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

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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

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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.

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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

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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.

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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,

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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

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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.

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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

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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).

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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.

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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

16 http://www.who.int/nha/docs/English_PG.pdf

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.

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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 sub-

accounts

Characteristic Reproductive health or child health

sub-accounts

WHO-supported annual monitoring survey

for government RMNCH spending

Resource

requirements

Resource intensive, often require national team inputs for 2-3 months.

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.

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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): 314-321.

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

Financing Agents of Child Health

5.0%

15.7%

26.2%

12.0%

11.2%

34.5%44.6%

58.3%

40.1%

55.5%

60.5%

39.7%

15.5%

47.9%33.3%

0%

20%

40%

60%

80%

100%

Banglahesh

(1997-2002

average)

Ethiopia

(2005)

Malawi

(2003-2005

average)

Sri Lanka

(1995-2003

average)

Tanzania

(2002-03 &

2005-06

average)Countries (with years)

Pe

rce

nta

ges

Public sector

Non-public sector excluding household OOP

Non-public sector (household OOP) Source: Child Health Subaccounts data

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 Sub-accounts for HIV and AIDS, Reproductive and Child Health Bethesda, MD: Partners for Health Reformplus project, Abt Associates Inc.

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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) Survey

tool

Institutio

n

managing

survey

reporting

Programm

e/ Disease

area

covered

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

WHO/ UNICEF Joint Reporting Form

WHO Immunization

Annual One year This is a YES/NO question. The user does not indicate an amount

Yes No No 1998

GAVI annual report

GAVI Immunization

One year

Two years (T+1), (T+2)

No

NIDI tools UNFPA/ NIDI *

Reproductive health (ICPD definition)

One year Four years Yes

WHO Malaria Programme Expenditure Study

WHO Malaria Yearly? Three years Two years Yes (funding)

Yes No

TB data collection tool

WHO Tuberculosis

Yearly One year (T-1)

Two years (T), (T+1)

Yes Yes No Since 2002 for the 22 high-burden countries; Since 2006 for all other countries

UNGASS UNAIDS HIV/AIDS Yearly Three years (T-1), (T-2), (T-3)

Yes (both) Yes No

Tobacco control survey

WHO Tobacco prevention and regulation

One year None Yes No Data collected in 2008 and 2009. Year reported varies by country and ranges between 2003 and 2008 .

WHO/RHR survey

WHO Sexual and Reproductive Health

Bi-yearly One year None Yes No No Since 2009

Notes to Table 2.2: T = current year; the year in which the survey is sent out. NIDI: Netherlands Interdisciplinary Demographic Institute

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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. Methodology development Drawing upon the experience of other programmes, a technical working group was set up within WHO to develop a methodology for informing processes and tools to track government expenditures for RMNCH. The methodology was informed by a review of the existing tools for expenditure tracking (in general and specific to RMNCH), undertaken with the objective to 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

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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

Sheet Type of sheet Function

1. Country identification Input sheet Respondent selects country

2. General health system info. Input sheet Respondent enters data for general health expenditure and overall utilization data that can be used to apportion expenditures.

3a. Expenditure_CH Input sheet Respondent enters data for child health expenditures and budgets. This is used to assess spending related to MDG 4.

3b. Results_CH Results Results presented as based on the inputs provided in sheet "3a. Expenditure_CH"

4a. Expenditure_MNH+SRH Input sheet Respondent enters data for expenditures and budgets related to maternal and reproductive health. This is used to assess spending related to MDG 5.

4b. Results_ MNH+SRH Results Results presented as based on the inputs provided in sheet "4a. Expenditure_MNH+SRH"

Annex 1_Comments summary Reference Pop-up comments are reproduced here to allow them to be printed.

Annex 2 UNFPA contacts Reference List of Focal points for UNFPA resource tracking surveys

Database Reference Contains default data for population size, coverage, currency exchange rates, etc.

Database_wallchart FP Reference Contains default data on current contraceptive 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.

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Table 2.4. Common challenges for expenditure tracking and mechanisms proposed to

mitigate these for the MNCAH survey and RMNCH-GET

Issues22 Mechanism proposed to ensure that the

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.

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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.

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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,

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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

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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). b. Per capita Government expenditure going to reproductive and maternal health, per

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

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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

Component Measurement approach

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 expenditure category.

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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:

Budget line RMNCH Amount

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/.

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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 facility costs.

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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-

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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

DAC CRS Code Imputed

Percentages

for RMNCH

Criteria used for allocation

12110 Health policy and administrative management 40% Assumed share of women and children in population

12181 Medical education/training 40% As above

12191 Medical services 40% As above

12220 Basic health care 40% As above

12230 Basic health infrastructure 40% As above

12240 Basic nutrition 100% 100% since activities targeted entirely or mostly at women of reproductive age and/or children under five years.

12250 Infectious disease control 40% Assumed share of women and children in population

12261 Health education 40% Assumed share of women and children in population

12262 Malaria control 88.5% The share of 88.5% is based on global 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).

12263 Tuberculosis control 18.5% The share of 88.5% is based on global 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).

12281 Health personnel development 40% Assumed share of women and children in population

13010 Population policy and administrative management

40% Assumed share of women and children in population

13020 Reproductive health care 100% 100% since activities targeted entirely or mostly at women of reproductive age and/or children under five years.

13030 Family planning 100% 100% since activities targeted entirely or mostly at women of reproductive age and/or children under five years.

13040 STD control including HIV/AIDS 46.1% The share of 88.5% is based on global

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. 30 http://canadainternational.gc.ca/g8/summit-sommet/2010/muskoka-methodology-muskoka.aspx?lang=eng

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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).

13081 Personnel development for population and reproductive health

100% 100% since activities targeted entirely or mostly at women of reproductive age and/or children under five years.

14030 Basic drinking water supply and basic sanitation

15% Assumed share of children in population

14031 Basic drinking water supply 15% Assumed share of children in population

14032 Basic sanitation 15% Assumed share of children in population

51010 General budget support 4% Estimated the average percentage of 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/

30

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. 33 See www.who.int/nha for a link to the WHO global health expenditure database (GHED).

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

31

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 non-specific to RMNCH such as general inpatient and outpatient clinical services. In the approach 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:

32

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.34 The 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. 2006] - PubMed result. Social Science & Medicine, 2006. 63: p. 1700-1710.

33

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.

2009 2010 2011 2012

inpatient care - - - -

outpatient care - - - -

inpatient care 0% 0% 0% 0%

outpatient care 0% 0% 0% 0%

2009 2010 2011 2012

inpatient care 82% 0% 0% 0%

outpatient care18% 100% 100% 100%

2009 2010 2011 2012

inpatient care82% 0% 0% 0%

outpatient care18% 100% 100% 100%

Based on data entered above for "Split Service Delivery Spending by inpatient / outpatient Care", the split in expenditure between inpatient

and outpatient services that is used in the model calculations is:

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 model will therefore use the following ratios for the calculations to apportion

expenditure between inpatient and outpatient care

Note: Proxy for 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.

34

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 health accounts in the European Union, Final report, April 2003. Supported by Eurostat, Grant no. 200135100020; p.78

35

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 admission for a RH-related service at selected public hospitals type N

X

Number of patient days for RH care at selected public hospitals type N

≈

Average cost overall per admission at selected public hospitals type N

X

Number of patient days for all care at selected public hospitals type N

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.

36

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.

b) Expenditure data:

• Service delivery expenditure, preferably broken down into total public spending on outpatient care and inpatient care,

• Estimated total Ministry of Health programme spending on programme management activities and staff to support and promote RMNCH

• Estimated total Ministry of Health expenditure on commodities for direct provision of key RMNCH health service interventions.

Table 3.3 provides examples of country data sources.

38 It is noted that outreach services may be counted as part of health facility delivery. Based on experience from countries it may be assumed that utilization data for outreach is included in Health Centre or Health Post / Dispensary level service utilization data.

37

Table 3.3: Example of data sources

Type of data collected Methods and data sources

Utilization data

• Percentage (%) share of inpatient admissions, outpatient visits, average length of stay, inpatients days, hospital discharges attributable to children / maternal care / SRH.

• These proportions may be used to estimate the amount of general revenues that is indirectly used to deliver RMNCH services.

• HMIS

• Household survey data, e.g., DHS has data on visits by level of delivery, ANC etc.

• Estimation process using coverage and normative average number of visits

Government expenditure on drugs and commodities

• National Medical Stores; records of purchase and

distribution in the past year for relevant drugs

• National programs data on drugs and commodities

purchase and distributed in the past year, for

example ITNs (malaria program), vaccines

(immunization program).

• Government financial statements

Service delivery expenditures

• General expenditure breakdown by level of facilities as well as breakdown between inpatient and outpatient care.

• NHA

• Existing Public Health Expenditure Review reports

• MOH executed budget

• Government budget books

• Budget and expenditure review of budget books, Consolidated Appropriation Accounts, audited accounts

• Approximation methods for allocating between inpatient and outpatient expenditures

Government spending on programme costs:

• Staff of the national programme (administrative costs)

• Programme activities (advocacy, training etc)

• IEC and social mobilization

• NHA

• National programme budgets

• Existing Public Health Expenditure Review reports

• Government budget books (financial statements)

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.

38

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.

39

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

40

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.

41

3.11 Sources of funding considered

In addition to entering the total amount spent and/or budgeted, the country respondent using RMNCH-GET is requested to also look at the sources of funds in order to analyze and discuss the financial sustainability of activities. The following six specific sources of funding are programmed into the WHO Annex help tool: Domestic funding:

• Central level of the Government

• Peripheral government sources (provinces, districts, etc.). Foreign resources:

• Concessional loans

• Grants awarded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).

• Funds made available through GAVI

• Other sources

42

4. Monitoring Government expenditure on Child health (MDG4)

4.1 Child health expenditure questions in the main MNCAH survey tool

The country respondent is requested to enter the following information in the MNCAH survey:42 1. Government expenditures on child health (total amount - US$ or local currency) 2. Government expenditures on child health as a share of total government spending on health (%) 3. Government expenditures on child health per capita (US$) 4. Government expenditures on child health per capita (Local currency) 5. Government expenditures on child health per child under five years old (US$) 6. Government expenditures on child health per child under five years old (Local currency) This information is requested for a total of four years, as shown in Fig 4.1 below. In addition the respondent is asked to describe the method used to derive the estimates, to indicate if a reference document is available, and to provide a contact name and email address (not shown in the Figure). Fig 4.1 table for entering CH expenditure data in the main MNCAH survey tool Note: this shows the format that was used for the first round survey in 2009/2010. Subsequent versions may change.

