GUIDELINES FOR

PRODUCING CHILD HEALTH
SUBACCOUNTS WITHIN THE
NATIONAL HEALTH ACCOUNTS
FRAMEWORK
PREPUBLICATION VERSION
2

All standard disclaimers of each of the sponsoring organizations apply to this publication.
The author’s views expressed in this publication do not necessarily reflect the views of the United States
Agency for International Development (USAID) or the United States Government


1.1. Background 1
1.2. Concept of NHA 2
1.3. Overview of the child health subaccounts 4
1.4. Policy purpose of child health subaccounts 5
1.5. Indicators produced by child health subaccounts 7
1.6. Outline of methodological approach and structure of these guidelines 7
2. Definitions and scope for the child health subaccounts 9
2.1. Child health interventions and programmes involved in their delivery 9
2.2. Scope and boundaries of the NHA child health subaccounts 11
2.2.1. Child health expenditures in the NHA 11
2.2.2. Child health and other NHA subaccounts 14
2.2.3. Geographic boundaries 15
2.2.4. Time boundaries 15
2.2.5. NHA and the health information system 16
3. Classification scheme and tables 17
3.1. Dimensions of NHA and their codes 17
3.2. Approach to assigning classification categories 17
3.3. NHA tables and the child health subaccounts 18
3.3.1. Basic tables for child health subaccounts 19
3.3.2. Aggregates 20
3.4. Child health expenditures: illustrative examples 21
4. Data identification and collection 27
4.1. Approaching the data identification process 27
4.1.1. Understanding what you need and why you need it 28
4.2. Data collection 28
4.2.1. Types of data 28
4.2.2. Identifying data sources 32
4.3. Data collection plan 39
4.4. Summary 42
5. Data analysis 43

7.2.3. Sustainability and resource availability 71
7.3. Minimum set of indicators 71
Annex 1: Ethiopia donor questionnaire 79
Annex 2: Adding rider questions to ongoing surveys 83
Annex 3: Apportionment rules applied to expenditures in Bangladesh health accounts to
estimate child health spending 85

Annex 4: Apportionment rules applied to expenditures in Sri Lanka health accounts to estimate
child health spending 87

Annex 5: Methodology used in Bangladesh for estimating unit cost and utilization data 91
Annex 6: Optional indicators on intervention-specific expenditures 93
Annex 7: Summary of key statistics for child health subaccounts in Malawi, 2002/03-2004/05. 97
Annex 8: Summary of key statistics for child health subaccounts in Ethiopia, 2004/05 99
Annex 9: Summary of key statistics for child health subaccounts in Bangladesh (1999/2000) and
Sri Lanka (2003) 101
Guide to Producing CH Subaccounts Contents v
List of Tables
Table 2.1 Examples of activities included and not included within the CH expenditure boundaries 14
Table 2.2: Some examples of overlapping services among child health and other types of
subaccounts 15

Table 3.1 Functional classification for child health interventions and activities 21
Table 3.2 Financing sources (FS) by financing agents (HF) 24


Guide to Producing CH Subaccounts Foreword vii
Foreword
Worldwide, more than ten million children die every year before reaching the age of five, and many more
suffer life-long consequences of ill health during childhood. Over time, programmes and partnerships
have been developed to increase the delivery of simple, affordable and life-saving interventions for the
management of major childhood illnesses and malnutrition. They include the Partnership for Maternal,
Neonatal and Child Health (PMNCH), the Expanded Programme on Immunization (EPI), and country-
based programmes delivering the Integrated Management of Childhood Illness (IMCI), Insecticide
Treated Nets for malaria (ITNs), and interventions linked to the Prevention of Mother to Child
Transmission of HIV (PMTCT). Further, application of child health interventions (outside the programme
framework) by the many public and private sector providers provide the bulk of care for children in many
parts of the developing world. They all address different aspects of child survival, and have had positive
results in reducing deaths from common and preventable conditions.

Countries have pledged to scale-up the coverage of health services to reach the Millennium Development
Goals (MDGs). In the fourth goal (MDG4), countries have committed to a two-thirds reduction in under-
five mortality by 2015 from the 1990 baseline. Scaling up the delivery of interventions to address child
mortality will require additional investments in commodities, equipment, and human resources as well as
strengthening of the operational health system.

