1 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 2 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 3 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. 4 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 5 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. 6 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 of Child and Adolescent Health, and Making Pregnancy Safer, 7 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. 5 The 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. 2 http://www.unmillenniumproject.org/goals/gti.htm 3 Bhutta et al, Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival, Lancet 2010; 375: 2032–44. 4 http://www.un.org/millenniumgoals/pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20- .pdf 5 http://www.who.int/pmnch/activities/jointactionplan/en/index.html 8 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, http://www.cgdev.org/section/initiatives/_active/ghprn/workinggroups/rtrwg 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. 9 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 10 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, accessed 10 September 2011). [...]... 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... 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... 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... 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. .. 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. .. displayed regarding the split of inpatient and outpatient care in a hospital in Malawi: 31 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... 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... outpatient services, or for major aggregates, such as 32 33 Information based on data available from WHO sources of NHA data See www.who.int/nha for a link to the WHO global health expenditure database (GHED) 30 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... 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... facilitate use of the help aids, to understand gaps in the data and to ensure quality control of data provided Data will be made publicly available through WHO Global Health Expenditure Database (GHED) Non-standardized interpretation of categories In several countries administration is not at the national but at the regional level Information on financial resources is not readily accessible at central . Maternal, Neonatal and Child Health MNCAH - Maternal Newborn Child and Adolescent Health MOH - Ministry of Health NHA - National Health Accounts NASA. Guidelines for RMNCH-GET: A Reproductive, Maternal, Newborn, and Child Health Government Expenditure (and budget) Tracking tool A Methodology and Data