REPUBLIC OF NAMIBIA
Ministry of Health and Social Services
Windhoek, June 2015
NAMIBIA 2012/13 HEALTH ACCOUNTS:
STATISTICA...
Recommended citation: Ministry of Health and Social Services. June 2015. Namibia 2012/13 Health
Accounts: Statistical Repo...
NAMIBIA 2012/13
HEALTH ACCOUNTS:
STATISTICAL REPORT
CONTENTS
Acronyms ...........................................................................................................
ii
D.2. Recurrent: Institutional Units providing revenues to financing
schemes (FS.RI) x Financing scheme (HF)...............
iii
Acronyms
ARV Anti-retroviral
CHE Total Current Health Expenditure
GDP Gross Domestic Product
HA Health Accounts
HAPT H...
1. Purpose and Content
This methodological note provides an overview of the System of Health Accounts 2011
framework used ...
2
flows. SHA 2011 is now the international standard for national-level health accounts
estimations.
The SHA 2011 methodolo...
3
and vulnerable children (e.g. education, community support and institutional care), enabling
environment programs (e.g. ...
4
governmental agencies, direct foreign financial transfers (e.g. external donors providing
funds to NGOs); and voluntary ...
5
Government spending on health as percentage of general government expenditure:
Health expenditure financed by government...
6
further stratified into twelve groups based on size: above 2,000 employees, between
1,000 and 2,000 employees, and then ...
7
 Unit Cost Data
o WHO CHOICE database was consulted to triangulate distribution keys
between inpatient and outpatient c...
8
team decided to err on the side of underestimating NGO spending rather than introduce
baseless assumptions about the spe...
9
percentage of their claims reimbursed to their members as opposed to the percentage of
claims paid directly to the healt...
10
care, general outpatient curative care, and prevention (including immunization programs,
healthy condition monitoring, ...
11
The same disease distribution key that was developed based on the government utilization
data was used to determine the...
12
6. Comparing the 2008/09 exercise methodology with the current 2012/13 exercise
methodology
Table 2. Comparison of 2008...
13
Employer Surveyed a sample size of 100 employers. Similar, but the response rate from employers was low. Gaps from the
...
14
Annex A: Recommended Workshop Participants
These representatives were invited to the launch and dissemination of the HA...
15
Annex B: List of Organizations Surveyed
Name Type
GIZ Donor
Global Fund programme managed by Ministry of
Health and Soc...
16
Ombetja Yehinga Organisation Trust NGO
PACT NGO
PharmAccess NGO
Philippi Trust Namibia NGO
Positive Vibes NGO
Project H...
17
Demersal Fishing Joint Venture Employer
Development Bank of Namibia Employer
DHL Namibia (Pty) Ltd Employer
Dimension D...
18
Namibia Diamond Trading Company (Pty) Ltd Employer
Namibia Engineering Corporation NEC Employer
Namibia Post Ltd Employ...
19
Wispeco Namibia (Pty) Ltd Employer
Woermann Brock Company Employer
Employer Zeda Namibia (Pty) Ltd Employer
Zimmermann ...
20
Annex C: General Health Accounts Statistical Tables
The statistical tables provided in this section summarize the HA da...
21
C.2. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing scheme (HF)
22
C.3. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing agent (FA)
23
C.4. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Function (HC)
24
C.5. Recurrent: Financing scheme (HF) x Health care function (HC)
25
C.6. Recurrent: Health care provider (HP) X Health care function (HC)
26
C.7. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Classification of diseases /
cond...
27
C.8. Capital: Institutional unit providing revenues to financing scheme (FS.RI) x Gross fixed capital formation (HK)
28
C.9. Capital: Health care provider (HP) x Gross fixed capital formation (HK)
29
C.10. Capital: Institutional unit providing revenues to financing scheme (FS.RI) x Classification of diseases /
conditi...
30
C.11. Capital: Financing agent (FA) x Gross fixed capital formation (HK)
31
Annex D: HIV Statistical Tables
D.1. Recurrent: Revenues of health care financing schemes (FS) x Financing scheme (HF)
32
D.2. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing scheme (HF)
33
D.3. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Health care function (HC)
34
D.4. Recurrent: Financing scheme (HF) x Health care provider (HP)
35
D.5. Recurrent: Financing scheme (HF) x Health care function (HC)
36
D.6. Recurrent: Health care provider (HP) x Function (HC)
37
D.7. HIV Health care related spending
38
Annex E: Reproductive Health Statistical Tables
E.1. Recurrent: Revenues of health care financing schemes (FS) x Financ...
39
E.2. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing scheme (HF)
40
E.3. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Health care function (HC)
41
E.4. Recurrent: Financing scheme (HF) x Health care provider (HP)
42
E.5. Recurrent: Financing scheme (HF) x Health care function (HC)
43
E.6. Recurrent: Health care provider (HP) x Function (HC)
Namibia 2012-13 Health Accounts: Statistical Report
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Namibia 2012-13 Health Accounts: Statistical Report

Resource Type: Brochure Authors: Ministry of Health and Social Services, Republic of Namibia Published: June 30, 2015 Resource Description:This Namibia 2012/13 HA was conducted between July 2014 and March 2015. Following the launch workshop in September 2014, the HA team, with representation from the Government of Namibia, the HFG Project, and the World Health Organization (WHO), began primary and secondary data collection. Collected data were then compiled, cleaned, triangulated, and reviewed. Data was imported into the HA Production Tool and mapped to each of the SHA 2011 classifications. The results of the analysis were verified with Ministry of Health and Social Services management at a validation meeting on March 10th, 2015. The purpose of the HA exercise was to estimate the amount and flow of health spending in the Namibia health system. In addition to estimating general health expenditures, this analysis also looked closely at spending on priority diseases, the sustainability of financing in light of trends of decreasing donor funding, levels of risk pooling and contributions by private sector, and beneficiaries of health services. For more information on the policy questions driving the estimation as well as a report compiling findings and their policy implications, please see the HA report. This methodological note provides an overview of the System of Health Accounts 2011 framework used for the 2012/13 Health Accounts (HA) estimation. It provides a record of data collection approaches and results, analytical steps taken and assumptions made. This note is intended for government HA practitioners and researchers.
