Provincial Health Account (PHA) and District Health Account (DHA): Tracking Local Health Expenditures

Many countries only develop their National Health Accounts, but Indonesia is implementing an innovative approach by developing Provincial Health Accounts (PHA) and District Health Accounts(DHA). This is a remarkable initiative and is part of the commitment of the Government of Indonesia through the Ministry of Health in establishing a stronger and more accountable national health system.

The innovation of PHA and DHA specifically provides information on who pays for health services at provincial and district level, how much money is absorbed by which type of services, and who will benefit from health spending. This information is very useful because it will provide a basis for evidence-based planning and decision making that, in turn, can improve corporate governance and accountability of local government.

Stethoscope with financial statement, calculator, pen

From legal perspective, according to the Health Act no. 36 in 2009, 10% of the budget must be allocated to the health sector. In this case, PHA and DHA can be used to evaluate whether that requirement has been fulfilled. If the target percentage has been met, DHA can further be used to indicate whether the funds are allocated according to the health needs and priorities. On the other hand, if the required percentage is not met, DHA can be used to show where the gaps are and how big is the gap.

From the equity perspective, PHA and DHA can be used to indicate who benefits from health spending, and whether the health financing has fulfilled its purpose, namely ensuring availability of sufficient funding to protect the poor. DHA may also indicate who bears health expenditures more, the public sector or the private sector.

All information that are generated from the PHA and DHA can be used for advocacy when additional funding is needed and what additional funds are required. Also, it can be used for advocacy related to better allocation for health, which in turn will contribute to strengthening the health systems that fit the specific needs of the district.

The AIPHSS Legacy in Strengthening Health Financing System

The institutionalisation of the health financing system is one of the necessities for strengthening national health systems in order to assist the Ministry of Health use evidence-based data and up-to-date information to support national policies, particularly related to improving access and quality of health services for the poor and the near poor.

Intitusionalisation of health financing is done by developing National Health Accounts (NHA) and a data bank at national level, as well as developing Health Accounts at the Provincial/District level. A productive collaboration between the Ministry of Health and the Faculty of Public Health Universitas Indonesia in 2010-2014, with the support of the Australian Indonesia Partnership Program for Health Systems Strengthening (AIPHSS), has produced a final draft of 2011 NHA document using SHA methodology 1.0.

Now, the next steps are implementing the training using the latest version of WHO instrument (SHA 2011); disseminating NHA results at Central level; and developing PHA and DHA that includes: integrating NHA and PHA/DHA modules; training, and disseminating the results to policy makers; and finally, developing the module for PHA and training for PHA at the central level.

There are three major results from the abovementioned process: (1) the production of NHA in 2012 through 2014; (2) the establishment of the PHA team in East Java Province and East Nusa Tenggara Province which are able to prepare PHA; (3) the establishment of DHA teams in eight (8) districts that also have produced a document analyzing the DHA in North Central Timor, Ngada, Southwest Sumba (SBD), East Flores, Bondowoso, Sampang, Bangkalan and Situbondo.

As a follow-up, the next task for NHA is to complete the state-owned sector data that will be used to supplement and adjust the NHA data for Indonesia. As for the 2015 NHA production, it is proposed in 2016; Procurement of Server/Data Bank for NHA / PHA / DHA is proposed in fiscal year 2016. Impending activities related to PHA/DHA are a PHA training for provinces that have not been trained, and mentoring; Training Provincial Officer to train DHA in District/City, and mentoring; and Adjustments of PHA / DHA instruments that are integrated with the NHA.

Developing PHA & DHA

The key in maintaining the continuity of PHA / DHA is a long-term commitment from policy makers in various sectors. Commitment should be clearly manifested in the form of institutionalization of a PHA / DHA team through regulation and allocation of financial resources and human resources. In addition, the sustainability of PHA / DHA also requires interaction between policy makers and the PHA / DHA technical team that allows the team to respond to the needs of specific policies using a sub-sector analysis as detailed as needed.

In the end, the successful development of PHA and DHA in the East Java and East Nusa Tenggara province and their eight districts (North Central Timor, Ngada, Southwest Sumba, East Flores, Bondowoso, Sampang, Bangkalan and Situbondo) will be an important lesson for replicating the development of PHA / DHA in other provinces and districts/cities in Indonesia, with the commitment and strong support of the Central Government and the Regions.