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GUIDE FOR THE INSTITUTIONALIZATION OF
NATIONAL HEALTH ACCOUNTS IN THE
AFRICAN REGION
November 2021
GUIDE FOR THE INSTITUTIONALIZATION
OF NATIONAL HEALTH ACCOUNTS IN
THE AFRICAN REGION
NOVEMBER 2021
GUIDE FOR THE INSTITUTIONALIZATION
OF NATIONAL HEALTH ACCOUNTS IN
THE AFRICAN REGION
NOVEMBER 2021
WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR AFRICA
BRAZZAVILLE bull 2021
Guide for the institutionalization of national health accounts in the African Region
ISBN 978-929023461-6
copy WHO Regional Office for Africa 2021
Some rights reserved This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 30 IGO licence (CC BY-NC-SA 30 IGO httpscreativecommonsorglicensesby-nc-sa30igo)
Under the terms of this licence you may copy redistribute and adapt the work for non-commercial purposes provided the work is appropriately cited as indicated below In any use of this work there should be no suggestion that WHO endorses any specific organization products or services The use of the WHO logo is not permitted If you adapt the work then you must license your work under the same or equivalent Creative Commons licence If you create a translation of this work you should add the following disclaimer along with the suggested citation ldquoThis translation was not created by the World Health Organization (WHO) WHO is not responsible for the content or accuracy of this translation The original English edition shall be the binding and authentic editionrdquo
Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization
Suggested citation Guide for the institutionalization of national health accounts in the African Region Brazzaville WHO Regional Office for Africa 2021 Licence CC BY-NC-SA 30 IGO
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General disclaimers The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country territory city or area or of its authorities or concerning the delimitation of its frontiers or boundaries Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement
The mention of specific companies or of certain manufacturersrsquo products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned Errors and omissions excepted the names of proprietary products are distinguished by initial capital letters
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Designed in Brazzaville Congo by the TIP Unit WHO Regional Office for Africa
Page | iii
CONTENTS
ACRONYMS iv
FOREWORD v
ORGANIZATION OF THIS GUIDE v i i
ACKNOWLEDGEMENTS v i i i
DEFINITIONS OF KEY TERMS ix
EXECUTIVE SUMMARY x
National Health Accounts governance capacity and funding x
Data demand and use production dissemination and translation into policies xi
1 BACKGROUND 1
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE 1
21 Rationale 1
22 Scope and intended audience of this guide 2
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF N ational Health
Accounts 2
4 STEPS FOR THE INSTITUTIONALIZATION OF N ational Health Accounts 3
41 Governing ensuring capacity and financing National Health Accounts 3
42 Meeting the needs for the demand and use production and dissemination of National Health Accounts and translation of data into policies 16
43 Monitoring National Health Accounts institutionalization progress 19
44 Gantt Chart for National Health Accounts institutionalization 20
5 CONCLUSION 21
RECOMMENDED LITERATURE 22
LIST OF TABLES
Table 1 Illustrative list of stakeholders in the health sector in African countries 6
Table 2 Country leadership for National Health Accounts in Africa 9
Table 3 Planning for National Health Accounts governance capacity and financing 11
Table 4 Meeting National Health Accountsneeds in terms of institutionalization 12
Table 5 Situation analysis results and resources needed 13
Table 6 Analysis of potential National Health Accounts hosts for sustainability 16
Table 7 Assessing country status on the demand and use of National Health Accounts 17
Table 8 Assessing country status on data production 18
Table 9 Assessment country National Health Accounts dissemination data translation 19
Table 10 Progress indicators towards National Health Accounts institutionalization 20
Table 11 Gantt chart for National Health Accounts institutionalization 21
Page | iv
ACRONYMS
EMR electronic medical records
HMIS health management information systems
IFMIS integrated financial management systems
IMF International Monetary Fund
MoH ministry of health
NHA national health accounts
SDGs Sustainable Development Goals
SIDA Swedish International Development Agency
UHC universal health coverage
UNAIDS Joint United Nations Programme on HIVAIDS
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNICEF United Nations Childrenrsquos Fund
USAID United States Agency for International Development
WHO World Health Organization
Page | v
FOREWORD
The World Health Organizationrsquos (WHO) mission is to work for better health for everyone To
that end the WHO Regional Office for Africa translates this complex global mission into goals
and activities that require considerable resources at both regional and country levels Given
that resources are ever limited smart investments with enhanced value are required for
decision-making Smart decisions need answers to key questions on health expenditure Who
is financing the health services and how much are they spending What type of services are
available and who provides them Who is benefiting from these health expenditures To
answer these questions national health accounts (NHA) a standardized international system
of accounting for health care expenditure was developed (OECD 2000) It has been improved
over time and scaled up
Now more than ever smart investments are needed to achieve the Sustainable Development
Goals In that context NHA has become a key evidence base to inform decisions at all levels
NHA is even more important in the current context of the COVID-19 pandemic that has
plunged the world economy into recession With countries facing lower resource levels and
higher service demands NHA provides them the much-needed basis for assessing priorities
in health In addition scrutiny from an increasingly informed population and academia
requires greater accountability for committed resources
NHA is an indispensable tool in our time and there is an urgent need to address the
bottlenecks to its effective institutionalization in Africa During the 27th African Union Summit
in 2016 the Heads of State and Government adopted the Africa Scorecard on Domestic
Financing for Health for measuring progress towards meeting domestic and external health
financing commitments The quality of the data related to the scorecard depends on the
timely production of health accounts
WHO and other partners are supporting countries in strengthening NHA To that end an
assessment of the status of NHA institutionalization in African countries was undertaken in
2020 One of the recommendations from that assessment was to support African countries
to institutionalize the demand use production and dissemination of NHA data This guide
builds on the findings of that assessment to move forward the NHA agenda in Africa by
fostering country ownership of the process and sharing best practices This guide intends to
provide practical steps to strengthen systems structures and institutions that ensure timely
provision of quality National Health Accounts (NHA) data This guide is intended for the WHO
African Region Member States to be used by the ministries of health and finance the
parliament academia civil society donor organizations regional bodies and the private
sector for supporting institutionalisation of NHA The guide will be adapted to each countryrsquos
context In terms of expected benefits NHA is an effective tool to provide evidence on who is
covered and who is not where are the uncovered and what services have low coverage how
Page | vi
much more money is needed to achieve agreed targets In this perspective NHA indicators
support the monitoring of health spending and critically analyze health care financing to
ensure evidence-based resource mobilization pooling purchasing of health care services and
benefits distribution and provide rationale for policy options The institutionalization of
process would result in timely availability of NHA data at country level which will help in
health financing policy decisions by the member states to advance towards universal health
coverage It is my sincere hope that this guide will be used extensively for that purpose
Dr Kasonde Mwinga
Director Universal Health CoverageLife Course Cluster
Page | vii
ORGANIZATION OF THIS GUIDE
This guide has been developed to support the progress towards the use of evidence for
decision-making with the necessary policy institutional legal and funding arrangements to
mainstream national health accounts (NHA) within African countriesrsquo routine data systems
The assessment of the status of NHA institutionalization in the African Region that inspired
the production of this guide and which was undertaken in seven countries adequately
selected to account for country location and performance levels showed that greater efforts
were needed to achieve full NHA institutionalization
This guide has four main sections
bull The background is an introduction to the general NHA concept and its importance for the
Sustainable Development Goals (SDGs) towards which all countries are currently
marching
bull The rationale intended audience and scope of the guide present the justification for
producing evidence for sound investment decision-making in health This section covers
the boundaries and intended users of the guide
bull The third section is on the World Bank framework for the institutionalization of NHA
which is the basis for understanding the components required for NHA institutionalization
at the country level (1) governance needed capacities and finances (2) demand and use
