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

Transcription

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 1

2 Purpose This document is intended to provide an overview of the methodology proposed, developed and tested by WHO for tracking government expenditure on reproductive, maternal, newborn and child health (RMNCH). The intended audience is users of the expenditure reporting tool at country level as well as readers who wish to acquire a better understanding of methods that can be used to estimate government expenditure going towards RMNCH. This may include Ministry of Health government staff, national health accountants, expenditure tracking experts and consultants supporting the implementation of routine expenditure tracking, as well as staff at international organizations supporting the development and application of monitoring mechanisms for RMNCH programmes. Abbreviations used in this document ARV - Anti Retroviral drugs CH - Child Health CoIA - Commission on Information and Accountability for Women's and Children's Health GAVI - The Global Alliance for Vaccines and Immunization GDP Gross Domestic Product GGHE - General Government Health Expenditures HMIS - Health Management Information System ICD - International Classification of Diseases IMCI - Integrated Management of Childhood Illness IPD - Inpatient days ITN - Insecticide Treated Net JRF - Joint Reporting Form (for Immunization) MNH - Maternal and Neonatal Health MNCH Maternal, Neonatal and Child Health MNCAH - Maternal Newborn Child and Adolescent Health MOH - Ministry of Health NHA - National Health Accounts NASA - National AIDS Spending Assessment NIDI - Netherlands Interdisciplinary Demographic Institute OPV - Outpatient visits PG WHO National Health Accounts Producers Guide RMNCH - Reproductive, Maternal, Newborn, and Child Health RMNCH-GET - Reproductive, Maternal, Newborn, and Child Health Government Expenditure (and budget) Tracking tool RTI - Reproductive Tract infection SRH - Sexual and Reproductive Health STI - Sexually Transmitted Infection UNFPA - United Nations Population Fund WHO World Health Organization 2

3 Responsibilities and Acknowledgments The methodology outlined in this document was developed jointly by staff members from the following Departments of the World Health Organization: Child and Adolescent Health (CAH) Global Malaria Programme (GMP) Health Systems Financing (HSF) Immunizations, Vaccines and Biologicals (IVB) Making Pregnancy Safer (MPS) Reproductive Health and Research (RHR) For questions please contact Karin Stenberg, Technical Officer, Department of Health Systems Financing, World Health Organization ( This work received financial support from the Government of Norway. 3

4 Table of Contents 1. Introduction Overall approach General Methodology Monitoring Government expenditure on Child health (MDG4) Monitoring Government expenditures on Maternal Health, as related to MDG5a Monitoring Government expenditures on Sexual and Reproductive Health (excluding Maternal and Newborn health), as related to MDG5b Preliminary findings and lessons learnt...64 Annexes Annex 1. Members of WHO working group on RMNCH expenditure tracking for MDGs 4 and 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

5 Glossary Government Expenditure: in the approach used in RMNCH-GET, public expenditures refer to funds that are managed by the government. As such the tool defines government health expenditure as per the Financing Agent function in National Health Accounts. This means that public expenditures can include government spending from tax revenue and social security contributions, as well as external funds passing through the government from the Global Fund, GAVI, or bilateral donors. It also includes expenditure by parastatals. The scope of Government is the same as in government finance statistics reported to the International Monetary Fond (GFS-IMF). Government expenditure on service delivery: refers to the capital and recurrent (public) expenditure for maintaining facilities providing health services in the country. This refers to expenditure on resources that are shared across programmes and includes the budget going towards the salaries of health care workers and other staff working at the facilities and hospitals, and the running cost for electricity, water and maintenance in health facilities. These expenditures can be further split into outpatient care and inpatient care. Child health expenditure: expenditures during a specified period of time on goods, services and activities delivered to the child after birth or its caretaker whose primary purpose is to restore, improve and maintain the health of children in the nation between zero and less than five years of age. Maternal health expenditure: For the purposes of routine monitoring expenditures towards MDG5a and MDG5b, a distinction is made here between maternal and newborn health (MNH), and sexual and reproductive health (SRH). Maternal health expenditure refers to expenditure incurred during antenatal care, birth, and postpartum care. Sexual and reproductive health expenditure: For the purposes of routine monitoring expenditures towards MDG5a and MDG5b, a distinction is made here between maternal and newborn health (MNH), and sexual and reproductive health (SRH). SRH expenditure refers to four areas: (i) providing high-quality services for family planning, including infertility services. (ii) Eliminating unsafe abortion. (iii) Combating STIs including HIV, Reproductive Tract Infections, Reproductive health-related cancers, and other gynecological morbidities. (iv) Promoting sexual health. 5