If the user enters information on any one of six indicators (questions numbered 9.13-9.18), the other indicators, if left blank, can be calculated with the help of default data on government spending, population demographics, and currency exchange rates.

In order to assist with the standardization of measuring child health spending and to control for the quality of estimates reported, the RMNCH-GET is sent as an accompanying tool in order to help the country respondents to calculate the indicators that they are requested to report on. In order to determine the questions to be included in the RMNCH-GET for the area of child health, the boundaries of child health are first determined (section 4.2). Then an assessment of existing tools

42 These were the questions used for the survey 2009/2010. They may be subject to revision.

43

and allocation factors used in countries to date (section 4.3) is undertaken. All of this together helps inform the decision on what data to collect through the RMNCH-GET tool accompanying the MNCAH survey (section 4.4).

4.2 Defining the boundaries of Child Health expenditures and suggesting measurement proxies

The boundaries for child health (CH) expenditures are defined in the CH subaccount guidelines as those expenditures incurred on goods, services and activities delivered to the child or its caretaker after the birth of the child and whose primary purpose is to restore, improve and maintain the health of children of a country between zero and less than five years of age. This includes newborn health. Table 4.1 below presents an overview of the expenditure categories as per the CH subaccount guidelines, and the suggested measurement approach for each component within the RMNCH-GET.43 In addition the working group has agreed that it is considered important to track cash transfers /financial incentives relevant to child health. This has therefore been included as a separate category in RMNCH-GET.

Table 4.1 Categories of CH expenditure in the CH subaccount guidelines

ICHA

Code

Description Suggested measurement

approach for the annual

reporting survey

Information requested in WHO

tool "RMNCH-GET" (or link to other surveys)

HC.1-

HC.5

Personal health services and

goods

HC.1 Services of curative care

(inpatient and outpatient)

HC 1.1 Inpatient curative care

HC1.1.1 Care of the newborn – management of illness in children aged 0–28 days, including clean cord care, newborn resuscitation, temperature management, case management of neonatal pneumonia and infections including sepsis

Allocate an appropriate

proportion of overall

service delivery costs for

inpatient care to under-five

care

Data is requested on inpatient care

0-4 years of age. Data is not

specifically requested for the

newborn period since the data will

be presented as an aggregate for

child and newborn health.

HC1.1.2 Management of childhood

illness – in children aged 29

days to 59 months (e.g.

intravenous infusion for severe

dehydration; treatment of

cerebral malaria; severe

malnutrition and severe

pneumonia)

Allocate an appropriate

proportion of overall

service delivery costs for

inpatient care to under-five

care

Data is requested on inpatient care

for children 0-4 years of age

HC1.1.3 Management of children

exposed to HIV/AIDS

HIV/AIDS care is assumed

to be included in the overall

proportion of ipd and opd

for under-fives.

(1) Data on inpatient or outpatient

care is assumed to be captured In

general ipd and opd for under-fives.

(2) Expenditure data should also be

43 It should be noted that the CH subaccount guidelines were developed from the basis of SHA.1, and will therefore not match the SHA 2011 classifications. For more information on SHA.1, Guide to producing health accounts, and SHA 2011, please visit www.who.int/nha,

44

ICHA

Code

Description Suggested measurement

approach for the annual

reporting survey

Information requested in WHO

tool "RMNCH-GET" (or link to other surveys)

Obtain data from NASA if

available but be careful with

overlaps

included from NASA. However NASA

is not available in all countries. The

UNGASS reporting form does not

separate out pediatric ARTs.

(3) "Expenditures on pediatric

ARVs" is included in the commodity

section.

HC1.1.4 All other curative inpatient

services provided to children

aged 0–5 years (e.g. injuries)

Should be included in

overall data on inpatient

care 0-5 years of age

HC1.2 Day cases of curative care

HC1.3 Outpatient curative care

HC1.3.1 Care of the newborn –

management of illness in

children aged 0–28 days,

including clean cord care,

newborn resuscitation,

temperature management, case

management of neonatal

pneumonia and infections

including sepsis

Allocate an appropriate

proportion of overall

service delivery costs for

outpatient care to under-

five care

Data is requested on outpatient

care 0-5 years of age, which includes

newborns.

HC1.3.2 Management of childhood

illness – in children aged 29

days to 59 months (e.g.

treatment of malaria with

antimalarials, malnutrition,

pneumonia and diarrhoea)

Allocate an appropriate

proportion of overall

service delivery costs for

outpatient care to under-

five care

Data is requested on outpatient

care for children 0-4 years of age.

HC1.3.3 Management of children with

symptomatic HIV/AIDS or

exposed to HIV/AIDS

See comments above for HC

1.1.3

See comments above for HC 1.1.3

HC1.3.4 All other curative outpatient

services provided to children

aged 0–5 years

Included in general

outpatient care statistics.

Data is requested on outpatient

visits for children 0-4 years of age

HC 1.4 Services of curative home care Not Applicable for Annual survey given low expenditure share and scarce data

HC.2 Services of rehabilitative

care

Not Applicable for Annual survey given low expenditure share and scarce data

HC.3 Services of long-term nursing

care

Not Applicable for Annual survey given low expenditure share and scarce data

HC.4 Ancilliary services to medical

care

Not Applicable for Annual survey given low expenditure share and scarce data

45

ICHA

Code

Description Suggested measurement

approach for the annual

reporting survey

Information requested in WHO

tool "RMNCH-GET" (or link to other surveys)

HC.5 Medical goods dispensed (to

outpatients) 44

HC 5.1 Pharmaceuticals and other

non-medical durables

HC 5.1.1

HC 5.1.2.

HC 5.1.3

Prescribed medicines

Over-the counter medicines

Other medical nondurables

We will seek to assess spending on selected commodities, including Pediatric formulations (syrups etc).

Include lines for specific commodities within RMNCH-GET

HC 5.1.4 Oral rehydration salts Should be included as a priority commodity.

Include lines for specific commodities within RMNCH-GET

HC 5.1.5 Breast milk substitutes for

HIV/AIDS-exposed children

A decision was taken not to include this since governments would rarely fund this. 45

HC 5.1.6 • Vaccines Should be included when child health related.

(1) Include lines for specific commodities within RMNCH-GET (2) There should be a link to the vaccine spending measured by UNICEF & WHO in the JRF

HC 5.1.7 • Micronutrient

supplementation given

directly to all under five-

year-olds (e.g. vitamin A

programme, Iodized salt

etc)

Should be included as a priority commodity.

(1) Include lines for specific commodities within RMNCH-GET (2) Note that this amount may also be counted under vaccines and included in JRF.

HC.5.2 • Therapeutic appliances

and other medical

durables

A decision was taken not to include this since it is not specific enough.

HC 5.2.1 Insecticide-treated nets for

child health

Should be included when financed by government and child health related.

Not Applicable here 46

HC.6-7 Collective health services

HC.6 Prevention and public health

services47

HC 6.1. Promotion of child health (information, education and communication (IEC), social mobilization)

Included in programme

administration expenditure

Information entered on the estimated spending on government programs that support or promote child health such as IEC, public awareness, health education campaigns, training, and research.

44 Self-purchased only. 45 Initially the intention was to capture expenditure on breast milk substitutes as (given current WHO recommendations) this would be a less desired expenditure item. It is however expected to be a small amount and not usually publicly funded which is why it was dropped in the end. 46 ITN purchase by a private person/family would fall under HC5 but government purchased nets would fall under HC6. 47 This category includes expenditures on services specifically intended to enhance the health status of the population or specific population subgroups, as distinct from the personal medical services, which repair health dysfunction. Many of these expenditures on these services may be provided in an integrated fashion by general medical institutions as part of their normal activities. Typical examples are vaccination services, campaigns and special reproductive health programmes.

46

ICHA

Code

Description Suggested measurement

approach for the annual

reporting survey

Information requested in WHO

tool "RMNCH-GET" (or link to other surveys)

HC 6.1.1

HC 6.1.2

HC 6.1.9

• Promotion of Breast feeding, including counseling

• Promotion of complementary feeding

• Other activities aimed at

promoting health of

children from 0 to less than

5 years, including general

IEC to promote care

seeking, promotion of Child

Health Days, activities

aimed at prevention of

injuries and violence, and

support to Early Child

Development

Assume included in OP visits

Assume included in OP visits

Assume included in programme administration expenditure

Efforts are made to capture preventive visits, and to encourage users to consider the inclusion of these in the total outpatient statistics reported.

HC 6.2. School health services Ignore since does not apply

to children under five

HC 6.3. Prevention of communicable disease 48

HC 6.3.1 • Expenditure on PMTCT

Should be included Expenditures on pediatric Anti-retrovirals (ARVs) is requested. Data on nevirapine may be requested from the drug survey component.

HC 6.3.2

• Immunization programme

Should be included

(1) A line for vaccine programme activity costs is included.

(2) Note that this amount may also be counted under vaccines and included in JRF.

HC 6.3. 3

• Water and sanitation

activities targeted at

eliminating water borne disease

when part of child survival

program

The country may indicate this if they want as part of the programme costs. However in general do not expect this to be included.

The respondent can indicate programme costs if s/he wants but this is not a default category listed.

HC 6.3.4

• Insecticide-treated

materials/ insecticide-treated

net activities

• Should be included Information on the total spending on ITNs is requested in the RMNCH-GET along with the proportion that should be allocated to child health

HC 6.3.9

• Other - other preventive

health services provided to

children from 0 to less than 5

years, (e.g. deworming)

The respondent can indicate spending for albendazole if s/he wants but this is not a default category listed under commodities

HC 6.4. Prevention of non-communicable disease

HC 6.4.1

HC 6.4.9

• Targeted food fortification and micronutrient supplementation to identified malnourished children: Nutrition programme

• The user can indicate nutrition-related spending in the tool under programme administration expenditure

• Expenditure on Ready to Use Therapeutic Food may be

48 Expenditure related to service delivery, including time of health workers and operational costs of running facilities.

47

ICHA

Code

Description Suggested measurement

approach for the annual

reporting survey

Information requested in WHO

tool "RMNCH-GET" (or link to other surveys)

• Other - other preventive health services provided to children up to the age of 5 years, (e.g. prevention of injuries and violence)

specifically indicated (it is listed as a default commodity listed due to its significant cost implications),

• Data on micronutrient supplementation may be added (optional).

• For other preventive services these can be assumed to be covered in programme administration expenditure.

