2011 within the national health accounts framework Guide to Producing Child Health Subaccounts Guide to producing child health subaccounts within the national health accounts framework WHO Library Cataloguing-in-Publication Data Guide to producing child health subaccounts within the national accounts frameworks. 1.Health expenditures - standards. 2.Accounting - standards. 3.Data collection - methods. 4.Child welfare. 5.Health status indicators. 6.Financing, Health. 7.Delivery of health care - economics. 8.Developing countries. I.World Health Organization. ISBN 978 92 4 150301 3 (NLM classication: WA 320) © World Health Organization 2012 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). 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Printed in (country name) v Contents Acronymns viii Foreword x Acknowledgements xii 1 Introduction 1 1.1 Background 1 1.2 The NHA concept 3 1.3 Overview of the child health subaccounts 3 1.4 Policy purpose of child health subaccounts 4 1.5 Indicators produced by child health subaccounts 5 1.6 Methodological approach and structure of the guide 7 2 Denitions and scope of the child health subaccounts 8 2.1 Child health interventions and programmes involved in their delivery 8 2.2 Boundaries of the NHA child health subaccounts 10 2.2.1 Child health expenditures in the NHA 10 2.2.2 Child health and other NHA subaccounts and distributional accounts 13 2.2.3 Geographic boundaries 15 2.2.4 Time boundaries 15 2.2.5 NHA and the health information system 15 3 Classication scheme and tables 17 3.1 Dimensions of NHA and their codes 17 3.2 Approach to classication 18 3.3 NHA tables and the child health subaccounts 19 3.3.1 Basic tables for child health subaccounts 20 3.3.2 Aggregates 20 3.4 Illustrative examples of child health expenditure 21 4 Data identication and collection 27 4.1 Approaching the data identication process 27 4.1.1 Understanding what you need and why you need it 28 4.2 Data collection 29 4.2.1 Types of data 29 4.2.2 Identifying data sources 33 4.3 Secondary sources 33 4.3.1 Routine data reports 33 4.3.2 Non-routine data reports 35 4.4 Primary data sources 38 4.4.1 Special surveys for the child health subaccount 38 4.4.2 Adding rider questions to other planned surveys 39 4.4.3 Household surveys: a few considerations 39 4.5 Data collection plan 40 4.6 Summary 43 5 Data analysis 44 5.1 Getting organized: what is needed? 44 5.2 Conducting the analysis 47 5.2.1 Step 1: creating a T-account 47 5.2.2 Step 2: populating the tables 48 5.2.3 Step 3: review and documentation 49 5.3 Estimating expenditures for child health subaccounts 49 5.3.1 Targeted expenditure 49 5.3.2 Non-targeted expenditures for child health 51 vi Guide to producing child health subaccounts within the national health accounts framework 5.3.3 Capital expenditure 56 5.3.4 Out-of-pocket spending 57 5.3.5 Integrated expenditures for curative and preventive services 58 5.3.6 Tracking commodity-related expenditures 58 5.3.7 Tracking intervention-specic expenditures 60 5.3.8 Other data analysis issues 60 5.4 Summary 61 6 Preparing child health subaccounts 62 6.1 Objectives and general considerations 62 6.2 Resources needed 64 6.2.1 Equipment 64 6.2.2 Other resources 64 6.2.3 Limited resources 64 6.3 Writing the report and communicating the results 65 6.4 Workplan 67 6.5 Complementarity of child health subaccounts and cost estimates 68 6.6 Child health subaccounts not done in conjunction with NHA 69 6.7 Institutionalization 69 7 Child health subaccounts indicators 72 7.1 Background 72 7.2 Key health policy objectives 73 7.2.1 Equity in health care nancing 73 7.2.2 Eciency 73 7.2.3 Sustainability and resource availability 74 7.2.4 Expenditure monitoring as rights-based monitoring 74 7.3 Proposed set of indicators 75 7.3.1 Selecting indicators that are relevant for policy 79 8 Summary 80 9 References 82 Annex 1. Example of donor questionnaire (Ethiopia) 85 Child health (Part D of the questionnaire) 85 Annex 2. Adding questions to ongoing surveys 88 A 2.1 Donor and NGO NHA surveys 88 A 2.2 Household surveys 88 Annex 3. Apportionment rules used in Bangladesh and Sri Lanka 90 Annex 4. Methodology used in Bangladesh for estimating unit cost and use data 96 Annex 5. Optional indicators for intervention-specic expenditure 98 A 5.1 Expenditure on breastfeeding promotion 99 A 5.2 Expenditure on ITNs 100 A 5.3 Expenditure on immunizations 101 A 5.4 Expenditure on integrated management of sick children 104 A 5.5 Expenditure on newborn care 105 A5.6 Assessing expenditure by