(3) production and quality assurance (4) dissemination and (5) translation of NHA data
into specific policies
bull The steps for the institutionalization of NHA are this guidersquos originality in defining the four
major components necessary to make progress towards the full institutionalization of
NHA appropriate leadership structures an implementation plan an appropriate host
institution and funding options for sustainability A country situational analysis provides
evidence on country context and gaps in mainstreaming NHA in national data systems
including comprehensive guidance on the approach to address the gaps related to the
demand and use of NHA its production and dissemination and data translation into
policy
Page | viii
ACKNOWLEDGEMENTS
This guide was prepared by the WHO Regional Office for Africa - Health Financing and
Investment Programme under the leadership of the Director of the Universal Health
CoverageLife Course Cluster Dr Kasonde Mwinga The key people involved in the process
were Dr Juliet Nabyonga Ms Diane Karenzi Muhongerwa Dr Benjamin Nganda Dr Seydou
Coulibabby Mr Farba Sall and Mr Brandan Kwesiga We thank Chandrakant Laharia for
reviewing the draft guide The Regional Office would like to thank Angelique K Rwiyereka
who led the process of developing this guide
Page | ix
DEFINITIONS OF KEY TERMS
National health accounts are a way for countries to monitor health spending across multiple
streams regardless of the entity or institution that financed and managed that spending NHA
reflects the main functions of health care financing resource mobilization pooling
purchasing of care and distribution of benefits NHA classification schemes are designed to
be compatible with those used internationally for comparison Maeda et al1 provide the
main definitions
Institutionalization of national health accounts is the routine government-led and country-
owned production and utilization of an essential set of policy-relevant health expenditure
data using an internationally accepted health accounting framework The World Bank
framework for institutionalization of NHA outlines the key components for the
institutionalization of NHA to be effective including (1) ensuring country ownership of the
governance capacity and financing for NHA leading to a complete routinization of the
demand and use of NHA data and (2) producing and managing data and ensuring their
quality disseminating results and translating the data into relevant policy decisions
Stakeholders are any people groups or organizations that have a stake in the subject of
interest Stakeholders are positively or negatively impacted by a prospective policy
programme initiative or project In the context of NHA stakeholders are defined as actors
who have an interest or obligation to contribute to the financing production or use of NHA
data or who may be impacted positively or negatively by the use of NHA data
1 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for
Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development--Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
GUIDE FOR THE INSTITUTIONALIZATION
OF NATIONAL HEALTH ACCOUNTS IN
THE AFRICAN REGION
NOVEMBER 2021
WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR AFRICA
BRAZZAVILLE bull 2021
Guide for the institutionalization of national health accounts in the African Region
ISBN 978-929023461-6
copy WHO Regional Office for Africa 2021
Some rights reserved This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 30 IGO licence (CC BY-NC-SA 30 IGO httpscreativecommonsorglicensesby-nc-sa30igo)
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Designed in Brazzaville Congo by the TIP Unit WHO Regional Office for Africa
Page | iii
CONTENTS
ACRONYMS iv
FOREWORD v
ORGANIZATION OF THIS GUIDE v i i
ACKNOWLEDGEMENTS v i i i
DEFINITIONS OF KEY TERMS ix
EXECUTIVE SUMMARY x
National Health Accounts governance capacity and funding x
Data demand and use production dissemination and translation into policies xi
1 BACKGROUND 1
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE 1
21 Rationale 1
22 Scope and intended audience of this guide 2
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF N ational Health
Accounts 2
4 STEPS FOR THE INSTITUTIONALIZATION OF N ational Health Accounts 3
41 Governing ensuring capacity and financing National Health Accounts 3
42 Meeting the needs for the demand and use production and dissemination of National Health Accounts and translation of data into policies 16
43 Monitoring National Health Accounts institutionalization progress 19
44 Gantt Chart for National Health Accounts institutionalization 20
5 CONCLUSION 21
RECOMMENDED LITERATURE 22
LIST OF TABLES
Table 1 Illustrative list of stakeholders in the health sector in African countries 6
Table 2 Country leadership for National Health Accounts in Africa 9
Table 3 Planning for National Health Accounts governance capacity and financing 11
Table 4 Meeting National Health Accountsneeds in terms of institutionalization 12
Table 5 Situation analysis results and resources needed 13
Table 6 Analysis of potential National Health Accounts hosts for sustainability 16
Table 7 Assessing country status on the demand and use of National Health Accounts 17
Table 8 Assessing country status on data production 18
Table 9 Assessment country National Health Accounts dissemination data translation 19
Table 10 Progress indicators towards National Health Accounts institutionalization 20
Table 11 Gantt chart for National Health Accounts institutionalization 21
Page | iv
ACRONYMS
EMR electronic medical records
HMIS health management information systems
IFMIS integrated financial management systems
IMF International Monetary Fund
MoH ministry of health
NHA national health accounts
SDGs Sustainable Development Goals
SIDA Swedish International Development Agency
UHC universal health coverage
UNAIDS Joint United Nations Programme on HIVAIDS
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNICEF United Nations Childrenrsquos Fund
USAID United States Agency for International Development
WHO World Health Organization
Page | v
FOREWORD
The World Health Organizationrsquos (WHO) mission is to work for better health for everyone To
that end the WHO Regional Office for Africa translates this complex global mission into goals
and activities that require considerable resources at both regional and country levels Given
that resources are ever limited smart investments with enhanced value are required for
decision-making Smart decisions need answers to key questions on health expenditure Who
is financing the health services and how much are they spending What type of services are
available and who provides them Who is benefiting from these health expenditures To
answer these questions national health accounts (NHA) a standardized international system
of accounting for health care expenditure was developed (OECD 2000) It has been improved
over time and scaled up
Now more than ever smart investments are needed to achieve the Sustainable Development
Goals In that context NHA has become a key evidence base to inform decisions at all levels
NHA is even more important in the current context of the COVID-19 pandemic that has
plunged the world economy into recession With countries facing lower resource levels and
higher service demands NHA provides them the much-needed basis for assessing priorities
in health In addition scrutiny from an increasingly informed population and academia
requires greater accountability for committed resources
NHA is an indispensable tool in our time and there is an urgent need to address the
bottlenecks to its effective institutionalization in Africa During the 27th African Union Summit
in 2016 the Heads of State and Government adopted the Africa Scorecard on Domestic
Financing for Health for measuring progress towards meeting domestic and external health
financing commitments The quality of the data related to the scorecard depends on the
timely production of health accounts
WHO and other partners are supporting countries in strengthening NHA To that end an
assessment of the status of NHA institutionalization in African countries was undertaken in
2020 One of the recommendations from that assessment was to support African countries
to institutionalize the demand use production and dissemination of NHA data This guide
builds on the findings of that assessment to move forward the NHA agenda in Africa by
fostering country ownership of the process and sharing best practices This guide intends to
provide practical steps to strengthen systems structures and institutions that ensure timely
provision of quality National Health Accounts (NHA) data This guide is intended for the WHO
African Region Member States to be used by the ministries of health and finance the
parliament academia civil society donor organizations regional bodies and the private
sector for supporting institutionalisation of NHA The guide will be adapted to each countryrsquos
context In terms of expected benefits NHA is an effective tool to provide evidence on who is
covered and who is not where are the uncovered and what services have low coverage how
Page | vi
much more money is needed to achieve agreed targets In this perspective NHA indicators
support the monitoring of health spending and critically analyze health care financing to
ensure evidence-based resource mobilization pooling purchasing of health care services and
benefits distribution and provide rationale for policy options The institutionalization of
process would result in timely availability of NHA data at country level which will help in
health financing policy decisions by the member states to advance towards universal health
coverage It is my sincere hope that this guide will be used extensively for that purpose
Dr Kasonde Mwinga
Director Universal Health CoverageLife Course Cluster
Page | vii
ORGANIZATION OF THIS GUIDE