HC 6.6. Central level management functions for child health

Assume included in programme administration expenditure

HC 6.6.1. Guideline development, Included in programme administration expenditure

HC 6.6.2. In-service training

• In-service training of

health facility staff for the

delivery of child health

services

• In-service training of

hospital staff for the

delivery of child health

services

Included in programme administration expenditure

HC 6.6.3 Monitoring and surveillance Included in programme administration expenditure

HC 6.6.4 Training of Community Health Workers to deliver specific child health activities such as immunization

Included in programme

administration expenditure

HC.7 Health administration

(stewardship) and health

insurance

Not applicable for the annual routine survey

HC7.1 General government

administration of health (e.g. formulation, coordination, administration and monitoring of child health policies, programs and plans, preparation of legislation, production and dissemination of information)

Included in programme administration expenditure

HCR.1-

HCR.5

Health-related functions

HCR.1 Capital formation of health care provider institutions

Not applicable for the annual routine survey

HCR.2 Education and training of health personnel

• Pre-service training for the delivery of child health services

Not applicable for the annual routine survey

HCR.3 Research and development in child health

Included in programme administration expenditure

HCR.5

Environmental health General Water and sanitation activities - i.e. those not specifically delivered as part of a

Not applicable for the annual routine survey

48

ICHA

Code

Description Suggested measurement

approach for the annual

reporting survey

Information requested in WHO

tool "RMNCH-GET" (or link to other surveys)

child survival program, e.g., reducing indoor air pollution.

4.3 Country experience and allocation mechanisms

Comprehensiveness The child health subaccounts (CHA) for Malawi 2002-05 showed that the major financing source for child health was public funds, in particular the Ministry of Finance through its funding to the annual health budget managed by the MoH (30-41% of total CH expenditures). The major financing agent (controller of funds) for child health was the public health sector, mainly the Ministry of Health, accounting for 54%-63% of total child health expenditures in 2002-05. One of the findings of the Malawi CHA was that the MoH faces challenges to demonstrate that it uses the funds for their intended purpose, and specifically for child health since the MoH does not have a single reference point for child health issues. Current functions are split between Integrated Management of Childhood Illness (IMCI), the Department of Nutrition, the Malaria Control Programme, immunization and others. The report concludes that the establishment of a single high-level authority, with reporting and stewardship responsibilities for child health would greatly assist in ensuring a more coordinated approach and sound financial planning. In Malawi immunization expenditures were 10%-16% of total child health spending. Almost all funding (approximately 90%) for immunization programmes came from external donors. This raises serious issues with regard to sustainability should donor assistance stop, for political or other reasons. In summary, experience from countries indicate that a routine tracking of child health spending needs to consider immunization as well as other programmes such as IMCI, Nutrition, etc. Using patient utilization data to allocate inpatient expenditures towards child health: The patterns observed in different countries indicate that the proportion of outpatient visits (as a percentage of total outpatient visits) in public facilities for children under five years of age ranges considerably, from 19% in Ethiopia to about 30% in Rwanda. Data for inpatient admissions indicate that about 30% (33% in Kenya and 32% in Ethiopia) are for children under five.49 These findings indicate that it is preferable to get data on the relative utilization specific to the country, and to use this as an allocation factor, rather than using fixed percentage factors. The use of fixed percentages in past studies was discussed in section 3.4 of this document. Allocation mechanisms for specific diseases and programmes: For the WHO-MNCAH survey the respondent is requested to enter a percentage for how much of ITN spending should be allocated to child health. The default is set to 50%. For paediatric HIV/AIDS, the RMNCH-GET asks the respondent to enter the exact spending on paediatric ARVs. Any allocation would therefore need to be done outside the tool so that data can be directly entered.

49 (WHO, 2009) Guidelines for producing child health subaccounts within the national health accounts framework - prepublication version

49

4.4 Summary of data needs for monitoring expenditure on child health

Having defined the scope of what can be measured for an annual survey, based on the boundaries set up by the guidelines for child health subaccounts, the next step is to summarize the data needs for child health.

Table 4.2 Data analysed in the RMNCH-GET section on child health

Data requested in RMNCH-GET Recommended source at country

level

Fallback option

General data

Total government spending on

outpatient care

Obtain from government financial

documents

Total government spending on in-

patient care

Obtain from government financial

documents

Total outpatient visits by year (use

public if possible, otherwise total)

Should be available from HMIS,

Total inpatient visits (days)

Should be available from HMIS, would

have been analysed in a past NHA

study

CH -specific data

Outpatient visits for children under 5

by year (give public if possible,

otherwise give total)

Should be available from HMIS

Outpatient visits for Immunizations for

children under 5

May need to use coverage

rates as fall-back option

Inpatient visits (days) for children

under 5 by year (use public if possible,

otherwise total)

Should be available from HMIS

Government spending on relevant

commodities:

• ITNs

• ORS and zinc

• Vaccines

• Pediatric ARVs

• Ready to Use Therapeutic food

for malnourished children

Asses national budget documents.

• ITN spending may also be

available from malaria survey

• Vaccines may also be available

from JRF

• Pediatric ARVs may also be

available from NASA

Possible fallback option to

obtain data from malaria

survey, JRF and NASA

Immunization programme activities MOH to estimate based on records. Should be reported in JRF

Estimated spending on government

programmes that support or promote

child health such as IEC, public

awareness, health education

campaigns, training, and research.

MOH to estimate based on records.

Cash transfers / financial incentives to

promote child health care.

MOH to estimate based on records.

Note: utilization data is requested for two years (T-2, and T-1). Since it is not possible to make future projections about service utilization, it is assumed that the % share of service delivery costs going towards SRH remains constant from T-1 onwards, For example, for the first round of the survey sent out in 2009, the user entered allocation factors for 2008 and 2008. The % allocation factor derived from 2008 data was used for the two subsequent years 2009 and 2010 as a proxy.

In addition it was agreed that the respondent should be prompted to separate out any capital spending such as that related to construction of buildings.

50

Selected components of the RMNCH-GET are reproduced in Annex 4 together with information on

the help notes and definitions to guide the user through the tool.

4.5 Child health-specific issues that may require additional methodological development and field

testing

With regards to commodities relevant to child health, Annex 3 outlines a list of essential child health

medicines. However the initial exploratory field tests/discussions with country counterparts

suggested that it would be difficult to obtain such detailed data and so it was agreed to focus on five

key commodities for the first round of the survey (ITNs, ORS and zinc, Vaccines, paediatric ARVs,

and Ready to Use Therapeutic food for malnourished children). It may be feasible to explore

additional methods for tracking the more expanded list as part of field tests in selected countries if

there is interest.

Regarding linkages with data from other surveys such as expenditure on paediatric ARVs from NASA, it is important to emphasize the link to these surveys but also to give additional instructions on how to review and improve the estimates. It is expected that data on inpatient days for children under five years will be available at country level. However this data may not always be available. There may be a need to develop a method to weight the data on inpatient care so that one inpatient visit for adult corresponds to (x) inpatient visits for children under five. The value of (x) would need to be determined. This may warrant further studies to come up with appropriate allocation factors.

Section 7 provides an overview of feedback received to date and lessons learnt.

4.6 Components likely to be included and excluded from the final estimate for child health

expenditure as derived if the respondent uses the RMNCH-GET tool

If the user includes all relevant categories as prompted in the tool then the following expenditure categories would be included in a final estimate of government spending on child health: Data entered into the tool:

• Estimated government spending on five key child health commodities, plus any other commodities that the respondent enters as additional (here the full amount indicated will be allocated for child health, except for ITNs where a proportion is allocation to child health).

• Estimated portion of government spending on service delivery for child health (inpatient + outpatient)

• Estimated government expenditure on programme activities for child health, where amounts can be entered for several different programmes. The default categories listed are IMCI, Malaria, nutrition and immunization. The user can overwrite these as needed.

• Government expenditure on cash transfers/financial incentives specific to child health. Complementary data collected from other sources (used when possible):

• JRF estimate on immunization-related spending (may need to be adjusted to not include the estimated cost of Tetanus Toxoid immunization).

• NASA estimate on pediatric ARVS (only available for some countries).

51

Omissions: The proposed approach may not capture all of government expenditure on child health. Specifically it is likely to miss:

• Expenditure on commodities for management of common childhood illnesses such as pneumonia and malaria. The reason for this omission is that the diagnostics tests and drugs used for such care tend not to be specific to child health and thus it would be difficult to allocate a share of total spending towards child health.

• Service delivery costs for preventive visits such as growth monitoring, unless these are included in the aggregate national level service utilization data on number of outpatient visits for children under five.

In summary, with the proposed approach aiming to capture expenditure categories as per the above list of items, it is likely that the gross amount spent by the public authorities on child health-related activities can be estimated and that this will support monitoring of trends over time. Any changes in boundaries over time should be clearly highlighted so that time trend analysis takes into account changes due to estimation methods.

52

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

5.1 Maternal health expenditure questions in the main MNCAH survey tool

The country respondent is requested to enter the following information in the MNCAH survey:50 1. Government expenditures on maternal health (total amount - US$ or local currency) 2. Government expenditures on maternal health as a share of total government expenditures on

health (%) 3. Government expenditures on maternal health per capita (US$) 4. Government expenditures on maternal health per capita (Local currency)

This information is requested for a total of four years, as shown in Figure 5.1 below. In addition the respondent is asked to describe the method used to derive the estimates, to indicate if a reference document is available, and to provide a contact name and email address (not shown in Figure 5.1). Note that the wording in the first survey (2009) was "maternal health". The issue of whether "newborn health" is included here or not is addressed below. Fig 5.1 Table for entering maternal health expenditure data in the main MNCAH survey tool Note: this shows the format that was used for the first round survey in 2009/2010. Subsequent versions may change.

For maternal health, if the user enters information on any one indicator (9.1 - 9.4 in Figure 5.1), the other indicators can be calculated with the help of default data on government spending, population demographics, and currency exchange rates.

In order to assist with the standardization of measuring maternal health spending and to control for the quality of estimates reported, the RMNCH-GET is sent as an accompanying tool in order to help the country respondents to calculate the indicators listed above. In order to determine the questions to be included in the questionnaire and tool for the area of maternal health, the boundaries were first determined (section 5.2). Then an assessment of existing tools and allocation factors used in countries to date (section 5.3) was undertaken. All of this together was used to inform the decision on what data to collect for the RMNCH routine reporting survey.

50 These were the questions used for the survey 2009/2010. They may be subject to revision.

53

5.2 Defining the content of maternal health expenditures and suggesting measurement proxies

The Guidelines for undertaking Reproductive Health subaccounts outline five main areas of spending for SRH including maternal health, as follows:

1. Maternal health care; improving antenatal and postpartum care.

2. Providing high-quality services for family planning, including infertility services. 3. Eliminating unsafe abortion. 4. Combating STIs including HIV, Reproductive Tract Infections, Reproductive health-related

cancers, and other gynecological morbidities. 5. Promoting sexual health.

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). The first area covers maternal health while areas 2-5 in the above list are covered under

SRH as described in section 6 of this document.