Published on: Mar 3, 2016
Published in: Healthcare      
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Transcripts - Namibia 2012-13 Health Accounts: Statistical Report

  • 1. REPUBLIC OF NAMIBIA Ministry of Health and Social Services Windhoek, June 2015 NAMIBIA 2012/13 HEALTH ACCOUNTS: STATISTICAL REPORT
  • 2. Recommended citation: Ministry of Health and Social Services. June 2015. Namibia 2012/13 Health Accounts: Statistical Report. Windhoek, Namibia. Program management and support and funding for the health accounts estimation were provided by the United States Agency for International Development (USAID) through the Health Finance and Governance (HFG) project, implemented by Abt Associates Inc. under cooperative agreement AID- OAA-A-12-00080.
  • 3. NAMIBIA 2012/13 HEALTH ACCOUNTS: STATISTICAL REPORT
  • 4. CONTENTS Acronyms ...........................................................................................................iii 1. Purpose and Content ...........................................................................1 2. Concepts for Health Accounts Estimation.........................................1 i. Overview of Approach ............................................................................1 ii. Health Accounts Methodology ................................................................1 iii. Key Boundaries and Dimensions............................................................2 3. Data Sources.........................................................................................5 i. Primary Institutional Data Sources..........................................................5 ii. Secondary Data Sources........................................................................6 iii. Primary Health Expenditure Survey of Households................................7 4. Data Analysis ........................................................................................7 i. Weighting................................................................................................7 ii. Double counting......................................................................................8 iii. Estimation and application of distribution keys .......................................9 5. Use of HA Production Tool ................................................................11 6. Comparing the 2008/09 exercise methodology with the current 2012/13 exercise methodology ........................................................................12 Annex A: Recommended Workshop Participants..........................................14 Annex B: List of Organizations Surveyed.......................................................15 Annex C: General Health Accounts Statistical Tables...................................20 C.1. Recurrent: Revenues of health care financing schemes (FS) x Financing scheme (HF) ........................................................................20 C.2. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing scheme (HF)..........................................21 21 C.3. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing agent (FA)..............................................22 C.4. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Function (HC).........................................................23 C.5. Recurrent: Financing scheme (HF) x Health care function (HC) ..........24 C.6. Recurrent: Health care provider (HP) X Health care function (HC) ......25 C.7. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Classification of diseases / conditions (DIS) .........26 C.8. Capital: Institutional unit providing revenues to financing scheme (FS.RI) x Gross fixed capital formation (HK).........................................27 C.9. Capital: Health care provider (HP) x Gross fixed capital formation (HK) ......................................................................................................28 C.10. Capital: Institutional unit providing revenues to financing scheme (FS.RI) x Classification of diseases / conditions (DIS)..........................29 C.11. Capital: Financing agent (FA) x Gross fixed capital formation (HK) ..30 Annex D: HIV Statistical Tables ......................................................................31 D.1. Recurrent: Revenues of health care financing schemes (FS) x Financing scheme (HF) ........................................................................31
  • 5. ii D.2. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing scheme (HF)..........................................32 D.3. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Health care function (HC).......................................33 D.4. Recurrent: Financing scheme (HF) x Health care provider (HP) ..........34 D.5. Recurrent: Financing scheme (HF) x Health care function (HC) ..........35 D.6. Recurrent: Health care provider (HP) x Function (HC).........................36 D.7. HIV Health care related spending.........................................................37 Annex E: Reproductive Health Statistical Tables .........................................38 E.1. Recurrent: Revenues of health care financing schemes (FS) x Financing scheme (HF) ........................................................................38 E.2. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing scheme (HF)..........................................39 E.4. Recurrent: Financing scheme (HF) x Health care provider (HP) ..........41 E.5. Recurrent: Financing scheme (HF) x Health care function (HC) ..........42 E.6. Recurrent: Health care provider (HP) x Function (HC) .........................43 List of Tables Table 1. Response rate of organizations sampled……….....………6 Table 2. Comparison of 2008/09 and 2012/13 exercises.……...….12
  • 6. iii Acronyms ARV Anti-retroviral CHE Total Current Health Expenditure GDP Gross Domestic Product HA Health Accounts HAPT Health Accounts Production Tool HC Healthcare function HFG Health Finance and Governance Project ICD International classification of disease IP Inpatient MOHSS Ministry of Health and Social Services NGO Nongovernmental organization NHA National Health Accounts NHE National Health Expenditure OECD Organisation of Economic Cooperation and Development OOP Out-of-pocket OP Outpatient PLHIV People living with HIV SHA System of Health Accounts THE Total Health Expenditure USAID United States Agency for International Development VCT Voluntary counselling and testing WHO World Health Organization
  • 7. 1. Purpose and Content This methodological note provides an overview of the System of Health Accounts 2011 framework used for the 2012/13 Health Accounts (HA) estimation. It provides a record of data collection approaches and results, analytical steps taken and assumptions made. This note is intended for government HA practitioners and researchers. 2. Concepts for Health Accounts Estimation i. Overview of Approach This Namibia 2012/13 HA was conducted between July 2014 and March 2015. Following the launch workshop in September 2014, the HA team, with representation from the Government of Namibia, the Health Finance and Governance (HFG) Project, and the World Health Organization (WHO), began primary and secondary data collection. Collected data were then compiled, cleaned, triangulated, and reviewed. Data was imported into the HA Production Tool and mapped to each of the SHA 2011 classifications. The results of the analysis were verified with Ministry of Health and Social Services management at a validation meeting on March 10th , 2015. Participants invited to the launch workshop, and recommended for future HA workshops, are listed in Annex A. The purpose of the HA exercise was to estimate the amount and flow of health spending in the Namibia health system. In addition to estimating general health expenditures, this analysis also looked closely at spending on priority diseases, the sustainability of financing in light of trends of decreasing donor funding, levels of risk pooling and contributions by private sector, and beneficiaries of health services. For more information on the policy questions driving the estimation as well as a report compiling findings and their policy implications, please see the HA report.1 ii. Health Accounts Methodology HA is an internationally recognized methodology used to track expenditures in a health system for a specified period of time. It follows the flow of funding for health from its origins to end use, answering questions such as: how are health care goods and services financed? Where are health care goods and services consumed by the population? What goods and services are financed? By breaking down health spending by different classifications, HA provide insight into issues such as whether resources are being allocated to national priorities; health spending is sufficient relative to need; and the sustainability of health financing and the extent to which there is financial risk protection for households. It provides sound evidence for decision making and is a useful tool in informing health financing reforms. HA is based on the System of Health Accounts (SHA) framework, which was developed and revised by key international stakeholders over the past two decades. First published in 2000 by OECD, EUROSTAT, and WHO, the framework was updated in 2011 (OECD et al. 2011). The SHA 2011 methodology (producing “HA”) improves upon the original by strengthening the classifications to support production a more comprehensive look at health expenditure 1 Ministry of Health and Social Services. June 2015. Namibia 2012/13 Health Accounts. Windhoek, Namibia.