This guide has been developed to support the progress towards the use of evidence for
decision-making with the necessary policy institutional legal and funding arrangements to
mainstream national health accounts (NHA) within African countriesrsquo routine data systems
The assessment of the status of NHA institutionalization in the African Region that inspired
the production of this guide and which was undertaken in seven countries adequately
selected to account for country location and performance levels showed that greater efforts
were needed to achieve full NHA institutionalization
This guide has four main sections
bull The background is an introduction to the general NHA concept and its importance for the
Sustainable Development Goals (SDGs) towards which all countries are currently
marching
bull The rationale intended audience and scope of the guide present the justification for
producing evidence for sound investment decision-making in health This section covers
the boundaries and intended users of the guide
bull The third section is on the World Bank framework for the institutionalization of NHA
which is the basis for understanding the components required for NHA institutionalization
at the country level (1) governance needed capacities and finances (2) demand and use
(3) production and quality assurance (4) dissemination and (5) translation of NHA data
into specific policies
bull The steps for the institutionalization of NHA are this guidersquos originality in defining the four
major components necessary to make progress towards the full institutionalization of
NHA appropriate leadership structures an implementation plan an appropriate host
institution and funding options for sustainability A country situational analysis provides
evidence on country context and gaps in mainstreaming NHA in national data systems
including comprehensive guidance on the approach to address the gaps related to the
demand and use of NHA its production and dissemination and data translation into
policy
Page | viii
ACKNOWLEDGEMENTS
This guide was prepared by the WHO Regional Office for Africa - Health Financing and
Investment Programme under the leadership of the Director of the Universal Health
CoverageLife Course Cluster Dr Kasonde Mwinga The key people involved in the process
were Dr Juliet Nabyonga Ms Diane Karenzi Muhongerwa Dr Benjamin Nganda Dr Seydou
Coulibabby Mr Farba Sall and Mr Brandan Kwesiga We thank Chandrakant Laharia for
reviewing the draft guide The Regional Office would like to thank Angelique K Rwiyereka
who led the process of developing this guide
Page | ix
DEFINITIONS OF KEY TERMS
National health accounts are a way for countries to monitor health spending across multiple
streams regardless of the entity or institution that financed and managed that spending NHA
reflects the main functions of health care financing resource mobilization pooling
purchasing of care and distribution of benefits NHA classification schemes are designed to
be compatible with those used internationally for comparison Maeda et al1 provide the
main definitions
Institutionalization of national health accounts is the routine government-led and country-
owned production and utilization of an essential set of policy-relevant health expenditure
data using an internationally accepted health accounting framework The World Bank
framework for institutionalization of NHA outlines the key components for the
institutionalization of NHA to be effective including (1) ensuring country ownership of the
governance capacity and financing for NHA leading to a complete routinization of the
demand and use of NHA data and (2) producing and managing data and ensuring their
quality disseminating results and translating the data into relevant policy decisions
Stakeholders are any people groups or organizations that have a stake in the subject of
interest Stakeholders are positively or negatively impacted by a prospective policy
programme initiative or project In the context of NHA stakeholders are defined as actors
who have an interest or obligation to contribute to the financing production or use of NHA
data or who may be impacted positively or negatively by the use of NHA data
1 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for
Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development--Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Guide for the institutionalization of national health accounts in the African Region
ISBN 978-929023461-6
copy WHO Regional Office for Africa 2021
Some rights reserved This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 30 IGO licence (CC BY-NC-SA 30 IGO httpscreativecommonsorglicensesby-nc-sa30igo)
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Suggested citation Guide for the institutionalization of national health accounts in the African Region Brazzaville WHO Regional Office for Africa 2021 Licence CC BY-NC-SA 30 IGO
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Designed in Brazzaville Congo by the TIP Unit WHO Regional Office for Africa
Page | iii
CONTENTS
ACRONYMS iv
FOREWORD v
ORGANIZATION OF THIS GUIDE v i i
ACKNOWLEDGEMENTS v i i i
DEFINITIONS OF KEY TERMS ix
EXECUTIVE SUMMARY x
National Health Accounts governance capacity and funding x
Data demand and use production dissemination and translation into policies xi
1 BACKGROUND 1
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE 1
21 Rationale 1
22 Scope and intended audience of this guide 2
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF N ational Health
Accounts 2
4 STEPS FOR THE INSTITUTIONALIZATION OF N ational Health Accounts 3
41 Governing ensuring capacity and financing National Health Accounts 3
42 Meeting the needs for the demand and use production and dissemination of National Health Accounts and translation of data into policies 16
43 Monitoring National Health Accounts institutionalization progress 19
44 Gantt Chart for National Health Accounts institutionalization 20
5 CONCLUSION 21
RECOMMENDED LITERATURE 22
LIST OF TABLES
Table 1 Illustrative list of stakeholders in the health sector in African countries 6
Table 2 Country leadership for National Health Accounts in Africa 9
Table 3 Planning for National Health Accounts governance capacity and financing 11
Table 4 Meeting National Health Accountsneeds in terms of institutionalization 12
Table 5 Situation analysis results and resources needed 13
Table 6 Analysis of potential National Health Accounts hosts for sustainability 16
Table 7 Assessing country status on the demand and use of National Health Accounts 17
Table 8 Assessing country status on data production 18
Table 9 Assessment country National Health Accounts dissemination data translation 19
Table 10 Progress indicators towards National Health Accounts institutionalization 20
Table 11 Gantt chart for National Health Accounts institutionalization 21
Page | iv
ACRONYMS
EMR electronic medical records
HMIS health management information systems
IFMIS integrated financial management systems
IMF International Monetary Fund
MoH ministry of health
NHA national health accounts
SDGs Sustainable Development Goals
SIDA Swedish International Development Agency
UHC universal health coverage
UNAIDS Joint United Nations Programme on HIVAIDS
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNICEF United Nations Childrenrsquos Fund
USAID United States Agency for International Development
WHO World Health Organization
Page | v
FOREWORD
The World Health Organizationrsquos (WHO) mission is to work for better health for everyone To
that end the WHO Regional Office for Africa translates this complex global mission into goals
and activities that require considerable resources at both regional and country levels Given
that resources are ever limited smart investments with enhanced value are required for
decision-making Smart decisions need answers to key questions on health expenditure Who
is financing the health services and how much are they spending What type of services are
available and who provides them Who is benefiting from these health expenditures To
answer these questions national health accounts (NHA) a standardized international system
of accounting for health care expenditure was developed (OECD 2000) It has been improved
over time and scaled up
Now more than ever smart investments are needed to achieve the Sustainable Development
Goals In that context NHA has become a key evidence base to inform decisions at all levels
NHA is even more important in the current context of the COVID-19 pandemic that has
plunged the world economy into recession With countries facing lower resource levels and
higher service demands NHA provides them the much-needed basis for assessing priorities
in health In addition scrutiny from an increasingly informed population and academia
requires greater accountability for committed resources
NHA is an indispensable tool in our time and there is an urgent need to address the
bottlenecks to its effective institutionalization in Africa During the 27th African Union Summit
in 2016 the Heads of State and Government adopted the Africa Scorecard on Domestic
Financing for Health for measuring progress towards meeting domestic and external health
financing commitments The quality of the data related to the scorecard depends on the
timely production of health accounts
WHO and other partners are supporting countries in strengthening NHA To that end an
assessment of the status of NHA institutionalization in African countries was undertaken in
2020 One of the recommendations from that assessment was to support African countries
to institutionalize the demand use production and dissemination of NHA data This guide
builds on the findings of that assessment to move forward the NHA agenda in Africa by
fostering country ownership of the process and sharing best practices This guide intends to
provide practical steps to strengthen systems structures and institutions that ensure timely