National policy makers need precise information on the funding gap between the resources currently
available for child health and those additional investments required to achieve national targets. In
addition, they need to assess whether current child health expenditure is targeted towards the key
interventions with the greatest impact on child survival, to determine the source of funding and
understand which institutions determine how funds flow within a country’s health system. Such
information provides the evidence necessary to make informed decisions, to allocate resources between

methodology. Efforts were made to ensure consistency with the Guide to Producing National Health
Accounts with special applications for low-income and middle-income countries. Intended for NHA
country experts as well as health account novices, these Guidelines aim to facilitate the production of
child health subaccounts on a regular basis in order to better inform child survival policies.

David B. Evans

Elizabeth Mason Richard Greene
Director Director Director
Department of Health
System Financing
World Health Organization
Department of Child and
Adolescent Health and
Development
World Health Organization
Office of Health, Infectious
Diseases and Nutrition
Bureau for Global Health
United States Agency for
International Development

Peter Salama Flavia Bustreo


These guidelines also benefited from the inputs in two working group meetings for the Child Health Survival
Partnership forum.
1

2
The work of Anne Mills and Tim-Powell Jackson for capturing donor flows for Child
health at the international level and of Jane Briggs for tracking expenditures of commodities for child health
provided input in developing the child health analytical framework and field work methodology.

Critical to the development of the Child Health subaccounts approach was its application in Bangladesh,
Ethiopia, Malawi and Sri Lanka. The issues raised, strategies employed, and lessons learned from these
country experiences were integral to defining the methodology outlined in these guidelines as well as to
determining the feasibility of tracking child health-specific health expenditures in the developing country
context. The following comprised the country teams:

Bangladesh team, based at Data International, led by Dr. Ghulam Rabbani with Dr. Najmul Hossain, Khairul
Abrar and A. K. M. Shoab.

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

Malawi team led by Mr. Edward Kaita (Ministry of Health), with Mr. Paul Revill (DFID), Dr. Eyob Zere
(WHO) and Mr. Davie Kalomba (National AIDS Commission).

Sri Lanka team based at the Institute for Health Policy was led by Dr. Ravi P. Rannan-Eliya, assisted by Dr.
K.C.S. Dalpathadu and Tharanga Fernando together with Aparnaa Somanathan.

Finally, the authors would like to acknowledge the efforts of Jenna Wright, Manjiri Bhawalkar and Ricky
Merino (HS 20/20) for their help in finalizing this prepublication version.


GH General Hospital
GMP Global Malaria Programme
GRN Goods Received Notes
HA Health Accounts
HC Functions
HCR Health Related Functions
HDS Health and Demographic Survey
HF Financing Agents
HIS Health Information System
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HP Providers
ICD International Classification of Diseases
ICHA International Classification of Health Accounts
IDS International Development Statistics
IEC Information, Education, and Communication
xii Guide to Producing CH Subaccounts
IHP Institute for Health Policy, Sri Lanka
IMCI Integrated Management of Childhood Illness
IP Inpatient
ITN Insecticide Treated Nets
IYCF Infant and Young Child Feeding
LG Local Governments
LSMS Living Standards Measurement Study
MCH Maternal, Newborn, and Child Health
MCH Maternal and Child Health
MDG Millennium Development Goals
MICS Multiple Indicator Cluster Survey
MK Malawi Kwacha
MOD Ministry of Defense

ROWHE Rest of the World Health Expenditure
ROWHECH Rest of the World Health Expenditure on Child Health
SHA System of Health Accounts
SNA System of National Accounts
SNNPR Southern Nations, Nationalities, and People’s Region
SPA Service Provision Assessment
SWAP Sector-wide Approach
Tar-HE-CH Targeted Health Expenditures on Child Health
TB Tuberculosis
TCHE-CH Total Current Health Expenditures on Child Health
THC Thana Health Complex
THE Total Health Expenditure
THECH Total Health Expenditures on Child Health
THE-CH Total Health Expenditures on Child Health
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WB World Bank
WHO World Health Organization



Guide to Producing CH Subaccounts Introduction 1
1. Introduction
1.1. Background
Policymakers are constantly faced with difficult decisions in selecting appropriate policies and
implementation strategies in order to achieve public health targets. Information on how much is being
spent on the health of a population is a key element in supporting solid decisions and policy-making.

targets. The use of cost estimates along with assessments of current expenditures can help to raise the
funds required to close the resource gap.