  • 8. 2 flows. SHA 2011 is now the international standard for national-level health accounts estimations. The SHA 2011 methodology was used to complete this health accounts estimation. iii. Key Boundaries and Dimensions Boundary Definitions The boundaries, presented below, define the HA estimation based on SHA 2011 and articulate which expenditures are included and excluded. Health boundary: The boundary of “health” in the HA is “functional” in that it refers to activities whose primary purpose is disease prevention, health promotion, treatment, rehabilitation, and long-term care. This boundary includes services provided directly to individual persons and collective health care services covering traditional tasks of public health. Examples of personal health care services include facility-based care (curative, rehabilitative, and preventive treatments involving day time or overnight visits to health care facilities); ancillary services to health care such as laboratory tests and imaging services; and medical goods dispensed to patients. Examples of collective health care services include health promotion and disease prevention campaigns as well as government and insurance health administration that target large populations. National standards of accreditation and licensing delineate the boundary of health within SHA – providers and services that are not licensed or accredited, for example some traditional healers, are not included in the boundary of health. Similarly, services that fall outside of the functional definition of health are not counted. Health care related and capital formation spending is tracked separately in SHA 2011. Health care related activities are intended to improve the health status of the population, but their primary purpose lies elsewhere. Examples of health care related activities include food, hygiene, and drinking water control and the social component of long term care for the elderly. Capital formation of health care providers covers investment lasting more than a year such as infrastructure or machinery investment as well as education and training of health personnel, research and development in health. Capital formation contrasts with “current health expenditure” which is completely consumed within the annual period of analysis. Time Boundary: The HA time boundary specifies that each analysis covers a one-year period and includes the value of the goods and services that were consumed during that period. HA includes expenditure according to accrual accounting, by which expenditures are classified within the year they create economic value rather than when the cash was received. Space Boundary: HA “focuses on the consumption of health care goods and services of the resident population irrespective of where this takes place” (OECD et al. 2011). This means that goods and services consumed by residents (citizens and non-citizens) are included while non-residents in Namibia are excluded. Disease Boundary: HA according to SHA 2011 methodology focuses on the spending on priority diseases whose primary purpose is prevention, health promotion, treatment, rehabilitation, and long term care. This boundary of disease spending does not include spending on other activities key to the priority disease responses such as care for orphans
  • 9. 3 and vulnerable children (e.g. education, community support and institutional care), enabling environment programs (e.g. advocacy, human rights programs, and programs focused on women and gender-based violence), and social protection and social services (e.g. monetary benefits, social services, and income-generation projects). Although not part of the core HA boundary, the spending data on the HIV related non-health services were tracked separately and provided in the 2012/13 NHA report.2 Curative Care Boundary: Curative care starts with the onset of disease and encompasses health care during which the “principal intent is to relieve symptoms of illness or injury, to reduce the severity of an illness or injury, or to protect against exacerbation and/or complication of an illness and/or injury that could threaten life or normal function” (OECD et al. 2011). It includes inpatient, outpatient, home-based, and day curative care. Across each of these types, it also includes general and specialized curative care. Inpatient vs. Outpatient Care Boundary: Inpatient care involves a formal admission to a health care facility that involves an overnight stay after admission. Day care involves a formal admission to a health care facility where the patient is discharged the same day and does not require an overnight stay. Outpatient care is delivered from the health care providers’ premises but does not involve a formal admission to a health care facility. Prevention Boundary: Prevention interventions start with an individual in a healthy condition and the aim is to “enhance health status and to maintain a condition of low risk of diseases, disorders or injuries – in other words, to prevent their occurrence, through vaccinations or an injury prevention programme, for example. Preventive interventions also cover individuals at specific risk and those who have either no symptoms of the disease or early signs and symptoms, where early case detection will assist in reducing the potential damage by enabling a more successful intervention. Take the examples of breast and prostate cancer, where age and sex affect the risk; certain lifestyle choices increase the risks, as smoking does for lung cancer” (OECD et al. 2011). Definitions of the Classifications The HA exercise involves analyzing data on health expenditure according to a set of classifications, defined below. For additional details on the SHA 2011, please refer to the SHA 2011 Brief or the SHA 2011 manual.3,4 Financing schemes (HF): the main funding mechanisms by which people obtain health services, answering the question “how are health resources managed and organized?” Financing schemes categorizes spending according to criteria such as: mode of participation in the scheme (compulsory vs. voluntary), the basis for entitlements (contributory vs. non- contributory), the method for fund-raising (taxes/ compulsory pre-payments vs. voluntary payments) and the extent of risk pooling. Examples include: government programs; voluntary private insurance; and direct (i.e. out-of-pocket (OOP)) payments by households for goods and services. Revenue of financing schemes (FS): the types of transactions through which funding schemes mobilize their income. Examples include: transfers from the ministry of finance to 2 Ministry of Health and Social Services. June 2015. Namibia 2012/13 Health Accounts. Windhoek, Namibia. 3 Cogswell, Heather, Catherine Connor, Tesfaye Dereje, Avril Kaplan, and Sharon Nakhimovsky. September 2013. System of Health Accounts 2011 What is SHA 2011 and How Are SHA 2011 Data Produced and Used?. Bethesda, MD: Health Finance & Governance project, Abt Associates Inc. 4 OECD, European Union, and the World Health Organization. 2011. A System of Health Accounts.
