Overview Overall, governments have too little information on financial flows and the generatie of human and material resources. To rectify this, national health accounts(NHAs) should be much more widely calculated and used. They provide the essential information needed to monitor the ratio of capital to recurrent expenditure, or of any one input to the total, and to observe trends. NHAs capture foreign as well as domestic, public as well as private in puts and usefully assemble data on physical quantities-such as the numbers of nurses, ledical equipment, district hospitals-as well as their costs NHAs in some form now exist for most countries, but they are still often rudimentary and are not yet widely used as tools of stewardship. NHA data allow the ministry of health to think critically about input purchases by all fundholders in the health system. The concept of strategic purchasing, discussed in this report, does not only apply to the purchase of health care services: it applies equally to the purchase of health system inputs Where inputs such as trained personnel, diagnostic equipment and vehicles are purchased directly with public funds, the ministry of health has a direct responsibility to ensure that value for money is obtained -not only in terms of good prices, but also in ensuring that effective use is made of the items purchased Where health system inputs are purchased by other agencies(such as private insurers, roviders, households or other public agencies)the ministry's stewardship role consists of using its regulatory and persuasive influence to ensure that these purchases improve, rather than worsen, the efficiency of the input mix. The central ministry may have to decide on major capital decisions, such as tertiary hospitals or medical schools. But regional and district health authorities should be en trusted with the larger number of lower-level purchasing decisions, using guidelines, crite ria and procedures promoted by central government Ensuring a healthy balance between capital and recurrent spending in the health sys- tem requires analysis of trends in both public and private spending and a consideration of both domestic and foreign funds. A clear policy framework, incentives, regulation and pub- lic information need to be brought to bear on important capital decisions in the entire system to counter ad hoc decisions and political influence In terms of human resources, similar combinations of strategy have had some success in ackling the geographical imbalances common within countries. In general, the content of training needs to be reassessed in relation to workers'actual job content, and overall supply often needs to be adjusted to meet employment opportunities In some countries where the social return to medical training is negative, educational banai institue being considered for privatization or closure. Certainly, public subsidies for Institutions ions often need to be reconsidered in the light of strategic purchasing Re- ing the intake levels of different training facilities is often possible without closure, nd might free resources which could be used to retrain in scarcer skills those health work- ers who are clearly surplus to requirements Major equipment purchases are an easy way for the health system to waste resources, nd use up staff time and recurrent budget They are also difficult to control. All countries need access to information on technology assessment, though they do not necessarily need to produce this themselves. The steward- ship role lies in ensuring that criteria for technology purchase in the public sector(which all countries need) are adhered to, and that the private sector does not receive incentives or bsidy for its ted Providers frequently mobilize public support or subscriptions for technology purchase, nd stewardship has to ensure that consumers understand why technology purchases haveOverview xvii Overall, governments have too little information on financial flows and the generation of human and material resources. To rectify this, national health accounts (NHAs) should be much more widely calculated and used. They provide the essential information needed to monitor the ratio of capital to recurrent expenditure, or of any one input to the total, and to observe trends. NHAs capture foreign as well as domestic, public as well as private in￾puts and usefully assemble data on physical quantities – such as the numbers of nurses, medical equipment, district hospitals – as well as their costs. NHAs in some form now exist for most countries, but they are still often rudimentary and are not yet widely used as tools of stewardship. NHA data allow the ministry of health to think critically about input purchases by all fundholders in the health system. The concept of strategic purchasing, discussed in this report, does not only apply to the purchase of health care services: it applies equally to the purchase of health system inputs. Where inputs such as trained personnel, diagnostic equipment and vehicles are purchased directly with public funds, the ministry of health has a direct responsibility to ensure that value for money is obtained – not only in terms of good prices, but also in ensuring that effective use is made of the items purchased. Where health system inputs are purchased by other agencies (such as private insurers, providers, households or other public agencies) the ministry’s stewardship role consists of using its regulatory and persuasive influence to ensure that these purchases improve, rather than worsen, the efficiency of the input mix. The central ministry may have to decide on major capital decisions, such as tertiary hospitals or medical schools. But regional and district health authorities should be en￾trusted with the larger number of lower-level purchasing decisions, using guidelines, crite￾ria and procedures promoted by central government. Ensuring a healthy balance between capital and recurrent spending in the health sys￾tem requires analysis of trends in both public and private spending and a consideration of both domestic and foreign funds. A clear policy framework, incentives, regulation and pub￾lic information need to be brought to bear on important capital decisions in the entire system to counter ad hoc decisions and political influence. In terms of human resources, similar combinations of strategy have had some success in tackling the geographical imbalances common within countries. In general, the content of training needs to be reassessed in relation to workers’ actual job content, and overall supply often needs to be adjusted to meet employment opportunities. In some countries where the social return to medical training is negative, educational institutions are being considered for privatization or closure. Certainly, public subsidies for training institutions often need to be reconsidered in the light of strategic purchasing. Re￾balancing the intake levels of different training facilities is often possible without closure, and might free resources which could be used to retrain in scarcer skills those health work￾ers who are clearly surplus to requirements. Major equipment purchases are an easy way for the health system to waste resources, when they are underused, yield little health gain, and use up staff time and recurrent budget. They are also difficult to control. All countries need access to information on technology assessment, though they do not necessarily need to produce this themselves. The steward￾ship role lies in ensuring that criteria for technology purchase in the public sector (which all countries need) are adhered to, and that the private sector does not receive incentives or public subsidy for its technology purchases unless these further the aim of national policy. Providers frequently mobilize public support or subscriptions for technology purchase, and stewardship has to ensure that consumers understand why technology purchases have