Guidelines for RMNCH-GET: A Reproductive, Maternal, Newborn, and Child Health Government Expenditure (and budget) Tracking tool pot

Guidelines for RMNCH-GET: A Reproductive, Maternal, Newborn, and Child Health Government Expenditure and budget Tracking tool A Methodology and Data Collection Tool to support tracking

Guidelines for RMNCH-GET:

A Reproductive, Maternal, Newborn, and Child Health Government Expenditure (and budget) Tracking tool

A Methodology and Data Collection Tool to support tracking of Government expenditure on Reproductive, Maternal, Newborn, and Child Health as part of

an annual routine survey

Working Document

01 November 2011

World Health Organization

Purpose

This document is intended to provide an overview of the methodology proposed, developed and tested by WHO for tracking government expenditure on reproductive, maternal, newborn and child health (RMNCH) The intended audience is users of the expenditure reporting tool at country level

as well as readers who wish to acquire a better understanding of methods that can be used to estimate government expenditure going towards RMNCH This may include Ministry of Health government staff, national health accountants, expenditure tracking experts and consultants supporting the implementation of routine expenditure tracking, as well as staff at international organizations supporting the development and application of monitoring mechanisms for RMNCH programmes

Abbreviations used in this document

ARV - Anti Retroviral drugs

CH - Child Health

CoIA - Commission on Information and Accountability for Women's and Children's Health

GAVI - The Global Alliance for Vaccines and Immunization

GDP – Gross Domestic Product

GGHE - General Government Health Expenditures

HMIS - Health Management Information System

ICD - International Classification of Diseases

IMCI - Integrated Management of Childhood Illness

IPD - Inpatient days

ITN - Insecticide Treated Net

JRF - Joint Reporting Form (for Immunization)

MNH - Maternal and Neonatal Health

MNCH – Maternal, Neonatal and Child Health

MNCAH - Maternal Newborn Child and Adolescent Health

MOH - Ministry of Health

NHA - National Health Accounts

NASA - National AIDS Spending Assessment

NIDI - Netherlands Interdisciplinary Demographic Institute

OPV - Outpatient visits

PG – WHO National Health Accounts Producers Guide

RMNCH - Reproductive, Maternal, Newborn, and Child Health

RMNCH-GET - Reproductive, Maternal, Newborn, and Child Health Government Expenditure (and budget) Tracking tool

RTI - Reproductive Tract infection

SRH - Sexual and Reproductive Health

STI - Sexually Transmitted Infection

UNFPA - United Nations Population Fund

WHO – World Health Organization

Responsibilities and Acknowledgments

The methodology outlined in this document was developed jointly by staff members from the following Departments of the World Health Organization:

Child and Adolescent Health (CAH)

Global Malaria Programme (GMP)

Health Systems Financing (HSF)

Immunizations, Vaccines and Biologicals (IVB)

Making Pregnancy Safer (MPS)

Reproductive Health and Research (RHR)

For questions please contact Karin Stenberg, Technical Officer, Department of Health Systems Financing, World Health Organization (E-mail: stenbergk@who.int)

This work received financial support from the Government of Norway

Table of Contents

1 Introduction 7

2 Overall approach 11

3 General Methodology 22

4 Monitoring Government expenditure on Child health (MDG4) 42

5 Monitoring Government expenditures on Maternal Health, as related to MDG5a 52

6 Monitoring Government expenditures on Sexual and Reproductive Health (excluding Maternal and Newborn health), as related to MDG5b 57

7 Preliminary findings and lessons learnt 64

Annexes Annex 1 Members of WHO working group on RMNCH expenditure tracking for MDGs 4 and 5 68

Annex 2 Child and Reproductive health subaccounts to date 69

Annex 3 Essential medicines for child health 70

Annex 4 Overview of the Annex tool section on child health expenditure and budget 71

Annex 5 Overview of the Annex tool section on maternal and newborn health expenditure and budget 75

Annex 6 Overview of the Annex tool section on SRH expenditure and budget 78

Glossary

Government Expenditure: in the approach used in RMNCH-GET, public expenditures refer to funds that are managed by the government As such the tool defines government health expenditure

as per the Financing Agent function in National Health Accounts This means that public

expenditures can include government spending from tax revenue and social security contributions,

as well as external funds passing through the government from the Global Fund, GAVI, or bilateral donors It also includes expenditure by parastatals The scope of Government is the same as in government finance statistics reported to the International Monetary Fond (GFS-IMF)

Government expenditure on service delivery: refers to the capital and recurrent (public) expenditure for maintaining facilities providing health services in the country This refers to

expenditure on resources that are shared across programmes and includes the budget going towards the salaries of health care workers and other staff working at the facilities and hospitals, and the running cost for electricity, water and maintenance in health facilities These expenditures can be further split into outpatient care and inpatient care

Child health expenditure: expenditures during a specified period of time on goods, services and activities delivered to the child after birth or its caretaker whose primary purpose is to restore, improve and maintain the health of children in the nation between zero and less than five years of age

Maternal health expenditure: For the purposes of routine monitoring expenditures towards MDG5a and MDG5b, a distinction is made here between maternal and newborn health (MNH), and sexual and reproductive health (SRH) Maternal health expenditure refers to expenditure incurred during antenatal care, birth, and postpartum care

Sexual and reproductive health expenditure: For the purposes of routine monitoring expenditures towards MDG5a and MDG5b, a distinction is made here between maternal and

newborn health (MNH), and sexual and reproductive health (SRH) SRH expenditure refers to four areas: (i) providing high-quality services for family planning, including infertility services (ii) Eliminating unsafe abortion (iii) Combating STIs including HIV, Reproductive Tract Infections, Reproductive health-related cancers, and other gynecological morbidities (iv) Promoting sexual health

Overview

This document provides an overview of the methodology developed and supported by WHO in

2009 for monitoring government expenditures on Reproductive, Maternal, Newborn, and Child Health (RMNCH) in low and middle income countries

The development of a methodology for tracking government expenditure on RMNCH was

undertaken in recognition of the need to strengthen methods and tools to allow for routine

monitoring of expenditures directed towards reproductive, maternal and child health, particularly

in view of the recognition that countries need to significantly increase expenditure in national health programmes in order to reach the health-related Millennium Development Goals For this purpose a technical working group was set up within WHO, led by the Department of Health Systems Financing, to agree on an approach for incorporating questions on RMNCH expenditure into the annual routine monitoring surveys of WHO technical programmes

Specifically, the objective was to collect data through the questionnaires sent out on a regular basis

by the WHO Departments of Maternal, Newborn, Child, and Adolescent Health,1 and Reproductive Health and Research The group met in 2009 and agreed on the approach outlined in this document The approach was implemented in the MNCAH survey sent out by WHO in 2009/2010 Additional work has since been supported to further develop the methodology and tools Members of the working group are listed in Annex 1

This document is organized into seven sections:

Section 1 Introduction

Section 2 Overall approach

Section 3 General Methodology

Section 4 Monitoring Government expenditures on child health (MDG4)

Section 5 Monitoring Government expenditures on maternal health (MDG5a)

Section 6 Monitoring Government expenditures on sexual and reproductive health (MDG5b) Section 7 Experience to date

The first section provides an introduction to the topic of expenditure tracking and the rationale for strengthening efforts in this area The subsequent two sections provide an overview of the overall approach used (an annual survey) and discusses general methodological issues when it comes to collecting and analysing expenditure data Sections 4-6 focus on each respective area to outline the key programmatic areas for which expenditure data should be collected, and provides an overview

of the approach adopted to select specific questions to be inserted in the annual reporting survey Section 7 summarizes some of the experience to date

1 The WHO department of Maternal, Newborn, Child, and Adolescent Health incorporates the former two WHO Departments

1 Introduction

1.1 Reproductive and child health is high on the political agenda

Countries have pledged to scale-up the coverage of health services to reach the Millennium

Development Goals (MDGs), where MDGs 4 and 5 refer to reducing child and maternal mortality, and imply improving access to reproductive health care.2

In many low-income countries, coverage of proven interventions remains low.3 Scaling up the delivery of interventions to improve the health and survival of women, newborns, and children worldwide, and to ensure expanded access to reproductive and sexual health, will require

additional investments in commodities, equipment, and human resources as well as strengthening

of the operational health system

This document describes an approach developed to track expenditure on Reproductive, Maternal, Newborn, and Child Health (RMNCH) in low and middle income countries The reason for the RMNCH focus is threefold Firstly, MDGs 4 and 5 lag behind in performance when compared to other health-related goals, such as scaling up services to reduce the transmission of malaria, TB and HIV/AIDS as per MDG6 The Millennium Development Goals Report 2010 pointed to striking progress since 1990 but also underlined that only 10 of the 67 countries with high mortality rates were on track to meet the MDG target on child survival With regards to maternal health,

preliminary data indicate some progress, with significant declines in maternal mortality in several countries, but the overall progress has been slow and the rate of maternal death reduction is short

of the 5.5% annual decline needed to meet the MDG target.4

Secondly, RMNCH outcomes are intrinsically linked and a "continuum of care" is needed to ensure that health outcomes are achieved The concept of a RMNCH continuum of care is based on the assumption that the health and well-being of women, newborns, and children are closely linked and should be managed in a unified way Strengthening monitoring efforts jointly for MDGs 4 and 5 is therefore logical At the same time and as outlined below, there may be some components of expenditure requiring more resources than others, and for which there may be a rationale to focus resource tracking efforts