  • 10. 4 governmental agencies, direct foreign financial transfers (e.g. external donors providing funds to NGOs); and voluntary prepayment from employers. Financing agents (FA): the institutional units that manage one or more health financing schemes. Examples include: Ministry of Health, commercial insurance companies, NGOs and international organizations. Health care providers (HP): organizations and actors who provide medical goods and services as their main activity, as well as those for whom the provision of health care is only one activity among many others. Examples include: Hospitals, clinics, health centers, pharmacies. Health care functions (HC): the goods and services consumed by health end-users. Examples include: Curative care, information, education, and counseling programs, medical goods such as supplies and pharmaceuticals, and governance and health system administration. Factors of Provision (FP): the inputs to the production of health care goods and services by health care providers. Examples include: compensation of employees, health care goods and services (e.g. pharmaceuticals, syringes, or lab tests used up as part of a curative or preventive contact with the health system) and non-health care goods and services (e.g. electricity and training). Beneficiary Characteristics: the groups that consume, or benefit from, the health care goods and services. Beneficiaries can be grouped in several ways including: disease, gender and age classifications. Health Accounts Aggregates and Indicators The aggregates and indicators defined below are among those estimated as part of this HA. Some of these aggregates and indicators rely exclusively on HA estimates while others require additional information from other sources. Some are used as part of other indicators – for example, total OOP spending on health as a percentage of total current health expenditure. Total Current Health Expenditure (CHE): Total current expenditure on health quantifies the economic resources spent on health functions and represents final consumption on health goods and services by residents of the country within the year of estimation. A related indicator is CHE-HIV, which includes all current spending on HIV specifically. Gross capital formation: Gross capital formation on health is measured as the total value of assets that providers have acquired during the estimation year (less the value of sales of similar assets) and that are used for longer than one year in the provision of health services. Total Health Expenditure (THE)5 : The sum of current health spending and gross capital formation. National Health Expenditure (NHE)6 : The sum of current health spending, health care related spending, and gross capital formation. 5 This aggregate is comparable to NHA and SHA 1.0 estimations. 6 This aggregate is not an internationally standardized indicator as part of the SHA 2011 methodology, but can have relevance for national level policy making in Namibia.
  • 11. 5 Government spending on health as percentage of general government expenditure: Health expenditure financed by government agencies as a percentage of total government expenditure. The estimate of general government expenditure for 2012/13 came from the Estimates of Revenue and Expenditure for 2012/13.7 Total current health expenditure as percentage of gross domestic product (GDP): CHE as a percentage of GDP. The estimate of GDP for 2012/13 came from the World Bank’s DataBank.8 Total Current Health Expenditure per capita (CHE per capita): CHE divided by the population. The estimation of population for 2012/13 came from the 2011 National Population Census of Namibia.9 3. Data Sources i. Primary Institutional Data Sources The HA team conducted primary data collection from the below listed institutions. The HA team provided each institution with a HA survey covering health spending. A list of these organizations is provided in Annex B. Underestimation of private spending as a result of the low response rates for employers and medical aid companies was dealt with by extracting the required information from secondary sources, such as the NAMFISA annual report which provides the total health expenditure by all private medical aid funds in Namibia. Table 1 shows the response rate of organizations sampled.  Donors (both bilateral and multilateral donors) to estimate the level of external funding for health programs in Namibia. A list of all donors involved in the health sector was compiled through consultation with the MOHSS and other key stakeholders and a survey was sent to each of them. Ten donors were identified; all of them completed the NHA survey.  Nongovernmental organizations (NGOs) involved in health to estimate flows of health resources through NGOs that manage health programs. A complete list of NGOs involved in the health sector was compiled through consultation with the MOHSS and other key stakeholders. Thirty-five NGOs were identified and all were sent a survey; 74% of these NGOs responded to the questionnaire.  Employers to estimate the extent to which employers provide health insurance through the workplace and the amount spent by employers to manage their own health facilities or run workplace programs. A complete list of formal sector employers with more than 50 employees was obtained from the Social Security Commission. A total of 933 employers were identified and a sample of 100 was surveyed. In order to obtain the sample frame, employers based on Windhoek, Walvis Bay and Swakopmund only were selected as these are the economically dominant towns in Namibia. A total of 84 companies were selected from Windhoek due to the high level of economic activity in the capital in comparison to the coastal towns where a total of 16 companies were selected. The selection of employers was 7 http://www.mof.gov.na/documents/57508/107403/Estimate+of+Revenue++and+expenditure+1+April+2012+to+31+March+201 5.pdf/e0fcfbe3-d5a4-49c8-9177-e44831397941?version=1.0 Accessed November 2014. 8 http://databank.worldbank.org/data/home.aspx. Accessed November 2014. 9 Source: 2011 National Population Census of Namibia http://www.gov.na/population
  • 12. 6 further stratified into twelve groups based on size: above 2,000 employees, between 1,000 and 2,000 employees, and then into 10 categories by hundreds for employers with less than 1,000 employees. The sample selection per size category was based on the total number of employers within each category as a proportion of the total number of employers identified. In total, 45 employers responded to the questionnaire.  Private medical aid schemes, the Public Service Employees Medical Aid Scheme (PSEMAS), the Social Security Commission’s workman’s compensation fund and the Motor Vehicle Accident Fund to estimate total expenditures on health by medical aid schemes and other health expenditure funds. A list of medical aid schemes providing medical and health coverage through risk-pooling mechanisms was compiled through consultation with the MOHSS and other key stakeholders. All 10 open and closed medical aid schemes identified were sent a survey and data was received from 6. Expenditure information for the remaining schemes that did not complete the survey was extracted from the NAMFISA annual report. In addition, surveys were sent to PSEMAS, the Social Security Commission Workmen Compensation Fund and the Motor Vehicle Accident Fund; data from all three of these sources was received. Table 1. Response rate of organizations sampled Target Group Number of Organizations Targeted Number of Respondents Response Rate NGOs 35 26 74% Employers 100 45 45% Donors 10 10 100% Medical Aid Schemes 10 6 60% ii. Secondary Data Sources The HA team also gathered secondary data. These data included spending on health as well as service utilization and unit cost data. Service utilization and unit cost data were used in order to calculate distribution keys (see below for more detail), which seek to break down spending aggregates to the level of detail required by the SHA 2011 framework. A list of secondary data sources used in this estimation is as follows:  Spending Data o Republic of Namibia Estimates of Revenues and Expenditures 2012/13. Government health expenditure by Ministry o Namibia Financial Institutions Regulatory Authority (NAMFISA) Annual report 2012 for total health expenditure by medical aid schemes o Namibia Demographic and Health Survey (DHS), 2013.  Utilization Data o MOHSS Annual Report 2012/13 o Utilization data extracted from the National Health Information System o Provision of ART services by facility extracted from the Electronic Patient Monitoring System (e-PMS) and the Electronic Dispensing Tool (EDT).
