PRODUCING CHILD HEALTH
SUBACCOUNTS WITHIN THE
NATIONAL HEALTH ACCOUNTS
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
PRODUCING CHILD HEALTH
SUBACCOUNTS WITHIN THE
NATIONAL HEALTH ACCOUNTS
Guide to Producing CH Subaccounts Contents iii
1. Introduction 1
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
5.1. Getting organized: what is needed? 43
5.2. Conducting the analysis itself 45
5.2.1. Step one - creating a T-account 45
5.2.2. Step two - populating the NHA tables 46
5.2.3. Additional steps 47
5.3. Specific issues that may arise with the child health subaccounts 47
5.3.1. Dealing with targeted expenditure 47
iv Guide to Producing CH Subaccounts
5.3.2. Dealing with non-targeted expenditures for child health 49
5.3.3. Dealing with out of pocket expenditures 55
5.3.4. Dealing with integrated expenditures for curative and preventive services 55
5.3.5. Tracking commodity related expenditures 56
5.3.6. Other data analysis issues 57
5.4. Summary 58
6. Implementation process for child health subaccounts 59
6.1. Objectives and general considerations 59
6.2. Resources needed 62
6.2.1. Equipment 62
6.2.2. Other needed resources 62
6.2.3. Limited resources 62
6.3. Report writing and efficient communication of results 63
6.4. Work plan 64
6.5. Complementarity of child health subaccounts with costing estimates 65
6.6. Child health subaccounts when not done in conjunction with NHA 66
6.7. Institutionalization 66
7. Child health subaccounts indicators 69
7.1. Background 69
7.2. Key health policy objectives 70
7.2.1. Equity in health care financing 70
7.2.2. Efficiency 70
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
Table 3.1 Functional classification for child health interventions and activities 21
Table 3.2 Financing sources (FS) by financing agents (HF) 24
Table 3.3 Financing agents (HF) by providers (HP) 25
Table 3.4 Financing agents (HF) by functions (HC) 26
Table 4.1. Relationship between needed data estimates and the child health subaccounts-related
questions they inform and potential data sources 30
Table 4.2: Examples of routine financial information data sources 33
Table 4.3: Information needed for data analysis from the Health Information System 33
Table 4.4. Examples of survey reports available in-country “On Office Shelves” and used for child
health subaccounts 35
Table 4.5: Examples of international databases for non-routine survey reports 36
Table 4.6: Kenya NHA data collection plan for secondary sources 40
Table 5.1. Information needed for data analysis 44
Table 5.2: Example of child health T-accounts: Malawi, 2004/05 46
Table 5.3 Expenditure for the Ministry of Health in Malawi 50
Table 5.4. Financing agents contribution to non-targeted child health spending on inpatient care 54
Table 6.1: Activities and timeline for conducting the child health subaccounts 65
Table 7.1. Proposed list of indicators for the child health subaccount report 73
List of Figures
Figure 1.1 Tri Axial Framework: the three dimensions to measure health expenditure flows 3
Figure 2.1. Causes of child and neonatal deaths 2000-2003. 10
Figure 2.2. Expenditure boundaries of NHA 12
Figure 3.1: Construction of classification codes in the ICHA 18
Figure 3.2 NHA tables 19
Figure 3.3 Recommended tables for child health subaccounts 20
Figure 4.1 Example of a map of the flow of funds for child health 29
Figure 6.1: Stakeholders involved in the production of NHA and child health subaccounts 61
Guide to Producing CH Subaccounts Foreword vii
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
competing needs, to help set strategic priorities and to ensure sustainable funding for child health
programmes and strategies.
National Health Accounts (NHA) is an internationally accepted tool that provides a comprehensive
estimate of all national health expenditures, whether it is contributed by donors or from domestic public
and private sources. Subaccounts generate information on expenditure in accordance with the NHA
framework. The term ’subaccounts’ refers to an additional and more detailed reporting of spending levels
and patterns for a particular component of health care. The child health subaccounts have been designed
to provide financial information to policy makers, programme managers and service providers on the
resources spent on child health interventions. Expenditure on child health is defined as expenditure during
a specified period of time on goods, services and activities delivered to the child after birth or to its
caretaker. Only those goods, services and activities whose primary purpose is to restore, improve and
maintain the health of children of the country between birth and the child's fifth birthday are included.
