregated into federal, provincial ABs/C. Table 6 gives an overview of total health expenditure with percentage shares by financing agents for 2019-20 & 2021-22. Table 6: Current and development health expenditure by financing agents for 2019-20 & 2021-22 (Million Rs.)
Agents by HF Classification
2019-20 2021-22 % Share Current Exp. Develop- ment Exp. Total Current Exp. Develop- ment Exp. Total million Rs. million Rs. HF.1
General Govt. 521,557 62,686 584,243 894,416 27,029 921,445 46.95
HF.1.1 Territorial Govt. 487,840 62,675 550,515 856,878 27,029 883,907 45.04
HF.1.1.1 Federal Govt. 73,246 13,672 86,918 219,982 9,530 229,512 11.70
HF.1.1.1.1 Federal (Civil) 19,067 13,672 32,739 159,422 9,530 168,952 8.61
HF.1.1.1.1.1 MoNHS 11,279 13,554 24,833 152,875 9,505 162,380 8.27
HF.1.1.1.1.2 Other* 7,788 118 7,906 6,547 25 6,572 0.33
HF.1.1.1.1.3 Population Welfare
HF.1.1.1.2 Military 54,179
54,179 60,055
60,550 3.09
HF.1.1.2 Provincial Govt. 311,023 47,093 358,116 504,351 15,609 519,960 26.50
HF.1.1.2.1 Punjab 139,445 25,844 165,289 269,494 3,819 273,313 13.93
HF.1.1.2.1.1 Dept. of Health 133,846 25,844 159,690 243,269 3,704 246,973 12.58
HF.1.1.2.1.2 Other* 265
265 387
387 0.95
HF.1.1.2.1.3 Dept. of Population Welfare 5,334
5,334 7,524 115 7,639 0.39
HF.1.1.2.2 Sindh 111,793 7,032 118,825 111,310 1,667 112,977 5.76
HF.1.1.2.2.1 Dept. of Health 110,169 7,032 117,201 107,278 1,634 108,912 5.55
Pakistan Bureau of Statistics National Health Accounts
15
HF.1.1.2.2.2 Other* 1,623
1,623 4,032 33 4,065 0.21
HF.1.1.2.2.3 Dept. of Population Welfare 1
1
HF.1.1.2.3 KP** 36,992 8,927 45,919 88,950 9,618 98,568 5.02
HF.1.1.2.3.1 Dept. of Health 35,538 8,927 44,465 70,176 9,588 79,764 4.06
HF.1.1.2.3.2 Other* 1,417
1,417 18,556
18,556 0.95
HF.1.1.2.3.3 Dept. of Population Welfare 37
37 218 30 248 0.01
HF.1.1.2.4 Baluchistan 22,793 5,290 28,083 34,597 505 35,102 1.79
HF.1.1.2.4.1 Dept. of Health 21,972 5,290 27,262 33,175 505 33,680 1.72
HF.1.1.2.4.2 Other* 821
821 1,422
1,422 0.07
HF.1.1.2.4.3 Dept. of Population Welfare
HF.1.1.3 District/Tehsil Government 103,571 1,910 105,481 132,545 1,890 134,435 6.85
HF.1.1.3.1 District Govt. 102,546 1,570 104,116 131,345 1,829 133,174 6.79
HF.1.1.3.2 Cantonments Boards 1,025 340 1,365 1,200 61 1,261 0.06
HF.1.2 Social Security Funds 17,062 11 17,073 17,931
17,931 0.91
HF.1.2.1 Social Security Funds through Gov- ernment 17,062 11 17,073 17,931
17,931 0.91
HF.1.2.1.1 ESSI 12,881 11 12,892 15,083
15,083 0.77
HF.1.2.1.2 Zakat Council 1,346
1,346 625
625 0.03
HF.1.2.1.3 Bait ul Mal 2,835
2,835 2,223
2,223 0.11
HF.1.3 Autonomous Bodies/Corporation 16,655
16,655 19,607
19,607 1.00
HF.1.3.1 Federal Govt. 15,308
15,308 18,021
18,021 0.92
HF.1.3.2 Provincial Govt. 1,347
1,347 1,586
1,586 0.08 HF.2
Private Sector 874,810
874,810 1,032,928
1,032,928 52.63
HF.2.1 Other private health insurance 14,269
14,269 16,260
16,260 0.83
HF.2.2 Pvt. Households Out of Pocket pay- ments 775,412
775,412 916,727
916,727 46.71
HF.2.3 Local Non-Govern- ment Organizations (NGO’s) 85,129
85,129 99,941
99,941 5.09 HF.3
Rest of the World 7,373
7,373 8,099
8,099 0.41
HF.3.1 Official Donor Agencies 7,373
7,373 8,099
8,099 0.41 Total Health Expenditure 1,403,740 62,686 1,466,426 1,935,443 27,029 1,962,472 100.0 *Lump sum reimbursements of the federal, provincial/district governments’ agencies have been included in the respective health expenditures of financing agent defined as "Other”. HF.2 shows the private sector health expenditure which is further disaggregated into HF.2.1 private health insurance, HF.2.2 household OOP health expenditures and HF.2.3 lo- cal/national NGOs. HF.3 (Row) shows the expenditures by donor agencies/development part- ners as financing agents. There are four main types of financing for healthcare: Government funded (through taxes), social insurance (through payroll, taxes or direct contributions) private insurance and OOP. The first three types are pre-paid financing mechanisms and have some form of risk pooling. There is variation across. Countries in determining their health financing mechanism, but it mainly depends
Pakistan Bureau of Statistics National Health Accounts
16 on the country’s economic status. The poorer the country, the more depended on out -of-pocket payment. OOP is the most inefficient, inequitable and regressive forms of healthcare financing. How- ever, it is the most important and crucial component o f healthcare financing in most developing country. It can be divided into direct or indirect costs. Direct costs include doctor’s consultation fees, medications, tests, procedures, hospital bills etc. Indirect costs include transport charges to treatment site, daily living cost for accompanying household members and loss of income due to illness. In 2007, OOP payment accounts for 50% of total health expenditure in 33 low -income countries5. According to this NHA report, out of total health expenditures in Pakistan, 47% is made by general government agents which include the social security, Zakat, Baitul Mal and ABs/C health expenditures as well. The private expenditures constitute the 52.6% of total health expenditures in Pakistan, out of which 89% are households’ OOP health expenditures. The share of development partners/donor’s organizations in total health expenditures is almost 0.4%. Figure 4 shows the share of financing agents namely- federal government, provincial governments, district/tehsil governments, social security funds & ABs/C in the “General Government health ex- penditures” of Pakistan for FY 2021-22. Figure 5: General Government Health Expenditure by its financing agents 2021-22 in %
The table below gives an overview of the total health expenditure with percent- age shares by financing agents for 2019-20 & 2021-22.
