Tài liệu GUIDELINES FOR PRODUCING CHILD HEALTH SUBACCOUNTS WITHIN THE NATIONAL HEALTH ACCOUNTS

GUIDELINES FOR

PRODUCING CHILD HEALTH

SUBACCOUNTS WITHIN THE

NATIONAL HEALTH ACCOUNTS

FRAMEWORK

PREPUBLICATION VERSION

2

All standard disclaimers of each of the sponsoring organizations apply to this publication.

The author’s views expressed in this publication do not necessarily reflect the views of the United States

Agency for International Development (USAID) or the United States Government

GUIDELINES FOR

PRODUCING CHILD HEALTH

SUBACCOUNTS WITHIN THE

NATIONAL HEALTH ACCOUNTS

FRAMEWORK

PREPUBLICATION VERSION

Guide to Producing CH Subaccounts Contents iii

Contents

Foreword .............................................................................................................................................vii

Acknowledgements..............................................................................................................................ix

Acronyms .............................................................................................................................................xi

1. Introduction................................................................................................................................1

1.1. Background........................................................................................................................1

1.2. Concept of NHA................................................................................................................2

1.3. Overview of the child health subaccounts.........................................................................4

1.4. Policy purpose of child health subaccounts.......................................................................5

1.5. Indicators produced by child health subaccounts ..............................................................7

1.6. Outline of methodological approach and structure of these guidelines.............................7

2. Definitions and scope for the child health subaccounts..........................................................9

2.1. Child health interventions and programmes involved in their delivery.............................9

2.2. Scope and boundaries of the NHA child health subaccounts ..........................................11

2.2.1. Child health expenditures in the NHA...............................................................11

2.2.2. Child health and other NHA subaccounts .........................................................14

2.2.3. Geographic boundaries ......................................................................................15

2.2.4. Time boundaries ................................................................................................15

2.2.5. NHA and the health information system ...........................................................16

3. Classification scheme and tables.............................................................................................17

3.1. Dimensions of NHA and their codes...............................................................................17

3.2. Approach to assigning classification categories..............................................................17

3.3. NHA tables and the child health subaccounts .................................................................18

3.3.1. Basic tables for child health subaccounts ..........................................................19

3.3.2. Aggregates.........................................................................................................20

3.4. Child health expenditures: illustrative examples.............................................................21

4. Data identification and collection ...........................................................................................27

4.1. Approaching the data identification process....................................................................27

4.1.1. Understanding what you need and why you need it ..........................................28

4.2. Data collection.................................................................................................................28

4.2.1. Types of data .....................................................................................................28

4.2.2. Identifying data sources.....................................................................................32

4.3. Data collection plan.........................................................................................................39

4.4. Summary..........................................................................................................................42

5. Data analysis.............................................................................................................................43

5.1. Getting organized: what is needed?.................................................................................43

5.2. Conducting the analysis itself..........................................................................................45

5.2.1. Step one - creating a T-account .........................................................................45

5.2.2. Step two - populating the NHA tables...............................................................46

5.2.3. Additional steps .................................................................................................47

5.3. Specific issues that may arise with the child health subaccounts....................................47

5.3.1. Dealing with targeted expenditure.....................................................................47

iv Guide to Producing CH Subaccounts

5.3.2. Dealing with non-targeted expenditures for child health .................................. 49

5.3.3. Dealing with out of pocket expenditures........................................................... 55

5.3.4. Dealing with integrated expenditures for curative and preventive services...... 55

5.3.5. Tracking commodity related expenditures........................................................ 56

5.3.6. Other data analysis issues.................................................................................. 57

5.4. Summary ......................................................................................................................... 58

6. Implementation process for child health subaccounts ......................................................... 59

6.1. Objectives and general considerations ............................................................................ 59

6.2. Resources needed............................................................................................................ 62

6.2.1. Equipment ......................................................................................................... 62

