National health accounts – estimates of national health expenditures

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WHO/Europe produces reliable and transparent estimates of health expenditures for Member States. It uses the International Classification for Health Accounts to produce internationally comparable data, in close collaboration with the national health accounts (NHA) team at WHO headquarters.

WHO/Europe produces estimates annually, based on a consultative process with technical specialists in all Member States and with partner agencies. WHO publishes aggregate health expenditure estimates in the annual world health statistics report, and makes them available online in the European Health for All, Global Health Expenditure Database and WHO Statistical Information System (WHOSIS) databases. WHO/Europe also actively partners countries implementing health accounts.

WHO coordinates a network of specialists in health accounting in the Region to improve: capacity for health system monitoring and analysis, the cross-country comparability of national health expenditure estimates and skills among technical specialists.


In countries with low government spending on health, private out-of-pocket spending tends to dominate. While absolute levels of government health spending per capita are closely associated with a country’s level of income, government spending on health as a percentage of gross domestic product (GDP) depends on two factors.

The first is the ability of a government to mobilize public revenues. For example, the potential to provide financial protection for the entire population is much greater in countries where total government spending exceeds 40% of GDP than in those where it is less than 20%.

The second factor is the priority that government gives to the health sector through its resource allocation decisions, measured as the percentage of total government spending devoted to health. An analysis of health spending patterns in Europe in 2006 revealed very wide variation, with government health spending ranging from under 4% to over 18% of total public spending.

Taken together, the combination of overall fiscal capacity and government prioritization decisions resulted in a wide range of government health spending among the countries in the Region in 2006: 1.1–9.2% of GDP and about US$ 20–5000 per capita (measured in purchasing-power-adjusted dollar terms).

WHO/Europe’s analysis shows that the level of government health spending (whether in percent GDP or per capita dollar terms) explained about 75% of the variation in out-of-pocket payment as a percentage of total health spending . High levels of out-of-pocket payments reduce the extent to which key policy objectives, such as financial protection and equity in access to care, can be achieved. More and more Member States are conducting analyses on this issue.

Health expenditure accounting currently follows two systems: National Health Accounts for the low-income countries and System of Health Accounts for the hi-income countries. SHA 2011 version was developed by WHO, OECD and Eurostat to standardize internationally collected data. As part of the international efforts to prepare the countries for the implementation of the new standard in 2016. WHO EURO is engaged in a large-scale capacity building process in collaboration with other international partners. Some of the recent events include “Technical workshop on the Implementation of the health financing framework under SHA 2011” in Paris in October 2012 and “Training workshop on the System of Health Accounts 2011 and tracking of RMNCH expenditures” in Bishkek in October 2012.

WHO has a platform built around SHA 2011. It is made up of tools supporting the production of health accounts at a low human and financial cost. Since end 2011, WHO began training health accountants on the revised framework (SHA 2011) and the tools Health Accounts Production Tool (HAPT) and the Health Accounts Analysis Tool (HAAT), as well as the methodology for estimating expenditure by disease.

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