Child health subaccounts results can be used in various ways to inform child health policy and
programming. They provide answers to specific questions regarding child health financing in the same
way that general NHA answers questions on overall health care financing. For example, the child health
subaccounts reveal how much is being spent, who is paying, what services and products are purchased
and for whom. Because the subaccounts use the internationally recognized NHA framework, child health
expenditure can be compared across countries. Once subaccounts results become available at regular
intervals, trends in expenditure levels can be tracked, patterns of resource use monitored over time and
their relation to the achievement of child health programme goals assessed. Ultimately such assessments
can be used to adjust and inform financing strategies to scale up key child survival interventions.
viii Guide to Producing CH Subaccounts
The Health System Financing and the Child and Adolescent Health and Development Departments at the
World Health Organization; the United States Agency for International Development/Partners for Health
Reformplus (PHRplus) Project and its successor the Health Systems 20/20 (HS 20/20) project worked
together to prepare these Guidelines. The Guidelines benefited from the participation and contribution of
numerous child health and NHA experts, and from four country pilots for the development of the
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
World Health Organization
Department of Child and
Adolescent Health and
World Health Organization
Office of Health, Infectious
Diseases and Nutrition
Bureau for Global Health
United States Agency for
Peter Salama Flavia Bustreo
Chief, Health Section
UNICEF, New York
Partnership for Maternal, Newborn and Child
Guide to Producing CH Subaccounts Acknowledgements ix
The child health subaccounts Guidelines were produced with support from the World Health Organization
departments of Health System Financing (WHO/HSF) and Child and Adolescent Health and Development
(WHO/CAH); the United States Agency for International Development/Partners for Health Reformplus
(PHRplus) Project and its successor the Health Systems 20/20 (HS 20/20) project.
The production of this report has benefited from discussions with the advisory group established for this
purpose and led by the Department of health system financing at World Health Organization, the input of
numerous child health and NHA experts, Meetings of the Global Child Survival Partnership (now the
Partnership for Maternal, Newborn and Child Health (PMNCH)), and from country implementation
experiences in Bangladesh, Ethiopia, Malawi and Sri Lanka. The core drafting team consisted of Maria
Fernanda Merino, Stephanie Boulenger, Takondwa Mwase (PHRplus and HS 20/20), Charu C. Garg
(WHO/HSF), and Karin Stenberg (WHO/ CAH). Initial drafts received input and valuable feedback from an
internal review team consisting of Al Bartlett (USAID), Flavia Bustreo (PMNCH/WHO), Karen Cavanaugh
(USAID), David Collins (Management Sciences for Health), Tania Dmytraczenko (PHRplus), Tessa Tan-
Torres Edejer (WHO/HSS), Daniel Kraushaar (Bill & Melinda Gates Foundation), Yogesh Rajkotia (USAID),
Ravi Rannan-Eliya (Institute for Health Policy, Sri Lanka), Aparnaa Somanathan (Institute for Health Policy,
Sri Lanka), Robert Scherpbier (WHO/ CAH), and Abdelmajid Tibouti (UNICEF).
These guidelines also benefited from the inputs in two working group meetings for the Child Health Survival
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
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.
Tracking Progress in Child Survival. Countdown 2015. Meeting hosted by the Working Group in December 2005
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.