Thirdly, the development of standardized tools and methods for monitoring financial commitments and execution has seen less progress than other monitoring areas (e.g., measurement of related health outcomes such as under-five mortality) With the UN Secretary-General Ban Ki-moon's Global Strategy for Women's and Children's Health launched in September 2010, there is increasing attention to holding partners accountable to realizing the promised commitments, following the principle of alignment with country-led health plans, and strengthening national health systems.5The Global Strategy sets out a framework to measure progress and enhance accountability to improve advancement towards the health-MDGs, including efforts in resource tracking for RMNCH

http://www.un.org/millenniumgoals/pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20-5 http://www.who.int/pmnch/activities/jointactionplan/en/index.html

1.2 The importance of tracking expenditure as an indicator of efforts to improve health

In order to strengthen service delivery and performance of the health system, information

is needed to assess how resources are currently distributed and used within the health

sector National policy-makers and their development partners need information on the financial resources available and how they are used Information on budget and expenditure allows planners

to assess the distribution of resources and current priority setting within the health sector, and to determine the funding gap between the resources currently available and those needed to achieve national targets Such information provides the evidence necessary to make informed decisions, to allocate resources between competing needs, and to ensure sustainable funding for national

programmes and strategies This is particularly true in low-income countries where available resources are scarce, and the issues of fund raising and allocation of funds are all the more

important (Box 1.1) Experience has shown that information on the expenditure level and the use of resources allows for informed decisions to improve allocation of current spending, to reduce waste

of resources and to prepare scaling up of services

In general, routine and timely information on health expenditure, and its distribution across

priority areas, is scattered and without detail This is constraining good policymaking and effective use of limited resources.6

6 Global Health Resource Tracking Working Group,

Box 1.1 Country health expenditure and health outcomes

Source: Reproduced from World Health Report 2008

HALE = health adjusted life expectancy

The graph illustrates that on average health outcomes are better with higher per capita health expenditure, particularly at lower expenditure levels This implies that a close examination of the effectiveness of health spending is justified specifically when the level of per capita expenditure is relatively low

The development of systems of health accounts and in particular National Health Accounts (NHA) in the 1990s has provided countries with standardized tools for monitoring the actual spending of funds NHA have to date been implemented in over 130 countries However, implementation of NHA is still fairly limited in many low-income countries Several low-income countries have done one or two NHA analyses in the past decade but may still struggle with ensuring institutionalization

of the required skills and the political process While an increasing number of countries are looking

at producing NHA reports at regular intervals, the process of setting up a monitoring system is not easily achieved It takes time to build capacity, to ensure that the national health information system captures relevant data, and that audit mechanisms are in place to assess actual spending It

is particularly in poor resource settings that data is generally scarce and this holds also for financial and expenditure data Out of the 68 Countdown countries,7 only 32 countries have a recent NHA (NHA data for years 2006-2009).8 Moreover out of the 49 lowest-income countries listed in the Global Strategy, only 23 countries have conducted at least one NHA in the last 5 years.9

In recent years there has been growing interest in health resource tracking at the national and global level, in particular with the MDGs for which both the donor community and governments are held accountable to their commitments Interest in specific health programmes and the drive towards specialization has contributed to the development of NHA sub-account guidelines for monitoring spending on specific programmatic areas such as child health, reproductive health, and malaria Considerable efforts have gone into ensuring that methods are standardized.10

While many countries and development partners recognize sub-accounts and expenditure

distribution by codes related to the International Classification of Diseases (ICD) as a useful

approach to assess RMNCH spending, 11 implementation of subaccounts to date has been limited (see Annex 2) Moreover subaccounts are generally not done on an annual basis (see section 2)

In an effort to bridge the gap in information on RMNCH expenditure tracking, WHO is therefore supporting the routine assessment of government spending on RMNCH, complementing and consolidating other health expenditure tracking activities in WHO related to total health

expenditure on MDG 6 diseases (HIV/AIDS, TB and malaria)

1.3 Objectives of these guidelines

This document outlines the proposed approach for a process to track government expenditures for child, maternal and reproductive health as part of routine monitoring The aim is to strengthen mechanisms for monitoring of expenditures in all countries, making use of data that is usually readily available from budget records The guidelines are also constructed to support the

institutionalization of government RMNCH expenditure tracking so as to make yearly reporting a possibility and as such better inform policy makers with indicators of a country’s commitment to achieving universal access to RMNCH services and reaching MDGs 4 and 5

There is a global push to strengthen monitoring of RMNCH spending The Countdown to 2015 is one

of the processes whereby expenditure data is consolidated and reported.12 Other initiatives such as the International Budget Partnership are also working in this area.13 The data collection supported

by WHO will feed into the reporting processes for Countdown to 2015 and the monitoring for the UNSG Global Strategy, and as such unifying efforts

7 For a list of Countdown countries, see http://www.countdown2015mnch.org/

8 Information compiled by WHO/HSF staff Charu C Garg in 2011, based on data available from WHO sources of NHA data and OECD sources of NHA data

9

Keeping promises, measuring results United Nations Commission on Information and Accountability for Women’s and Children’s Health, 2011 ( http://www.who.int/topics/millennium_development_goals/accountability_commission/en , accessed 10 September 2011).

10 Guidelines for undertaking subaccounts are available at: http://www.who.int/nha/

11 Following the money: Monitoring financial flows for child health at global and country levels - presentation by Anne Mills

at Countdown to 2015 conference, London 2006

12 http://www.countdown2015mnch.org/

13 http://www.internationalbudget.org

The methods outlined in this paper take into consideration exchanges with other agencies such as UNFPA/NIDI that collects information on reproductive health spending, and GAVI regarding information on immunization spending

It is important to note that the methodology outlined in this document refer to a first round of materials and are likely to be further developed over time This document is to be seen in this light and refers to the first round of surveys sent out by WHO in 2009/2010, and adjustments made to the second round survey (2011)

1.4 How can the RMNCH-GET be used at country level?

The Commission on Information and Accountability for Women's and Children's Health

recommends that by 2015, all 74 countries where 98% of maternal and child deaths take place are tracking and reporting total reproductive, maternal, newborn and child health expenditure by financing source, per capita 14

However, not all countries have institutionalized measures for monitoring health expenditure, nor have considered how an assessment of expenditure specific to RMNCH may be monitored and used

to evaluate progress towards programme goals and commitments, and to inform the national planning process The RMNCH-GET can facilitate country teams to start working with available data on budgets and expenditures, to identify which particular expenditure components relate to RMNCH, and to begin a discussion around the current public sector resource allocation towards RMNCH, as part of annual monitoring towards the MDGs and other goals

Countries that already have experience with sub-accounts or are planning to conduct such studies may still wish to use RMNCH-GET to support an annualized monitoring process, complementary to NHA sub-accounts Other countries may wish to instead institutionalize the production of sub-accounts on an annual basis to facilitate RMNCH expenditure monitoring from all sources

The purpose of RMNCH-GET is to provide a tool to facilitate expenditure reporting and budget mapping towards RMNCH classification, and may therefore be most useful to countries that are considering the implementation of detailed sub-accounts reporting in the future, but for the meantime could use RMNCH-GET to inform reporting processes The tool, being user-friendly, can also facilitate capacity development for RMNCH programme managers who may not be familiar with concepts of expenditure and budget tracking

Section 2.8 of this document provides more information on how the results can be used for

advocacy and programme planning

14 Keeping promises, measuring results United Nations Commission on Information and Accountability for Women’s and Children’s Health, 2011 ( http://www.who.int/topics/millennium_development_goals/accountability_commission/en ,

2 Overall approach

2.1 Objective

The overall objective is to support the collection of data on government expenditure on

reproductive, maternal, newborn, and child health programs (here referred to as RMNCH)

The scope of RMNCH as defined here includes adolescent health, to the extent that it falls within the scope of maternal or reproductive health programmes, i.e., those programmes addressing

adolescent sexual and reproductive health.15

2.2 Scope of "RMNCH"

The expenditures on RMNCH are defined as those incurred for the provision of interventions and activities primarily aimed at improving the health of mothers and children, as well as overall sexual and reproductive health The definition of the scope follows the standardized definitions provided within the guidelines for producing Reproductive and Child health subaccounts The reproductive health expenditure as defined according to the Reproductive health subaccounts include maternal health Box 2.1 provides an overview

Box 2.1 Definition of Child and Reproductive health expenditure

Child health expenditure * Reproductive health expenditure * *

Expenditures incurred on goods, services and

activities delivered to the child after birth or its

caretaker and whose primary purpose is to

restore, improve and maintain the health of

children in the nation between zero and less

than five years of age

Includes 5 priority areas identified in Global Reproductive Health Strategy:

• Antenatal, delivery, postpartum and newborn care

• High-quality services for family planning, including infertility,

• Eliminating unsafe abortion

• Combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer etc., and

• Promoting sexual health

* Definition as per the (WHO, 2009) Guidelines for producing child health subaccounts within the national health accounts framework - prepublication version; ** Definition as per the WHO (2009) Guidelines for producing Reproductive health subaccounts within the national health accounts framework Documents are available from http://www.who.int/nha

In general there is some overlap between the reproductive and child health accounts Child health is

an age account which aims to measure all expenditures on children under five years old The

reproductive health accounts are programme based and monitor expenditures delivered as part of the reproductive and maternal health programmes, which by necessity includes some neonatal care Newborn health expenditures are therefore included both in child health and reproductive health sub accounts Other examples of "shared" activities between child and reproductive health accounts are prevention of mother to child transmission of HIV (PMTCT) and breastfeeding counselling When the findings from two or more subaccounts are combined, care must be taken to avoid double counting

15 Adolescent health activities that fall outside the scope of RMNCH, such as those addressing accidents, suicide, violence, or illnesses such as tuberculosis, are not included

2.3 Focus on government spending

The method outlined in this document looks at public sector finances only, i.e., government

expenditure going towards RMNCH activities, as they will be defined in more details later in this document The definition of government expenditure follows that outlined in the Guide to

producing National Health Accounts16, where General Government Health Expenditures (GGHE) is identified at the financing agent level, and includes government expenditure funded by donor money (see Box 2.2) The measure is used to evaluate stewardship of the Government and the allocation of expenditure towards priority areas

2.4 Added value of an annual routine expenditure monitoring survey

The NHA methodology involves the use of standard rules for handling resources and standard classifications grouping them, in order to provide a comprehensive estimate of all national health expenditures, be it public or private, and whether funded with domestic or external resources NHA has been implemented to date in over 130 countries The NHA methodology has been further developed to track expenditures within several priority areas of health, such as HIV/AIDS,

reproductive health, and child health These estimations are called “subaccounts” and have a more

Box 2.2 Financing Sources and Financing Agents: NHA terminology

NHA makes the distinction between:

• Financing Sources: institutions or entities that provide the funds used in the health system This answers the question on “where does the money come from?” This

includes all sources of income of government (e.g., including oil sale revenue)

• Financing Agents: institutions or entities that have power and control over how funds are used i.e., programmatic responsibilities, and use those funds to pay for, or purchase, health activities This information answers the question “Who manages and organizes the funds?"