provision of quality National Health Accounts (NHA) data This guide is intended for the WHO
African Region Member States to be used by the ministries of health and finance the
parliament academia civil society donor organizations regional bodies and the private
sector for supporting institutionalisation of NHA The guide will be adapted to each countryrsquos
context In terms of expected benefits NHA is an effective tool to provide evidence on who is
covered and who is not where are the uncovered and what services have low coverage how
Page | vi
much more money is needed to achieve agreed targets In this perspective NHA indicators
support the monitoring of health spending and critically analyze health care financing to
ensure evidence-based resource mobilization pooling purchasing of health care services and
benefits distribution and provide rationale for policy options The institutionalization of
process would result in timely availability of NHA data at country level which will help in
health financing policy decisions by the member states to advance towards universal health
coverage It is my sincere hope that this guide will be used extensively for that purpose
Dr Kasonde Mwinga
Director Universal Health CoverageLife Course Cluster
Page | vii
ORGANIZATION OF THIS GUIDE
This guide has been developed to support the progress towards the use of evidence for
decision-making with the necessary policy institutional legal and funding arrangements to
mainstream national health accounts (NHA) within African countriesrsquo routine data systems
The assessment of the status of NHA institutionalization in the African Region that inspired
the production of this guide and which was undertaken in seven countries adequately
selected to account for country location and performance levels showed that greater efforts
were needed to achieve full NHA institutionalization
This guide has four main sections
bull The background is an introduction to the general NHA concept and its importance for the
Sustainable Development Goals (SDGs) towards which all countries are currently
marching
bull The rationale intended audience and scope of the guide present the justification for
producing evidence for sound investment decision-making in health This section covers
the boundaries and intended users of the guide
bull The third section is on the World Bank framework for the institutionalization of NHA
which is the basis for understanding the components required for NHA institutionalization
at the country level (1) governance needed capacities and finances (2) demand and use
(3) production and quality assurance (4) dissemination and (5) translation of NHA data
into specific policies
bull The steps for the institutionalization of NHA are this guidersquos originality in defining the four
major components necessary to make progress towards the full institutionalization of
NHA appropriate leadership structures an implementation plan an appropriate host
institution and funding options for sustainability A country situational analysis provides
evidence on country context and gaps in mainstreaming NHA in national data systems
including comprehensive guidance on the approach to address the gaps related to the
demand and use of NHA its production and dissemination and data translation into
policy
Page | viii
ACKNOWLEDGEMENTS
This guide was prepared by the WHO Regional Office for Africa - Health Financing and
Investment Programme under the leadership of the Director of the Universal Health
CoverageLife Course Cluster Dr Kasonde Mwinga The key people involved in the process
were Dr Juliet Nabyonga Ms Diane Karenzi Muhongerwa Dr Benjamin Nganda Dr Seydou
Coulibabby Mr Farba Sall and Mr Brandan Kwesiga We thank Chandrakant Laharia for
reviewing the draft guide The Regional Office would like to thank Angelique K Rwiyereka
who led the process of developing this guide
Page | ix
DEFINITIONS OF KEY TERMS
National health accounts are a way for countries to monitor health spending across multiple
streams regardless of the entity or institution that financed and managed that spending NHA
reflects the main functions of health care financing resource mobilization pooling
purchasing of care and distribution of benefits NHA classification schemes are designed to
be compatible with those used internationally for comparison Maeda et al1 provide the
main definitions
Institutionalization of national health accounts is the routine government-led and country-
owned production and utilization of an essential set of policy-relevant health expenditure
data using an internationally accepted health accounting framework The World Bank
framework for institutionalization of NHA outlines the key components for the
institutionalization of NHA to be effective including (1) ensuring country ownership of the
governance capacity and financing for NHA leading to a complete routinization of the
demand and use of NHA data and (2) producing and managing data and ensuring their
quality disseminating results and translating the data into relevant policy decisions
Stakeholders are any people groups or organizations that have a stake in the subject of
interest Stakeholders are positively or negatively impacted by a prospective policy
programme initiative or project In the context of NHA stakeholders are defined as actors
who have an interest or obligation to contribute to the financing production or use of NHA
data or who may be impacted positively or negatively by the use of NHA data
1 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for
Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development--Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | iii
CONTENTS
ACRONYMS iv
FOREWORD v
ORGANIZATION OF THIS GUIDE v i i
ACKNOWLEDGEMENTS v i i i
DEFINITIONS OF KEY TERMS ix
EXECUTIVE SUMMARY x
National Health Accounts governance capacity and funding x
Data demand and use production dissemination and translation into policies xi
1 BACKGROUND 1
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE 1
21 Rationale 1
22 Scope and intended audience of this guide 2
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF N ational Health
Accounts 2
4 STEPS FOR THE INSTITUTIONALIZATION OF N ational Health Accounts 3
41 Governing ensuring capacity and financing National Health Accounts 3
42 Meeting the needs for the demand and use production and dissemination of National Health Accounts and translation of data into policies 16
43 Monitoring National Health Accounts institutionalization progress 19
44 Gantt Chart for National Health Accounts institutionalization 20
5 CONCLUSION 21
RECOMMENDED LITERATURE 22
LIST OF TABLES
Table 1 Illustrative list of stakeholders in the health sector in African countries 6
Table 2 Country leadership for National Health Accounts in Africa 9
Table 3 Planning for National Health Accounts governance capacity and financing 11
Table 4 Meeting National Health Accountsneeds in terms of institutionalization 12
Table 5 Situation analysis results and resources needed 13
Table 6 Analysis of potential National Health Accounts hosts for sustainability 16
Table 7 Assessing country status on the demand and use of National Health Accounts 17
Table 8 Assessing country status on data production 18
Table 9 Assessment country National Health Accounts dissemination data translation 19
Table 10 Progress indicators towards National Health Accounts institutionalization 20
Table 11 Gantt chart for National Health Accounts institutionalization 21
Page | iv
ACRONYMS
EMR electronic medical records
HMIS health management information systems
IFMIS integrated financial management systems
IMF International Monetary Fund
MoH ministry of health
NHA national health accounts
SDGs Sustainable Development Goals
SIDA Swedish International Development Agency
UHC universal health coverage
UNAIDS Joint United Nations Programme on HIVAIDS
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNICEF United Nations Childrenrsquos Fund
USAID United States Agency for International Development
WHO World Health Organization
Page | v
FOREWORD
The World Health Organizationrsquos (WHO) mission is to work for better health for everyone To
that end the WHO Regional Office for Africa translates this complex global mission into goals
and activities that require considerable resources at both regional and country levels Given
that resources are ever limited smart investments with enhanced value are required for
decision-making Smart decisions need answers to key questions on health expenditure Who
is financing the health services and how much are they spending What type of services are
available and who provides them Who is benefiting from these health expenditures To
answer these questions national health accounts (NHA) a standardized international system
of accounting for health care expenditure was developed (OECD 2000) It has been improved
over time and scaled up
Now more than ever smart investments are needed to achieve the Sustainable Development
Goals In that context NHA has become a key evidence base to inform decisions at all levels
NHA is even more important in the current context of the COVID-19 pandemic that has
plunged the world economy into recession With countries facing lower resource levels and
higher service demands NHA provides them the much-needed basis for assessing priorities
in health In addition scrutiny from an increasingly informed population and academia
requires greater accountability for committed resources
NHA is an indispensable tool in our time and there is an urgent need to address the
bottlenecks to its effective institutionalization in Africa During the 27th African Union Summit
in 2016 the Heads of State and Government adopted the Africa Scorecard on Domestic
Financing for Health for measuring progress towards meeting domestic and external health
financing commitments The quality of the data related to the scorecard depends on the
timely production of health accounts