Table 5.1 outlines the main categories of spending on maternal health as per the RH subaccount

guidelines, and how these can be mapped to the proposed approach here for routine RMNCH

expenditure monitoring.

Table 5.1 Defining the content of MNH expenditures and suggesting measurement proxies

for WHO routine monitoring survey (RMNCH-GET tool)

Categories of spending as per

the RH subaccounts

Suggested approach for

incorporating measure into

routine monitoring approach

Information requested in

RMNCH-GET (or link to other

surveys)

RH1. Maternal health care.

Improving antenatal and

postpartum care

MNH 1.1. Prenatal and postnatal care:

(a) Including the provision

of micronutrients (such as

iron sulfate, folic acid,

vitamin A) and food

supplements to mothers

before, during, and after

pregnancy;

1. Outpatient visits for Antenatal

Care (ANC) as % of total

outpatient visits (total or public)

* Total government spending on

Outpatient care.

2. Spending on commodities

provided during prenatal care

such as iron sulfate, folic acid,

vitamin A, Oxytocin, and food

supplements to mothers.

3. Expenditure on SP for IPT

(specific dose formulation)

4. Expenditure on Tetanus Toxoid

Vaccine spending.

5. Programme administration for

Maternal health care, improving

antenatal and postpartum care

6. Expenditure on conditional cash

transfers (CCT)/ financial

incentives specific to maternal

health

Data collected on:

(i) total government spending

on outpatient care

(ii) outpatient visits for ANC.

Note that this is likely to

exclude community based

postnatal care.

(iii) expenditure on selected

commodities.

(iv) expenditures

of Government programmes

that support or promote

maternal (and newborn) health

54

(b) Postnatal care refers

to services rendered up to

six weeks post-delivery

for the mother and 28

days post-birth for routine

care for the infant.

Outpatient visits for Postnatal Care

(PNC) as % of total outpatient visits

(total or public) * Total government

spending on OP care.

Data collected on outpatient

visits for Postnatal care

MNH 1.2 Deliveries:

(a) Including emergency

obstetric care to deal with

complications;

Number of institutional deliveries

inpatient days required as % of total

inpatient days (total or public) * total

government spending on IP care.

Data collected on:

• number of inpatient days

for births level, and/or

• the number of admissions

for delivery and the average

number of inpatient days

per institutional delivery,

and/or

• population coverage of

deliveries/births and the

average number of

inpatient days per

institutional delivery.

(b) Including

transportation for

emergency obstetric care.

Transportation costs not included in

the RMNCH-GET since such costs are

complex to measure and estimated to

be a limited share of government MNH

related expenditure in low income

countries.

5.3 Allocation mechanisms - Country examples

The methodology outlined here is based on lessons learnt from countries that have used service utilization data to allocate shared costs to MNH when undertaking assessments of reproductive health spending. Using inpatient data to allocate MNH inpatient expenditures: In a RH subaccounts study undertaken in Egypt, the proportion of inpatient service expenditures by the government due to childbirth was estimated as the proportion of childbirths in hospital admissions. While the investigators agree that the method could have been refined by estimating the relative cost of an average delivery in relation to an average admission cost, no such data was available. Official birth registration data indicated that births in public and private hospitals in Egypt made up 8.1% of total inpatient visits (in this study no weighting was applied to account for days spent in hospital by different patient groups/admission types). Moreover, the Egypt study estimated the inpatient expenditures for treatment of other obstetric and gynecological cases as the proportion (%) of overall inpatient admissions that were reported by MOH hospitals as being due to obstetric and gynecological reasons - minus the proportion that was accounted for by delivery cases. The estimated ratio derived was 7%. This would correspond to the Sexual and Reproductive Health (SRH) category of surgeries due to SRH complications (see section 6 below). Using outpatient data to allocate outpatient expenditures towards MNH: The Egypt study used a simple utilization factor to allocate costs to reproductive health services. The data indicated that 6% of all outpatient visits were due to treatment of other obstetric and gynecological cases, therefore 6% of outpatient expenditures was allocated to this area.

55

In the Tanzania GFATM NHA report it was noted that the list of outpatient visits as monitored by MOH did not include family planning or pre or post natal visits (in addition to immunizations and treatments for TB and anti-retroviral drugs). The number of outpatient visits for these services was therefore calculated using coverage rates for these interventions applied on the target population in order to get the number of individuals and then multiplied by the number of visits supplied using expert opinion.

5.4 Summary of data needs for maternal and newborn health

Having defined the scope of what can be measured for an annual survey, based on the boundaries set up by the guidelines for reproductive health subaccounts and an assessment of likely cost drivers, the next step is to summarize the data needs for maternal and newborn health.

Table 5.2 Data analysed in RMNCH-GET section on maternal and newborn health

Data requested in tool Recommended source at country

level

Fallback option

General data

Total government spending on

outpatient care

Obtain from government financial

documents

Total government spending on in-

patient care

Obtain from government financial

documents

Total outpatient visits by year (use

public if possible, otherwise total)

Should be available from HMIS,

Total inpatient visits (days)

Should be available from HMIS, would

have been analysed in a past NHA

study

Maternal health -specific data

Outpatient visits for MNH (Prenatal

and postnatal care) by year (give

public if possible, otherwise give total)

HMIS and/or expert assessment May need to use coverage

rates as fall-back option for

ANC

Inpatient visits for Institutional

Deliveries

HMIS and/or expert assessment May need to use coverage

rates as fall-back option

Government spending on Commodities

provided during prenatal care such as

iron sulfate, folic acid, vitamin A and

food supplements to mothers.

SP for IPT.

MOH to estimate based on records.

Tetanus Toxoid (TT) immunization It is presumed that the country would

only report the vaccine cost and most

likely not the related cost for

supporting activities

TT vaccine and associated

cost is reported as part of

the JRF for vaccines. Here it

is suggested to account for

TT costs using globally

available data on TT

coverage and multiply by

globally available cost for

TT vaccine.

Expenditure of Government

programme to support or promote

maternal health

Cash transfers / financial incentives to

promote maternal health

MOH to estimate based on records.

56

Note: utilization data is requested for two years (T-2, and T-1). Since it is not possible to make future projections about service utilization, it is assumed that the % share of service delivery costs going towards SRH remains constant from T-1 onwards, For example, for the first round of the survey sent out in 2009, the user entered allocation factors for 2008 and 2008. The percentage (%) allocation factor derived from 2008 data was used for the two subsequent years 2009 and 2010 as a proxy.

In addition it was agreed that the respondent should be prompted to separate out any capital spending such as that related to construction. To see an overview of the actual questions inserted into the RMNCH-GET tool to facilitate country reporting on maternal health spending, refer to Annex 5.

5.5 MNH-specific issues that may require additional methodological development and field testing

There may be interest to look at specific measurement of expenditure on newborn health in the

future.

Section 7 provides an overview of feedback received to date and lessons learnt.

5.6 Components likely to be included and excluded from the final estimate for MNH expenditure as

derived if the respondent uses the RMNCH-GET

If the user enters data into all relevant categories considered in the RMNCH-GET tool then the following expenditure categories would be included in a final estimate of government spending on maternal and newborn health: Data entered into the tool

• Estimated government spending on key maternal health commodities

• Estimated government spending on Tetanus Toxoid vaccine

• Estimated government spending on service delivery for maternal and newborn health (outpatient care for prenatal and postnatal care, and inpatient care for deliveries)

• Estimated expenditure on programme activities for maternal and newborn health.

• Expenditure on cash transfers/financial incentives specific to maternal and newborn health. Complementary data collected from other sources (to be used when possible):

• UNFPA/NIDI survey estimates when specifically separating out expenditure on maternal health.

• JRF assessments of expenditure for Tetanus Toxoid vaccine, or estimated using globally available data on coverage and unit cost.

Omissions: The approach will not capture all spending on maternal health. For example it is likely to ignore expenditures for transportation for emergency obstetric care. However, if information is captured on expenditure categories as per the above list of items, it is likely to capture the gross amount spent by the public authorities on maternal health, to be estimated and tracked over time on a routine basis. Changes in methodology or boundaries over time should be made explicit.

57

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

6.1 Sexual and Reproductive Health (SRH) expenditure questions in the main MNCAH survey tool

The country respondent is requested to enter the following information in the MNCAH survey:51 1. Government expenditures on Reproductive Health (total amount - US$ or local currency)

2. Government expenditures on Reproductive Health as a share of total government expenditures

on health (%) 3. Government expenditures on Reproductive health per capita (US$)

4. Government expenditures on Reproductive health per capita (Local currency)

5. Government expenditures on Family Planning (total amount)

This information is requested for a total of four years, as shown in Fig 6.1 below. In addition the respondent is asked to describe the method used to derive the estimates, to indicate if a reference document is available, and to provide a contact name and email address (not shown in Figure 6.1). Fig 6.1 Table for entering SRH expenditure data in the main MNCAH survey tool Note: this shows the format that was used for the first round survey in 2009/2010. Subsequent versions may change.

For reproductive health, if the user enters information on any one of the first 4 indicators (9.5 - 9.8), the other indicators can be calculated with the help of default data on government spending, population demographics, and currency exchange rates. For family planning-specific spending, the respondent has to enter information for the fifth indicator.

In order to assist with the standardization of measuring SRH spending and to control for the quality of estimates reported, the RMNCH-GET is sent as an accompanying tool in order to help the country respondents to calculate the indicators listed above In order to determine the questions to be included in the questionnaire and tool for the area of SRH, the boundaries of SRH were first determined (section 6.2). Then an assessment of existing tools (section 6.3), and allocation factors used in countries to date (section 6.4) was undertaken. All of this together was used to inform the decision on what data to collect for the RMNCH routine reporting survey.

51 These were the questions used for the survey 2009/2010. They may be subject to revision.

58

6.2 Definition of SRH spending

The Guidelines for Reproductive Health (RH) subaccounts outline five main areas of spending for SRH including maternal health, as follows:

1. Maternal health care. Improving antenatal and postpartum care

2. Providing high-quality services for family planning, including infertility services 3. Eliminating unsafe abortion 4. Combating STIs including HIV, Reproductive Tract Infections, Reproductive health-related

cancers, and other gynecological morbidities 5. Promoting sexual health

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 is here defined as encompassing areas 2-5 in the above list, while Area 1 is covered

under MNH as described in chapter 6 of this document.

Table 6.1 provides additional detail on how the main categories of spending as per the RH

subaccounts can be mapped to the proposed approach here for expenditure monitoring.