Source: Guide to producing national health accounts

In the Financing Agent function, public expenditures include government spending from tax revenue and social security contributions, as well as external funds passing through the

government and parastatals Private expenditures, on the other hand, refer to spending by the corporate sector (employees, companies), insurance companies, NGOs, private foundations and households Household spending is known to be frequently the largest component

The Financing Agent role is a strong determinant for how money is actually managed and spent, thus affecting actual coverage, health outcomes and therefore the focus of the approach

described in this document A strong indicator, which these guidelines will recommend to

produce, is the share of General Government Expenditure on health (GGHE) going towards RMNCH services and programmes The share will highlight government’s efforts towards

RMNCH, as well as allow for comparison between countries

detailed reporting of spending levels and patterns for a particular component of health care, such as child health

Limited implementation of Child and Reproductive Health accounts to date highlights the need for complementary routine monitoring tools that could facilitate the collection of some of the

information that subaccounts make available, but on a more regular basis At the time of writing this document, reproductive health subaccounts have been undertaken in at least 20 countries (Bolivia, Colombia, Democratic republic of Congo, Dominican Republic, Egypt, Ethiopia, Georgia, Jordan, Karnataka State India, Kenya, Liberia, Malawi, Mexico, Morocco, Namibia, Rwanda, Senegal, Sri Lanka, Tanzania, and Ukraine); and child health subaccounts had been done in at least 5

countries (Bangladesh, Ethiopia, Malawi, Sri Lanka, and Tanzania).17 In addition a study had been undertaken in Rajasthan to look at joint spending on maternal and child health Annex 2 provides a list of the studies undertaken to date It should be noted that these assessments have been done for different years There are no countries that annually monitor RMNCH expenditure through the subaccounts approach, although several countries are looking at implementing approaches to facilitate annualized reporting of programme-specific expenditure.18

The implementation of an annual routine survey that collects information on government RMNCH expenditure is not intended to replace the existing more detailed methods for expenditure

monitoring such as the sub-accounts for child and reproductive health Rather the intention is to provide a rough complementary method for quickly determining the public sector resource

allocation towards RMNCH, as part of annual monitoring towards the MDGs and other goals

Moreover, for technical and cost reasons, measuring government expenditure on RMNCH can also

be undertaken as a part of an health accounts effort Table 2.1 below compares the characteristics of

an annual survey to that of health sub-accounts The latter is recommended to be implemented on a regular basis whenever there is strong policy interest

Table 2.1 Annual routine monitoring is complementary to reproductive health or child accounts

sub-Characteristic Reproductive health or child health

Less resource-intensive as public entities report expenditure yearly and budget reports can be adjusted to obtain the desired detail Data collection format facilitates combining existing data into a joint format

Number of

countries

covered

Produced by few countries per year Estimates produced for a large number

of countries per year

Scope Tracks financial flows from all

sources in the health system (public and private)

Tracks financial flows managed by the Government

Level of detail Provides detailed breakdown of

spending

Provides an indicative rough overview of public RMNCH spending

Frequency Implemented frequently every 3-5

years depending on policy relevance

Preferably implemented on an annual basis

Purpose Detailed analysis to inform national

policy discussion

Gross assessment of levels and trends to allow for continuous monitoring over time to be incorporated into the programme management and planning

17 The country assessments listed here are those of which we are aware This may not be a complete list

18 Personal communication, NHA team Senegal, 2009.

cycle

Resources Guidelines available WHO may

provide follow up long distance support (email, telephone)

Guidelines available WHO may provide follow up long distance support (email, telephone)

A support tool kit for estimation has been generated (including the RMNCH-GET) Hands-on workshops have been held to facilitate the use of the tool and information

The annual assessment of RMNCH spending as through the proposed WHO survey is limited in scope and detail and thus will not be able to assess all the relevant policy questions that a full subaccount can do In its initial years the WHO survey will only focus on monitoring government expenditure This is to be considered a first step, while ideally an assessment of funding that covers all sources will be more informative and should be considered for the longer run Given that

governments provide an oversight function for the entire health system, and often provide direct support to the implementation of strategic interventions, the measurement of governmental spending in itself is very useful

A restriction to government expenditure does not imply that expenditure by other agents is

irrelevant for RMNCH outcomes The role of the private sector is significant in many regions and countries In some countries where households finance a large share of health care there are economic barriers to care limiting access to cost-effective services, risk of catastrophic

expenditures, and inequities in care seeking and health outcomes Under these circumstances a detailed subaccount analysis would provide additional in-depth information For example an assessment of RMNCH spending in Rajasthan state in India indicated that only 20% of Reproductive and Child health was funded by the government in 1998-99.19 Figure 2.1.presents data from 5 countries regarding the share of resources for child health that is managed by the government A significant proportion of child health is funded by the non-public sectors

19 Sharma et al., Reproductive and child health accounts: an application to Rajasthan, Health Policy and Planning, 17 (3):

Figure 2.1 The role of government expenditure for RMNCH: country examples 20

Financing Agents of Child Health

Ethiopia (2005)

Malawi (2003-2005 average)

Sri Lanka (1995-2003 average)

Tanzania (2002-03 &

2005-06 average) Countries (with years)

Non-public sector excluding household OOP

In many countries the public sector is the main manager of RMNCH funds For example, the Malawi sub-accounts for 2002-2005 revealed that the public sector (in particular the MoH) managed about 60-65% of reproductive health funds and 54-63 % of child health funds.21

2.5 The RMNCH-GET tool: links to National Health Accounts and Public Expenditure Reviews

The primary purpose of the RMNCH-GET is to facilitate reporting on RMNCH expenditure managed

by the Government If an NHA has been done, NHA data relating to total government spending, the breakdown by inpatient care and ambulatory care, and expenditure by function or inputs may be used to inform the reported estimates on RMNCH expenditure If a sub-account has been done, that should be used as the gold standard for reporting, if results are available for the relevant year Public expenditure reviews (PERs) are diagnostic studies of government spending patterns,

prepared with the objective to help countries establish effective and transparent mechanisms to allocate and use available public resources in a way that promotes economic growth and helps in reducing poverty A public expenditure review may look specifically at the health sector (PERH) If a PERH has been undertaken, it can provide information on the allocation of public expenditure on health by levels (primary, secondary and tertiary), the public spending on health across functional classifications, and the distribution of public expenditure on health across age groups, geographical setting and regions, A previous PERH can also help provide information on expenditure from local government bodies, which may otherwise not be easily captured at national level This information, when available, should be used to inform the analysis and reporting of RMNCH expenditure

20 Note to Figure 2.1 OOP = Out of pocket expenditures

21 Ministry of Health, Government of Malawi March 2007 Malawi National Health Accounts (NHA) 2002-2004 With accounts for HIV and AIDS, Reproductive and Child Health Bethesda, MD: Partners for Health Reformplus project, Abt Associates Inc.

Sub-2.6 Disease-specific expenditure tracking as part of routine surveys

Given the interest to be able to assess expenditure trends on a continuous basis, efforts are ongoing

in a number of areas to track country level government expenditure and partners contribution in

specific health areas (see Table 2.2) There is growing experience in the areas of malaria, HIV/AIDS,

TB, and immunization Similar initiatives are being developed for new areas such as tobacco control

for non-communicable diseases

Table 2.2: Survey tools for disease specific expenditure tracking (status as of mid-2010)

Frequency

of survey

Expenditure data requested (Number of years)

Budget data requested (Number

of years)

Survey asks about governme

nt funding and/or expenditu re?

Survey asks about develop ment aid funding?

Survey asks about private sector expendit ure?