WHO and other partners are supporting countries in strengthening NHA To that end an
assessment of the status of NHA institutionalization in African countries was undertaken in
2020 One of the recommendations from that assessment was to support African countries
to institutionalize the demand use production and dissemination of NHA data This guide
builds on the findings of that assessment to move forward the NHA agenda in Africa by
fostering country ownership of the process and sharing best practices This guide intends to
provide practical steps to strengthen systems structures and institutions that ensure timely
provision of quality National Health Accounts (NHA) data This guide is intended for the WHO
African Region Member States to be used by the ministries of health and finance the
parliament academia civil society donor organizations regional bodies and the private
sector for supporting institutionalisation of NHA The guide will be adapted to each countryrsquos
context In terms of expected benefits NHA is an effective tool to provide evidence on who is
covered and who is not where are the uncovered and what services have low coverage how
Page | vi
much more money is needed to achieve agreed targets In this perspective NHA indicators
support the monitoring of health spending and critically analyze health care financing to
ensure evidence-based resource mobilization pooling purchasing of health care services and
benefits distribution and provide rationale for policy options The institutionalization of
process would result in timely availability of NHA data at country level which will help in
health financing policy decisions by the member states to advance towards universal health
coverage It is my sincere hope that this guide will be used extensively for that purpose
Dr Kasonde Mwinga
Director Universal Health CoverageLife Course Cluster
Page | vii
ORGANIZATION OF THIS GUIDE
This guide has been developed to support the progress towards the use of evidence for
decision-making with the necessary policy institutional legal and funding arrangements to
mainstream national health accounts (NHA) within African countriesrsquo routine data systems
The assessment of the status of NHA institutionalization in the African Region that inspired
the production of this guide and which was undertaken in seven countries adequately
selected to account for country location and performance levels showed that greater efforts
were needed to achieve full NHA institutionalization
This guide has four main sections
bull The background is an introduction to the general NHA concept and its importance for the
Sustainable Development Goals (SDGs) towards which all countries are currently
marching
bull The rationale intended audience and scope of the guide present the justification for
producing evidence for sound investment decision-making in health This section covers
the boundaries and intended users of the guide
bull The third section is on the World Bank framework for the institutionalization of NHA
which is the basis for understanding the components required for NHA institutionalization
at the country level (1) governance needed capacities and finances (2) demand and use
(3) production and quality assurance (4) dissemination and (5) translation of NHA data
into specific policies
bull The steps for the institutionalization of NHA are this guidersquos originality in defining the four
major components necessary to make progress towards the full institutionalization of
NHA appropriate leadership structures an implementation plan an appropriate host
institution and funding options for sustainability A country situational analysis provides
evidence on country context and gaps in mainstreaming NHA in national data systems
including comprehensive guidance on the approach to address the gaps related to the
demand and use of NHA its production and dissemination and data translation into
policy
Page | viii
ACKNOWLEDGEMENTS
This guide was prepared by the WHO Regional Office for Africa - Health Financing and
Investment Programme under the leadership of the Director of the Universal Health
CoverageLife Course Cluster Dr Kasonde Mwinga The key people involved in the process
were Dr Juliet Nabyonga Ms Diane Karenzi Muhongerwa Dr Benjamin Nganda Dr Seydou
Coulibabby Mr Farba Sall and Mr Brandan Kwesiga We thank Chandrakant Laharia for
reviewing the draft guide The Regional Office would like to thank Angelique K Rwiyereka
who led the process of developing this guide
Page | ix
DEFINITIONS OF KEY TERMS
National health accounts are a way for countries to monitor health spending across multiple
streams regardless of the entity or institution that financed and managed that spending NHA
reflects the main functions of health care financing resource mobilization pooling
purchasing of care and distribution of benefits NHA classification schemes are designed to
be compatible with those used internationally for comparison Maeda et al1 provide the
main definitions
Institutionalization of national health accounts is the routine government-led and country-
owned production and utilization of an essential set of policy-relevant health expenditure
data using an internationally accepted health accounting framework The World Bank
framework for institutionalization of NHA outlines the key components for the
institutionalization of NHA to be effective including (1) ensuring country ownership of the
governance capacity and financing for NHA leading to a complete routinization of the
demand and use of NHA data and (2) producing and managing data and ensuring their
quality disseminating results and translating the data into relevant policy decisions
Stakeholders are any people groups or organizations that have a stake in the subject of
interest Stakeholders are positively or negatively impacted by a prospective policy
programme initiative or project In the context of NHA stakeholders are defined as actors
who have an interest or obligation to contribute to the financing production or use of NHA
data or who may be impacted positively or negatively by the use of NHA data
1 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for
Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development--Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | iv
ACRONYMS
EMR electronic medical records
HMIS health management information systems
IFMIS integrated financial management systems
IMF International Monetary Fund
MoH ministry of health
NHA national health accounts
SDGs Sustainable Development Goals
SIDA Swedish International Development Agency
UHC universal health coverage
UNAIDS Joint United Nations Programme on HIVAIDS
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNICEF United Nations Childrenrsquos Fund
USAID United States Agency for International Development
WHO World Health Organization
Page | v
FOREWORD
The World Health Organizationrsquos (WHO) mission is to work for better health for everyone To
that end the WHO Regional Office for Africa translates this complex global mission into goals
and activities that require considerable resources at both regional and country levels Given
that resources are ever limited smart investments with enhanced value are required for
decision-making Smart decisions need answers to key questions on health expenditure Who
is financing the health services and how much are they spending What type of services are
available and who provides them Who is benefiting from these health expenditures To
answer these questions national health accounts (NHA) a standardized international system
of accounting for health care expenditure was developed (OECD 2000) It has been improved
over time and scaled up
Now more than ever smart investments are needed to achieve the Sustainable Development
Goals In that context NHA has become a key evidence base to inform decisions at all levels
NHA is even more important in the current context of the COVID-19 pandemic that has
plunged the world economy into recession With countries facing lower resource levels and
higher service demands NHA provides them the much-needed basis for assessing priorities
in health In addition scrutiny from an increasingly informed population and academia
requires greater accountability for committed resources
NHA is an indispensable tool in our time and there is an urgent need to address the
bottlenecks to its effective institutionalization in Africa During the 27th African Union Summit
in 2016 the Heads of State and Government adopted the Africa Scorecard on Domestic
Financing for Health for measuring progress towards meeting domestic and external health
financing commitments The quality of the data related to the scorecard depends on the
timely production of health accounts
WHO and other partners are supporting countries in strengthening NHA To that end an
assessment of the status of NHA institutionalization in African countries was undertaken in
2020 One of the recommendations from that assessment was to support African countries
to institutionalize the demand use production and dissemination of NHA data This guide
builds on the findings of that assessment to move forward the NHA agenda in Africa by
fostering country ownership of the process and sharing best practices This guide intends to
provide practical steps to strengthen systems structures and institutions that ensure timely
provision of quality National Health Accounts (NHA) data This guide is intended for the WHO
African Region Member States to be used by the ministries of health and finance the
parliament academia civil society donor organizations regional bodies and the private
sector for supporting institutionalisation of NHA The guide will be adapted to each countryrsquos
context In terms of expected benefits NHA is an effective tool to provide evidence on who is
covered and who is not where are the uncovered and what services have low coverage how
Page | vi