Guide to Producing CH Subaccounts Acronyms xi
AIDS Acquired Immunodeficiency Syndrome
ARI Acute Respiratory Infection
CAH Child and Adolescent Health and Development
CB Central Bank
CD Central Dispensaries
CFS Central Bank Consumer Finance Surveys
CH Child Health
CHA Child Health Subaccounts
CNAPT Ceylon National Association for the Prevention of Tuberculosis
CSP Child Survival Partnership
DG District Hospital
DRG Diagnosis Related Group
EFY Ethiopian Fiscal Year
EPI Expanded Program on Immunization
ESHE Essential Services for Health in Ethiopia
FMOH Federal Ministry of Health
FS Financing Sources
GDP Gross Domestic Product
GH General Hospital
GMP Global Malaria Programme
GRN Goods Received Notes
HA Health Accounts
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
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
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
MOE Ministry of Education
MOF Ministry of Finance
MOFED Ministry of Finance and Economic Development
MOH Ministry of Health
MOHFW Ministry of Health and Family Welfare
MPS Making Pregnancy Safer
MTEF Medium-term Expenditure Framework
NASCOP National AIDS Control Program
NGO Non-governmental Organization
NHA National Health Accounts
NHE National Health Expenditure
NHE-CH National Health Expenditures on Child Health
NHIF National Hospital Insurance Fund
OECD Organization for Economic Cooperation and Development
OOPCH Out-of-pocket Spending on Child Health
ORS Oral Rehydration Salts
PC Provincial Councils
PER Public Expenditure Review
PG Producers’ Guide
PHCU Primary Health Care Unit
PMNCH Partnership for Maternal, Newborn, and Child Health
PMTCT Prevention of Mother to Child Transmission
Guide to Producing CH Subaccounts Acronyms xiii
PRSP Poverty Reduction Strategy Paper
PuSHE Public Sector Health Expenditure
PuSHECH Public Sector Health Expenditure on Child Health
RH Reproductive Health
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
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
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.
Information on expenditures can be useful to:
• Monitor whether funds are directed towards effective strategies, in order to improve health
• Assess accountability of policy makers
• Determine the gaps between current expenditures and the financial resources needed to
achieve goals set for the health sector,
• Assess the current flows of funds from various financial sources in order to inform future
At the global level, countries have pledged to scale-up their provision of health services to reach the
Millennium Development Goals. At the national level, strategic plans for health include targets for the
expansion of services and for a reduction in disease. However, in many countries insufficient funding
remains a major constraint for scaling up delivery of priority interventions. Policymakers therefore need
instruments and tools that allow them to monitor financial resource flows within the health system in
order to assess how funds are currently spent, and for what purposes.
Moreover, information on health expenditure flows can be useful in many settings for assessing the
accountability of governments with regards to commitments made to channel resources towards health.
However, even when total health expenditures have reached a fair level, studies have shown that
expenditure patterns may not always be in line with policy priorities.
Health policies for target
populations or for combating certain diseases will therefore require information that is detailed beyond
that presented by total health expenditure aggregates. Information on expenditures for specific diseases,
programmes or age groups can be assessed in relation to the outcomes produced by specific investments
as a means to track attainment of global and national indicators.
Programme managers also need tools that estimate the financial resources required to reach programme
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
. The Millennium Development Goal 4 commits countries to reduce under-five child
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:
Gaborone 2005 declaration,
TEHIP assessment, Tanzania
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.
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
financing of child health services will lead to an understanding of how much is being spent and by whom,
which will help in setting strategic priorities.
Within the international community there is growing interest in uncovering how much is being spent on
child health. For example, one of the responsibilities of the global Child Health Survival Partnership
raise awareness of the funding gap between the resources that are currently available for child health and
the resources required for achieving the child survival Millennium Development Goal.
becomes an important policy and advocacy tool in engaging more resources, monitoring progress in
reducing child mortality, and holding stakeholders accountable.
National Health Accounts (NHA) is a tool used to monitor flow of funds and estimate all national health
expenditures across the health system. The NHA methodology has been used in more than 100 countries
to date. The objective of these guidelines is to offer an internationally-viable approach for countries to
track child health expenditures within the NHA framework. The methodology presented here has
benefited from discussions with the working group constituted for developing these guidelines.
adheres closely to the methodology for conducting general NHA and therefore presents a methodology
for tracking resources spent in child health that is consistent with a globally endorsed tool. The guidelines
are flexible enough for each country, while still maintaining a certain degree of comparability, to respond
to the local needs for information. Furthermore, these guidelines help comprise a set of internally
produced to track expenditure flows for specific programs, diseases, and age
groups. The multiple guidelines are developed by WHO and other international partners in order to
provide guidance for expenditure tracking and to ensure that methods and estimates are internationally
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
(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
United Nations General Assembly, 56
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.