6 Overview This document provides an overview of the methodology developed and supported by WHO in 2009 for monitoring government expenditures on Reproductive, Maternal, Newborn, and Child Health (RMNCH) in low and middle income countries. The development of a methodology for tracking government expenditure on RMNCH was undertaken in recognition of the need to strengthen methods and tools to allow for routine monitoring of expenditures directed towards reproductive, maternal and child health, particularly in view of the recognition that countries need to significantly increase expenditure in national health programmes in order to reach the health-related Millennium Development Goals. For this purpose a technical working group was set up within WHO, led by the Department of Health Systems Financing, to agree on an approach for incorporating questions on RMNCH expenditure into the annual routine monitoring surveys of WHO technical programmes. Specifically, the objective was to collect data through the questionnaires sent out on a regular basis by the WHO Departments of Maternal, Newborn, Child, and Adolescent Health, 1 and Reproductive Health and Research. The group met in 2009 and agreed on the approach outlined in this document. The approach was implemented in the MNCAH survey sent out by WHO in 2009/2010. Additional work has since been supported to further develop the methodology and tools. Members of the working group are listed in Annex 1. This document is organized into seven sections: Section 1. Introduction Section 2. Overall approach Section 3. General Methodology Section 4. Monitoring Government expenditures on child health (MDG4) Section 5. Monitoring Government expenditures on maternal health (MDG5a) Section 6. Monitoring Government expenditures on sexual and reproductive health (MDG5b) Section 7. Experience to date The first section provides an introduction to the topic of expenditure tracking and the rationale for strengthening efforts in this area. The subsequent two sections provide an overview of the overall approach used (an annual survey) and discusses general methodological issues when it comes to collecting and analysing expenditure data. Sections 4-6 focus on each respective area to outline the key programmatic areas for which expenditure data should be collected, and provides an overview of the approach adopted to select specific questions to be inserted in the annual reporting survey. Section 7 summarizes some of the experience to date. 1 The WHO department of Maternal, Newborn, Child, and Adolescent Health incorporates the former two WHO Departments of Child and Adolescent Health, and Making Pregnancy Safer, 6