In general, the RMNCH-GET tool prompts the user to indicate outpatient care for the following

categories:

• Family planning

• Sexually Transmitted Infections (STIs) and Reproductive Tract infections (RTIs)

• Outpatient visits for sexual and reproductive health that are not related to family planning, STIs, RTIs, or maternal health.52

and the following for inpatient care:

• Total number of inpatient admissions for surgery related to gynecological problems.

• Average number of days spent in hospital per surgery for sexual and reproductive health

Table 6.1. Defining the content of SRH expenditures and suggesting measurement proxies

for the WHO routine monitoring survey

Categories of spending as per the

RH subaccounts guidelines

Suggested approach for

incorporating measure into the

WHO routine monitoring

approach (MNCAH and SRH

survey)

Information requested in

RMNCH-GET (or link to other

surveys)

RH 1. Improving antenatal,

perinatal, and postnatal care

See chapter 6 in this document

RH 2. Providing high-quality

services for family planning,

including infertility services

2.1. This includes all programmes,

goods, and services intended to

assist people to control their

fertility, and all counseling, health

education, and information:

52 Includes patient visits regarding infertility, sterilization, abortion, and regular gynaecological exams.

59

(a) Outpatient counselling and

issuance of contraceptive

commodities such insertion

of IUDs and injectables;

(1) Outpatient visits for family

planning as % of total outpatient

visits (total or public) * Total

government spending on

Outpatient care.

(2) Government spending on

Family planning commodities.

(i) outpatient visits for family

planning,

(ii) direct expenditures on

contraceptives

(b) Retail sale of family

planning commodities such

as oral contraceptives,

condoms, spermicidals;

Retail sale is not included as the

routine survey will only consider

government spending.

N/A

(c) Female and male surgical

sterilization;

If available, Outpatient visits for

sterilization as % of total

outpatient visits (total or public) *

Total government spending on OP

care

(i) outpatient visits for general

SRH (where it is assumed that

sterilization is included) (*)

(d) Abortion where legal; If available, outpatient visits for

abortion as % of total outpatient

visits (total or public) * Total

government spending on

outpatient care

(i) outpatient visits for general

SRH (where it is assumed that

abortion related care is

included). (*)

(e) Programmes that support

or promote family planning

such as IEC, public

awareness, health

education campaigns,

training, and research.

This will be counted under

programme activity costs for

Family Planning.

Data collected on expenditures

for Ministry of Health

programme activity related to

Family Planning.

2.2 Infertility counselling, fertility

drugs, or procedures, etc.

(f) Infertility counselling,

fertility drugs, or

procedures, etc.

Counseling on infertility is

included together with general

SRH outpatient visits

(i) outpatient visits for general

SRH (*)

RH 3. Eliminating unsafe

abortion (**)

Eliminating unsafe abortion This category is excluded on the

basis that components have not

been defined in the RH sub

account.

N/A

RH 4. Combating STIs including

HIV, RTIs, RH cancers, and

other gynaecological

morbidities

4.1 including general

gynaecological care:

(a) Routine examinations (e.g.

pap smears);

Outpatient visits for SRH as % of

total outpatient visits (total or

public) * Total government

spending on OP care.

Data collected on outpatient

visits for general SRH. This

includes gynecological care (*)

(b) Diagnosis, management,

and treatment of STIs (may

be included in either the RH

subaccount or the

HIV/AIDS subaccount

depending on country

context);

Outpatient visits for STIs and RTIs

as % of total outpatient visits

(total or public) * Total

government spending on OP care.

Data collected on outpatient

visits for STI and RTI.

(c) Health education; Assume included in programme

costs

Data collected on expenditures

by Ministry of Health for

60

programme activities related to

promotion of SRH.

(d) Treatment of RTIs; Combine with STI measure as

above (b)

Data collected on outpatient

visits for STI and RTI.

(e) Screening and treatment of

uterine/cervical/ovarian/b

reast/prostate cancers, etc.

Try to capture for outpatient care.

Ignore for inpatient care on the

basis that treatment of fistulas is

likely to be a small proportion of

total SRH spending in low income

countries.

Data collected on outpatient

visits for general SRH (*).

(f) Treatment of fistulas. Try to capture for outpatient care.

Ignore for inpatient care on the

basis that treatment of fistulas is

likely to be a small proportion of

total SRH spending.

Data collected on outpatient

visits for general SRH (*).

4.2 STI prevention and

awareness programmes

Assume included in programme

administration cost

Prevention campaigns aimed at

stopping female genital

mutilation

Assume included in programme

administration costs

Data collected on expenditures

for Ministry of Health

programme activity related to

promotion of SRH.

SRH 5. Promoting sexual health (***)

(a) Programmes addressing

gender-based violence,

elimination of harmful

sexual practices, sexual

trafficking, and exploitation

of minors

Assume included in programme

administration cost

(b) Programmes addressing

adolescent sexual an d

reproductive health

Assume included in programme

administration cost

(c) Programmes addressing the

issue of sexual trafficking

(social protection, family

and children)

Assume included in programme

administration cost

(d) Programmes addressing the

issue of exploitation of

minors

Assume included in programme

administration cost.

(*) General SRH care is here defined as those outpatient visits for sexual and reproductive health that do not refer to family planning, STI, or maternal health. This includes patient visits regarding infertility, sterilization, abortion, and regular gynecological exams. (**) According to WHO, an “unsafe abortion is the termination of a pregnancy carried out by someone without the skills or training to perform the procedure safely, or in an environment that does not meet minimal medical standards, or both.” (***) considered as addendum activities in the RH subaccount guidelines.

The above Table is used to define the boundaries of the expenditure categories and what can be

expected to be included in a rough estimate based on collecting data on major cost categories.

6.3 Other tools and processes to measure RH spending

Reproductive Health spending is measured by the Resource Flows project53 in selected countries. This is a joint project of UNFPA and the Netherlands Interdisciplinary Demographic Institute (NIDI), aimed to survey financial flows going to reproductive health. The main approach used is e-mail

53 http://www.resourceflows.org/

61

surveys to collect financial data on population and AIDS expenditures by donors and Government. The definition used categorizes Population and AIDS activities into four categories based on the ICPD Programme of Action:

• Family Planning services

• Basic reproductive health services

• Sexually transmitted infection and HIV/AIDS prevention

• Basic research, data and population and development policy analysis Note that the NIDI questionnaires include questions to separate out other STI spending from HIV/AIDS prevention and treatment. An annual publication is prepared by NIDI: Financial Resource Flows for Population Activities. However data is treated as confidential property of UNFPA and is not made publicly available on a country-by-country basis. In the work described here to develop a standardized approach for country use, efforts were made to review and learn from the approach used by NIDI. The approach described here is shorter and less comprehensive in scope. It has other advantages such as a more straightforward and consistent format than the NIDI questionnaires. Also, the WHO survey approach asks for specific amounts rather than percentage share (%) allocations of total amounts. Moreover, the focus of the WHO approach is on building national programme staff capacity to monitor and report on expenditure and budgets, whereas NIDI data is usually collected by consultants, and not in all countries and every year. The two approaches should thus be seen as complementary.

The review of tools undertaken to inform the development of the methodology was carried out in

mid-2009 and since then there have been efforts to improve the NIDI instruments. The RMNCH-GET

includes references to the NIDI assessments and prompts the respondent to contact the UNFPA

counterpart in countries where a NIDI assessment has been done. A mapping table will be

developed to support harmonization and limitation of double work.

6.4 Country findings to date

The Malawi RH sub-accounts revealed that the public sector (in particular the MoH) is the major

manager of RH funds accounting for 65%, 58%, and 61% in 2002/03, 2003/04 and 2004/05

respectively.

Expenditure by government programmes may be substantial and important to monitor, in

particular for prevention. The RHA in Malawi showed that family planning and its promotion

through Information and Education campaigns and public awareness campaigns made up 18% -

22% of total reproductive health expenditure in 2002 - 2005.

Experience from country level thus indicate that a routine tracking of SRH spending needs to focus

on Family Planning as together with Delivery care, this component has been shown to constitute a

large share of total SRH spending.

In a RHA study undertaken in Egypt, the estimated inpatient expenditures for treatment of obstetric and gynecological complications was estimated as the proportion (%) of overall inpatient admissions that were reported by MOH hospitals as being due to obstetric and gynecological reasons - minus the proportion that was accounted for by delivery cases. The estimated ratio derived was 7%, which was taken to correspond to the SRH category of surgeries due to SRH complications.

62

6.5 Summary of data needs for SRH spending assessment

Having defined the scope of what can be measured and reported on within the annual survey, based on the boundaries set up by the guidelines for reproductive health subaccounts and an assessment of likely cost drivers, the next step is to summarize the data needs for SRH.

Table 6.2 Data analysed in RMNCH-GET section on SRH

Data requested in tool Recommended source at country

level

Fallback option

General data

Total government spending on

outpatient care

Obtain from government financial

documents

Total government spending on in-

patient care

Obtain from government financial

documents

Total outpatient visits by year (use

public if possible, otherwise total)

Should be available from HMIS,

Total inpatient visits (days)

Should be available from HMIS, would

have been analysed in a past NHA

study

SRH -specific data

Outpatient visits for SRH (family

planning, infertility, sterilization,

abortion, gynecological exams) by

year (give public if possible, otherwise

give total) - needs to be broken down

depending on specificity of indicators

HMIS and/or expert assessment May need to use coverage

rates as fall-back option for

family planning

Outpatient visits for STIs and RTIs by

year (give public if possible, otherwise

give total)

HMIS and/or expert assessment

Government spending on FP

commodities, such as oral

contraceptives, condoms,

spermicidals; intrauterine device (IUD)

and injectables.

MOH to estimate based on records.

Expenditure of Government

programme to support or promote

Family Planning

May be available from an

HIV/AIDS subaccount or

NIDI assessment.

Expenditure of Government

programme to support or promote

Sexual and Reproductive health

MOH to estimate based on records.

Expenditure of Government programme to manage sexually transmitted infections

Cash transfers / financial incentives to

promote SRH, including adolescent

SRH.

MOH to estimate based on records.

Note: utilization data is requested for two years (T-2, and T-1). Since it is not possible to make future projections about service utilization, it is assumed that the % share of service delivery costs going towards SRH remains constant from T-1 onwards, For example, for the first round of the survey sent out in 2009, the user entered allocation factors for 2008 and 2008. The % allocation factor derived from 2008 data was used for the two subsequent years 2009 and 2010 as a proxy.

In general the SRH section makes a distinction between three sets of programmes or activities:

• Family Planning

63

• Management of STI and RTI

• Other SRH - including infertility, abortion, and regular gynecological exams. In addition it was agreed that the respondent should be prompted to separate out any capital spending such as that related to construction. To see an overview of the actual questions inserted into the RMNCH-GET to facilitate country reporting on SRH spending, please refer to Annex 6. Section 7 provides an overview of feedback received to date and lessons learnt.