  • 13. 7  Unit Cost Data o WHO CHOICE database was consulted to triangulate distribution keys between inpatient and outpatient care at hospitals.10  Other Secondary Sources o Health Facility Census, 2009: Development of distribution key for the expenditure of the MoHSS. o National Population Census, 2011 iii. Primary Health Expenditure Survey of Households Data on household expenditures from Namibia’s DHS informed the estimates of household out-of-pocket spending in Namibia. The goal was to understand the direct health payments made by households i.e., patterns of health care usage such as inpatient, outpatient, pharmaceuticals; choice of health care providers whether public or private; expenditure associated with purchasing health services and the extent of health insurance coverage. The HA team worked in collaboration with an HFG statistician to complete the household estimation. The household survey covered a range of topics, including the following questions: 1. In the last six months, was a member of this household admitted overnight to stay at a health facility? and 2. In the last four weeks, did someone in this household receive care from a health provider, a pharmacy, or a traditional healer without staying overnight? If the answer to either question was yes, respondents were asked to describe only the most recent such visit, and to report the number of visits that person made. No information was collected about visits by any other household members. Consequently, the estimates under- report costs in households where two or more members received care. No attempts were made to correct for this bias. 4. Data Analysis i. Weighting Weights are used in the HA to inflate the survey responses to account for entities that were either not surveyed or did not return a survey. In the absence of a 100% response rate, weighting expenditure gathered through institutional surveys can minimize underestimation of health expenditure. In this exercise, the HA team did not apply any weights to NGOs. Given the variability in NGO spending and the limited knowledge about health related NGOs in Namibia, the HA 10 World Health Organization. n.d. WHO CHOICE database. Accessed November 2014 from: http://www.who.int/choice/country/country_specific/en/.
  • 14. 8 team decided to err on the side of underestimating NGO spending rather than introduce baseless assumptions about the spending of the nine NGOs which did not respond. No weights were used to extrapolate the total health expenditure of the sampled employers to the rest of the un-sampled employers operating in Namibia. Instead the employer sample frame was stratified by employer size and adjusted to the total number of employers within each size category as a proportion of the total number of employers identified. The contributions to medical aid coverage as reported by employers was triangulated with the information obtained from the medical aid schemes and therefore excluded from the total health expenditure calculation in order to prevent double-counting. For the estimation of the total expenditures on health by medical aid schemes and other health expenditure funds, there was no need to weight the results of the returned surveys. The difference between the expenditures reported by the medical aid schemes in the returned surveys and the total expenditure as per the NAMFISA annual report for 2012 was used to incorporate the health expenditures by the medical aid schemes that did not respond to the survey. ii. Double counting The HA analysis includes careful compilation from all data sources, and identification and management of instances when two data sources cover the same spending. For example, spending on donor-funded health programs administered by NGOs was reported both in donor surveys as well as NGO surveys. In these cases, the HA team selected the spending as reported by NGOs as opposed to the donors, as these agents were closer to the actual consumption of health care services than donors and are therefore likely to have more precise information about spending on actual, not just planned, consumption. It was not possible to triangulate the information provided by PEPFAR to the specific NGOs, since the PEPFAR survey was not completed in this level of detail. Therefore, all spending information reported by NGOs as having been received from PEPFAR specifically was excluded from analyses to prevent double-counting. This approach also ensures that PEPFAR spending is not under-reported as a result of excluding the entire amount that was spent by this donor as the full amount may not have been reported on by the NGO sample. Double counting can exist between NGOs if one NGO gives money to another NGO to implement a health program or provide a service. In this case, spending reported by the NGO providing the funding is equally reported as revenue by the NGO receiving the funding to implement a program or provide a service. The data of the organization closest to the spending, in this case the NGO that received the funding to provide health goods and services, took precedence and was included. Similarly, double-counting exists at the employer and medical aid scheme level since employers reporting spending for medical aid scheme coverage is equally reported as revenue by the medical aid schemes. As with the previous example, the data of the organization closest to the spending, in this case the medical aid schemes, took precedence and employer spending on medical aid scheme coverage was excluded. The health expenditure questions that were included in the DHS to determine the household expenditure on health did not specifically instruct the respondents to exclude amounts spent on health that are reimbursed to the household by medical aid schemes. Therefore, there is a risk of double-counting between the household expenditure and the expenditure reported by medical aid schemes. In order to address this possible double-counting of expenditures, selected medical aid funds were requested to provide additional information on the
  • 15. 9 percentage of their claims reimbursed to their members as opposed to the percentage of claims paid directly to the healthcare providers. The average percentage reimbursed to members amounted to 1.5% of the total claims or approximately N$51.7 million, which was found to be significant – especially in the context of the household expenditure, whereby it amounted to approximately 4.9% of the initially estimated household expenditure. Therefore, the household expenditure amount was reduced accordingly to adjust for the risk of double-counting. While some NGO, donor and employer data were excluded, this does not preclude the importance of collecting their spending information as a useful source of triangulation. iii. Estimation and application of distribution keys In some cases, health spending as reported in secondary sources or in surveys required additional breakdowns in order to allocate spending based on all classifications of the SHA framework. Part of the HA, therefore, involved estimating “distribution keys” to break down spending for the provider, functional and disease classifications. The following steps were used to derive the distribution keys: Step 1: Compiled utilization breakdown by disease classification Utilization of health services data was obtained from the MoHSS Health Information System and broken down into the standardized diseases/conditions as per the SHA 2011 methodology. Furthermore, the level where these services were provided (i.e. the inpatient or outpatient department at the clinic and health centre level or the inpatient or outpatient departments at the hospital level) was captured by deducting the services provided in hospitals from the total. Each of the disease classifications was then categorized as either preventative or curative care. Step 2: Convert Inpatient admissions to Bed Days The number of inpatient admissions was converted to bed days using average length of stay data for health centre/clinic level and hospital level respectively. This calculation is based on the assumption that the average length of stays remains similar across disease categories. Step 3: Assign unit costs to services utilized Unit costs were assigned to each type of service utilized based on the specific disease classification using the WHO CHOICE cost estimations for 2008. Different unit costs were used for hospital and clinic/health centre level and for outpatient versus inpatient services. This computation assumed that unit cost per outpatient visits is equal across diseases and similarly for inpatient days. There was an exception for the unit cost of immunization and family planning visits where expert opinion regarding the level of effort spent on these services vis á vis others dictated that these visits represent, on average, a third of the average unit cost per general outpatient visit. Step 4: Calculated the price x quantity The total cost of health services provided for the different disease classifications at the different health facility levels was calculated using the price information derived in step 3 and the quantity of services determined in steps 1 and 2. Step 5: Calculated Functional Distribution The information calculated in step 4 was then summarized according to the functional classifications at the different levels of care by adding the total cost per functional classification category. The functional classifications included general inpatient curative