7 1. Introduction 1.1. Reproductive and child health is high on the political agenda Countries have pledged to scale-up the coverage of health services to reach the Millennium Development Goals (MDGs), where MDGs 4 and 5 refer to reducing child and maternal mortality, and imply improving access to reproductive health care. 2 In many low-income countries, coverage of proven interventions remains low. 3 Scaling up the delivery of interventions to improve the health and survival of women, newborns, and children worldwide, and to ensure expanded access to reproductive and sexual health, will require additional investments in commodities, equipment, and human resources as well as strengthening of the operational health system. This document describes an approach developed to track expenditure on Reproductive, Maternal, Newborn, and Child Health (RMNCH) in low and middle income countries. The reason for the RMNCH focus is threefold. Firstly, MDGs 4 and 5 lag behind in performance when compared to other health-related goals, such as scaling up services to reduce the transmission of malaria, TB and HIV/AIDS as per MDG6. The Millennium Development Goals Report 2010 pointed to striking progress since 1990 but also underlined that only 10 of the 67 countries with high mortality rates were on track to meet the MDG target on child survival. With regards to maternal health, preliminary data indicate some progress, with significant declines in maternal mortality in several countries, but the overall progress has been slow and the rate of maternal death reduction is short of the 5.5% annual decline needed to meet the MDG target. 4 Secondly, RMNCH outcomes are intrinsically linked and a "continuum of care" is needed to ensure that health outcomes are achieved. The concept of a RMNCH continuum of care is based on the assumption that the health and well-being of women, newborns, and children are closely linked and should be managed in a unified way. Strengthening monitoring efforts jointly for MDGs 4 and 5 is therefore logical. At the same time and as outlined below, there may be some components of expenditure requiring more resources than others, and for which there may be a rationale to focus resource tracking efforts. Thirdly, the development of standardized tools and methods for monitoring financial commitments and execution has seen less progress than other monitoring areas (e.g., measurement of related health outcomes such as under-five mortality). With the UN Secretary-General Ban Ki-moon's Global Strategy for Women's and Children's Health launched in September 2010, there is increasing attention to holding partners accountable to realizing the promised commitments, following the principle of alignment with country-led health plans, and strengthening national health systems. 5 The Global Strategy sets out a framework to measure progress and enhance accountability to improve advancement towards the health-mdgs, including efforts in resource tracking for RMNCH Bhutta et al, Countdown to 2015 decade report ( ): taking stock of maternal, newborn, and child survival, Lancet 2010; 375:

8 1.2. The importance of tracking expenditure as an indicator of efforts to improve health In order to strengthen service delivery and performance of the health system, information is needed to assess how resources are currently distributed and used within the health sector. National policy-makers and their development partners need information on the financial resources available and how they are used. Information on budget and expenditure allows planners to assess the distribution of resources and current priority setting within the health sector, and to determine the funding gap between the resources currently available and those needed to achieve national targets. Such information provides the evidence necessary to make informed decisions, to allocate resources between competing needs, and to ensure sustainable funding for national programmes and strategies. This is particularly true in low-income countries where available resources are scarce, and the issues of fund raising and allocation of funds are all the more important (Box 1.1). Experience has shown that information on the expenditure level and the use of resources allows for informed decisions to improve allocation of current spending, to reduce waste of resources and to prepare scaling up of services. In general, routine and timely information on health expenditure, and its distribution across priority areas, is scattered and without detail. This is constraining good policymaking and effective use of limited resources. 6 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. 6 Global Health Resource Tracking Working Group, 8

9 The development of systems of health accounts and in particular National Health Accounts (NHA) in the 1990s has provided countries with standardized tools for monitoring the actual spending of funds. NHA have to date been implemented in over 130 countries. However, implementation of NHA is still fairly limited in many low-income countries. Several low-income countries have done one or two NHA analyses in the past decade but may still struggle with ensuring institutionalization of the required skills and the political process. While an increasing number of countries are looking at producing NHA reports at regular intervals, the process of setting up a monitoring system is not easily achieved. It takes time to build capacity, to ensure that the national health information system captures relevant data, and that audit mechanisms are in place to assess actual spending. It is particularly in poor resource settings that data is generally scarce and this holds also for financial and expenditure data. Out of the 68 Countdown countries, 7 only 32 countries have a recent NHA (NHA data for years ). 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) 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 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 ( accessed 10 September 2011). 10 Guidelines for undertaking subaccounts are available at: 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

10 The methods outlined in this paper take into consideration exchanges with other agencies such as UNFPA/NIDI that collects information on reproductive health spending, and GAVI regarding information on immunization spending. It is important to note that the methodology outlined in this document refer to a first round of materials and are likely to be further developed over time. This document is to be seen in this light and refers to the first round of surveys sent out by WHO in 2009/2010, and adjustments made to the second round survey (2011) 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 subaccounts 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 ( accessed 10 September 2011). 10

11 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 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 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. 11

12 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 Accounts 16, 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. 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. 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