Year in which expenditure data was first collected

The user does not indicate an amount

for the 22 high-burden countries; Since 2006 for all other countries

(T-1), (T-2), (T-3)

in 2008 and

2009 Year reported varies by country and ranges between

2003 and

2008 WHO/RHR

T = current year; the year in which the survey is sent out

NIDI: Netherlands Interdisciplinary Demographic Institute

2.7 Development of the WHO survey tool for RMNCH expenditure tracking and accompanying documents

This section outlines the process that was set up to develop a survey tool for RMNCH expenditure tracking Section 7 at the end of this document outlines some of the preliminary findings and lessons learnt from the first round of the survey in 2009/2010

harmonize RMNCH approaches as much as possible, avoid any duplication of work load and

monitoring processes, and create linkages to existing tools when feasible

The working group was led by the Department of Health Systems Financing (HSF) Members

included staff from Departments of Child and Adolescent Health (CAH), Immunizations, Vaccines and Biologicals (IVB), Global Malaria Programme (GMP), Making Pregnancy Safer (MPS), and Reproductive Health and Research (RHR) See Annex 1 for a list of working group members

The working group met several times to discuss various methodological issues and to agree on indicators and processes for collecting and reporting on the data A methodology was developed and agreed upon for collecting RMNCH expenditure and budget data Sections 3-6 in this document provide more detail on the methodological considerations

A couple of pre-tests were carried out during country missions, to find out from country partners

on the feasibility of reporting on expenditure data The reactions were mixed given countries' different stages of development with regards to accessibility to budgetary data There was overall agreement among country MoH staff and partners that tools and capacity to track current spending need to be strengthened

Tool development

A questionnaire on Maternal Newborn Child and Adolescent Health (MNCAH) was jointly developed

by the CAH and MPS Departments to monitor indicators related to strategic information and

programme implementation A separate section on Government total budget and total expenditure, and their allocation to RMNCH, was inserted into this tool The overall survey tool was translated into French, Spanish and Russian

Sections in first round MNCAH survey 2009/2010

Section 1: Identification and validation

Section 2: Rights, policies, and strategies

Section 3: Human resources and capacity building

Section 4: Essential technologies and pharmaceuticals

Section 5: Service delivery

Section 6: Financing

Section 7: Partnerships

Section 8: Health information systems

Section 9: Health expenditure

In order to facilitate the reporting on government health expenditure and budget allocation to RMNCH within section 9 of the survey form, the RMNCH-GET was developed as an Annex help tool and sent to countries along with the overall questionnaire The RMNCH-GET is developed in Excel and aims to support standardized reporting on government RMNCH spending by encouraging detailed annotation of metadata information (source of data; estimation methods used if any; comments on any departure from international definitions) Standardization of methods and their

consistency over time is particularly important when the persons filling in the estimates may change over time A key value of RMNCH-GET is that it allows for an assessment of what

expenditure components are included in the actual amounts reported

The structure of RMNCH-GET is further described in Table 2.3 Results in the form of Graphs and Tables are automatically produced based on the inputs provided and shown in the sheets

"Results_CH" and "Results MNH+SRH" Based on the data inputted, this tool assists in the estimation

of the indicators for reporting in the overall MNCAH survey tool

The RMNCH-GET also reminds the user to link to existing surveys already undertaken in the

country such as the NIDI surveys for reproductive health, and to connect with the focal points for National Health Accounts The tool also provides a number of default values and information, including a list of country focal points for NHA The tool was made available in English and French for the first round survey

Table 2.3: Sections included in RMNCH-GET accompanying the MNCAH survey 2009-2010

expenditure and overall utilization data that can

be used to apportion expenditures

expenditures and budgets This is used to assess spending related to MDG 4

provided in sheet "3a Expenditure_CH"

budgets related to maternal and reproductive health This is used to assess spending related to MDG 5

provided in sheet "4a Expenditure_MNH+SRH"

them to be printed

surveys

coverage, currency exchange rates, etc

prevalence rates

Evaluations of some of the existing data collection mechanisms have revealed weaknesses Table 2.4 provides a summary of how the RMNCH-GET approach aims to address these

Table 2.4 Common challenges for expenditure tracking and mechanisms proposed to mitigate these for the MNCAH survey and RMNCH-GET

MNCAH survey addresses these issues Survey format difficult to understand Survey tool includes help aides; Capacity

building sessions are organized as part of the start-up process

Non-standardized interpretation of categories RMNCH-GET is provided as a help tool and

includes help aides providing an explanation to what data should be reported (definitions)

In several countries administration is not at the

national but at the regional level Information on

financial resources is not readily accessible at

central level

This is an overall challenge that is difficult to address Linking RMNCH programme managers to the National Health Accountants will facilitate access to aggregated national level data

Reluctance to fill in the questionnaire as it is

seen as cumbersome and not a priority for the

technical programme

Capacity building sessions organized on the importance of financial monitoring and how this can help the national programme planning Information and final results are not shared

with Respondents

RMNCH-GET automatically produces indicators that the country respondent can relate to and use in the national policy context Data form is returned with gaps Follow-up support is provided to facilitate use

of the help aids, to understand gaps in the data and to ensure quality control of data provided Once collected, data is not made publicly

available

Data will be made publicly available through WHO Global Health Expenditure Database (GHED)

Data collection

The first round of the survey was sent out to WHO regional and country staff, who were asked to liaise with Ministry of Health counterparts in filling out the survey RMNCH-GET was sent out as a help tool together with the survey and was also sent out separately to country offices upon

verification whether they had received it or not Active follow-up was done by WHO/HQ

Intended users of the RMNCH expenditure tracking tool

The intended process is for the tool to be used by a multi-disciplinary team at country level, represented by a national accounts expert, and one or more Ministry of Health programme staff for the reproductive/maternal health area and from the child health programme

Capacity building, facilitating networks and information sharing

This work has as an overall objective to strengthen links between the national RMNCH programme managers and the country national health accountants The RMNCH expenditure monitoring is a concrete project where these two groups of professionals can work together and establish

relationships Linkages are made through the RMNCH-GET which includes country-specific

information on NHA focal points

In order to ensure that quality data is obtained on RMNCH expenditure, WHO supports intensive capacity building workshops, specifically with the aim to build Ministry of Health capacity on expenditure tracking mechanisms and to strengthen the institutionalization of routine reporting on RMNCH expenditure though partnerships at country level between RMNCH programme managers and national health accountants In addition to building capacity on the collection of data through

22 The list of issues draws upon the findings of the Resource Flows Project: Overview and assessment of the data collection process, page 45

the use of RMNCH-GET and other tools, the workshops also cover methods for extracting relevant

data from other sources available, such as national budgets and specific surveys, including the

UNFPA/NIDI surveys for reproductive health

2.8 Using the results for advocacy and programme planning

The impact of monitoring the RMNCH expenditure is through the evidence base that it provides for informing what resources the programme is getting with regards to its stated goals It can also help

to identify whether expenditures are in line with recent government policies for specific RMNCH

programmes or interventions (for example, financing policies on free care, or policies that relate to introducing new vaccines or making ITNs available)

The findings need to be interpreted within the country-specific context There is no global

recommendation for what percentage of government spending should be allocated towards RMNCH This depends on the disease burden, the prevalence of infectious diseases, and the political

priorities set for the health sector

However, information on the share of government spending that goes towards RMNCH can inform

an assessment of whether the current expenditure is in line with the stated commitments of

decision makers to improve RMNCH outcomes (see Box 2.3) Expenditure data can be compared

with the estimated costs of resources needed to achieve RMNCH targets, and inform a discussion

around eventual gaps between the identified needs and the current distribution of funds

Box 2.3: Examples of country commitments

In follow-up to the launch of the Global Strategy for Women’s and Children’s Health in 2010, almost 130 stakeholders from a variety of constituency groups made financial, policy and service-delivery

commitments Country governments have made specific commitments on the financial contributions to

be made towards RMNCH, including the extent of new and additional resources and projected

government health spending on RMNCH Two examples are shown below:

Central African Republic: commits to increase health sector spending from 9.7% to 15%, with 30% of the health budget focused on women and children’s health; ensure emergency obstetric care and

prevention of PMTCT in at least 50% of health facilities; and ensure the number of births assisted by skilled personnel increase from 44% to 85% by 2015 CAR will also create at least 500 village centers for family planning to contribute towards a target of increase contraception prevalence from 8.6% to 15%; increase vaccination coverage to 90%; and ensure integration of childhood illnesses including pediatric HIV/AIDS in 75% of the health facilities

Afghanistan: commits to increase public spending on health from $10.92 to at least $15 per capita by

2020 Afghanistan will increase the proportion of deliveries assisted by a skilled professional from 24%

to 75% through strategies such as increasing the number of midwives from 2400 to 4556 and increasing the proportion of women with access to emergency obstetric care to 80% Afghanistan will also improve access to health services - strengthening outreach, home visits, mobile health teams, and local health facilities Afghanistan will increase the use of contraception from 15% to 60%, the coverage of childhood immunization programs to 95%, and universalize Integrated Management of Childhood Illness

Source: The Partnership for Maternal, Newborn & Child Health 2011 Analysing Commitments to Advance the Global Strategy for Women’s and Children’s Health The PMNCH 2011 Report Geneva, Switzerland: PMNCH

Studying budgets can help to answer questions like:

Is the current share of health budget allocated to RMNCH adequate to meet policy

objectives?

How much priority is given to RMNCH when compared with other programmes?