6.2.2. Other needed resources ..................................................................................... 62

6.2.3. Limited resources.............................................................................................. 62

6.3. Report writing and efficient communication of results................................................... 63

6.4. Work plan........................................................................................................................ 64

6.5. Complementarity of child health subaccounts with costing estimates............................ 65

6.6. Child health subaccounts when not done in conjunction with NHA .............................. 66

6.7. Institutionalization .......................................................................................................... 66

7. Child health subaccounts indicators...................................................................................... 69

7.1. Background ..................................................................................................................... 69

7.2. Key health policy objectives ........................................................................................... 70

7.2.1. Equity in health care financing ......................................................................... 70

7.2.2. Efficiency .......................................................................................................... 70

7.2.3. Sustainability and resource availability............................................................. 71

7.3. Minimum set of indicators .............................................................................................. 71

Annex 1: Ethiopia donor questionnaire........................................................................................... 79

Annex 2: Adding rider questions to ongoing surveys ..................................................................... 83

Annex 3: Apportionment rules applied to expenditures in Bangladesh health accounts to

estimate child health spending.......................................................................................................... 85

Annex 4: Apportionment rules applied to expenditures in Sri Lanka health accounts to estimate

child health spending ......................................................................................................................... 87

Annex 5: Methodology used in Bangladesh for estimating unit cost and utilization data .......... 91

Annex 6: Optional indicators on intervention-specific expenditures ............................................ 93

Annex 7: Summary of key statistics for child health subaccounts in Malawi, 2002/03-2004/05. 97

Annex 8: Summary of key statistics for child health subaccounts in Ethiopia, 2004/05 ............. 99

Annex 9: Summary of key statistics for child health subaccounts in Bangladesh (1999/2000) and

Sri Lanka (2003)............................................................................................................................... 101

Guide to Producing CH Subaccounts Contents v

List of Tables

Table 2.1 Examples of activities included and not included within the CH expenditure boundaries ..14

Table 2.2: Some examples of overlapping services among child health and other types of

subaccounts ..................................................................................................................................15

Table 3.1 Functional classification for child health interventions and activities..................................21

Table 3.2 Financing sources (FS) by financing agents (HF)................................................................24

Table 3.3 Financing agents (HF) by providers (HP) ............................................................................25

Table 3.4 Financing agents (HF) by functions (HC)............................................................................26

Table 4.1. Relationship between needed data estimates and the child health subaccounts-related

questions they inform and potential data sources.........................................................................30

Table 4.2: Examples of routine financial information data sources .....................................................33

Table 4.3: Information needed for data analysis from the Health Information System .......................33

Table 4.4. Examples of survey reports available in-country “On Office Shelves” and used for child

health subaccounts........................................................................................................................35

Table 4.5: Examples of international databases for non-routine survey reports ..................................36

Table 4.6: Kenya NHA data collection plan for secondary sources.....................................................40

Table 5.1. Information needed for data analysis ..................................................................................44

Table 5.2: Example of child health T-accounts: Malawi, 2004/05.......................................................46

Table 5.3 Expenditure for the Ministry of Health in Malawi...............................................................50

Table 5.4. Financing agents contribution to non-targeted child health spending on inpatient care .....54

Table 6.1: Activities and timeline for conducting the child health subaccounts ..................................65

Table 7.1. Proposed list of indicators for the child health subaccount report .....................................73

List of Figures

Figure 1.1 Tri Axial Framework: the three dimensions to measure health expenditure flows...............3

Figure 2.1. Causes of child and neonatal deaths 2000-2003. ...............................................................10

Figure 2.2. Expenditure boundaries of NHA........................................................................................12

Figure 3.1: Construction of classification codes in the ICHA..............................................................18

Figure 3.2 NHA tables..........................................................................................................................19

Figure 3.3 Recommended tables for child health subaccounts.............................................................20

Figure 4.1 Example of a map of the flow of funds for child health .....................................................29

Figure 6.1: Stakeholders involved in the production of NHA and child health subaccounts..............61