much more money is needed to achieve agreed targets In this perspective NHA indicators
support the monitoring of health spending and critically analyze health care financing to
ensure evidence-based resource mobilization pooling purchasing of health care services and
benefits distribution and provide rationale for policy options The institutionalization of
process would result in timely availability of NHA data at country level which will help in
health financing policy decisions by the member states to advance towards universal health
coverage It is my sincere hope that this guide will be used extensively for that purpose
Dr Kasonde Mwinga
Director Universal Health CoverageLife Course Cluster
Page | vii
ORGANIZATION OF THIS GUIDE
This guide has been developed to support the progress towards the use of evidence for
decision-making with the necessary policy institutional legal and funding arrangements to
mainstream national health accounts (NHA) within African countriesrsquo routine data systems
The assessment of the status of NHA institutionalization in the African Region that inspired
the production of this guide and which was undertaken in seven countries adequately
selected to account for country location and performance levels showed that greater efforts
were needed to achieve full NHA institutionalization
This guide has four main sections
bull The background is an introduction to the general NHA concept and its importance for the
Sustainable Development Goals (SDGs) towards which all countries are currently
marching
bull The rationale intended audience and scope of the guide present the justification for
producing evidence for sound investment decision-making in health This section covers
the boundaries and intended users of the guide
bull The third section is on the World Bank framework for the institutionalization of NHA
which is the basis for understanding the components required for NHA institutionalization
at the country level (1) governance needed capacities and finances (2) demand and use
(3) production and quality assurance (4) dissemination and (5) translation of NHA data
into specific policies
bull The steps for the institutionalization of NHA are this guidersquos originality in defining the four
major components necessary to make progress towards the full institutionalization of
NHA appropriate leadership structures an implementation plan an appropriate host
institution and funding options for sustainability A country situational analysis provides
evidence on country context and gaps in mainstreaming NHA in national data systems
including comprehensive guidance on the approach to address the gaps related to the
demand and use of NHA its production and dissemination and data translation into
policy
Page | viii
ACKNOWLEDGEMENTS
This guide was prepared by the WHO Regional Office for Africa - Health Financing and
Investment Programme under the leadership of the Director of the Universal Health
CoverageLife Course Cluster Dr Kasonde Mwinga The key people involved in the process
were Dr Juliet Nabyonga Ms Diane Karenzi Muhongerwa Dr Benjamin Nganda Dr Seydou
Coulibabby Mr Farba Sall and Mr Brandan Kwesiga We thank Chandrakant Laharia for
reviewing the draft guide The Regional Office would like to thank Angelique K Rwiyereka
who led the process of developing this guide
Page | ix
DEFINITIONS OF KEY TERMS
National health accounts are a way for countries to monitor health spending across multiple
streams regardless of the entity or institution that financed and managed that spending NHA
reflects the main functions of health care financing resource mobilization pooling
purchasing of care and distribution of benefits NHA classification schemes are designed to
be compatible with those used internationally for comparison Maeda et al1 provide the
main definitions
Institutionalization of national health accounts is the routine government-led and country-
owned production and utilization of an essential set of policy-relevant health expenditure
data using an internationally accepted health accounting framework The World Bank
framework for institutionalization of NHA outlines the key components for the
institutionalization of NHA to be effective including (1) ensuring country ownership of the
governance capacity and financing for NHA leading to a complete routinization of the
demand and use of NHA data and (2) producing and managing data and ensuring their
quality disseminating results and translating the data into relevant policy decisions
Stakeholders are any people groups or organizations that have a stake in the subject of
interest Stakeholders are positively or negatively impacted by a prospective policy
programme initiative or project In the context of NHA stakeholders are defined as actors
who have an interest or obligation to contribute to the financing production or use of NHA
data or who may be impacted positively or negatively by the use of NHA data
1 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for
Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development--Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | v
FOREWORD
The World Health Organizationrsquos (WHO) mission is to work for better health for everyone To
that end the WHO Regional Office for Africa translates this complex global mission into goals
and activities that require considerable resources at both regional and country levels Given
that resources are ever limited smart investments with enhanced value are required for
decision-making Smart decisions need answers to key questions on health expenditure Who
is financing the health services and how much are they spending What type of services are
available and who provides them Who is benefiting from these health expenditures To
answer these questions national health accounts (NHA) a standardized international system
of accounting for health care expenditure was developed (OECD 2000) It has been improved
over time and scaled up
Now more than ever smart investments are needed to achieve the Sustainable Development
Goals In that context NHA has become a key evidence base to inform decisions at all levels
NHA is even more important in the current context of the COVID-19 pandemic that has
plunged the world economy into recession With countries facing lower resource levels and
higher service demands NHA provides them the much-needed basis for assessing priorities
in health In addition scrutiny from an increasingly informed population and academia
requires greater accountability for committed resources
NHA is an indispensable tool in our time and there is an urgent need to address the
bottlenecks to its effective institutionalization in Africa During the 27th African Union Summit
in 2016 the Heads of State and Government adopted the Africa Scorecard on Domestic
Financing for Health for measuring progress towards meeting domestic and external health
financing commitments The quality of the data related to the scorecard depends on the
timely production of health accounts
WHO and other partners are supporting countries in strengthening NHA To that end an
assessment of the status of NHA institutionalization in African countries was undertaken in
2020 One of the recommendations from that assessment was to support African countries
to institutionalize the demand use production and dissemination of NHA data This guide
builds on the findings of that assessment to move forward the NHA agenda in Africa by
fostering country ownership of the process and sharing best practices This guide intends to
provide practical steps to strengthen systems structures and institutions that ensure timely
provision of quality National Health Accounts (NHA) data This guide is intended for the WHO
African Region Member States to be used by the ministries of health and finance the
parliament academia civil society donor organizations regional bodies and the private
sector for supporting institutionalisation of NHA The guide will be adapted to each countryrsquos
context In terms of expected benefits NHA is an effective tool to provide evidence on who is
covered and who is not where are the uncovered and what services have low coverage how
Page | vi
much more money is needed to achieve agreed targets In this perspective NHA indicators
support the monitoring of health spending and critically analyze health care financing to
ensure evidence-based resource mobilization pooling purchasing of health care services and
benefits distribution and provide rationale for policy options The institutionalization of
process would result in timely availability of NHA data at country level which will help in
health financing policy decisions by the member states to advance towards universal health
coverage It is my sincere hope that this guide will be used extensively for that purpose
Dr Kasonde Mwinga
Director Universal Health CoverageLife Course Cluster
Page | vii
ORGANIZATION OF THIS GUIDE
This guide has been developed to support the progress towards the use of evidence for
decision-making with the necessary policy institutional legal and funding arrangements to
mainstream national health accounts (NHA) within African countriesrsquo routine data systems
The assessment of the status of NHA institutionalization in the African Region that inspired
the production of this guide and which was undertaken in seven countries adequately
selected to account for country location and performance levels showed that greater efforts
were needed to achieve full NHA institutionalization
This guide has four main sections
bull The background is an introduction to the general NHA concept and its importance for the
Sustainable Development Goals (SDGs) towards which all countries are currently
marching
bull The rationale intended audience and scope of the guide present the justification for
producing evidence for sound investment decision-making in health This section covers
the boundaries and intended users of the guide