6.6 Components likely to be included and excluded from the final estimate for SRH spending as

derived if the respondent uses the RMNCH-GET

If the user includes all relevant categories as prompted in the help tool then the following expenditure categories would be included in a final estimate of government spending on SRH: Data entered into the tool:

• Estimated government spending on family planning commodities

• Estimated government spending on service delivery for family planning

• Estimated government spending on service delivery for STI and RTI (does not include drugs)

• Estimated government spending on service delivery for "Other SRH" - ( infertility, abortion, and regular gynecological exams) - does not include drugs

• Estimated programme costs for family planning

• Estimated programme costs for STI prevention and awareness

• Estimated programme costs for "Other SRH"

• Cost for cash transfers/financial incentives specific to SRH. Complementary data collected from other sources (to be used when available):

• NIDI/UNFPA estimate on STI spending (according to recommended methodology). Omissions: The approach will not capture all of the spending on SRH. Specifically it is likely to ignore:

• Expenditures on commodities for management of STIs and RTIs. The reason for this omission is that the antibiotics used for management of STIs and RTIs are not specific to SRH and thus it would be difficult to allocate a share of total spending towards SRH. In summary, with the proposed approach aiming to capture expenditure categories as per the above list of items, it is likely that the gross amount spent by the public authorities on SRH-related activities can be estimated and that this will support monitoring of trends over time.

64

7. Preliminary findings and lessons learnt

This section provides an overview of some of the findings to date and feedback obtained during the first round of the survey.

7.1 Response rates in first round survey

By April 2011, 70 countries had returned the questionnaire sent out in 2009/2010.54 The expenditure section was a new section and therefore had a relatively low completion rate (36%).55 A low response rate for expenditure reporting in initial years is consistent with findings from other programme surveys (e.g., TB and malaria). At that time 25 countries had provided data through the survey on the share of expenditure and budgets going to RMNCH. However the data provided was not always complete and/or covering all 4 years (2007-2010) and/or all components of RMNCH.

Figure 7.1: Response rates for expenditure data, by RMNCH component and country category

10 9 8

5 5 9

0

5

10

15

20

Chi ld hea l th MNH SRH

Nu

mb

er

of

cou

ntr

ies

Countdown countries Other countries

Note: the Figure indicates when the country has provided some data for at least one year. MNH: Maternal and Newborn Health; SRH: Sexual and reproductive health.

7.2 Reporting of expenditure data in the MNCAH survey

In total 25 countries reported expenditures using section 9 of the questionnaire. One additional country left section 9 blank but submitted a copy of the RMNCH-GET help tool (see below). Only 7 of 25 countries filled in data in all three sections (Child Health (CH); Maternal and Newborn Health (MNH) and Sexual and reproductive health (SRH)). As shown in Table 7.1, distribution among the three sections was even, and there was no one section which in general contained less information.

54 The questionnaire was sent to total 148 countries of which 70 countries responded. Out of the 68 Countdown countries, 37 countries responded. Out of the remaining 80 countries, 33 countries responded 55 The estimated response rate, calculates as 25 out of 70 countries, is 36%.

65

Table 7.1:Data provided, by section and country

Countdown Other countries

Reported expenditures

Number of

countries Countries

Number of

countries Countries

CH only 1 Czech

MNH only 1 Azerbaijan

SRH only 3 Cote d'Ivoire,

Guatemala, Togo 4 Albania, Malaysia,

Nicaragua, Surinam

CH and MNH 4 Madagascar, Mali,

Mexico, PNG

CH and SRH 1 Burundi 1 Paraguay

MNH and SRH 1 Guyana

All (CH, MNH, SRH) 4 Bangladesh, Ethiopia,

Nepal, Zimbabwe 3 Armenia, Kyrgyzstan,

Uzbekistan

MNCH presented jointly but classified as MNH or CH

only 2 Myanmar, Lao PDR.

Total 15 10

7.3 Added value of the RMNCH-GET

In order to facilitate the reporting on health expenditures and budgets for child and maternal health, the RMNCH-GET was developed as an Annex help tool and sent to countries along with the overall questionnaire. The tool is developed in Excel and aims to support standardized reporting on RMNCH spending. This has several benefits:

• Standardization of reporting: the use of standardized methods ensures that estimates are consistent over time, and can be compared across time and across countries.

• The tool allows for transparent assessment of what expenditure components are included in the actual amounts reported. For example, in the first round of reporting several countries only reported spending for vaccines or paediatric ARVs in the section on child health expenditure, and/or only reported on family planning estimates for SRH spending.

• User friendly features and automatic formulas built in: the tool has several user friendly features. The Excel format includes drop-down lists, help comments, and uses hyperlinks to jump between sheets. When data is available by country at the global level, such as the estimated total government expenditure on health, or the family planning coverage, these defaults are automatically presented for the selected country and the user can choose to agree with them or to enter new data. Results in the form of Graphs and Tables are automatically produced based on the inputs provided and shown in separate results sheets. The user can also view the allocation formulas used if s/he wants to.

• Links to other surveys: the tool reminds the user to link to existing surveys already undertaken in the country such as the UNFPA/NIDI assessment on reproductive health spending, and encourages the user to connect with the focal points for National Health Accounts in the country.

• The tool reveals what information is available at country level Few countries reported utilization data which limited the ability to apportion general spending. Follow-up by telephone and email with selected countries indicated that age-specific or programme-specific data was not always available.

66

7.4 Use of the RMNCH-GET as an annex help tool among first round respondents

In 2009/2010, a total of seven countries submitted a version of the tool into which they had entered data. It is possible that more countries used it but did not submit it. Moreover, two out of the seven copies of the tools received were submitted with incomplete data, and did not allow for an assessment of RMNCH expenditure (one of the countries had entered data on general health spending only, and a second country had only indicated health service utilization data, without indicating any RMNCH-specific expenditure). These findings underline that country respondents may be in need of training to understand the tool and its use.

7.5 RMNCH expenditure data reported in the first round, and issues raised for reporting

Figure 7.2 shows expenditure as reported by three countries though the MNCAH survey. The graph illustrates that spending levels as reported are significantly below the estimated needs. Following the first round survey, efforts were made to contact country respondents to obtain further information to find out to what extent different types of expenditure had been included within the reported expenditure estimates. However, the kind of information obtained through follow-up was limited and for the next round of the survey it is encouraged that data providers are instead prompted directly when providing their data to give more details on the comprehensiveness of the estimates. This will also be beneficial at country level as the data providers will immediately note any costs that are left out of the estimates. Such functions, in the form of reminders, will be automatically built into the tool for the next round.

Figure 7.2: Preliminary findings from first round MNCAH survey (2009/2010)

Note: GGHE = General government health expenditure

The distinction between SRH and Maternal health is artificial in many countries. It would be preferable to allow for joint reporting of SRH and maternal health expenditure in such instances rather than having these as two separate indicators to report on. Similarly, some country respondents expressed a preference to report spending on RMNCH as one aggregate category rather than broken down for child, maternal and SRH.

Reported Government spending on MNCH per capita, US$

$-

$0.5

$1.0

$1.5

$2.0

$2.5

$3.0

2007 2008 2009 2010 2007 2008 2009 2010 2007 2008 2009 2010

Asian country U5MR 50,

MMR> 500. GGHE/capita: $5

Asian country U5MR 50,

MMR> 800. GGHE/capita: $8

African country U5MR 100,

MMR>500, GGHE/capita:

$11

CH

SRH

MNH

67

Upon contacting countries for follow-up it was discovered that not all had used the same age categories for child health. While the expectation is that expenditure should be reported for children aged 0-4 years, in several instances the data entered for expenditure on child health programmes covered a different age group. This only became apparent in interviews with respondents. In the next version of the tool, a place should be set aside for the respondent to indicate the age for which data is reported. The first round also revealed some errors in the reporting due to respondents shifting between different currencies in their reporting.

7.6 Key lessons learnt

The key lessons learnt based on feedback from countries are as follows:

1. Capacity building and training is essential 2. Accompanying guidance materials and technical support is essential 3. Follow-up with country respondents is required to find out what were the challenges in

filling out the form, what specific items and activities were included in the financial reporting, and how reporting can be improved.

7.7 Recommendations for next steps

The working group has reviewed the feedback from countries and made adjustments as needed. Additional feedback from the second round of the survey (2011) will help identify further what adjustments need to be made to the expenditure section of the general MNCAH survey as well as to the RMNCH-GET as a help tool, in order to facilitate the use of these tools by country respondents. Taking into account lessons learnt from disease-tracking for TB, malaria and HIV/AIDS, the plan to organize regional workshops in 2011 and 2012 to build capacity, share information and experiences, collect expenditure data for reporting, and encourage the set up of peer-review mechanisms, is reiterated. It is envisioned that the discussions in the workshops will inform the recommendations to move forward on record development and the use of standard classifications such as the one of products and services and to enhance the quality of data through triangulation. It is envisioned that this process will support:

a) Validation of the proposed indicators b) The development of a list of recommended data sources and specific questions or items

desirable to be collected (e.g. in household surveys, in facility records and service utilization reports, etc)

c) Identify linkages between the data to be collected with available records by type in country (including budget mapping)

d) Identify linkages between the data to be collected within the RMNCH-GET with reference to values that are collected through health accounts, such as total government spending by level, health expenditure funded by the government, etc.

Research should be carried out over the coming years to inform methodological development and field testing of approaches that utilize coverage data versus utilization data, and the use of various proxies for allocating expenditure on shared resources. Moreover there is a need to review the list of cost drivers at country level and whether the tracking of selected proxy indicators such as expenditure on specific commodities and /or service utilization data could be sufficient to track trends over time. WHO should also work with partners to support harmonization of methods used in this field.

68

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

The following working group members contributed to the development of the methodology and

tools at various stages of their development 2009-2011.