  • 16. 10 care, general outpatient curative care, and prevention (including immunization programs, healthy condition monitoring, and other preventive care). The proportional share of the total costs by level of service provision was calculated for each functional classification category. The formula used is as follows: the average cost of inpatient care multiplied by the total number of inpatient episodes at health facilities, divided by the average cost of inpatient and outpatient care multiplied by total episodes of care at health facilities. Step 6: Calculated Provider Distribution for Government Spending The government expenditure data flowing to the regions was not disaggregated by provider and required the Health Accounts team to tease out the portion of the expenditures going to health centers and clinics, district hospitals, and health care administration by the regional and district offices. The proportions between these different provider levels were calculated by analyzing the distribution of personnel expenditures between the three broad categories from Karas region. To minimize possible bias from using one region to calculate the distribution key for government spending, especially related to the proportions between the district hospitals and health centers and clinics, the Health Accounts team used the Namibia National Workload Indicators of Staffing Needs (WISN)11 data to separately calculate the proportion between the facilities and compare the ratios. Given they were closely comparable, the Health Accounts team maintained the ratios calculated earlier. Step 7: Calculated Disease Distribution for Health Centres and Clinics At the health centre and clinic level the disease distribution was calculated for inpatient and outpatient services by calculating the proportional share of costs of each disease category of the total costs incurred for inpatient and outpatient services at this level of service provision. Step 8: Calculated Disease Distribution for Hospitals At hospital level the disease distribution was calculated for inpatient and outpatient services by calculating the proportional share of costs of each disease category of the total costs incurred for inpatient and outpatient services at this level of service provision. Step 9: Calculated Disease Distribution for Medical Aid Schemes Information from medical aid schemes did not disaggregate spending by disease classification; therefore, to determine the contribution from insurance companies to the disease categories, the team applied the same disease distribution key that was developed based on the government utilization data. Refer above for details on the disease distribution key. For the Public Service Employees Medical Aid Scheme (PSEMAS), the team obtained data detailing expenditures for HIV/AIDS based on NASA that was conducted for the same period. This was used to develop a ratio for splitting PSEMAS expenditures into HIV/AIDS and non-HIV/AIDS spending. The total of the non-HIV/AIDS spending was then split using the overall disease distribution ratio. Step 10: Calculated Disease Distribution for OOP spending Information on household expenditure was obtained from health spending specific questions that were included in the Demographic Health Survey of 2013. The survey asked specific questions on spending on both in-patient and out-patient services received within the last 6 months and four weeks period respectively. 11 The Workload Indicators of Staffing Need (WISN) method, is a human resource management tool developed by the World Health Organization. The WISN method calculates the number of health workers per cadre, based on health facility workload. It provides two indicators to assess staffing: (1) the gap/excess between current and required number of staff, and (2) the WISN ratio, a measure of workload pressure. Source: http://www.human-resources-health.com/content/11/1/64
  • 17. 11 The same disease distribution key that was developed based on the government utilization data was used to determine the disease categories for the household expenditure. Step 9: Calculated Age Distribution The age distribution was calculated based on information on utilization of services in outpatients departments at the different levels of facilities by age category as obtained from the MoHSS Health Information System. It was assumed that the same ratio applies to inpatient admissions. 5. Use of HA Production Tool Throughout the HA process, the technical team utilized the HA Production Tool (HAPT), a software developed by WHO. The HAPT is a tool that facilitates the planning and production of Health Accounts. It automates several previously time-consuming procedures e.g. repeat mapping, and incorporates automatic quality checks. Its advantage also lies in providing a repository for HA data and HA tables which can be easily accessed by team members years after the production of Health Accounts. In addition, distribution keys and mapping decisions from previous years can be used to facilitate data analysis in subsequent years. A list of all institutions to be surveyed was entered into the HAPT. All data collected was imported into the HAPT and was mapped to the SHA 2011’s key classifications. The team utilized the Data Validation module in the Tool to verify the final data and check for any errors, before generating the HA tables.
  • 18. 12 6. Comparing the 2008/09 exercise methodology with the current 2012/13 exercise methodology Table 2. Comparison of 2008/09 and 2012/13 exercises Framework 2008/09 2012/13 NHA methodology (based on SHA 1.0 framework) was used to calculate the total expenditure on health in Namibia. SHA 2011, a refined version of SHA 1.0, was used (see description of refinements below). Refinements between SHA 1.0/NHA and SHA 2011 methodology  Updated classification to add the “how” component: The old framework focused a lot on who financed and managed health resources (i.e. which institutions). SHA 2011 reflects the who but also the how (e.g. who = National Health Insurance Agency; how = managing mandatory payroll deductions and voluntary insurance scheme payments from the informal sector).  SHA 2011 provides a full disease breakdown which was previously captured in subaccounts: Previously, countries could choose to track 1 or 2 diseases via subaccounts. These subaccounts were voluntary and did not necessarily form part of every NHA exercise. With the updated framework, over time, countries will be able to track spending for all diseases not just for selected diseases and that this is done as part of every health accounts exercise.  Based on in-country experience, SHA 2011 provides refined classifications for providers and health care functions: For example, under the old framework there was confusion around the classification “prevention and public health” because it mixed the activity with the provider. The SHA 2011 framework has clarified some of the definitions for provider and function so that they are more distinct and their boundaries are clear. This will allow for greater consistency in the way countries classify their expenditures by provider and function. Data Collection 2008/09 2012/13 Government Captured spending from key government ministries. Similar. Donor Surveyed and captured data from all donors active in the health domain. Similar. NGO Surveyed and captured data from key NGOs working in the health domain. Similar. Medical Aid Scheme (MAS) Surveyed all MAS that operate in Namibia. Similar.