bull The third section is on the World Bank framework for the institutionalization of NHA
which is the basis for understanding the components required for NHA institutionalization
at the country level (1) governance needed capacities and finances (2) demand and use
(3) production and quality assurance (4) dissemination and (5) translation of NHA data
into specific policies
bull The steps for the institutionalization of NHA are this guidersquos originality in defining the four
major components necessary to make progress towards the full institutionalization of
NHA appropriate leadership structures an implementation plan an appropriate host
institution and funding options for sustainability A country situational analysis provides
evidence on country context and gaps in mainstreaming NHA in national data systems
including comprehensive guidance on the approach to address the gaps related to the
demand and use of NHA its production and dissemination and data translation into
policy
Page | viii
ACKNOWLEDGEMENTS
This guide was prepared by the WHO Regional Office for Africa - Health Financing and
Investment Programme under the leadership of the Director of the Universal Health
CoverageLife Course Cluster Dr Kasonde Mwinga The key people involved in the process
were Dr Juliet Nabyonga Ms Diane Karenzi Muhongerwa Dr Benjamin Nganda Dr Seydou
Coulibabby Mr Farba Sall and Mr Brandan Kwesiga We thank Chandrakant Laharia for
reviewing the draft guide The Regional Office would like to thank Angelique K Rwiyereka
who led the process of developing this guide
Page | ix
DEFINITIONS OF KEY TERMS
National health accounts are a way for countries to monitor health spending across multiple
streams regardless of the entity or institution that financed and managed that spending NHA
reflects the main functions of health care financing resource mobilization pooling
purchasing of care and distribution of benefits NHA classification schemes are designed to
be compatible with those used internationally for comparison Maeda et al1 provide the
main definitions
Institutionalization of national health accounts is the routine government-led and country-
owned production and utilization of an essential set of policy-relevant health expenditure
data using an internationally accepted health accounting framework The World Bank
framework for institutionalization of NHA outlines the key components for the
institutionalization of NHA to be effective including (1) ensuring country ownership of the
governance capacity and financing for NHA leading to a complete routinization of the
demand and use of NHA data and (2) producing and managing data and ensuring their
quality disseminating results and translating the data into relevant policy decisions
Stakeholders are any people groups or organizations that have a stake in the subject of
interest Stakeholders are positively or negatively impacted by a prospective policy
programme initiative or project In the context of NHA stakeholders are defined as actors
who have an interest or obligation to contribute to the financing production or use of NHA
data or who may be impacted positively or negatively by the use of NHA data
1 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for
Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development--Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | vi
much more money is needed to achieve agreed targets In this perspective NHA indicators
support the monitoring of health spending and critically analyze health care financing to
ensure evidence-based resource mobilization pooling purchasing of health care services and
benefits distribution and provide rationale for policy options The institutionalization of
process would result in timely availability of NHA data at country level which will help in
health financing policy decisions by the member states to advance towards universal health
coverage It is my sincere hope that this guide will be used extensively for that purpose
Dr Kasonde Mwinga
Director Universal Health CoverageLife Course Cluster
Page | vii
ORGANIZATION OF THIS GUIDE
This guide has been developed to support the progress towards the use of evidence for
decision-making with the necessary policy institutional legal and funding arrangements to
mainstream national health accounts (NHA) within African countriesrsquo routine data systems
The assessment of the status of NHA institutionalization in the African Region that inspired
the production of this guide and which was undertaken in seven countries adequately
selected to account for country location and performance levels showed that greater efforts
were needed to achieve full NHA institutionalization
This guide has four main sections
bull The background is an introduction to the general NHA concept and its importance for the
Sustainable Development Goals (SDGs) towards which all countries are currently
marching
bull The rationale intended audience and scope of the guide present the justification for
producing evidence for sound investment decision-making in health This section covers
the boundaries and intended users of the guide
bull The third section is on the World Bank framework for the institutionalization of NHA
which is the basis for understanding the components required for NHA institutionalization
at the country level (1) governance needed capacities and finances (2) demand and use
(3) production and quality assurance (4) dissemination and (5) translation of NHA data
into specific policies
bull The steps for the institutionalization of NHA are this guidersquos originality in defining the four
major components necessary to make progress towards the full institutionalization of
NHA appropriate leadership structures an implementation plan an appropriate host
institution and funding options for sustainability A country situational analysis provides
evidence on country context and gaps in mainstreaming NHA in national data systems
including comprehensive guidance on the approach to address the gaps related to the
demand and use of NHA its production and dissemination and data translation into
policy
Page | viii
ACKNOWLEDGEMENTS
This guide was prepared by the WHO Regional Office for Africa - Health Financing and
Investment Programme under the leadership of the Director of the Universal Health
CoverageLife Course Cluster Dr Kasonde Mwinga The key people involved in the process
were Dr Juliet Nabyonga Ms Diane Karenzi Muhongerwa Dr Benjamin Nganda Dr Seydou
Coulibabby Mr Farba Sall and Mr Brandan Kwesiga We thank Chandrakant Laharia for
reviewing the draft guide The Regional Office would like to thank Angelique K Rwiyereka
who led the process of developing this guide
Page | ix
DEFINITIONS OF KEY TERMS
National health accounts are a way for countries to monitor health spending across multiple
streams regardless of the entity or institution that financed and managed that spending NHA
reflects the main functions of health care financing resource mobilization pooling
purchasing of care and distribution of benefits NHA classification schemes are designed to
be compatible with those used internationally for comparison Maeda et al1 provide the
main definitions
Institutionalization of national health accounts is the routine government-led and country-
owned production and utilization of an essential set of policy-relevant health expenditure
data using an internationally accepted health accounting framework The World Bank
framework for institutionalization of NHA outlines the key components for the
institutionalization of NHA to be effective including (1) ensuring country ownership of the
governance capacity and financing for NHA leading to a complete routinization of the
demand and use of NHA data and (2) producing and managing data and ensuring their
quality disseminating results and translating the data into relevant policy decisions
Stakeholders are any people groups or organizations that have a stake in the subject of
interest Stakeholders are positively or negatively impacted by a prospective policy
programme initiative or project In the context of NHA stakeholders are defined as actors
who have an interest or obligation to contribute to the financing production or use of NHA
data or who may be impacted positively or negatively by the use of NHA data
1 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for
Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development--Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | vii
ORGANIZATION OF THIS GUIDE
This guide has been developed to support the progress towards the use of evidence for
decision-making with the necessary policy institutional legal and funding arrangements to
mainstream national health accounts (NHA) within African countriesrsquo routine data systems
The assessment of the status of NHA institutionalization in the African Region that inspired
the production of this guide and which was undertaken in seven countries adequately
selected to account for country location and performance levels showed that greater efforts
were needed to achieve full NHA institutionalization
This guide has four main sections
bull The background is an introduction to the general NHA concept and its importance for the
Sustainable Development Goals (SDGs) towards which all countries are currently
marching
bull The rationale intended audience and scope of the guide present the justification for
producing evidence for sound investment decision-making in health This section covers
the boundaries and intended users of the guide
bull The third section is on the World Bank framework for the institutionalization of NHA
which is the basis for understanding the components required for NHA institutionalization
at the country level (1) governance needed capacities and finances (2) demand and use
(3) production and quality assurance (4) dissemination and (5) translation of NHA data
into specific policies