Richard Cibulskis, Global Malaria Programme (GMP)

Patricia Hernandez, Health Systems Financing (HSF)

Dale Huntington, Reproductive Health and Research (RHR)

Thierry Lambrechts, Child and Adolescent Health (CAH),

Patrick Lydon, Immunizations, Vaccines and Biologicals (IVB)

Blerta Maliqi, Making Pregnancy Safer (MPS)

Lale Say, Reproductive Health and Research (RHR)

Robert Scherpbier, Child and Adolescent Health (CAH)

Anuraj Shankar, Making Pregnancy Safer (MPS)

Karin Stenberg, Health Systems Financing (HSF)

Tessa Tan-Torres Edejer, Health Systems Financing (HSF)

Nathalie Van de Maele, Health Systems Financing (HSF)

69

Annex 2 Child and Reproductive health subaccounts to date

Year Document

Reproductive and Child

Health

Democratic Republic of Congo

2007/2008 Comptes nationaux de la Sante 2008-2009 RDC

Ethiopia 2004/2005 2007/2008

Ethiopia’s Third National Health Accounts, 2004/05 Ethiopia’s Fourth National Health Accounts, 2007/2008

Kenya 2009/2010 Kenya National Health Accounts 2009/2010

Liberia 2007/2008 Liberia National Health Accounts 2007/2008

Malawi 2002-2004 Malawi National Health Accounts (NHA) 2002-2004, with Sub-accounts for HIV and AIDS, Reproductive and Child Health

Nigeria 2006-2009 forthcoming

Rajasthan state, India 1998-99 Reproductive and child health accounts: an application to Rajasthan, Health Policy and Planning, 17 (3): 314-321.

Rwanda 2008/2009 National Health Accounts Rwanda 2008/09 (forthcoming)

Senegal (*) N/A Forthcoming

Sierra Leone 2011 Forthcoming

Tanzania 2002/03 + 2005/06

Tanzania National Health Accounts (NHA) Year 2002/3 and 2005/6

Child Health

Bangladesh 1990-2002 Institute for Health Policy, Child health accounts: Bangladesh & Sri Lanka

Sri Lanka 1990-2003 Institute for Health Policy, Child health accounts: Bangladesh & Sri Lanka (200Q)

Reproductive Health

Bolivia 2004 Cuentas de Salud Reproductiva 2004. Ministerio de Salud y Deportes (draft)

Burkina Faso 2010 Forthcoming

Georgia

Jordan 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.

Karnataka State, India

Kenya 2005/2006 Kenya National Health Accounts 2005/06

Mexico 2003-2009 Cuentas en salud reproductiva y equidad de género. Estimación 2009 y comparativo 2003-2009. Instituto Nacional de Salud Pública 2003-2009

Namibia 2007/08-2008/09

Namibia health and HIV/AIDS resource tracking report: 2007/08 & 2008/09

Rwanda 2002 2006

Rwanda National Health Accounts 2002 National Health Accounts 2006

Sri Lanka

Tanzania 2009 forthcoming

Uganda ? forthcoming

Ukraine

(*) Analysis was ongoing at the time of designing this Table. The final format and presentation of child vs. reproductive health spending is not yet certain.

70

Annex 3. Essential medicines for child health

The working group explored methods for tracking government purchase and distribution of essential medicines and supplies for children. Table A3.1 below highlights key medicines for children as per a recent publication. However some of these formulations may also be given to adults, which makes it challenging to track the amounts going exclusively to children. Table A3.1: List of essential pediatric medicines (1)

Medicine Dosage form

Indication in WHO

treatment guidelines Target Group

Albendazole Chewable tablet, 200 mg Helminthiasis children/adults

Albendazole (*) Suspension, 100 mg/5 ml Helminthiasis Children

Amoxicillin Suspension, 125 mg/5 ml

Infections including

pneumonia Children

Artemether plus

lumefantrine Tablet, 20 mg + 120 mg Malaria Children

Beclometasone Inhaler, 50 μg/dose Asthma Children

Ceftriaxone Injection, 1-g vial Severe infections, including meningitis children/adults

Ceftriaxone 250-mg vial

Severe infections, including

meningitis children

Co-trimoxazole

Suspension, 200 mg + 40 mg/5

ml

Pneumonia or prophylaxis of

Pneumocystis carinii

pneumonia children

Isoniazid Tablet, 100 mg Tuberculosis

Mebendazole Chewable tablet, 100 mg Helminthiasis children/adults

Mebendazole (*) Syrup, 100 mg/5 ml Helminthiasis children

Nevirapine Syrup, 50 mg/5 ml HIV infection children

Nystatin (*) Drops, 100 000 IU/ml Oral candidiasis children/adults

Oral rehydration salts (*) Packet Diarrhoea children mainly

Paracetamol Syrup, 120 mg/5 ml Pain children

Rifampicin (*) Syrup, 100 mg/5 ml Tuberculosis children

Salbutamol Inhaler, 100 μg/dose Asthma children/adults

Vitamin A Capsules, 100 000 IU (30 mg) Prophylaxis children

Vitamin A (*)

Liquid preparation, 50 000

IU/ml Prophylaxis children

Zinc Tablet, 20 mg dispersible Diarrhoea children mainly (1) The list was derived from Jane Robertson et al., What essential medicines for children are on the shelf? Bull World Health Organ 2009;87:231–237. (*). Not included in the WHO model list of essential medicines, 15th list, March 2007

Medicines listed in bold with blue background are those found to be most specific to children and their expenditure for child health should therefore be easier to track.

71

Annex 4. Overview of the RMNCH-GET section on child health expenditure and budget

Note that this Annex provides examples of screen shots from the 2009/2010 survey and tool which has since been subject to some revision. The general framework presented here still applies to later versions of the survey.

The respondent is first asked to enter data on General health service expenditure and total health utilization statistics. This is done in a separate sheet and the same data is used for all three areas: maternal health, CH and SRH. Next, the respondent continues to the child health sheet and fills in the following:

First section: utilization data

The respondent is asked to enter data on service utilization statistics specific to child health.

Explanatory notes to Table above: Q.5. Total number of outpatient visits by children 0-4 years. Q.6 The tool asks about immunization visits separately as in many countries preventive visits are

not captured in general morbidity statistics. Please only enter data in this row if in your country

the immunization related outpatient visits are NOT included in the total number of outpatient

visits

Q.7. Total number of inpatient days by children 0-4 years (total number of days in year 2008).

Questions 8-9 refer to reporting completeness. If the utilization data presented only accounts for a share of facilities, then it needs to be adjusted in order to represent all public facilities. Coverage Data An estimation process that makes use of coverage is also a valuable approach and may be used as appropriate. It can also be used to compare estimates calculated by utilization statistics with those estimated using coverage data (as a form of validation). The following Table has been inserted into the tool.

72

Second section: expenditure data

The Respondent selects which currency to report in (local currency, or US$). The Respondent is first asked to enter the total amount spent by the Government on Service delivery at facilities. This is a shared expenditure. The approach uses Service Utilization data in order to allocate a share of this general spending towards child health.

Explanatory notes (appear as pop-ups): Q.8. Indicate 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. Many countries have a separate budget line for Facility costs.

Q.9.Indicate the amount of the government budget/expenditures that went to Hospital level care (staff costs, facilities running costs, etc)

Q.10. By primary level care here is meant Health Centres, health posts, community, etc. Indicate the amount of the government budget/expenditures that went to Primary level care (staff costs, facilities running costs, etc)

Notes/pop-ups to explain the different categories for Source of funding:

(a) Indicate the total expenditure regardless of source of funds. (b) Include funding from the central level of the Government (c) Include funding from the peripheral government sources (provinces, districts, etc.). (d) Refers to concessional loans (e) Grants awarded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).

The amount for the relevant fiscal year only and NOT the total amount of the grant. (f) Funds made available through GAVI (g) All grants, excluding Global Fund grants. The amount should be for the relevant fiscal year

and not the total amount of the grant. Expenditure questions specific to child health:

Next the respondent enters data for the key activities and investments for child health, as managed by the government:

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Explanatory notes to Expenditure questions: Q.20. Indicate the spending on Insecticide Treated Bednets. Only include the spending on the

commodity itself (no distribution costs). Please note that in the presentation of results, only

a certain % of the ITN cost will be allocated to child health, since benefits accrue beyond

childhood period. The default allocation is 50%. You can change this as needed in the

indicated cell to the right side of this Table.

Q.21 Indicate the spending on ORS and zinc tablets. Only include the spending on the commodity

itself (no distribution costs). Please note that in some countries, the budget for zinc and

ORS may be included under total spending on Facilities and Service delivery, as indicated in

Q.17. In this case, you should not report any spending on ORS and zinc here.

Q.22 Indicate the spending on ARVs for children. Only include the spending on the commodity

itself (no distribution costs).In some countries the information may be obtained through

consultation with national HIV programme or national medical store

Q.23. Indicate the spending on Ready to Use Therapeutic Food (RUTF). Only include the spending

on the commodity itself (no distribution costs). Please note that in some countries, the

budget for RUTF may be included in the amount reported as total spending on Facilities

and Service delivery, as indicated in Q.20. In this case, you should not report any spending

on RUTF here.

Q.24. Spending on Vaccines and injectables is reported through the UNICEF-WHO joint reporting

form for immunization. Please indicate the amount here. Only include the cost for

commodities (vaccines and injectables), and not for other activities or staff. To the extent

possible please adjust the estimate to exclude spending on Tetanus Toxoid, since this is

reported under Reproductive and Maternal Health spending.

Q.25. If spending on any other commodity not mentioned above is of particular relevance for

child health programming in your country, please indicate here.

Q.26. Estimated spending on government programs that support or promote child health such as

IEC, public awareness, health education campaigns, training, and research.

Sometimes it may be easier to enter information separately for each programme, such as

IMCI, CDC and ARI programmes, Nutrition, Malaria, HIV, Immunization, etc.

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The amount indicated should cover the estimated spending incurred for routine

programme management and supervision activities aimed at improving child health,

training activities supported by the national programme at national, province and district

level, policy development, development and printing guidelines, handbooks and training

materials; advocacy and social mobilization; operational research; surveys and monitoring

work; purchase of office equipment/vehicles, construction of buildings for use by staff

programme, recording and reporting, and commodity management and distribution.

Please indicate the total budget related to these activities, including salary spending on

staff working within the central programme unit and at sub national level.

Q.27 Indicate any significant spending on capital items (construction of buildings, purchase

equipment, etc) specific to child health. First indicate the amount (if any), and then provide a brief

description below.

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Annex 5. Overview of the RMNCH-GET section on maternal and newborn health expenditure and budget

Note that this Annex provides examples of screen shots from the 2009/2010 survey which has since been subject to some revision. The general framework still applies.

First section: utilization data

The respondent is first asked to enter data on General Utilization statistics

Government health

services only All providers (government and

other sectors)

General Utilization statistics Year 2007

Year 2008

Source

Year 2007

Year 2008 Source

Total number of outpatient visits (all ages) info

(Q.3)

Total number of inpatient days (all ages) info

(Q.4)

Then he/she is asked to enter data on Utilization statistics specific to maternal health.

Explanatory notes to Table above: Q.5. Outpatient visits for ANC: note that preventive visits may not be available from routine

utilization statistics. If number of outpatient visits is not available then it needs to be

estimated by using coverage data. If this is the case, please choose "NOT AVAILABLE" from

the drop-down menu.