All of the above are relevant for child health and child survival. The global burden of child health is high,
with more than ten million children in low and middle-income countries dying each year before reaching
the age of five
5
. The Millennium Development Goal 4 commits countries to reduce under-five child

3
For example, in the Abuja declaration African leaders pledge to set a target of allocating at least 15 percent of public budgets to
the improvement of the health sector.: http://www.uneca.org/adf2000/Abuja%20Declaration.htm
Maputo 2003 declaration:
http://www.africaunion.org/Official_documents/Decisions_Declarations/Assembly%20final/Assembly%20%20DECLARATION
S%20%20-%20Maputo%20-%20FINAL5%2008-08-03.pdf
Gaborone 2005 declaration,
http://www.africaunion.org/root/au/Conferences/Past/2006/March/SA/Mar6/GABORONE_DECLARATION.pdf
4
TEHIP assessment, Tanzania
5
Jones G, Steketee RW, Black RE et al. How many child deaths can we prevent this year? Lancet 2003; 362:65-71.
2 Guide to Producing CH Subaccounts
mortality by two thirds from the 1990 baseline.
6
The attainment of this goal requires the promotion of
efficient, low-cost interventions. To assess the adequacy of expenditures, it is necessary to collect relevant
and sound information on how much is being spent on child health and how the funds are flowing within
a country’s health system. Knowledge generated from such information, together with evidence on the
effectiveness of interventions at different levels of the health system, provides the evidence to make
informed decisions and to allocate resources between competing needs. Analyzing the organization and

comparable.

This document is intended for the technical staff conducting NHA subaccounts, though policymakers and
analysts will find the introductory and final chapters useful for understanding the policy motivation for
this analysis. It is strongly recommended that the Guide to Producing National Health Accounts with
special applications for low-income and middle-income countries
11
(hereafter referred to as the
Producers’ Guide, or PG), compliments these guidelines when one embarks on child health subaccounts.

1.2. Concept of NHA
NHA is a policy tool that presents the expenditure in health, both public and private, in a given country in
a defined period of time. NHA tracks both the amount spent and the flow of funds across the health

6
United Nations General Assembly, 56
th
session. Road map toward the implementation of the United Nations Millennium
Declaration: report of the Secretary General. New York: United Nations, 2001.
7 Since September 2005 the Child Health Survival Partnership is part of the Partnership for Maternal, Newborn & Child Health.
8
Powell-Jackson T, Mueller D, Borghi J, Mills A. Tracking Official Development Assistance for Child Health, Challenges and
Prospects. Arlington, VA., USA: Basic Support for Institutionalizing Child Survival (BASICS) for the United States Agency for
International Development (USAID).
9
Members/organizations participating: WHO, USAID, Health Systems 20/20, UNICEF, Institute for Health Policy, PMNCH
10
Other subaccounts guidelines include HIV/AIDS, Reproductive Health, and Malaria
11
WHO, World Bank, USAID. Guide to Producing National Health Accounts with special applications for low-income and
The flow of funds is presented in a series of tables that show the transaction between two different
dimensions, allowing for a comprehensive overview of the financing of the health system. The
expenditures are recorded using a classification scheme that group transactions sharing common
characteristics in the dimensions mentioned in Figure 1.1.

The United Nations developed in the 1940’s a System of national accounts (commonly referred to as SNA
93)
12
as a methodology for understanding the inputs and products produced by different sectors of the
economy.
13
The System of health accounts (SHA), developed by the Organisation for Economic Co-
Operation and Development (OECD), shares the underlying principles used in the SNA 93 in that it

12
United Nations, Commission of European Communities, International Monetary Fund, OECD, World Bank
http://unstats.un.org/unsd/sna1993/tactop.asp
13
The SNA has undergone various rounds of revision with the countries and different international organizations. Most
industrialized countries utilize the latest version of SNA (updated in 1993) as a planning tool. Different “Satellite Accounts” have
been proposed to focus on particular sectors of the economy, such as tourism or education. National Accounts serve the purpose
of tracking factors of production and types of goods and services produced and NHA are created for the purpose of knowing the
amount and flow of funds among and between the different actors of the health system.(for a more detailed explanation of the
similarities and differences of the two types of account, the reader can refer to the Guide to producing national health accounts
and the OECD manual A System of Health Accounts)
Financing
Sources Agents