region 108 Annex 6. Key statistics from child health subaccounts in Bangladesh, Ethiopia, Malawi and Sri Lanka 109 Annex 7. Developments on health accounts 113 vii List of tables Table 2.1 Examples of what should and should not be included in the child health subaccounts 12 Table 2.2. Possible overlapping services in child health and other subaccounts 14 Table 3.1 Classication of child health functions 21 Table 3.2 Flow of funds from nancing sources (FS) to nancing agents (HF) 24 Table 3.3 Flow of funds from nancing agents (HF) to providers (HP) 25 Table 3.4 Flow of funds from nancing agents (HF) to functions (HC) 26 Table 4.1. Examples of information data sources used in the construction of child health subaccounts 30 Table 4.2. Examples of sources of nancial information 33 Table 4.3. Information needed from the health information system 34 Table 4.4. Examples of survey reports available in countries and used for child health subaccounts 35 Table 4.5. Examples of international databases for non-routine survey reports 37 Table 4.6. Kenyan NHA data collection plan for secondary sources 41 Table 5.1. Information needed for data analysis 45 Table 5.2. Example of a T-account for child health expenditure by a local NGO, Malawi, 2004–05 48 Table 5.3 Expenditure for the Ministry of Health in Malawi 51 Table 5.4. Contribution of nancing agents to non-targeted spending on inpatient care for child health 56 Table 6.1. Activities and timeline for preparing child health subaccounts 68 Table 7.1. Proposed indicators for the child health subaccount report a 75 Table A3.1. Apportionment rules applied in Bangladesh to estimate spending on child health 90 Table A3.2. Apportionment rules applied in Sri Lanka to estimate spending on child health 92 Table A4.1. Allocation of recurrent expenditures to inpatient and outpatient services 96 Table A4.2. Unit cost of inpatient and outpatient service (in taka) 97 Table A5.1. Functional classication for breastfeeding promotion activities 100 Table A5.2. Functional classication for ITNs for children under ve 101 Table A5.3. Functional classication for immunization interventions and activities 102 Table A5.4. Functional classication for integrated management of sick children 105 Table A5.5. Functional classication for newborn health activities 108 Table A6.1. Key statistics from child health subaccounts in Malawi, 2002–03 to 2004–05 109 Table A6.2. Key statistics from child health subaccounts in Ethiopia, 2004–05 110 Table A6.3. Key statistics from child health subaccounts in Bangladesh (1999–2000) and Sri Lanka (2003) 111 Table A7.1 Classication of child health functions 116 Table A7.2 Preventive and public health classes and examples listed in SHA 1.0 and corresponding codes in SHA 2011 119 Table A7.3 Classication of health care functions 121 Table A7.4 Classication of health care providers 123 Table A7.5 ICHA-HF in SHA 2011 in comparison to SHA 1.0 125 Table A7.6 Classication of revenues of health care nancing schemes 127 Table A7.7 Classication of factors of provision 129 Table A7.8 Classication of Capital Formation 130 Table A7.9 Classication of capital formation and examples for Child Health components 131 List of gures Figure 2.1. Causes of child and neonatal deaths worldwide 2008 9 Figure 2.2. Expenditure boundaries of NHA 10 Figure 3.1. Construction of classication codes in the ICHA 18 Figure 3.2 NHA tables 19 Figure 4.1 Example of a map of the ow of funds for child health 28 Figure 6.1. Stakeholders involved in the production of NHA and child health subaccounts 63 Figure A5.1 Distribution of expenditure on immunization based on data from 50 low-income countries (2005) 103 Figure A5.2. Overlaps between child health subaccounts (CHA ) and reproductive health subaccounts (RHA) 108 viii AIDS acquired immunodeciency syndrome ARI acute respiratory infection ART Antiretroviral treatment BFHI Baby-Friendly Hospital Initiative CB central bank CD central dispensaries CFS Central Bank consumer nance surveys (Sri Lanka) CH child health CHA child health subaccount CHW community health worker CNAPT Ceylon National Association for the Prevention of Tuberculosis CRC Convention on the Rights of the Child CSP Child Survival Partnership DH district hospital DHS Demographic and Health Survey DRG diagnosis-related group EFY Ethiopian scal year EPI Expanded Programme on Immunization ESHE Essential Services for Health in Ethiopia FS nancing sources GDP gross domestic product GH general hospital HA health accounts HFS health facility survey HIS health