  • 19. 13 Employer Surveyed a sample size of 100 employers. Similar, but the response rate from employers was low. Gaps from the low response rate were captured through the Medical Aid Scheme data. Household A general household spending survey was used -- 2003/04 Namibia Household Income and Expenditure Survey (NHIES). A health-specific household spending survey was used -- the Demographic and Health Survey (DHS). Double counting 2008/09 2012/13 Double-counting was removed between: - Employers and insurers - Households and employers - Households and MAS - NGOS and donors - Between NGOs - Donors and government Similar. Mapping 2008/09 2012/13 Used health accounts classifications to codify expenditures by: - Sources: Institutional units providing revenues to financing schemes - Financing agents - Health care providers - Health care functions Similar. Added additional classifications: - Revenues of financing schemes (how resources are mobilized) - Financing schemes (how the resources are managed) - Disease - Age - Inputs Split rules 2008/09 2012/13 Disease Distribution Split rules for RH and HIV/AIDS was calculated as the proportional share of the total costs incurred based on utilization and unit cost data. Full disease breakdown: used utilization and unit cost to split the expenditure into The WHO choice costing study was used to provide unit costs. In addition to HIV and RH spending the current Health Accounts provides a full disease breakdown. Inpatient/Outpatient splits Outpatient and inpatient ratios were derived from health information system utilization rates at health facilities and estimated costs of these services as determined by a WHO Choice costing study. Similar. Age split Age splits were calculated based on the proportion outpatient visits for patients under 5 years broken out by clinic versus hospital. Similar.
  • 20. 14 Annex A: Recommended Workshop Participants These representatives were invited to the launch and dissemination of the HA estimation. At the launch, these representatives participated in discussion about the key questions of the analysis as well as the scope and process. At the dissemination event, these representatives responded to the findings and discussed their policy implications. These stakeholders are recommended as minimum participants for the launch and dissemination of HA results.  Ministry of Health and Social Services: Deputy Minister; Director of Policy Planning and Human Resources Development; Deputy Director of Policy Planning and Human Resources Development, Director of Special Programs, and other relevant staff  Ministry of Finance  Ministry of Education  Ministry of Gender Equality and Child Welfare  Ministry of Defense  Ministry of Safety and Security  Ministry of Youth  National Planning Commission  Social Security Commission  Namibia Financial Institutions Regulatory Authority (NAMFISA)  Namibia Association of Medical Aid Funds (NAMAF)  Polytechnic of Namibia  National Statistics Agency  PEPFAR, WHO, UNAIDS, USAID, and other donor representatives  Representatives of large non-governmental organizations active in health  Namibia Chamber of Commerce and Industry  Representatives of several large employers that provide health care benefits to employees
  • 21. 15 Annex B: List of Organizations Surveyed Name Type GIZ Donor Global Fund programme managed by Ministry of Health and Social Services Donor Global Fund programme managed by Namibia Network of AIDS Service Organisations Donor PEPFAR including USAID, CDC, DOD and Peacecorps Donor Spanish Corporation Donor UNAIDS Donor UNFPA Donor UNICEF Donor UNDP Donor WHO Donor AIDS Law Unit (Legal Assistance Centre) NGO AMICAAL NGO Building Local Capacity NGO Catholic AIDS Action NGO Church Alliance for Orphans (CAFO) NGO COHENA NGO Council of Churches in Namibia (CCN) NGO Desert Soul NGO Development Aid from People to People (DAPP) NGO Dynamic Sign Language Consultancy NGO FHI 360 NGO Health Finance & Governance NGO IntraHealth NGO ITECH NGO KAYEC NGO KNCV NGO Lifeline/Childline NGO Management Sciences for Health NGO Namibia Business Coalition NGO Namibia Planned Parenthood Association NGO Namibia Red Cross Society NGO NANASO NGO NAGOF NGO National Social Marketing Programme (NASOMA) NGO Nawalife Trust NGO
  • 22. 16 Ombetja Yehinga Organisation Trust NGO PACT NGO PharmAccess NGO Philippi Trust Namibia NGO Positive Vibes NGO Project Hope NGO Society for Family Health NGO Strengthening Health Outcomes through the Private Sector (SHOPS) NGO Synergos NGO Turuisa AIDS project NGO Walvis Bay Corridor Group NGO Renaissance Health Medical aid scheme Nammed Medical aid scheme NHP Medical aid scheme NMC Medical aid scheme Namdeb Medical aid scheme Bankmed Medical aid scheme Woermann & Brock Medical aid scheme Napotel Medical aid scheme RCC Medical aid scheme PSEMAS Medical aid scheme SSC – Workman’s Compensation Medical aid scheme Motor Vehicle Accident Fund Medical aid scheme Absolute Logistics (Pty) Ltd Employer Africa Glass (Pty) Ltd Employer Air Namibia (Pty) Ltd Employer Alexander Forbes Financial Services Employer Auas Motors (Pty) Ltd Employer AVI Distributors Namibia (Pty) Ltd Employer Bank Windhoek (Pty) Ltd Employer Blood Transfusion Services Employer Blue Sea Fishing (Pty) Ltd Employer Burmeister & Partners Employer China State Construction Employer Coastal Couriers Employer CYMOT (Pty) Ltd Employer Dany Construction CC Employer De Beers Marine Namibia Employer Deloitte & Touche Employer