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).
Members/organizations participating: WHO, USAID, Health Systems 20/20, UNICEF, Institute for Health Policy, PMNCH
Other subaccounts guidelines include HIV/AIDS, Reproductive Health, and Malaria
WHO, World Bank, USAID. Guide to Producing National Health Accounts with special applications for low-income and
middle-income countries. Geneva, 2003
Guide to Producing CH Subaccounts Introduction 3
system. By doing so, it presents the information across different dimensions summarized in the box
Figure 1.1 Tri Axial Framework: the three dimensions to measure health expenditure flows
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
as a methodology for understanding the inputs and products produced by different sectors of the
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
United Nations, Commission of European Communities, International Monetary Fund, OECD, World Bank
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)
Factors of production Providers
Health Functions Beneficiaries
Changes in level and distribution of health by:
Geopolitical sub national entities,
Demographic & socio-economic characteristics
Disease/programmes/cluster of interventions
Source: National Health Accounts, Health System Financing, EIP; World Health Organization
4 Guide to Producing CH Subaccounts
constitutes a system of comprehensive, internally consistent and internationally comparable accounts of
the health sector for a given country in a specified period of time.
An important methodological contribution to the construction of health accounts is the Producers’ Guide,
itself grounded on the OECD SHA principles.
This methodology rests on the foundations of the United
Nations SNA 93 (World Health Report 2006).
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
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,
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”
• for activities defining the “functions” of the health system
The proposed priority tables for child health subaccounts are the following:
• Financing sources to financing agents (FS x HF)
• Financing agents to providers (HFxHP)
There are many similarities between the SHA and the SNA 93 Satellite Accounts. For example, both types of accounts use a
similar concept of output, have the same production boundary and the same approach to placing value on output. Some of the
differences between the two accounts refer to the different perspective of the economic activity of a society
, an expression of
the different purposes of each account.
Organisation for Economic Co-operation and Development, A system of health accounts, Version 1.0, 2000
WHO. World Health Report 2006, Working together for Health, p. 159
For a more detailed definition refer to chapter 2.
Guide to Producing CH Subaccounts Introduction 5
• Financing agents to functions (HFxHC)
• Providers to functions (HPxHC)
The tables are described in greater detail in Chapter 3.
Child health accounts as described in these guidelines can be done as subaccounts using the general NHA
methodology. As the subaccounts methodology is consistent with the NHA framework, it is
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.
Despite 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
amount spent and resource flows in child health is a requisite for advocating for increased investment in
child health, including the health of newborns. This investment is not only a priority for saving lives, but
is also critical in advancing other goals related to human welfare, equity and poverty reduction.
The Bellagio Study Group on Child Survival has identified 23 priority interventions for child survival.
A recent study on the cost associated with delivering the 23 interventions suggests that effective strategies
for achieving the Millennium Development Goal for child survival would include: focus on prevention in
order to decrease treatment costs, use of integrated delivery strategies, and expanded coverage through
WHO. World Health Report 2005, Making every mother and child count.
A continuum of care to save newborn lives. The Lancet. Published online, March 2005.
The Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet 2003; 362: 323-327.
6 Guide to Producing CH Subaccounts
improved delivery of existing care.
Furthermore, Darmstadt et al identified 16 interventions with
proven efficacy for neonatal survival, while recognizing that improving neonatal care requires not only
the identification of effective interventions, but also a clear implementation process and framework for
applying such interventions within existing programmes.
In order to put in practice these strategies, key
information is needed about the way resources for child health are being allocated, the amount spent on
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
• 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
• 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
• To what extent are child health expenditures dependent on foreign aid?
• What has been the trend of child health expenditure over the past years?