information system HIV human immunodeciency virus HMIS health management information system ICD International Classication of Diseases ICHA International Classication of Health Accounts IDS international development statistics IEC information, education and communication IHP Institute for Health Policy, Sri Lanka IMCI integrated management of childhood illness IP inpatient ITN insecticide-treated nets IYCF infant and young child feeding LG local government LSMS Living Standards Measurement Study Acronyms ix MCH maternal and child health MNCH maternal, newborn, and child health MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MK Malawi Kwacha MoH Ministry of Health MPS Making Pregnancy Safer MTEF medium-term expenditure framework NGO nongovernmental organization NHA national health accounts NHE national health expenditure NHE-CH national health expenditure on child health NHIF National Hospital Insurance Fund (Kenya) OECD Organisation for Economic Co-operation and Development OOP out-of-pocket OP outpatient ORS oral rehydration salts PC provincial council PER public expenditure review PG Producers’ Guide PHCU primary health care unit PHR Partners for Health Reform PMNCH Partnership for Maternal, Newborn and Child Health PMTCT prevention of mother-to-child transmission (of HIV) PRSP Poverty Reduction Strategy Paper RH reproductive health SHA System of Health Accounts SNA System of National Accounts SNNPR Southern Nations, Nationalities, and People’s Region SPA service provision assessment SPR short programme review SWAp sector-wide approach Tar-HE-CH targeted health expenditures on child health TB tuberculosis TCHE-CH total current health expenditures on child health THC Thana Health Complex THE total health expenditure THE-CH total health expenditure on child health UNICEF United Nations Children’s Fund USAID United States Agency for International Development WB World Bank Acronyms x Foreword Every year, more than eight million children under the age of ve die; while many more suer lifelong consequences of ill-health during childhood (UNICEF, 2010). A number of programmes and partnerships have been set up to improve the delivery of simple, aordable and life-saving interventions for the management of major childhood illnesses and malnutrition. They include the Partnership for Maternal, Newborn and Child Health (PMNCH) and the Expanded Programme on Immunization (EPI), as well as country-based programmes delivering integrated management of childhood illness (IMCI), insecticide-treated nets (ITNs), and interventions linked to the prevention of mother-to-child transmission (PMTCT) of HIV. Outside the programme framework, many public and private-sector providers deliver essential care for children in developing countries. All these eorts address dierent aspects of child survival, and many have succeeded in reducing deaths from common and preventable conditions. In 2000, countries pledged to scale up the coverage of their health services as part of eorts to achieve the Millennium Development Goals (MDGs). In the fourth goal (MDG4), countries committed themselves to reduce under-ve mortality by two-thirds from the 1990 baseline by 2015. Scaling up the delivery of interventions to reduce child mortality will require additional investments in commodities, equipment, and human resources, as well as the strengthening of the operational health system. National policy-makers need precise information on the gap between the resources currently available for child health and the investments required to achieve national targets. In addition, they need to assess whether current child health expenditure is going to the interventions with the greatest impact on child survival, to determine the sources of funding, and to understand how funds ow within the health system. There is also a need for information on the nancial burden of child health expenditure on households. This information provides the evidence necessary to make informed decisions, allocate resources between competing needs, help set strategic priorities, and ensure sustainable funding for child health programmes and strategies. The national health accounts (NHA) framework is an internationally accepted methodology that provides a comprehensive estimate of all national health expenditures, whether from donors or from domestic public and private sources. An NHA subaccount is a more detailed reporting of spending levels 1 The implementation in Rwanda was led by the Ministry of Health, with technical support from the USAID PHRplus project. The implementation in the Philippines was led by the Department of Health with technical support from WHO. [...]