Has progress been made in terms of the government budgetary allocation to RMNCH over time? This analysis requires data for several years to be available

Did the budget allocation of previous years translate into expenditure on RMNCH? This analysis can be undertaken if the RMNCH-GET is used for multiple years, such that data initially entered as provisional budget estimates can later be compared with data entered for the same year(s) for actual expenditure in a subsequent cycle of reporting,

3 General Methodology

The purpose of this section is to provide an overview of the general methods developed Sections

4-6 provide more detail on each of the three programmatic areas of child health (CH), maternal and neonatal health (MNH); and sexual and reproductive health (SRH)

3.1 Guiding principles for methodology development

The guiding principles set up by the working group in 2009 are:

• The method should follow the boundaries for the scope of RMNCH expenditure as outlined

in of the guidelines for child and reproductive health subaccounts

• The approach should focus on capturing data on the main categories of expenditure (cost drivers) of RMNCH at national level

• The approach should allow for a quick estimation of government RMNCH expenditure using available government financial data

• The approach should explore methods to obtain data from all sources when there is quality information available, to triangulate data or results, e.g.:

o Spending on Insecticide Treated Bednets from national malaria surveys

o Spending on Sexually Transmitted Infections from National Assessment of

Spending on AIDS (NASA) or UNFPA/NIDI surveys

o Spending on pediatric ART from NASA surveys

• The approach should allow for separate estimates on CH, MNH and SRH spending, where available

• Field testing and validation of the methodology should be supported throughout its development, preferably in countries that have conducted national health accounts and sub-accounts in order to allow for quality control and comparison with a "gold standard"

• The final method developed should be flexible and allow for data collection and analysis in countries regardless of whether NHA is available or not

A two-step process was adopted First the desired indicators were determined, drawing upon the subaccounts guidelines and the minimum desired information that should be reported Next the overall methodology was developed

3.2 Indicators

Indicators for RMNCH expenditures aim to facilitate monitoring of expenditure and budgets in relation to achieving globally agreed goals Indicators should relate to three aspects:

• Total amount spent and in budget

• Share of Government health spending going to the priority area

• Amount spent per beneficiary

The indicators follow the standard format of child and reproductive health subaccounts, as part of the standardized NHA framework While the guidelines for reproductive health subaccounts address expenditures on both maternal, newborn and sexual and reproductive health, for purposes

of programming and advocacy there may be a need to separately assess spending on MNH and SRH

as these are two distinct areas, both relevant for MDG5 – improving maternal health This is

highlighted in the two separate targets for MDG5 - target 5.A to reduce by three quarters, between

1990 and 2015, the maternal mortality ratio, and target 5.B to achieve, by 2015, universal access to reproductive health The below list of indicators takes into account the expectation that reporting

of RMNCH expenditure data will be most useful if available separately for child health, MNH and SRH

The objective is to produce the following indicators for two retrospective years, for the current year and for one prospective year:

Expenditure related to MDGs 4 (reduce child mortality) and 5 (improve maternal health) (aggregate measures):

1 Total expenditure on reproductive, maternal, newborn, and child health (RMNCH)23:

a Proportion (%) of general government expenditure on health going to RMNCH (this is the sum of 2a, 3a and 4a below)

b Per capita government expenditure on RMNCH (this is the sum of 2b, 3b and 4c below)

Expenditure on MDG4 (reduce child mortality):

2 Expenditure on Child Health:

a Proportion (%) of general government expenditure on health going to Child Health

b Per capita government expenditure on child health

c Government expenditures on child health per child under five

Expenditure on MDG5 (improve maternal health):

3 Expenditure on Maternal and Newborn Health (MNH):

a Proportion (%) of general government expenditure on health going to maternal and newborn health

b Per capita government expenditure on MNH

c Government expenditure on MNH per live birth

4 Expenditure on Sexual and Reproductive Health (SRH):24

a Proportion (%) of general government expenditure on health going to SRH

b Proportion (%) of general government expenditure on health going to Family Planning

c Per capita Government expenditure on SRH

d Government expenditure on Family Planning per woman of reproductive age

5 Total expenditure related to MDG5:

a Proportion (%) of general government expenditure on health going to

reproductive and maternal health (This would be the sum of indicators 3a and 4a)

capita (This would be the sum of indicators 3b and 4c)

The following principles and considerations were agreed upon by the working group:

• Indicators should be standardized with those in the child and reproductive health subaccounts

• Expenditure on adolescent health programmes is covered under MNH and SRH in line with the guidelines for reproductive health accounts

• Expenditure boundaries should follow NHA framework, and include all programme-specific expenditures beyond individual disease control programmes

• The aim is to track the same list of items for expenditures and budgets

• In addition to per capita indicators, there is a need to have other denominator-specific

indicators (e.g., MNH expenditures per pregnant woman, etc) This requires that data for the denominator is already available or needs to be built into the data collection form In order to reduce the amount of data collected, the help tools should link to default data such as the United Nations population division demographic projection estimates

• There is interest to look specifically at certain areas, such as Family Planning expenditure.25

23 MNCH, Family Planning and SRH/STIs

24 Covers mainly Family Planning and SRH/STIs

3.3 Tracking RMNCH expenditures through input components

Having defined the desired list of indicators, the next step is to understand the scope of what should

be included under RMNCH expenditure, which can reasonably be tracked through a routine survey The four main input components are described in Table 3.1

Table 3.1: Components to be tracked

a) Government spending on commodities (drugs,

vaccines, and supplies)

The country respondent is asked to identify expenditure associated with commodities of specific importance to RMNCH

b) Government spending on activities related to

programme administration and management,

including:

• Staff of the national programme

(administrative costs),

• Programme activities (advocacy, training

etc), IEC and social mobilization

• Expenditure on capital investments

The country respondent is asked to identify expenditure associated with activities of the national disease control programme of the Ministry of Health

c) Government expenditure on health service

delivery (mainly human resources at community

and facility level)

The country respondent is asked to identify expenditure associated with general health service delivery; and to provide service utilization data The service utilization data provided is used to allocate a share of the spending on general health service delivery to RMNCH

d) Incentives for demand generation 26 The country respondent is asked to identify

whether the government managed funds for conditional cash transfers or financial incentives specific to RMNCH, and if so, to indicate the amount

3.4 Mapping RMNCH expenditure and budget categories

Government expenditure reports (and budgets) will likely not be structured in a way that will directly provide detail of expenditure on RMNCH In other words, budget categories will

probably not directly correspond with the categories of RMNCH spending as outlined in the

RMNCH-GET or RH/CH subaccounts For this reason, data trackers will need to “map” the two classifications Mapping two classifications is to establish a correspondence between categories

of one classification with categories of another classification: in this case we would like to map government’s executed health budget categories with RMNCH categories and in doing so

25 There was interest to develop a tracer indicator for assessing spending on the newborn However no agreement was

reached within the working group on a suitable indicator for which data would be available at country level This issue may

be addressed in future versions of the survey.

26 The working group felt that expenditure estimates need to take into consideration cash transfers and other financial

incentives e.g., payment for facility based deliveries Incentives for demand generation has therefore been added as an

creating a crosswalk table between the budget line items and the corresponding RMNCH categories

One additional advantage of “mapping” budget line items with RMNCH is that it will ease expenditure tracking of subsequent years for as long as neither classifications are revised (and

if they are revised, the effort of adjusting the mapping framework is likely to be less than mapping government line items with RMNCH categories all over again) The mapping of categories is often said to be participating in the institutionalization of health expenditure tracking It enables health accountants to generate health expenditure series more quickly and effectively, and ensure that statistics are consistent from year to year

Overall the added value of a mapping is the greatest when the budget structure is the same as the expenditure reports In case the executed expenditures are reported in a different format than that of the budget, expenditure reports categories should also be mapped

Other general government expenditure classifications can also be mapped with RMNCH categories General government spending includes expenditure by the territorial governmental entities (ministries, regions, districts), expenditure by extrabudgetary entities (for example, social security offices may be autonomous entities from territorial government), and

expenditure by parastatals For this reason, mappings could also be prepared for these other governmental institutions

Multiple mapping can also be prepared between three categories: between a line item and an RMNCH category as we have just seen, and also between a line item and a given source of revenue As RMNCH-GET is tracking government expenditure on RMNCH, including monitoring the sources of revenue that funded these expenditures, it will be of interest to further

strengthen the mapping table with sources of funding categories This will require that some line items be split in order to assign it to more than one source of revenue For example, government expenditure on IMCI can be 100% mapped to the RMNCH expenditure category of child health In the case that IMCI is funded 30% by the government and 70% by development partners, the line item IMCI will need to be divided between the two sources:

With one to one mapping:

IMCI Child health 125,000

One to One mapping with metadata on sources of revenue:

Budget line RMNCH Government

funding

Development partners IMCI Child health 30% 125,000 70% 125,000

Mapping between three categories:

Budget line RMNCH Source of

revenue

Amount IMCI Child health Government 37,500

IMCI Child health Dev partners 87,500

As this example illustrates, mapping is likely to require some apportioning between one category of the budget classification, and two or more categories of the RMNCH and Source of revenue categories In some cases, the apportioning may also mean that only a share of the given line item is attributed to RMNCH expenditures, and the rest is to be left out

The preparation of a mapping table requires time and details It is important to prepare well and understand the intricacies of the work A guide was prepared by USAID and HS2020 for mapping budgets to NHA classification This guide is available on the web page:

http://www.healthsystems2020.org/content/resource/detail/2236/

3.5 Methodological challenges: apportioning shared expenditure

Measurement of expenditure on health for a specific population group may involve different type of approaches The ideal is to generate a bottom-up approach, for which the amount of the various components is estimated (e.g., through a mapping as seen in section 3.4), and then the amounts are added

The amount for expenditure earmarked to the RMNCH programmes or groups of population under study should be fully estimated The challenge is to identify the specific amounts, through the appropriate data sources In the case of government spending, budgets are the more direct choice

An example is the amount devoted to the administration of child health programmes In this case it should be accounted for the full amount used in the administration of the IMCI

programme When, the total expenditure on RMNCH components is not available as a single aggregate, the various sub-components have to be identified and added up It may happen that some earmarked products can be identified as specific items, in which case the total amount spent can be generated through the multiplication approach The underlying principle is the equation: Value 27= cost * quantity

An example of this approach is used to estimate the total amount of expenditure on Oral Rehydration Salts (ORS):