The conceptual and methodological NHA framework can be used for conducting analysis of expenditure
for particular areas of interest within each country. For this purpose several methodological guidelines
have been developed for conducting accounts for HIV/AIDS, reproductive health, child health and
malaria. It is important to note that subaccounts provide information on the expenditures along the various
dimensions mentioned in Figure 1.1 for a particular disease or population group, or for the program or
regional level. In these guidelines, child health subaccounts are developed at the program level and
therefore some of the expenditures incurred for the boundaries defined for child health subaccounts will
tend to overlap with other programs and age groups. In adhering to the general NHA framework, the child
health subaccounts are only concerned with direct expenditures on health services and do not measure
expenditures on indirect activities, that is, activities that are associated with the loss of income due to
child health (e.g., the loss of income of a parent that stays home to care for the sick child, expenditure on
transportation, complementary feeding, etc.), or expenditures associated with child care such as social
services.

1.3. Overview of the child health subaccounts
These guidelines present the methodology for tracking expenditures for child health within the general
NHA framework. The expenditures on child health are defined as expenditures during a specified period
of time on goods, services and activities delivered to the child or its caretaker after birth,
17
and whose
primary purpose is to restore, improve and maintain the health of children between zero and less than five
years of age in a given country.

While countries can track resources along any dimensions, the major dimensions defined for tracking
expenditures for child health are

• From the financers of health care called “financing sources”
• to the principal managers of the funds, called “financing agents”
• to those that deliver the services, referred to as “health providers”

recommended that whenever possible, child health subaccounts are done within the context of the general
NHA. This approach has several advantages. First, the child health subaccounts can benefit from the
routine data collection efforts set in place for conducting general NHA. It is therefore cost effective to do
both analyses concurrently since effort needed for child health data collection is marginal. Second, the
estimation methods for missing data can be consistent with the sector wide approach and will therefore
ensure consistency when reporting health expenditures. Third, conducting specific subaccounts builds on
existing technical capacity, and it provides a platform for dissemination of results. Fourth, conducting the
subaccounts as part of the general NHA effort allows identification of expenditures that fit into more than
one programme and therefore identification of possible overlaps. Fifth, a general NHA benefits from the
different subaccounts because they more clearly expose the need for detailed information and therefore
“lobbies” among the producers of data for the need to disaggregate information when gathering and
processing data. Finally, the suggested approach helps to place a country’s pattern of expenditure on child
health within the context of overall health spending. In all, it is a symbiotic endeavor.

The child health subaccounts provide information useful for measuring the expenditure flows between
financing sources, financing agents, providers and functions particular to child health interventions and
activities for both the public and private sectors. It may also be particularly relevant for some countries to
track the expenditure on child health from multilateral, bilateral and donor agencies, which is also
captured by the NHA methodology.

1.4. Policy purpose of child health subaccounts
As underlined in the World Health Report 2005: Make every mother and child count, the health of
children is today seen as a priority in the improvement of population health worldwide. Recent years have
seen a shift in the way child health is envisioned: from being a technical issue pertaining to the delivery of
certain programmes it is now seen as a moral and political concern for all.
18Despite the moral concerns of child mortality and the attention given by the media, policy makers and
civil society to this subject, many child health programmes remain under funded. Understanding the

preventive and curative care, the contribution of household expenditures on child health, etc. The overall
improvement of child health requires political will and leadership. This statement is supported by studies
on the amount and efficiency of expenditures for improving and maintaining the health of children zero to
five years of age.

The child health subaccounts as presented here encourage disaggregation of expenditures by priority
interventions and activities aimed at reducing child mortality. This level of disaggregation is an ideal
method for conducting a thorough analysis of the amount and flow of funds spent on activities to reduce
child mortality. Obtaining such a detailed disaggregation can be difficult technically due to limitations of
existing information systems. However, any information produced, even if at a more aggregate level, will
be helpful for policy makers to assess current expenditure patterns. The level of disaggregation can be
improved upon gradually as the country works towards strengthening their health information system.
These guidelines therefore encourage country teams to work on the subaccounts even if the level of detail
suggested as ideal cannot be achieved. A classification scheme is presented in Chapter 3.