... expenditure; out-of-pocket spending on child health as a percentage of total child health expenditure; expenditure on preventive and curative services for child health as a percentage of total child health expenditure;; 1 Introduction total child health expenditure per child total child health expenditure per child by region or population group; A complete set of indicators, with detailed definitions and... services outputs and health outcomes in order to evaluate the appropriateness, equity and efficiency of the delivery of child health care Some suitable indicators are: child health expenditure as a percentage of total health expenditure; government expenditure on child health as a percentage of total child health expenditure; external funds for child health as a percentage of total health expenditure;... activities delivered to the child after birth or to its caretaker Only those goods, services and activities whose primary purpose is to restore, improve or maintain the health of children from birth until the fifth birthday are included Child health subaccounts can be used in various ways to inform child health policy and programming They provide answers to specific questions regarding child health financing,... Overview of the child health subaccounts This guide presents a methodology for tracking expenditure on child health within the general NHA framework Expenditure on child health is defined as expenditure on goods, services and activities delivered to the child or its caretaker after birth, the primary purpose of which is to restore, improve or maintain the health of the child from birth up to five years... The results obtained for child health subaccounts will not be the same as the distributional accounts for children aged up to 5 years The expenditures registered in the child health subaccount cut across all three classifications This means that there will be overlap between the different accounts For example: 13 Guide to producing child health subaccounts within the national health accounts framework... services in child health and other subaccounts Overlapping service Subaccounts that could include overlapping services with the child health subaccounts Child health subaccounts PMTCT services X Reproductive health subaccounts X Intermittent preventive therapy and antimalarial chemoprophylaxis (given to pregnant women for malaria prevention) X Care during the perinatal period, a before birth Malaria subaccounts. .. delivered to the child or its caretaker after the birth, whose primary purpose is to restore, improve or maintain the health of the child, should be included in the child health subaccount The question then arises of what to do with interventions that are delivered jointly to mother and child, or those delivered to the mother that benefit both mother and child (such as ITNs), or those delivered to both... general NHA Total health expenditure on child health (THE-CH) This represents expenditures on core child health activities, goods and services (i.e TCHE-CH) plus capital formation for child health This total will be comparable with estimates from other countries and with the THE from the general NHA National health expenditure on child health (NHE-CH) This total includes THE-CH plus health- related... analysis The guidelines have been designed to be flexible enough for each country to adapt them to their own needs, while maintaining comparability It is strongly recommended that users of this guide should already be familiar with the basic principles of producing health accounts, as outlined in the Guide to producing national health accounts (WHO, 2003) (hereafter referred to as the Producers’ Guide) 1... activities, such as research and development in child health (Table 3.1) The core functions are denoted by the code HC and the health- related functions by the code HCR The availability of data for this dimension tends to drive the health accounts 18 Guide to producing child health subaccounts within the national health accounts framework 3.2 Approach to classification Each NHA dimension comprises a . 2011 within the national health accounts framework Guide to Producing Child Health Subaccounts Guide to producing child health subaccounts within. child health subaccounts 49 5.3.1 Targeted expenditure 49 5.3.2 Non-targeted expenditures for child health 51 vi Guide to producing child health subaccounts within