Q.6 Outpatient visits for postnatal care: note that preventive visits may not be available from

routine utilization statistics. If number of outpatient visits is not available then it needs to be

estimated by using coverage data. If this is the case, please choose "NOT AVAILABLE" from

the drop-down menu.

Q.7a. If total number of inpatient days for maternal health is available please select "AVAILABLE"

from the drop-down menu and enter the data in the Table. If such data is not available, then

enter data on number of admissions and average number of days per delivery (Q.7 b and c)

Q.7b. Enter the number of women admitted to a facility for delivering their baby, Enter data for Government Facilities only, and then for all providers.56

Q.7c. Estimate the average number of days that a woman will spend in hospital or facility after giving birth.

56 Total number of deliveries in institutions- This should be available from national statistics. A proxy is to take the

estimated % of births with Skilled Birth Attendance and multiply by the Crude Birth Rate.

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Note: when there is no general data available on the number of OPVs and IPDs, we will use coverage to approximate the number of visits taking place, in order to allow for a % share of total health service delivery to be allocated towards MNH. The following Table has been inserted into the Annex tool. After the preliminary field tests and the first round of application and country feedback, there may be a need to review the use of coverage data.

The help note Q.14 reads:

� In the first column indicate the % coverage achieved in year 2007 for pregnant women/mothers receiving the services in health facilities.

� In the second column indicate the % distribution that go to Government health services � In the third column indicate the % distribution that go to Non-Government health

services. � (the 2nd and 3rd column should add up to 100%) � Then enter similar data for year 2008.

Second section: expenditure data

The Respondent is first asked to enter the total amount spent by the Government on Service delivery at facilities. This is a shared expenditure. The approach uses Service Utilization data in order to allocate a share of spending towards maternal health.

Explanatory notes: Q.29. Indicate the capital and recurrent cost 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 Facility costs. Notes/pop-ups to explain the different categories for Source of funding:

(a) Indicate the total expenditure regardless of source of funds. (b) Include funding from the central level of the Government (c) Include funding from the peripheral government sources (provinces, districts, etc.). (d) Refers to concessional loans (e) Grants awarded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).

The amount for the relevant fiscal year only and NOT the total amount of the grant. (f) Funds made available through GAVI

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(g) All grants, excluding Global Fund grants. The amount should be for the relevant fiscal year and not the total amount of the grant.

Explanatory notes to Expenditure questions: Q.30. Indicate the total amount spent on commodities essential for maternal health prenatal care

- excluding SP and Tetanus Toxoid which should be indicated separately below

Q.31. Indicate the total amount spent on SP to prevent intermittent transmission of malaria from

mother to child

Q.32. Spending on Vaccines and injectables is reported through the UNICEF-WHO joint reporting

form for immunization. Please indicate the amount here for Tetanus Toxoid.Only include

the cost for commodities (vaccines and injectables), and not for other activities or staff.

Q.33. Estimated spending on government programs that support or promote maternal health

such as IEC, public awareness, health education campaigns, training, and research.

Sometimes it may be easier to enter information separately for each programme, such as

Making Pregnancy Safer, Nutrition, Malaria, HIV, Immunization, etc. The amount indicated

should cover the estimated spending incurred for routine programme management and

supervision activities aimed at improving maternal health, training activities supported by

the national programme at national, province and district level, policy development,

development and printing guidelines, handbooks and training materials; advocacy and

social mobilization; operational research; surveys and monitoring work; purchase of office

equipment/vehicles, construction of buildings for use by staff programme, recording and

reporting, and commodity management and distribution. Please indicate the total budget

related to these activities, including salary spending on staff working within the central

programme unit and at sub national level.

Q.34. Take care to ensure that the amount entered here is not double counted under any of the

other categories in this Table.

Q.34b. Please indicate whether the incentive programme is budgeted for nationally (and if you can

indicate the amount spent), or if this is rather a decentralized programme and financing

(and therefore difficult to indicate the amount spent).

Q.35. Indicate any significant spending on capital items (construction of buildings, purchase

equipment, etc) specific to maternal health. First indicate the amount (if any), and then

provide a brief description below.

The same categories of spending are repeated in four Tables of data collection, one for each year. The help notes appear in all Tables.

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Annex 6. Overview of the RMNCH-GET section on SRH expenditure and budget

Note that this Annex provides examples of screen shots from the 2009/2010 survey which has since been subject to some revision. However the general framework still applies. The respondent is first asked to enter data on General health service expenditure and total health utilization statistics. This is done in a separate sheet and the same data is used for all three areas: maternal health, CH and SRH.

First section: utilization data

The User is first asked to enter data on General Utilization statistics

Government health

services only

All providers (government and other

sectors)

General Utilization statistics Year 2007

Year 2008 Source

Year 2007

Year 2008

Source

Total number of outpatient visits (all ages) info

(Q.3)

Total number of inpatient days (all ages) info

(Q.4)

Then in the sheet specific to MDG5, the respondent is asked to enter data on utilization statistics specific to SRH, as follows:

Explanatory notes to Tables above: Q.3.The total number of outpatient visits should be available from the national health information

system. Please provide an estimate that is representative for the whole country. In the first

instance provide estimates for government health services only. However, if data is not

available specifically for public providers but rather is nation-wide, then provide estimates

that refer to all providers.

Q.4.Total number of inpatient days should be available from the national health information system.

Please provide an estimate that is representative for the whole country. In the first instance

provide estimates for government health services only. However, if data is not available

specifically for public providers but rather is nation-wide, then provide estimates that refer

to all providers.

Q.8.Outpatient visits for Family Planning: note that preventive visits may not be available from routine utilization statistics. If number of outpatient visits for FP is available then select "AVAILABLE" from the drop-down menu, and enter the data. If the number of outpatient

79

visits for FP is not available then it needs to be estimated by using coverage data. If this is the case, please choose "NOT AVAILABLE" from the drop-down menu.

Q.9 Includes patient visits regarding infertility, abortion, and regular gynecological exams. Q.10. Outpatient visits for Sexually Transmitted infections (STIs) and Reproductive Tract Infections

(RTIs). Q.11. Based on official records, enter the number of persons admitted to hospital/facility due to

need for surgery related to reproductive health and gynecological problems. Average number of days spent in hospital per surgery - indicate the average number of days that a patient would spend in hospital

Q.12. Estimate the average number of days that a woman will spend in hospital or facility, including before, during and after surgery.

*General note on government service data: Please indicate the number of outpatient visits in government health services only. This should be available from national information system. If a National Health Accounts has been undertaken in your country, this data should be available from the NHA team.

As mentioned above, it is possible that utilization data for Family Planning, which is a preventive service, may not be included in general service statistics in which case coverage data can be used to assess number of visits. Coverage Data The estimation process using coverage is also a valuable approach and its use should be encouraged in order to assess data availability and to compare estimates calculated by utilization statistics by those estimated using coverage data (as a form of validation). The below Table has thus been inserted into the tool. After the first rounds of application this approach should be reviewed. Family Planning coverage data

The pop-up note to question Q.15 reads as follows:

- In the first column indicate the number of users of family planning in year 2007 . - In the second column indicate the % distribution that got the service through Government

health services - In the third column indicate the % distribution that got counseling/advice through non-

Government health services, including pharmacies. - In the fourth column indicate the average number of health service contacts per user per

year, specifically related to family planning. - Proceed to enter similar data for year 2008.

Second section: expenditure data

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The Respondent is first asked to enter the total amount spent by the Government on Service delivery at facilities. This is a shared expenditure. The approach uses Service Utilization data in order to allocate a share of spending towards SRH.

Explanatory notes: Q.29. Indicate the capital and recurrent cost 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 Facility costs. Notes/pop-ups to explain the different categories for Source of funding:

(a) Indicate the total expenditure regardless of source of funds. (b) Include funding from the central level of the Government (c) Include funding from the peripheral government sources (provinces, districts, etc.). (d) Refers to concessional loans (e) Grants awarded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).

The amount for the relevant fiscal year only and NOT the total amount of the grant. (f) Funds made available through GAVI (g) All grants, excluding Global Fund grants. The amount should be for the relevant fiscal year

and not the total amount of the grant.

Next the user enters specific spending on commodities and activities, by source of funds

Q.3Q. Government spending on FP commodities, such as oral contraceptives, condoms, spermicidals; IUDs and injectables;

Q. 37. Estimated expenditure on activities to manage and supervise the family planning programme. This would include Routine programme management and supervision

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activities, training activities supported by the national programme at national, province and district level, policy development, development and printing guidelines, handbooks and training materials; advocacy and social mobilization; operational research; surveys and monitoring work; purchase of office equipment/vehicles, construction of buildings for use by staff programme, recording and reporting, and commodity management and distribution. Please indicate the total expenditures related to these activities, including salary spending on staff working within the central program unit and at subnational level.

Q.38. Estimated expenditure on activities to manage and supervise government programs that support or promote management of STI and RTIs. This would include Routine programme management and supervision activities, training activities supported by the national programme at national, province and district level, policy development, development and printing guidelines, handbooks and training materials; advocacy and social mobilization; operational research; surveys and monitoring work; purchase of office equipment/vehicles, construction of buildings for use by staff programme, recording and reporting, and drug management and distribution. Please indicate the total expenditures related to these activities, including salary spending on staff working within the central programme unit and at subnational level.

Q.39 Estimated expenditure on activities to manage and supervise government programs that support or promote management of STI and RTIs. This would include Routine programme management and supervision activities, training activities supported by the national programme at national, province and district level, policy development, development and printing guidelines, handbooks and training materials; advocacy and social mobilization; operational research; surveys and monitoring work; purchase of office equipment/vehicles, construction of buildings for use by staff programme, recording and reporting, and drug management and distribution. Please indicate the total expenditures related to these activities, including salary spending on staff working within the central programme unit and at subnational level.

Q.39b. Select a response "Yes" or "No" from the drop-down menu. Q.40. If you have selected Yes above, you will need to enter here the amount of spending that was

related to HIV/AIDS that was reported as an estimate in question Q.39. Q.41 If YES, please indicate the type of cash transfer.

Note: In Q.41b the Respondent is asked to indicate the Objective/Area/focus population of the cash transfer programme. For now I have included 4 options: General SRH, Family Planning, Adolescent SRH, and Other. This drop-down list is included in order to allow for allocating cash transfer costs to Family Planning in the computation of the indicator for Total government spending on Family Planning.

Q.42. Indicate any significant spending on capital items (construction of buildings, purchase equipment, etc) specific to sexual and reproductive health. First indicate the amount (if any), and then provide a brief description below. Take care to ensure that the amount entered here is not double counted under any of the other categories in this Table.

The same categories of spending are repeated in order to cover all four years of interest. The help notes appear in all four versions of the Tables.