A survey or administrative record can provide information about children treated for diarrhea

in government health care services The unit cost of the ORS can be provided by the pharmacy The estimation of ORS expenditure can then be obtained as:

Expenditure on ORS = number of children receiving ORS treatment * cost of ORS

3.5.1 Allocation factors

A considerable amount of RMNCH spending comes from shared resources related to overall service delivery Any disease-specific expenditure tracking study faces specific methodological challenges related to the apportioning of funds that are channeled through integrated health services towards the disease of interest Tracking expenditures on RMNCH cuts across different diseases and vertical programmes, and must use methods to apportion not only integrated health funds but also disease-specific expenditures Figure 3.1 illustrates the need to separate out government expenditure on

"Service delivery",28 and allocate a share towards RMNCH Distribution is required when

expenditure is not earmarked for the RMNCH components and the appropriate share has to be identified from a group of interventions/services, as well as when a single RMNCH expenditure aggregate has to be decomposed into its components (medicines, activities, etc)

Ideally, information would first be made available on the amount spent on inpatient and outpatient services, and then a proportion of this allocated to RMNCH since the shares may be different for inpatient and outpatient care The data source used should be the one with greater level of detail available

27 The original equation refers to “value = price * quantity” However, in government services subsidies and other

instruments can modify prices For government services the convention is to use costs instead of prices

28 "Service delivery" refers to the capital and recurrent (public) expenditure for maintaining facilities providing services in the country This includes the budget going towards health care workers and other staff working at the facilities and hospitals, the running cost for electricity, water and maintenance Most countries have a separate budget line for such

Figure 3.1 Identifying government expenditure on service delivery and allocating a share towards RMNCH

The NHA rationale is to distribute expenditure through classifications that explore one single axis at

a time When dealing with functions as in the chart above, information on services are grouped in order to identify major components Greater disaggregation by RMNCH groups of population and services require a specific set of expenditure details generated by the “subaccounts”

The Figure above displays the standard first and second level digit NHA classes and expenditure aggregates These can be used both as reference to assess the plausibility of RMNCH estimations, and furthermore each category can be broken down into the specific components to be tracked A challenge related to the above Figure and how to draw upon National Health Accounts data is that NHA generally does not separate out all components in the same classification, e.g the functions or services are not broken down as Goods and commodities (medicines and supplies) and other components A cross-classification can be generated of services by factors of provision (inputs) to approach the disaggregated view of services When input data are not available by service, a

breakdown is needed through estimation procedures These NHA aggregates are homogeneous components which can be broken down in each case, through a selected allocation factor (see below)

Another way to apportion funds could be by level of care In a study by Powell-Jackson et al (2006) fixed apportionment factors were used to estimate the share of funding on maternal and child health. 29 The apportionment factors were specific to the level at which care is delivered

29 Powell-Jackson et al., Countdown to 2015: tracking donor assistance to maternal, newborn, and child health, Lancet 2006; 368: 1077–87 In their study, fixed shares were computed fixed to indicate the proportion of health provider costs that could

be assumed to be attributable to maternal and child health services, as follows:

For Primary-level health care - 40% was allocated to child health and 8% to maternal and newborn health

For Hospital-level health care - 11% was allocated to child health and 13% to maternal and newborn health

For General health care (not level specific) - 20 % was allocated to child health and 12% to maternal and newborn health with the factor being derived based on a weighted average of the above estimates at primary-level and hospital-level care Note that these allocation factors were based on estimates from very few countries (3 African countries) and should not be considered universally representative With regards to malaria-specific expenditure, Powell-Jackson et al used a region-

Another example of fixed allocation factors is the methodology developed by the G8 in 2010 for

assessing the share of official development aid going towards RMNCH.30 Table 3.2 below

summarizes some of the allocation factors used by the G8, which do not distinguish between the

level of care at which services are provided, nor between inpatient/outpatient care For activities

that target the entire population, the methodology developed by the G8 makes use of approximate estimates of the respective population shares in order to determine the percentage of the funds

going to each area, with the assumption that on average women of reproductive age (including

those who are pregnant) make up approximately 25% of the population and children under five

constitute 15% of the population

Table 3.2 Allocation factors used for G8 methodology 2010

Percentages for RMNCH

Criteria used for allocation

population

mostly at women of reproductive age and/or children under five years

population

population

estimates of the relative number of deaths in the populations of interest (children aged 0-4 years and women aged 15-44 years, based on WHO’s Global Burden of Disease (2004 update)

estimates of the relative number of deaths in the populations of interest (children aged 0-4 years and women aged 15-44 years, based on WHO’s Global Burden of Disease (2004 update)

mostly at women of reproductive age and/or children under five years

mostly at women of reproductive age and/or children under five years

specific allocation factors for child health that ranged from 42% in Europe to 54% in Africa, based on a combination of ITN

use in households with a net and regional malaria incidence rates Moreover, they assumed that a fixed share of 15% of total malaria funds is spent on a package of maternal and newborn health malaria services, i.e., preventive interventions (ITNs

and intermittent presumptive treatment) given to pregnant women For paediatric HIV/AIDS, Powell-Jackson et al used

country-specific allocation factors based on the percentage of children under five with HIV, and a similar approach was used for Tuberculosis

estimates of the relative number of deaths in the populations of interest (children aged 0-4 years and women aged 15-44 years, based on WHO’s Global Burden of Disease (2004 update)

reproductive health

mostly at women of reproductive age and/or children under five years

sanitation

national budgets allocated to health in the 49 high-burden countries at 10% (based on 2007 data from the World Health Statistics), and imputed to that

“health share” a percentage of 40% based on the assumed share of women and children in population

Source: Methodology for Calculating Baselines and Commitments: G8 Member Spending on Maternal, Newborn and Child

Health (accessed 21 September from

http://canadainternational.gc.ca/g8/summit-sommet/2010/mnch_methodology_isne.aspx?lang=eng&view=d )

As these few examples show, different methods may be used to track expenditure on RMNCH There

is a growing need to standardize methods for disease- and programme-specific tracking in order to ensure that estimates are consistent, particularly in the apportionment of shared health resources

At the same time, it should be recognized that these techniques provide indicative estimates only,

and that further work may be needed to determine the most appropriate allocation factors The

production of expenditure estimates should always be accompanied by clear communication on the assumptions used to apportion shared expenditure

The method used within the WHO RMNCH-GET tool to allocate shared expenditure is to primarily

make use of country-specific data on service utilization statistics This data should be entered by the user for the specific year(s) of interest, in order to derive factors that can be used to allocate a share

of resources towards RMNCH, rather than applying fixed percentages Country-derived allocation

factors will be more accurate and in line with the country-specific context The basic information

can refer to:

• service unit costs (based on real and not “ideal” costs)

• the cost or share of human resources involved and/or

• the quantity of specific services provided

• composite indexes that account for various inputs and costs More examples of various allocation factors specific to child health, SRH and maternal health are

included in sections 4-6 below

3.5.2 Determining the amount of expenditure that is "shared"

As discussed above, because a considerable amount of RMNCH spending comes from shared

resources, allocation factors need to be used Moreover data is required on government expenditure per component Countries with a recent NHA should have some of the data readily available

However, given that NHA is not necessarily carried out every year, the routine monitoring of

expenditure needs to allow for analysis even when there is no recent NHA An analysis of the

Countdown to 2015 countries in the WHO regions of AFRO and EMRO (total 46 countries),31

31 http://www.countdown2015mnch.org/

revealed that 34 countries have done at least one NHA, but only 19 countries have completed a NHA with data for year 2006 or more recent.32 This indicates that in the short run, for countries that are not yet at a stage where annual production of NHA is feasible, it is important to look at

complementary approaches to ensure that at least preliminary estimates be available by year, Ideally and as shown in Figure 3.1, there is a need to know the amount spent on general service delivery,and then allocate a proportion of this to RMNCH However in some countries it may be difficult to access data on the share of the government budget going specifically towards service delivery (excluding drugs and other commodities), since the NHA data matrices generally do not separate out Service Delivery from Goods and commodities (medicines and supplies) However it should be possible to at least estimate a proxy for the spending on Service Delivery, given available data that is directly available or derived from budgets and health account reports

Data from NHA may separate expenditure between outpatient and inpatient spending With the new system of health accounts (SHA 2011) launched in 2011, the methodology for NHA reporting is being updated Under the new guide, the typology of services can be better delineated to be further distributed by beneficiary group (cross-classification of functions by beneficiary) E.g., with more clear differentiation between preventive, curative, and rehabilitative care To identify components

as in the previous chart, containing inpatient and outpatient services, a two-digit approach is needed The SHA 2011 classification by function is shown in Box 3.1

Box 3.1 The functional health care classification at first digit level

In some countries the collection of expenditure data on RMNCH is already institutionalized; for example the Malaysia NHA includes a category on "Maternal and child health, family planning and counseling" (category HC.6.1 in the reporting based on SHA1) These types of efforts can be

continued with SHA 2011, but the new classification provides a standard way of disaggregating the components of the maternal, child and family planning programmes, instead of having a unique class to be broken down according to individual country preferences Guidance in the new SHA

2011 is more clear on the categories and will lead to greater comparability of the results

When possible, globally available NHA data (WHO GHED)33 can be used as quality control for the data provided through the RMNCH-GET and the annual routine survey on RMNCH expenditure, both for components such as inpatient or outpatient services, or for major aggregates, such as

32 Information based on data available from WHO sources of NHA data.

HC.1 Curative care

HC.2 Rehabilitative care

HC.3 Long term care (health)

HC.4 Ancillary services (not-specified by function)

HC.5 Medical goods (not-specified by function)

HC.6 Preventive care

HC.7 Governance and health system and financing administration

HC.9 Other health care services not elsewhere classified (n.e.c.)

