GUIDELINES FOR PRODUCING CHILD HEALTH SUBACCOUNTS WITHIN THE NATIONAL HEALTH ACCOUNTS FRAMEWORK PREPUBLICATION VERSION 2 All standard disclaimers of each of the sponsoring organizations apply to this publication. The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government GUIDELINES FOR PRODUCING CHILD HEALTH SUBACCOUNTS WITHIN THE NATIONAL HEALTH ACCOUNTS FRAMEWORK PREPUBLICATION VERSION Guide to Producing CH Subaccounts Contents iii Contents Foreword vii Acknowledgements ix Acronyms xi 1. Introduction 1 1.1. Background 1 1.2. Concept of NHA 2 1.3. Overview of the child health subaccounts 4 1.4. Policy purpose of child health subaccounts 5 1.5. Indicators produced by child health subaccounts 7 1.6. Outline of methodological approach and structure of these guidelines 7 2. Definitions and scope for the child health subaccounts 9 2.1. Child health interventions and programmes involved in their delivery 9 2.2. Scope and boundaries of the NHA child health subaccounts 11 2.2.1. Child health expenditures in the NHA 11 2.2.2. Child health and other NHA subaccounts 14 2.2.3. Geographic boundaries 15 2.2.4. Time boundaries 15 2.2.5. NHA and the health information system 16 3. Classification scheme and tables 17 3.1. Dimensions of NHA and their codes 17 3.2. Approach to assigning classification categories 17 3.3. NHA tables and the child health subaccounts 18 3.3.1. Basic tables for child health subaccounts 19 3.3.2. Aggregates 20 3.4. Child health expenditures: illustrative examples 21 4. Data identification and collection 27 4.1. Approaching the data identification process 27 4.1.1. Understanding what you need and why you need it 28 4.2. Data collection 28 4.2.1. Types of data 28 4.2.2. Identifying data sources 32 4.3. Data collection plan 39 4.4. Summary 42 5. Data analysis 43 5.1. Getting organized: what is needed? 43 5.2. Conducting the analysis itself 45 5.2.1. Step one - creating a T-account 45 5.2.2. Step two - populating the NHA tables 46 5.2.3. Additional steps 47 5.3. Specific issues that may arise with the child health subaccounts 47 5.3.1. Dealing with targeted expenditure 47 iv Guide to Producing CH Subaccounts 5.3.2. Dealing with non-targeted expenditures for child health 49 5.3.3. Dealing with out of pocket expenditures 55 5.3.4. Dealing with integrated expenditures for curative and preventive services 55 5.3.5. Tracking commodity related expenditures 56 5.3.6. Other data analysis issues 57 5.4. Summary 58 6. Implementation process for child health subaccounts 59 6.1. Objectives and general considerations 59 6.2. Resources needed 62 6.2.1. Equipment 62 6.2.2. Other needed resources 62 6.2.3. Limited resources 62 6.3. Report writing and efficient communication of results 63 6.4. Work plan 64 6.5. Complementarity of child health subaccounts with costing estimates 65 6.6. Child health subaccounts when not done in conjunction with NHA 66 6.7. Institutionalization 66 7. Child health subaccounts indicators 69 7.1. Background 69 7.2. Key health policy objectives 70 7.2.1. Equity in health care financing 70 7.2.2. Efficiency 70 7.2.3. Sustainability and resource availability 71 7.3. Minimum set of indicators 71 Annex 1: Ethiopia donor questionnaire 79 Annex 2: Adding rider questions to ongoing surveys 83 Annex 3: Apportionment rules applied to expenditures in Bangladesh health accounts to estimate child health spending 85 Annex 4: Apportionment rules applied to expenditures in Sri Lanka health accounts to estimate child health spending 87 Annex 5: Methodology used in Bangladesh for estimating unit cost and utilization data 91 Annex 6: Optional indicators on intervention-specific expenditures 93 Annex 7: Summary of key statistics for child health subaccounts in Malawi, 2002/03-2004/05. 97 Annex 8: Summary of key statistics for child health subaccounts in Ethiopia, 2004/05 99 Annex 9: Summary of key statistics for child health subaccounts in Bangladesh (1999/2000) and Sri Lanka (2003) 101 Guide to Producing CH Subaccounts Contents v List of Tables Table 2.1 Examples of activities included and not included within the CH expenditure boundaries 14 Table 2.2: Some examples of overlapping services among child health and other types of subaccounts 15 Table 3.1 Functional classification for child health interventions and activities 21 Table 3.2 Financing sources (FS) by financing agents (HF) 24 Table 3.3 Financing agents (HF) by providers (HP) 25 Table 3.4 Financing agents (HF) by functions (HC) 26 Table 4.1. Relationship between needed data estimates and the child health subaccounts-related questions they inform and potential data sources 30 Table 4.2: Examples of routine financial information data sources 33 Table 4.3: Information needed for data analysis from the Health Information System 33 Table 4.4. Examples of survey reports available in-country “On Office Shelves” and used for child health subaccounts 35 Table 4.5: Examples of international databases for non-routine survey reports 36 Table 4.6: Kenya NHA data collection plan for secondary sources 40 Table 5.1. Information needed for data analysis 44 Table 5.2: Example of child health T-accounts: Malawi, 2004/05 46 Table 5.3 Expenditure for the Ministry of Health in Malawi 50 Table 5.4. Financing agents contribution to non-targeted child health spending on inpatient care 54 Table 6.1: Activities and timeline for conducting the child health subaccounts 65 Table 7.1. Proposed list of indicators for the child health subaccount report 73 List of Figures Figure 1.1 Tri Axial Framework: the three dimensions to measure health expenditure flows 3 Figure 2.1. Causes of child and neonatal deaths 2000-2003. 