5 Health Systems and Policy Research (ISSN: 2254 -9137) journal. https://www.hsprj.com/health -maintanance/catastrophic- health-expenditure-among-developing-countries.php?aid=18514
229,512 , 25% 519,960 , 56% 134,435 , 15% 17,931 , 2% 19,607 , 2% Federal Government Provincial government District/Tehsil Government Social security funds Autonomous Bodies/Corporation Pakistan Bureau of Statistics National Health Accounts
17
Table 7: Total health expenditure by financing agents with % change for 2019-20 & 2021-22
Agents by HF classification
2019-20
2021-22
% Change
Total
(Million Rs.)
Total
(Million Rs.)
HF.1
General Government
584,243
921,445
57.7
HF.1.1
Territorial Government
550,515
883,907
60.6
HF.1.1.1
Federal Government
86,918
229,512
164.1
HF.1.1.1.1
Federal (Civil)
32,739
168,952
416.1
HF.1.1.1.1.1
MoNHS
24,833
162,380
553.9
HF.1.1.1.1.2
Other*
7,906
6,572
(16.9)
HF.1.1.1.1.3
Population Welfare
HF.1.1.1.2 Military 54,179 60,550 11.8 HF.1.1.2 Provincial Government 358,116 519,960 45.2 HF.1.1.2.1 Punjab 165,289 273,313 65.4 HF.1.1.2.1.1 Dept. of Health 159,690 246,973 54.7 HF.1.1.2.1.2 Other* 265 18,701 6,957.0 HF.1.1.2.1.3 Dept. of Population Welfare 5,334 7,639 43.2 HF.1.1.2.2 Sindh 118,731 112,977 (4.9) HF.1.1.2.2.1 Dept. of Health 117,201 108,912 (7.1) HF.1.1.2.2.2 Other* 1,529 4,065 150.5 HF.1.1.2.2.3 Dept. of Population Welfare 1
(100.0)
HF.1.1.2.3 KP** 45,919 98,568 114.7
HF.1.1.2.3.1 Dept. of Health 44,465 79,764 79.4
HF.1.1.2.3.2 Other* 1,417 18,556 1,209.5
HF.1.1.2.3.3 Dept. of Population Welfare 37 248 570.3
HF.1.1.2.4 Baluchistan 27,262 35,102 25.0
HF.1.1.2.4.1 Dept. of Health 27,262 33,680 23.5
HF.1.1.2.4.2 Other*
1,422 73.2
HF.1.1.2.4.3 Dept. of Population Welfare
HF.1.1.3 District/Tehsil Government 105,481 134,435 27.4
HF.1.1.3.1 District Government 104,116 133,174 27.9
HF.1.1.3.2 Cantonments Boards 1,365 1,261 (7.6)
HF.1.2 Social Security Funds 17,073 17,931 5.0
HF.1.2.1 Social Security Funds through Government 17,073 17,931 5.0
HF.1.2.1.1 ESSI 12,892 15,083 17.0
HF.1.2.1.2 Zakat Council 1,346 625 (53.6)
HF.1.2.1.3 Bait ul Mal 2,835 2,223 (21.6) HF.1.3 Autonomous Bodies Bodies/Corporation 16,655 19,607 17.7 HF.1.3.1 Federal Government 15,308 18,021 17.7 HF.1.3.2 Provincial 1,347 1,586 17.7 HF.2
Private Sector
874,810
1,032,928
18.1
HF.2.1
Other private health insurance
14,269
16,260
14.0
HF.2.2
OOP payment6
775,412
916,727
18.2
HF.2.3
Local/National (NGO’s)
85,129
99,941
17.4
HF.3
Rest of the World
7,373
1,962,472
9.8
HF.3.1
Donor Agencies
7,373
8,099
9.8
Total Health Expenditure
1,466,426
1,962,472
100.00
6 OOP payment stands for Out of Pocket payment