  • 23. 17 Demersal Fishing Joint Venture Employer Development Bank of Namibia Employer DHL Namibia (Pty) Ltd Employer Dimension Data Namibia Employer DR.Weder , Kauta & Hoveka INC Employer Elso Holdings CC Employer F.P. Du Toit Transport (Pty) Ltd Employer Feedmaster (Pty) Ltd Employer Financial Consulting Services CC Employer First National Bank of Namibia Employer FNB insurance brokers (Pty) Ltd Employer Freddie Fish Processors (Pty) Ltd Employer Freshers Meat Packers Namibia (Pty) Ltd Employer Gecko Minig (Pty) Ltd Employer Government Institutions Pension Fund Employer Grant Thornton Neuhaus Employer Grinaker LTA Namibia (Pty) Ltd Employer H H Furniture Removers Warehouse Employer Hartlief Continental Meat Market Employer John Meinert Printing (Pty) Ltd Employer Kalahari Wire Products (Pty) Ltd Employer Langer Heinrich Uranium (Pty) Ltd Employer Legal Shield (Ltd) Employer M Pupkewitz and Sons (Pty) Ltd Employer Major Drilling Namibia (Pty) Ltd Employer MANICA Group Namibia (Pty) Ltd Employer Marsh Namibia (Pty) Ltd Employer MCC Equipment Rental (Pty) Ltd Employer MEATCO (Pty) Ltd Employer Metje & Ziegler Group LTD Employer Metropolitan Life Limited Employer Mobile Telecommunications Limited Employer Mutual & Federal Insurance Brokers Ltd Employer NAKARA CC Employer Namibia College of Open Learning NAMCOL Employer NAMCOR (Pty) Ltd Employer NAMFISA Employer Namib Building Cleaners Employer Namib Foam Employer Namibia Breweries Limited Employer
  • 24. 18 Namibia Diamond Trading Company (Pty) Ltd Employer Namibia Engineering Corporation NEC Employer Namibia Post Ltd Employer Namibia Stevedoring Services CC Employer Namibia Tourism Board Employer Namwater Employer New Era Investment Employer New Era Publication Corporation Employer OJ Construction CC Employer Otjozondu Mining (Pty) Ltd Employer Paragon Investments (Pty) Ltd Employer Penny Pinchers Timbercity Windhoek Employer Penny Pinchers Timbercity Walvis Bay Employer Polana Pasta Manufacturers (Pty) Ltd Employer Pupkewitz Motors (Pty) Ltd Employer Raino’s Truck and Auto Repairs CC Employer Road Fund Administration Employer Roads Contractor Company Limited Employer SAB Miller (Namibia) Ltd Employer Salt Company (Pty) Ltd Employer Schoemans Office Systems (Pty) Ltd Employer Solitaire Press CC Employer Steel Force CC Employer Swart Grant Angula Auditors Windhoek Employer The Document Warehouse Namibia (Pty) Ltd Employer Torra Bay Fishing (Pty) Ltd Employer Transworld Cargo (Pty) Ltd Employer Trustco Group International (Pty) Ltd Employer Tunacor Fisheries Limited Employer Tusk Investments (Pty) Ltd Employer Tyre Corporation (Pty) Ltd Employer Tyrepro Namibia (Pty) Ltd Employer United Property Management (Pty) Ltd Employer Waltons Stationary Company Employer Watermeyer Mining & Construction CC Employer WB Hardware & Building Supplies Employer Wesbank Transport (Pty) Ltd Employer Westair Maintenance (Pty) Ltd Employer Windhoek Country Club Hotel Employer Windhoek Municipality Employer
  • 25. 19 Wispeco Namibia (Pty) Ltd Employer Woermann Brock Company Employer Employer Zeda Namibia (Pty) Ltd Employer Zimmermann Garage CC Employer
  • 26. 20 Annex C: General Health Accounts Statistical Tables The statistical tables provided in this section summarize the HA data through a series of two dimensional tables. Each table cross- tabulates spending for two HA classifications. Unless otherwise specified, these tables summarize recurring health spending only. C.1. Recurrent: Revenues of health care financing schemes (FS) x Financing scheme (HF)
  • 27. 21 C.2. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing scheme (HF)
  • 28. 22 C.3. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing agent (FA)
  • 29. 23 C.4. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Function (HC)
  • 30. 24 C.5. Recurrent: Financing scheme (HF) x Health care function (HC)
  • 31. 25 C.6. Recurrent: Health care provider (HP) X Health care function (HC)
  • 32. 26 C.7. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Classification of diseases / conditions (DIS)
  • 33. 27 C.8. Capital: Institutional unit providing revenues to financing scheme (FS.RI) x Gross fixed capital formation (HK)
  • 34. 28 C.9. Capital: Health care provider (HP) x Gross fixed capital formation (HK)
  • 35. 29 C.10. Capital: Institutional unit providing revenues to financing scheme (FS.RI) x Classification of diseases / conditions (DIS)
  • 36. 30 C.11. Capital: Financing agent (FA) x Gross fixed capital formation (HK)
  • 37. 31 Annex D: HIV Statistical Tables D.1. Recurrent: Revenues of health care financing schemes (FS) x Financing scheme (HF)
  • 38. 32 D.2. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing scheme (HF)
  • 39. 33 D.3. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Health care function (HC)
  • 40. 34 D.4. Recurrent: Financing scheme (HF) x Health care provider (HP)
  • 41. 35 D.5. Recurrent: Financing scheme (HF) x Health care function (HC)
  • 42. 36 D.6. Recurrent: Health care provider (HP) x Function (HC)
  • 43. 37 D.7. HIV Health care related spending
  • 44. 38 Annex E: Reproductive Health Statistical Tables E.1. Recurrent: Revenues of health care financing schemes (FS) x Financing scheme (HF)
  • 45. 39 E.2. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Financing scheme (HF)
  • 46. 40 E.3. Recurrent: Institutional Units providing revenues to financing schemes (FS.RI) x Health care function (HC)
  • 47. 41 E.4. Recurrent: Financing scheme (HF) x Health care provider (HP)
  • 48. 42 E.5. Recurrent: Financing scheme (HF) x Health care function (HC)
  • 49. 43 E.6. Recurrent: Health care provider (HP) x Function (HC)

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