13 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 subaccounts Characteristic Reproductive health or child health sub-accounts Resource requirements Number of countries covered Scope Resource intensive, often require national team inputs for 2-3 months. WHO-supported annual monitoring survey for government RMNCH spending 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. Produced by few countries per year Estimates produced for a large number of countries per year Tracks financial flows from all sources in the health system (public and private) Level of detail Provides detailed breakdown of spending Frequency Implemented frequently every 3-5 years depending on policy relevance Purpose Detailed analysis to inform national policy discussion. Tracks financial flows managed by the Government Provides an indicative rough overview of public RMNCH spending Preferably implemented on an annual basis 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,

14 Resources Guidelines available. WHO may provide follow up long distance support ( , telephone). cycle. Guidelines available. WHO may provide follow up long distance support ( , 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 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):

15 Figure 2.1. The role of government expenditure for RMNCH: country examples 20 Financing Agents of Child Health 100% Percentages 80% 60% 40% 20% 34.5% 5.0% 60.5% 44.6% 15.7% 39.7% 58.3% 26.2% 40.1% 12.0% 47.9% 55.5% 11.2% 33.3% 0% Public sector Banglahesh ( average) Ethiopia (2005) Non-public sector excluding household OOP Non-public sector (household OOP) 15.5% Malawi ( average) Countries (with years) Sri Lanka ( average) Tanzania ( & average) 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 revealed that the public sector (in particular the MoH) managed about 60-65% of reproductive health funds and % of child health funds 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) With Subaccounts for HIV and AIDS, Reproductive and Child Health Bethesda, MD: Partners for Health Reformplus project, Abt Associates Inc. 15

16 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 WHO/ UNICEF Joint Reporting Form Institutio n managing survey reporting WHO GAVI GAVI annual report NIDI tools UNFPA/ NIDI * WHO Malaria Programm e Expenditur e Study TB data collection tool Programm e/ Disease area covered Immunizati on Immunizati on Reproducti ve health (ICPD definition) 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? Annual One year This is a YES/NO question. The user does not indicate an amount Yes No No 1998 One year Two years No (T+1), (T+2) One year Four years Yes WHO Malaria Yearly? Three years Two years Yes (funding) WHO Tuberculos is Yearly One year (T- 1) UNGASS UNAIDS HIV/AIDS Yearly Three years (T-1),(T-2), (T-3) Tobacco control survey WHO/RHR survey WHO WHO Tobacco prevention and regulation Sexual and Reproducti ve Health Notes to Table 2.2: T = current year; the year in which the survey is sent out. NIDI: Netherlands Interdisciplinary Demographic Institute Two years (T), (T+1) Yes No Year in which expenditure data was first collected Yes Yes No Since 2002 for the 22 high-burden countries; Since 2006 for all other countries Yes (both) Yes No One year None Yes No Data collected in 2008 and Year reported varies by country and ranges between 2003 and Bi-yearly One year None Yes No No Since

17 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 17

18 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 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. 18

19 Table 2.4. Common challenges for expenditure tracking and mechanisms proposed to mitigate these for the MNCAH survey and RMNCH-GET Issues 22 Survey format difficult to understand Non-standardized interpretation of categories In several countries administration is not at the national but at the regional level. Information on financial resources is not readily accessible at central level. Reluctance to fill in the questionnaire as it is seen as cumbersome and not a priority for the technical programme Information and final results are not shared with Respondents Data form is returned with gaps Once collected, data is not made publicly available Mechanism proposed to ensure that the MNCAH survey addresses these issues Survey tool includes help aides; Capacity building sessions are organized as part of the start-up process. RMNCH-GET is provided as a help tool and includes help aides providing an explanation to what data should be reported (definitions) 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 Capacity building sessions organized on the importance of financial monitoring and how this can help the national programme planning. RMNCH-GET automatically produces indicators that the country respondent can relate to and use in the national policy context 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 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

20 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 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 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 Analysing Commitments to Advance the Global Strategy for Women s and Children s Health. The PMNCH 2011 Report. Geneva, Switzerland: PMNCH. 20