10 Figure 2.2. Expenditure boundaries of NHA 12 Figure 3.1: Construction of classification codes in the ICHA 18 Figure 3.2 NHA tables 19 Figure 3.3 Recommended tables for child health subaccounts 20 Figure 4.1 Example of a map of the flow of funds for child health 29 Figure 6.1: Stakeholders involved in the production of NHA and child health subaccounts 61 Guide to Producing CH Subaccounts Foreword vii Foreword Worldwide, more than ten million children die every year before reaching the age of five, and many more suffer life-long consequences of ill health during childhood. Over time, programmes and partnerships have been developed to increase the delivery of simple, affordable and life-saving interventions for the management of major childhood illnesses and malnutrition. They include the Partnership for Maternal, Neonatal and Child Health (PMNCH), the Expanded Programme on Immunization (EPI), and country- based programmes delivering the Integrated Management of Childhood Illness (IMCI), Insecticide Treated Nets for malaria (ITNs), and interventions linked to the Prevention of Mother to Child Transmission of HIV (PMTCT). Further, application of child health interventions (outside the programme framework) by the many public and private sector providers provide the bulk of care for children in many parts of the developing world. They all address different aspects of child survival, and have had positive results in reducing deaths from common and preventable conditions. Countries have pledged to scale-up the coverage of health services to reach the Millennium Development Goals (MDGs). In the fourth goal (MDG4), countries have committed to a two-thirds reduction in under- five mortality by 2015 from the 1990 baseline. Scaling up the delivery of interventions to address child mortality will require additional investments in commodities, equipment, and human resources as well as strengthening of the operational health system. National policy makers need precise information on the funding gap between the resources currently available for child health and those additional investments required to achieve national targets. In addition, they need to assess whether current child health expenditure is targeted towards the key interventions with the greatest impact on child survival, to determine the source of funding and understand which institutions determine how funds flow within a country’s health system. Such information provides the evidence necessary to make informed decisions, to allocate resources between competing needs, to help set strategic priorities and to ensure sustainable funding for child health programmes and strategies. National Health Accounts (NHA) is an internationally accepted tool that provides a comprehensive estimate of all national health expenditures, whether it is contributed by donors or from domestic public and private sources. Subaccounts generate information on expenditure in accordance with the NHA framework. The term ’subaccounts’ refers to an additional and more detailed reporting of spending levels and patterns for a particular component of health care. The child health subaccounts have been designed to provide financial information to policy makers, programme managers and service providers on the resources spent on child health interventions. Expenditure on child health is defined as expenditure during a specified period of time on goods, services and activities delivered to the child after birth or to its caretaker. Only those goods, services and activities whose primary purpose is to restore, improve and maintain the health of children of the country between birth and the child's fifth birthday are included. Child health subaccounts results can be used in various ways to inform child health policy and programming. They provide answers to specific questions regarding child health financing in the same way that general NHA answers questions on overall health care financing. For example, the child health subaccounts reveal how much is being spent, who is paying, what services and products are purchased and for whom. Because the subaccounts use the internationally recognized NHA framework, child health expenditure can be compared across countries. Once subaccounts results become available at regular intervals, trends in expenditure levels can be tracked, patterns of resource use monitored over time and their relation to the achievement of child health programme goals assessed. Ultimately such assessments can be used to adjust and inform financing strategies to scale up key child survival interventions. viii Guide to Producing CH Subaccounts The Health System Financing and the Child and Adolescent Health and Development Departments at the World Health Organization; the United States Agency for International Development/Partners for Health Reformplus (PHRplus) Project and its successor the Health Systems 20/20 (HS 20/20) project worked together to prepare these Guidelines. The Guidelines benefited from the participation and contribution of numerous child health and