Guide to Producing CH Subaccounts Foreword vii

Foreword

Worldwide, more than ten million children die every year before reaching the age of five, and many more

suffer life-long consequences of ill health during childhood. Over time, programmes and partnerships

have been developed to increase the delivery of simple, affordable and life-saving interventions for the

management of major childhood illnesses and malnutrition. They include the Partnership for Maternal,

Neonatal and Child Health (PMNCH), the Expanded Programme on Immunization (EPI), and country￾based programmes delivering the Integrated Management of Childhood Illness (IMCI), Insecticide

Treated Nets for malaria (ITNs), and interventions linked to the Prevention of Mother to Child

Transmission of HIV (PMTCT). Further, application of child health interventions (outside the programme

framework) by the many public and private sector providers provide the bulk of care for children in many

parts of the developing world. They all address different aspects of child survival, and have had positive

results in reducing deaths from common and preventable conditions.

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

Goals (MDGs). In the fourth goal (MDG4), countries have committed to a two-thirds reduction in under￾five mortality by 2015 from the 1990 baseline. Scaling up the delivery of interventions to address child

mortality will require additional investments in commodities, equipment, and human resources as well as

strengthening of the operational health system.

National policy makers need precise information on the funding gap between the resources currently

available for child health and those additional investments required to achieve national targets. In

addition, they need to assess whether current child health expenditure is targeted towards the key

interventions with the greatest impact on child survival, to determine the source of funding and

understand which institutions determine how funds flow within a country’s health system. Such

information provides the evidence necessary to make informed decisions, to allocate resources between

competing needs, to help set strategic priorities and to ensure sustainable funding for child health

programmes and strategies.

National Health Accounts (NHA) is an internationally accepted tool that provides a comprehensive

estimate of all national health expenditures, whether it is contributed by donors or from domestic public

and private sources. Subaccounts generate information on expenditure in accordance with the NHA

framework. The term ’subaccounts’ refers to an additional and more detailed reporting of spending levels

and patterns for a particular component of health care. The child health subaccounts have been designed

to provide financial information to policy makers, programme managers and service providers on the

resources spent on child health interventions. Expenditure on child health is defined as expenditure during

a specified period of time on goods, services and activities delivered to the child after birth or to its

caretaker. Only those goods, services and activities whose primary purpose is to restore, improve and

maintain the health of children of the country between birth and the child's fifth birthday are included.

Child health subaccounts results can be used in various ways to inform child health policy and

programming. They provide answers to specific questions regarding child health financing in the same

way that general NHA answers questions on overall health care financing. For example, the child health

subaccounts reveal how much is being spent, who is paying, what services and products are purchased

and for whom. Because the subaccounts use the internationally recognized NHA framework, child health

expenditure can be compared across countries. Once subaccounts results become available at regular

intervals, trends in expenditure levels can be tracked, patterns of resource use monitored over time and

their relation to the achievement of child health programme goals assessed. Ultimately such assessments

can be used to adjust and inform financing strategies to scale up key child survival interventions.

viii Guide to Producing CH Subaccounts

The Health System Financing and the Child and Adolescent Health and Development Departments at the

World Health Organization; the United States Agency for International Development/Partners for Health

Reformplus (PHRplus) Project and its successor the Health Systems 20/20 (HS 20/20) project worked

together to prepare these Guidelines. The Guidelines benefited from the participation and contribution of

numerous child health and NHA experts, and from four country pilots for the development of the

methodology. Efforts were made to ensure consistency with the Guide to Producing National Health

Accounts with special applications for low-income and middle-income countries. Intended for NHA

country experts as well as health account novices, these Guidelines aim to facilitate the production of

child health subaccounts on a regular basis in order to better inform child survival policies.