Memorandum items: Reporting items

HC.RI.1Total pharmaceutical expenditure

HC.RI.2Traditional complementary alternative medicines

HC.RI.3 Prevention and public health services (according to SHA 1.0)

Memorandum items: health care related

HCR.1 Long-term care (social)

HCR.2 Health promotion with a multi-sectoral approach

government expenditure on health The WHO database includes annual estimates of general

government expenditure on health (GGHE), funded with both domestic and external resources, i.e., the data collected in the annual RMNCH country questionnaire is triangulated with the GHED data when possible

3.5.3 Allocation of Shared Expenditure based on Utilization data

The largest share of RMNCH expenditure is incurred by spending on components that are specific to RMNCH such as general inpatient and outpatient clinical services In the approach

non-proposed in these guidelines for annual tracking, and following the standard methods in the CH and

RH subaccount guidelines, estimation techniques are used to allocate expenditures on personal health care, based on the share of child, maternal and reproductive health care out of the total inpatient days and outpatient visits per year

Main approaches to distribute expenditure

• Allocation using the main activity principle is used in national accounts and can be applied in these tracking when only minor components should be excluded

• The development of specific studies, from focal groups or expert opinions, to measuring actual activities through “time and motion” studies are useful but vary in accuracy and cost

• More accurate estimations are obtained through a bottom-up approach, which can also lead to case-by-case adjustments

If data is available from utilization records on the number of inpatient admissions and outpatient visits (with information on the patient‘s age), then one can calculate the proportion of admissions and visits that are for children under five Moreover, if data is available on which conditions were treated and /or the type of services provided, one could also estimate the proportion of admissions and visits for MNH and SRH

However, applying these percentages to overall expenditures for a provider assumes that the cost of each outpatient consultation and inpatient admissions are equal between age groups In the case of outpatient consultations, this may be a reasonable assumption to make if the cost is mainly driven

by the health personnel time, and if the average time per client is not expected to vary substantially between age groups On the other hand, the assumptions may not hold true for inpatient admissions, which is why a weighting by the average number of In-Patient Days (IPD) per patient group should

be applied when possible (if information is not available on average cost per service provided) The more specific the data, the better, as it can be found that averages mask huge dispersions of expenditure by type of service in a single establishment An example is displayed regarding the split

of inpatient and outpatient care in a hospital in Malawi:

Source: NHA report 2002-03 Malawi

3.5.4 Allocation between inpatient and outpatient care

In the ideal case, health expenditures for service delivery (mainly human resources and operational cost for running facilities; excluding expenditure on goods) are available separately for inpatient and outpatient care The purpose of separating out expenditure on goods (commodities) is to have this identified as a separate expenditure component However, whenever such desegregated data is not available, other methods are proposed to arrive at the relative distribution of service delivery expenditure between inpatient and outpatient care This includes using morbidity reports and utilization data for preventive care When data is very sparse, a WHO regression model for deriving the relative distribution between inpatient and outpatient visits can be used as fallback option.34The RMNCH-GET uses the regression model as default if the user does not indicate the split

between inpatient and outpatient expenditures See Box 3.2 for more detail However it is

preferable that country data be used when available

34 Regression model derived from Adam, T and D Evans, Determinants of variation in the cost of inpatient [Soc Sci Med

Box 3.2 Default split between inpatient and outpatient care within the RMNCH-GET: based on WHO regression model

If the user does not indicate data on the split of expenditure between inpatient and outpatient care, an allocation is performed automatically in the RMNCH-GET tool, based on a WHO regression model (*) The regression model calculates for each country, the ratio between the cost of an inpatient day and an outpatient visit This data is stored in the database sheet of the RMNCH-GET tool

The user should enter data on inpatient visits and outpatient days in the tool (sheet 2) in order for the formula

to be applied There are three options used by the tool to estimate the split between inpatient and outpatient care expenditure:

Option 1: the user enters data on the split of expenditure between inpatient and outpatient care (preferred option)

Option 2: the user enters data on total number of inpatient visits and outpatient days; as well as an estimated amount for Total Service Delivery expenditure (SDE) but no data on the split of expenditure between inpatient and outpatient care The tool will then automatically apply the Unit Cost Ratio and the data entered on service utilization data so as to derive a ratio, as follows:

(a) Total joint expenditure value (weight) on inpatient & outpatient care:

= Number of inpatient days x (Ratio of the economic value of OPV/IPD) x Number of OPVs

(b) Equivalent expenditure share for one IPD = SDE / (a)

(c) Expenditure share for IPD = ( (b) * Number of inpatient days identified ) / SDE

(d) Expenditure share for OPV = 1 - (c)

Option 3: the user has not entered any data on total number of inpatient visits and outpatient days In this case the default mode within the tool is to allocate the full amount for Total Service Delivery expenditure (SDE) towards outpatient care This should be a warning sign to the user that some data is missing

The screen shot below shows how the allocation mechanisms used are communicated to the user in sheet 2 of the tool In the example shown, option 2 is used for the first year, and option 3 for the remaining years

If data was not entered above for the "Split Service Delivery Spending by inpatient / outpatient Care", then the proxy for allocation used is:

Note to user: based on the data you have entered above, the m odel will therefore use the following ratios for the calculations to apportion expenditure between inpatient and outpatient care

Note: Proxy f or allocation is based on WHO allocation formula, and depends on data entered on total outpatient visits and inpatient days above in (Q3 and Q5)

(*) Regression model derived from Adam, T and D Evans, Determinants of variation in the cost of inpatient [Soc Sci Med 2006] - PubMed result Social Science & Medicine, 2006 63: p 1700-1710.

3.5.5 Allocation of outpatient expenditure, by disease/condition/programme

Once total expenditure on outpatient care is estimated, a share of this needs to be allocated towards RMNCH Allocation factors are typically based on the numbers of outpatient visits (OPV) as reported

by disease/programme/type of visit by the health service providers and recorded in the health information system (HMIS) Data on the number of outpatient visits is usually reported for those over and under five years of age separately

However it should be noted that in many countries OPV data is not available Moreover, even when OPV data is available, it may not include key preventive RMNCH activities such as immunization events, antenatal care, family planning and counselling In this case, the proposed method is to calculate the number of visits using coverage rates for these interventions applied on the target population, in order to get the number of individuals, and then multiply by the number of visits supplied using expert opinion

For example:

Immunization coverage ratio for children under 5 = 40%

Population under 5 years = 943,775

=> Immunized population = 40% of 943,775 = 377,510 people

On average, immunization requires 1.3 visits per child under five per year, which means a total of 490,763 visits

If the total number of OPV is N, and total expenditure on OPV is E, then expenditure on OPV for children under 5 = E * 490,763 / N

Moreover in many countries the service utilization statistics cover public, as well as private, health facilities (e.g., Tanzania).35 Through the RMNCH-GET tool, the Respondent is requested to provide data on public sector utilization in the first hand, but if this is not available then utilization by all sectors can be inputted The assumption would then be that utilization patterns do not distinctly differ between public and private sectors and therefore shares of all RMNCH-specific utilization to total utilization would be used for calculating government expenditure on RMNCH This is a

simplistic assumption but can be used if no other data available

3.5.6 Allocation of inpatient expenditure, by disease/condition/programme

Similar to outpatient care, once total expenditure on inpatient care is estimated, a share of this needs to be allocated towards RMNCH inpatient services Available measures for activity vary by country and include the number of inpatient admissions, number of persons treated, completed episodes or inpatient days The measure of inpatient days has been found to be most useful for international comparisons.36 If data is only available on the number of inpatient admissions, it is advisable to refine and weight these measures by the average length of stay data (by ward, type of disease or condition, age group)

35 The Tanzania GFATM NHA report also underlines the need to note that the listing of OPD cases probably overestimates malaria because it is based on presumptive diagnosis of fevers and under-reports HIV/AIDS and opportunistic infections because of stigma However for RMNCH services there should be less under- and over-reporting (Report available at: http://www.who.int/nha/country/tza/tanzania-nha-_2002-2003_and_2005-2006.pdf)

36 Age and gender-specific functional health accounts - A pilot study of the application of age and gender- specific functional

An illustration on how to apportion inpatient care to child health following these principles:

• Use the proportion of inpatient days for each patient group

• Example: Expenditure on IPD = E (ex $2,000,000)

• Total number of IPD = N (ex 10,000)

• Number of inpatient days for child health = Nc (ex 2,000)

• Expenditure on inpatient care for child health = Ec = E x (Nc/N)

Example: $2,000,000 x (2,000/10,000) = $400,000 Note: This is the methodology applied automatically within RMNCH-GET The tool derives the share

of expenditure for inpatient care, as explained above, and then uses the ratio of Nc / N to apportion

a share of the inpatient care expenditure towards Child Health

If there is no data on total inpatient days (IPD), the country analyst may estimate the total IPD based on data available from hospitals on diagnosis classification, and the estimated average

number of days per diagnosis

The use of available data to obtain better estimates may require adjustments E.g If only data on inpatient admissions is available and not inpatient days, as desired:

Example:

• Expenditure on IPD = E (ex $2,000,000)

• Total number of inpatient admissions = N (ex 2,000)

• Average length of an inpatient stay (Av): 4 days

• Number of inpatient admissions for birth delivery = NSD (ex 400) Average length of stay (AvSD) : 2 days

• Expenditure on inpatient care for skilled delivery:

= ESD = E x (NSD x AvSD) / (N x A)