NHA experts, and from four country pilots for the development of the methodology. Efforts were made to ensure consistency with the Guide to Producing National Health Accounts with special applications for low-income and middle-income countries. Intended for NHA country experts as well as health account novices, these Guidelines aim to facilitate the production of child health subaccounts on a regular basis in order to better inform child survival policies. David B. Evans Elizabeth Mason Richard Greene Director Director Director Department of Health System Financing World Health Organization Department of Child and Adolescent Health and Development World Health Organization Office of Health, Infectious Diseases and Nutrition Bureau for Global Health United States Agency for International Development Peter Salama Flavia Bustreo Chief, Health Section Deputy Director Programme Division UNICEF, New York Partnership for Maternal, Newborn and Child Health [...]... health subaccounts 8 Guide to Producing CH Subaccounts 2 Definitions and scope for the child health subaccounts The following chapter describes the scope of the NHA child health subaccounts within the context of general NHA The reader should refer to the Producers’ Guide for details on NHA The writing of these chapters is the result of discussions on methods for identifying and tracking child health. .. group, or for the program or regional level In these guidelines, child health subaccounts are developed at the program level and therefore some of the expenditures incurred for the boundaries defined for child health subaccounts will tend to overlap with other programs and age groups In adhering to the general NHA framework, the child health subaccounts are only concerned with direct expenditures on health. .. meetings for the Child Health Survival Partnership forum.1 2 The work of Anne Mills and Tim-Powell Jackson for capturing donor flows for Child health at the international level and of Jane Briggs for tracking expenditures of commodities for child health provided input in developing the child health analytical framework and field work methodology Critical to the development of the Child Health subaccounts. .. overlapping services among child health and other types of subaccounts Overlapping service Subaccounts that could include overlapping services with the child health subaccounts Child health subaccounts Reproductive health subaccounts HIV/AIDS subaccounts PMTCT services Component of PMTCT delivered to the child Component of PMTCT delivered to the mother XX Intermittent Preventive Therapy and Antimalarial... identified by the code HF, have the programmatic control over how the child health funds are allocated These entities are recipients of the funds from the financing sources but are the origin of the funds for the providers in the sense that they purchase their services directly Examples include the office of the child health programme within the Ministry of Health, insurance schemes and NGO’s The entities... expenditure and the flow of corresponding funds By doing so, the child health subaccounts can help answer the following policy relevant questions: • • • • • • • • • • What is the current level of funding for child health at national level? What are the current sources of funding for child health and who manages these funds? What is the direct contribution of households for child health? What is the distribution... associated with the loss of income due to child health (e.g., the loss of income of a parent that stays home to care for the sick child, expenditure on transportation, complementary feeding, etc.), or expenditures associated with child care such as social services 1.3 Overview of the child health subaccounts These guidelines present the methodology for tracking expenditures for child health within the general... (HPxHC) The tables are described in greater detail in Chapter 3 Child health accounts as described in these guidelines can be done as subaccounts using the general NHA methodology As the subaccounts methodology is consistent with the NHA framework, it is recommended that whenever possible, child health subaccounts are done within the context of the general NHA This approach has several advantages First, the. .. the need for detailed information and therefore “lobbies” among the producers of data for the need to disaggregate information when gathering and processing data Finally, the suggested approach helps to place a country’s pattern of expenditure on child health within the context of overall health spending In all, it is a symbiotic endeavor The child health subaccounts provide information useful for measuring... dimensions, the major dimensions defined for tracking expenditures for child health are • • • • From the financers of health care called “financing sources” to the principal managers of the funds, called “financing agents” to those that deliver the services, referred to as health providers” for activities defining the “functions” of the health system The proposed priority tables for child health subaccounts . GUIDELINES FOR PRODUCING CHILD HEALTH SUBACCOUNTS WITHIN THE NATIONAL HEALTH ACCOUNTS FRAMEWORK PREPUBLICATION VERSION. PRODUCING CHILD HEALTH SUBACCOUNTS WITHIN THE NATIONAL HEALTH ACCOUNTS FRAMEWORK PREPUBLICATION VERSION Guide to Producing CH Subaccounts Contents