As mentioned briefly, health accounts provide information about the expenditure and the flow of
corresponding funds. By doing so, the child health subaccounts can help answer the following policy
relevant questions:

• What is the current level of funding for child health at national level?
• What are the current sources of funding for child health and who manages these funds?
• What is the direct contribution of households for child health?
• What is the distribution of child health resources between various child health interventions
and total expenditures on core child health interventions?
• What is expenditure on preventive and curative services?
• What proportion of child health expenditures are in treatment in hospitals vs. outpatient care
facilities?
• Who provides child health care services and with what resources?
• What is the difference in per capita expenditure in child health between the insured and
uninsured?

Indicative estimates presented in the World Health Report 2005 predict that approximately an additional
US$ 50 billion is required for the period 2006 to 2015, in order to reach 95% coverage with 16 priority
child health interventions in 75 countries. This represents an increase in per capita health expenditure of
US$ 1.48 in 2015, equivalent to increasing average general government health expenditure over current
levels by 26%. In countries with the weakest health systems, the scale-up scenario implies considerable
increases in public expenditure on health, of up to 75%. Another estimate was produced by Bryce J et al,
who estimated that US$ 5.1 billion in new resources are needed annually to avoid 6 million child deaths.
25Given the importance of domestic and international investment in child health, it is important to track the
flow and amount of such investments, and assess this information in the context of health indicators in
order to evaluate the equity and efficiency of the delivery of child health.

Some of these indicators include:
• Child health expenditure as a percentage of total health expenditure,
• External funds for child health as a percentage of total health expenditure
• Percentage of out-of-pocket child health spending out of total health spending
• Expenditure on preventive and curative services
• Per capita expenditure on child health by region or population group
• National (or total) child health expenditure per child

A complete set of indicators with detailed definitions and explanations are presented in Chapter 7.

1.6. Outline of methodological approach and structure of these
guidelines
The approach suggested in these guidelines, as mentioned previously, adheres to the one described in the
Producers’ Guide. However, when a country decides to embark upon estimating NHA, local
organizational and political considerations must be taken into account so that the general methodology is
applied to a particular context. For example, issues such as the nature of provision of services, the specific

process of populating the NHA tables begins. Populating tables requires a thorough examination of
existing data gaps, resolving data conflicts, agreeing upon estimation techniques, and clearly documenting
these techniques. Chapter 5 describes some of the issues that are particular to child health subaccounts.

Chapter 6 presents a suggested process for implementation. These guidelines suggest, institutionalizing
the practice of producing information regarding expenditures in child health and making it a part of the
routine health information system outputs. Achieving this goal involves the will and commitment of the
political stakeholders, as well as the production, analysis and dissemination of sound information from
the technical experts. This chapter will also present a suggested time-frame for the development of child
health subaccounts and the resources needed for such implementation.

Finally, Chapter 7 will present the different indicators important for policy purposes that can be produced
by child health subaccounts. Guide to Producing CH Subaccounts Definitions and scope for the CH subaccounts 9
2. Definitions and scope for the child health
subaccounts
The following chapter describes the scope of the NHA child health subaccounts within the context of
general NHA. The reader should refer to the Producers’ Guide for details on NHA.

The writing of these chapters is the result of discussions on methods for identifying and tracking child
health expenditure as part of the efforts to track progress in child survival
26
stemming from the Child
Survival Partnership Meeting held in London in May 2005.
27
The production of this report has benefited
from discussions with the advisory group established for this purpose and led by the World Health
Organization.


Programmes have developed over time to address the major causes of mortality and morbidity. The
Expanded Program on Immunization (EPI) sets out to increase vaccination coverage in line with

26
Tracking Progress in Child Survival. Countdown 2015. Meeting hosted by the Working Group in December 2005
27
Child Health Resource Tracking Consultative Meeting: For the Global Child Survival Partnership (CSP). Hosted by the
London School of Hygiene and Tropical Medicine. May 5-6, 2005.
28
Jones G et al. Lancet (2003).