David B. Evans Elizabeth Mason Richard Greene

Director Director Director

Department of Health

System Financing

World Health Organization

Department of Child and

Adolescent Health and

Development

World Health Organization

Office of Health, Infectious

Diseases and Nutrition

Bureau for Global Health

United States Agency for

International Development

Peter Salama Flavia Bustreo

Chief, Health Section Deputy Director

Programme Division

UNICEF, New York

Partnership for Maternal, Newborn and Child

Health

Guide to Producing CH Subaccounts Acknowledgements ix

Acknowledgements

The child health subaccounts Guidelines were produced with support from the World Health Organization

departments of Health System Financing (WHO/HSF) and Child and Adolescent Health and Development

(WHO/CAH); the United States Agency for International Development/Partners for Health Reformplus

(PHRplus) Project and its successor the Health Systems 20/20 (HS 20/20) project.

The production of this report has benefited from discussions with the advisory group established for this

purpose and led by the Department of health system financing at World Health Organization, the input of

numerous child health and NHA experts, Meetings of the Global Child Survival Partnership (now the

Partnership for Maternal, Newborn and Child Health (PMNCH)), and from country implementation

experiences in Bangladesh, Ethiopia, Malawi and Sri Lanka. The core drafting team consisted of Maria

Fernanda Merino, Stephanie Boulenger, Takondwa Mwase (PHRplus and HS 20/20), Charu C. Garg

(WHO/HSF), and Karin Stenberg (WHO/ CAH). Initial drafts received input and valuable feedback from an

internal review team consisting of Al Bartlett (USAID), Flavia Bustreo (PMNCH/WHO), Karen Cavanaugh

(USAID), David Collins (Management Sciences for Health), Tania Dmytraczenko (PHRplus), Tessa Tan￾Torres Edejer (WHO/HSS), Daniel Kraushaar (Bill & Melinda Gates Foundation), Yogesh Rajkotia (USAID),

Ravi Rannan-Eliya (Institute for Health Policy, Sri Lanka), Aparnaa Somanathan (Institute for Health Policy,

Sri Lanka), Robert Scherpbier (WHO/ CAH), and Abdelmajid Tibouti (UNICEF).

These guidelines also benefited from the inputs in two working group meetings for the Child Health Survival

Partnership forum.1 2

The work of Anne Mills and Tim-Powell Jackson for capturing donor flows for Child

health at the international level and of Jane Briggs for tracking expenditures of commodities for child health

provided input in developing the child health analytical framework and field work methodology.

Critical to the development of the Child Health subaccounts approach was its application in Bangladesh,

Ethiopia, Malawi and Sri Lanka. The issues raised, strategies employed, and lessons learned from these

country experiences were integral to defining the methodology outlined in these guidelines as well as to

determining the feasibility of tracking child health-specific health expenditures in the developing country

context. The following comprised the country teams:

Bangladesh team, based at Data International, led by Dr. Ghulam Rabbani with Dr. Najmul Hossain, Khairul

Abrar and A. K. M. Shoab.

Ethiopia team based in the USAID ESHE project, conducted by Hailu Nega, Leulseged Ageze and Tesfaye

Dereje.

Malawi team led by Mr. Edward Kaita (Ministry of Health), with Mr. Paul Revill (DFID), Dr. Eyob Zere

(WHO) and Mr. Davie Kalomba (National AIDS Commission).

Sri Lanka team based at the Institute for Health Policy was led by Dr. Ravi P. Rannan-Eliya, assisted by Dr.

K.C.S. Dalpathadu and Tharanga Fernando together with Aparnaa Somanathan.

Finally, the authors would like to acknowledge the efforts of Jenna Wright, Manjiri Bhawalkar and Ricky

Merino (HS 20/20) for their help in finalizing this prepublication version.

1

Tracking Progress in Child Survival. Countdown 2015. Meeting hosted by the Working Group in December 2005

2

Child Health Resource Tracking Consultative Meeting: For the Global Child Survival Partnership (CSP). Hosted by the London

School of Hygiene and Tropical Medicine. May 5-6, 2005.