Additionally, each country must decide if there are specific questions the subaccounts must address. For
example, the priority for a country may be to distinguish between the per capita expenditure on child
health for the insured and uninsured, or to distinguish between preventive and curative care. Other
countries may have as a special focus of interest the geographic inequities in financing of child health
The effort of the NHA team conducting the child health subaccounts will lean towards
obtaining sufficient information to allow for these distinctions, as opposed to focusing on other questions.
Bryce J, Black RE, Walker N et al. Can the world afford to save the lives of 6 million children each year? Lancet 2005;
Darmstadt G, Bhutta ZA, Cousens S et al for the Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where?
Why?. Lancet 2005. Neonatal Survival: 19-30.
Please refer to the Regional subaccounts guidelines, produced under the same series as the child health subaccounts guidelines
Guide to Producing CH Subaccounts Introduction 7
1.5. Indicators produced by child health subaccounts
Among the requisites for attainment of public health goals is adequate and targeted financial resources.
It is widely recognized that in many countries insufficient funding remains a major constraint for scaling
up delivery of child survival interventions. The amount of additional per capita expenditures required
varies between countries depending upon their current health systems and epidemiological situations.
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.
Given 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
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
arrangements for the age group under study, the availability of information, the availability of output
indicators, etc. have an impact on the resulting NHA implementation strategy.
The initial step involves defining the purpose for conducting child health subaccounts. This in turn will
help establish the boundaries for each country. For example, what types of goods and services related to
the improvement of health of children will be included in the analysis? These issues are discussed in
The Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet 2003; 362: 323-327.
Bryce J, Black RE, Walker N et al. Can the world afford to save the lives of 6 million children each year? Lancet 2005; 365:
8 Guide to Producing CH Subaccounts
After the purpose and boundaries have been established, the expenditures are classified in accordance
with the classification recommended in Chapters 3 and 4 of the Producers’ Guide. In Chapter 3, a
breakdown for the specific dimensions of child health is outlined. The main difference with the general
NHA classification scheme refers to the level of detail relating to child health functions. This chapter also
presents mapping of classifications that provide the names and codes that will be the row and column
headings of the core NHA tables.
Chapter 4 outlines the desired data for child health subaccounts and suggests different methods for
obtaining it. In this chapter, reference is given to the use of available information as well as the possibility
of adding further questions to existing surveys that provide the data for general NHA. It is very important
that the team has a clear understanding of how child health is delivered and obtained within the national
context. This understanding facilitates the planning process for gathering data and ultimately facilitates its
Once all the data (or at least minimum data required) has been collected and its quality assessed, the
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
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
stemming from the Child
Survival Partnership Meeting held in London in May 2005.
The production of this report has benefited
from discussions with the advisory group established for this purpose and led by the World Health
2.1. Child health interventions and programmes involved in their
Children bear an undue share of the global burden of disease. Annually, approximately 10 million
children younger than five years of age will die, and many more suffer life-long consequences of
inappropriate care and ill health during childhood. The vast majority of neonatal and child deaths occur in
The brief background presented here on child health in less developed countries serves as a guide to
identifying and understanding the range of activities and expenditures included in child health
Diarrhoea, pneumonia, and neonatal conditions are the most important direct causes of childhood
mortality worldwide. Malaria and HIV infections are also important causes in some countries (Figure
2.1). The relative importance of different conditions will vary across countries and over time. For
example, neonatal mortality currently accounts for between 31% and 98% of infant deaths. In settings
where child deaths from common illnesses such as pneumonia and diarrhoea have been reduced, the
proportional contribution of neonatal mortality to under-five mortality is increased.
Malnutrition is the single most important underlying cause associated with 53% of all child deaths. In
low-income countries one in every three children suffers from stunted growth. The effects continue
throughout life contributing to poor school performance, reduced productivity, and impaired intellectual
and social development.
It is well known that proven interventions, properly implemented, could prevent millions of child deaths
For example, effective nutrition interventions including promotion of appropriate
breastfeeding and complementary feeding, Vitamin A and zinc supplementation could save 2.4 million
children each year or 25% of total annual deaths.
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
Tracking Progress in Child Survival. Countdown 2015. Meeting hosted by the Working Group in December 2005
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.
Jones G et al. Lancet (2003).