Example: $2,000,000 x [ (400 x 2 ) / (2,000 x 4) ] = $2,000,000 x ( 10%)

= $200,000 Ideally for an expenditure study the service utilization should also be weighted by cost data

However there is very limited data available on the relative cost of services Such data may

occasionally be available, for example an analysis on reproductive heath spending in Jordan used data on inpatient reproductive health care, and derived the inpatient allocation factor by a

combination of cost data and utilization data as shown below.37 Using this approach the allocation factor ratio for inpatient care was derived to be 24.4%

Example from Jordan reproductive health accounts

Average cost per

Z% of overall inpatient expenditure that are used for RH care at selected public hospitals

of type N

 Results for all 4 types of hospitals combined to represent the total number of public hospitals in the country

37 Partners for Health Reformplus July 2006 Jordan National Health Accounts Reproductive Health Subanalysis, 2001

Bethesda, MD: The Partners for Health Reformplus Project, Abt Associates Inc

Conclusions for the WHO tool: RMNCH-GET:

Taking into account the scarcity of data available the RMNCH-GET makes use of the number of inpatient days as the allocation measure for inpatient expenditure

An estimation process that uses coverage is also a valuable approach and may be tested in the field,

to see what type of responses are provided, and to compare estimates calculated by utilization statistics by those estimated using coverage data (as a form of validation)

3.6 Summary of key data required for allocation purposes

Taking the above into consideration, the following data would be required to estimate expenditure

on CH, MNH and SRH:

a) Service utilization data on outpatient care and inpatient care

• This should include all relevant levels, e.g., Central and Regional Hospital, District Hospital, Health centre, Dispensary / health post, Outreach38

• Share of patient load based on diagnosis/ condition (delivery, ANC, STI, etc)

• Share of patient load based on age / event (births, child under five, adult)

• Coverage data when applicable

Data on service utilization for potential use as distribution keys:

• For inpatient: number of admissions, discharges, inpatient bed days

• For outpatient: number of outpatient visits, prescriptions

• For other services: number of laboratory tests, number of operations, X-rays, staff hours, ambulance trips, administrative costs, etc

• For preventive services: covered population per activity

Table 3.3: Example of data sources

Type of data collected Methods and data sources

Utilization data

admissions, outpatient visits, average length

of stay, inpatients days, hospital discharges

attributable to children / maternal care / SRH

the amount of general revenues that is

indirectly used to deliver RMNCH services

by level of delivery, ANC etc

average number of visits

Government expenditure on drugs and

commodities

distribution in the past year for relevant drugs

purchase and distributed in the past year, for example ITNs (malaria program), vaccines (immunization program)

Service delivery expenditures

facilities as well as breakdown between

inpatient and outpatient care

Consolidated Appropriation Accounts, audited accounts

inpatient and outpatient expenditures

Government spending on programme costs:

• Staff of the national programme

3.7 Commodity-related expenditures on RMNCH

Through the RMNCH-GET tool accompanying the WHO survey, data is requested specifically for cost driving components and expenditures which can be identified as primarily used for RMNCH, such as:

• Vaccines, injection materials and Vitamin A capsules

• Paediatric formulations (syrups, etc), Oral Rehydration Salts and zinc tablets

For some drugs and commodities the methodology will assume that a proportion of the expenditure can be allocated to RMNCH (details about what proportion to use will be provided later) For example:

• Insecticide treated bed nets

It is expected that data on spending on paediatric formulations will be limited and is likely to underestimate commodity costs for under-five care Studies show that the availability of key essential medicines for children is poor in many low-income countries.39 There is often a shortage

of dosage forms suitable for children and children are therefore provided with substitutes - for example adult formulations which are broken in half or similarly reduced in dose to approximate the dosage of a paediatric formulation Nevertheless it is important to trace this information Note that ideally the reported expenditures for commodities should cover not only the cost of the physical commodities, but also include the expenditure on services such as distribution, storage, and sales

The target is to value the consumed commodities When data on commodities delivered is available, they can be then treated through the cost * quantity approach

As governments usually have bulk purchases and it is noted that the frequency and size of purchase may fluctuate from one year to the next, it is recommended to collect data on purchases for several years and to do trend analysis if possible Such analysis may not be included in the first round of estimates on RMNCH but may be considered in future rounds for validation checks The collection

of data for 4 consecutive years may also help control for variation

In summary, the key commodities for RMNCH will vary by country A list of key commodities to track for child health was put forth by members of the WHO working group (see Annex 3)

3.8 National programme expenditures on RMNCH

The proposed method aims to capture spending on government programme activities, including programme staff This category of spending may be open to subjective interpretation which is why guidance should be provided The RMNCH-GET contains suggestions of what type of activities should be covered During the process of recording programme administration-related expenditure, the respondent will be requested to separate out commodity costs if included in the programme budget (e.g., vaccines)

In some countries expenditure for demand generation may be planned for centrally, in which case the country analyst should be guided to contact the Health Promotion Unit or equivalent

3.9 Additional examples of identification and allocation of RMNCH expenditure

As explained in section 3.4, the specific budget categories to be mapped to RMNCH will vary from country to country Moreover, the decision on what proportion of expenditure should be included, and where it should be included, will be decided on a case-to case basis, to the extent possible following the general guidelines and categories outlines in this document

39 Jane Robertson et al., What essential medicines for children are on the shelf? Bull World Health Organ 2009;87:231–237

Example: expenditure on fridges for immunization

Here the suggestion would be to map the expenditure to the programme management costs for immunization

Example: expenditure on blood safety

Here the suggestion for the RMNCH-GET would be to include the expenditure on blood safety within the total amount reported for general service delivery inpatient care, whereby the tool would automatically allocate a proportional amount towards RMNCH, based on the data that the user has inputted for inpatient care visits

3.10 Overall challenges and issues to take into consideration

3.10.1 User guidance and comprehensiveness

On the issue of user guidance and ensuring comprehensiveness of the expenditure estimates reported, the working group has noted that:

• The data collection form should include warnings to indicate when data may be difficult to find; and caveats for example with regards to utilization data for preventive care Such information has therefore been included in RMNCH-GET and should also be discussed at the capacity building workshops

• Visits for preventive care that may be missing from utilization statistics would need to be added both to the denominator and numerators

• Experience from existing surveys indicate that reporting completeness in general ranges from 50 to 80%.40 Measures have thus been introduced to take reporting completeness into account specifically for service utilization data

• There is a need for intensive follow-up and support to countries to provide the expenditure estimates, in particular in the initial years

3.10.2 Structure of country health management information systems

An overall challenge is the variation between countries in the recording and management of

information Accounting systems in countries may categorize information in two ways – by type of resource (e.g salaries, equipment) or management cost centre (e.g health facility, vertical health programme).41

3.10.3 Decentralized systems

Another challenge is revenue which is collected and paid locally In many countries procurement of drugs for primary and secondary health services has been devolved to local councils An example is decentralized incentive programmes When resource allocations are taken at decentralized level, the final allocation may not be communicated up to central level which raises challenges for a survey tool that is administered at national level only

For the first round of the WHO questionnaire, the working group suggested to include a question on the availability of decentralized incentive programmes in RMNCH-GET, in order to identify

countries which can be followed up individually to gather information on such expenditure

It may also be considered for the second round of the survey to include qualitative questions to the respondent on whether local revenue generation is common practise in their country and to what extent the RMNCH costing reported may miss this part of expenditure

40 WHO/GMP survey

41 Powell Jackson and Mills, 2007

3.10.4 Fiscal or calendar year

Countries define their fiscal years differently The calendar year starts on 1 January until 31 December The utilization data may be reported for calendar year, but the expenditure data may only be available for fiscal year This is not a major issue of concern for expenditure reporting, since within NHA there are standardized methods for resolving this

3.10.6 Accounting basis

In general there are two accounting mechanisms to account for the fact that funds may be released

at a different time to when the activity takes place:

The cash method: a transaction is registered when the money is received or paid

The accrual method: a transaction is registered when the good or service is delivered

Health Accounts recommends use of the accrual approach, which means that the record of

expenditure is made when the services are delivered and not when the payments are done In practice, a mix of both methods may be implemented

3.10.6 Accounting for the total expenditure envelope

It is important that the disease- and programme-specific monitoring is conducted within a general, overarching framework for health expenditures If this is not done there is the potential for the sum

of the disease-specific expenditures to exceed total national health expenditure Estimates of disease-specific or programme-specific health spending must always be put in relation to (i) the total health spending, and (ii) the population need

3.10.7 Linkages with other surveys and tools

The RMNCH-GET working group noted that estimates from other survey instruments should be incorporated where relevant to minimize the reporting burden on countries and to ensure

consistency in the estimates reported

• For immunization related spending, such data can be imported from the JRF process into the section on child health costs for most of the vaccines

• For Tetanus Toxoid, such expenditures could be imported from the JRF into the maternal health section of the WHO survey

• Similar importing of SRH and HIV costs from NASAs should be explored

• The RMNCH-GET and accompanying materials should refer to other instruments such as NASA but also give additional instructions on how to review and improve the estimates

3.10.8 Expenditure vs budgets

The RMNCH-GET approach includes data collection of expenditures as well as budget estimates In all respects the methods should ensure consistency between scope of expenditure estimates and budget estimates

Expenditures are requested for two years (T-2, and T-1)

Budget data is requested for two years (T) and T+1

Where T = current year; the year in which the survey is sent out

For expenditures the method will use allocation measures to estimate a proportion of shared costs going to RMNCH For budgets, as there is no information on future utilization patterns, the method makes use of the utilization pattern from the latest year(s) for which data is available