bull The steps for the institutionalization of NHA are this guidersquos originality in defining the four
major components necessary to make progress towards the full institutionalization of
NHA appropriate leadership structures an implementation plan an appropriate host
institution and funding options for sustainability A country situational analysis provides
evidence on country context and gaps in mainstreaming NHA in national data systems
including comprehensive guidance on the approach to address the gaps related to the
demand and use of NHA its production and dissemination and data translation into
policy
Page | viii
ACKNOWLEDGEMENTS
This guide was prepared by the WHO Regional Office for Africa - Health Financing and
Investment Programme under the leadership of the Director of the Universal Health
CoverageLife Course Cluster Dr Kasonde Mwinga The key people involved in the process
were Dr Juliet Nabyonga Ms Diane Karenzi Muhongerwa Dr Benjamin Nganda Dr Seydou
Coulibabby Mr Farba Sall and Mr Brandan Kwesiga We thank Chandrakant Laharia for
reviewing the draft guide The Regional Office would like to thank Angelique K Rwiyereka
who led the process of developing this guide
Page | ix
DEFINITIONS OF KEY TERMS
National health accounts are a way for countries to monitor health spending across multiple
streams regardless of the entity or institution that financed and managed that spending NHA
reflects the main functions of health care financing resource mobilization pooling
purchasing of care and distribution of benefits NHA classification schemes are designed to
be compatible with those used internationally for comparison Maeda et al1 provide the
main definitions
Institutionalization of national health accounts is the routine government-led and country-
owned production and utilization of an essential set of policy-relevant health expenditure
data using an internationally accepted health accounting framework The World Bank
framework for institutionalization of NHA outlines the key components for the
institutionalization of NHA to be effective including (1) ensuring country ownership of the
governance capacity and financing for NHA leading to a complete routinization of the
demand and use of NHA data and (2) producing and managing data and ensuring their
quality disseminating results and translating the data into relevant policy decisions
Stakeholders are any people groups or organizations that have a stake in the subject of
interest Stakeholders are positively or negatively impacted by a prospective policy
programme initiative or project In the context of NHA stakeholders are defined as actors
who have an interest or obligation to contribute to the financing production or use of NHA
data or who may be impacted positively or negatively by the use of NHA data
1 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for
Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development--Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | viii
ACKNOWLEDGEMENTS
This guide was prepared by the WHO Regional Office for Africa - Health Financing and
Investment Programme under the leadership of the Director of the Universal Health
CoverageLife Course Cluster Dr Kasonde Mwinga The key people involved in the process
were Dr Juliet Nabyonga Ms Diane Karenzi Muhongerwa Dr Benjamin Nganda Dr Seydou
Coulibabby Mr Farba Sall and Mr Brandan Kwesiga We thank Chandrakant Laharia for
reviewing the draft guide The Regional Office would like to thank Angelique K Rwiyereka
who led the process of developing this guide
Page | ix
DEFINITIONS OF KEY TERMS
National health accounts are a way for countries to monitor health spending across multiple
streams regardless of the entity or institution that financed and managed that spending NHA
reflects the main functions of health care financing resource mobilization pooling
purchasing of care and distribution of benefits NHA classification schemes are designed to
be compatible with those used internationally for comparison Maeda et al1 provide the
main definitions
Institutionalization of national health accounts is the routine government-led and country-
owned production and utilization of an essential set of policy-relevant health expenditure
data using an internationally accepted health accounting framework The World Bank
framework for institutionalization of NHA outlines the key components for the
institutionalization of NHA to be effective including (1) ensuring country ownership of the
governance capacity and financing for NHA leading to a complete routinization of the
demand and use of NHA data and (2) producing and managing data and ensuring their
quality disseminating results and translating the data into relevant policy decisions
Stakeholders are any people groups or organizations that have a stake in the subject of
interest Stakeholders are positively or negatively impacted by a prospective policy
programme initiative or project In the context of NHA stakeholders are defined as actors
who have an interest or obligation to contribute to the financing production or use of NHA
data or who may be impacted positively or negatively by the use of NHA data
1 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for
Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development--Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | ix
DEFINITIONS OF KEY TERMS
National health accounts are a way for countries to monitor health spending across multiple
streams regardless of the entity or institution that financed and managed that spending NHA
reflects the main functions of health care financing resource mobilization pooling
purchasing of care and distribution of benefits NHA classification schemes are designed to
be compatible with those used internationally for comparison Maeda et al1 provide the
main definitions
Institutionalization of national health accounts is the routine government-led and country-
owned production and utilization of an essential set of policy-relevant health expenditure
data using an internationally accepted health accounting framework The World Bank
framework for institutionalization of NHA outlines the key components for the
institutionalization of NHA to be effective including (1) ensuring country ownership of the
governance capacity and financing for NHA leading to a complete routinization of the
demand and use of NHA data and (2) producing and managing data and ensuring their
quality disseminating results and translating the data into relevant policy decisions
Stakeholders are any people groups or organizations that have a stake in the subject of
interest Stakeholders are positively or negatively impacted by a prospective policy
programme initiative or project In the context of NHA stakeholders are defined as actors
who have an interest or obligation to contribute to the financing production or use of NHA
data or who may be impacted positively or negatively by the use of NHA data
1 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for
Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development--Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | x
EXECUTIVE SUMMARY
National health accounts (NHA) are an accounting system adopted internationally as the
global standard for health care expenditure tracking to support decision-making A situational
analysis of the institutionalization of NHA in Africa was conducted in 2020 using the World
Bank framework on the institutionalization of NHA The analysis revealed that despite its
relevance NHA had not been institutionalized in African countries mostly owing to the
limited political attention and funding and the poorly harmonized and unsustainable efforts
that did not build on existing resources and that resulted in expensive outdated and difficult-
to-read reports
NHA has been used inadequately for discussions in health The process has not been fully
institutionalized to ensure that such data is available in regular and timely manner With
adequate support NHA has the potential to be fully institutionalized2 in Africa this time
around because of the renewed momentum on the Sustainable Development Goals (SDGs)
building on the current knowledge on what worked or did not over the last two decades and
capitalizing on the current digital revolution in Africa In an effort to guide countries towards
the successful institutionalization of NHA and based on the World Bank framework this guide
presents a few general principles as detailed in the following paragraphs
NHA governance capacity and funding
Based on the World Bank NHA institutionalization framework governance capacity and
financing mechanisms will ensure NHA institutionalization will have a focus on sustainability
This implies the integration of health accounts within countriesrsquo governance systems and
capacity adequacy in terms of data infrastructure and funding The two key components are
bull Leadership and funding for NHA ndash These form the foundation for NHA institutionalization
To succeed three levels of leadership are needed
minus A champion to advocate for political attention and resources raise awareness
monitor the countryrsquos performance and build high-level consensus on key
milestones The champion will be a high level national leader
minus Steering and technical committees to oversee and implement the NHA
institutionalization processes and
minus Resource mobilization leadership to digitize and mainstream NHA in existing vital
statistics and data systems The resources will encompass both infrastructure and
human resources
2 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | xi
bull Country situational analysis ndash NHA institutionalization should build on an in-depth
country situational analysis NHA institutionalization is a customized and unique journey
for each country and to succeed it requires tailoring of its approach to the countryrsquos
reality This individualized journey will highly depend on the extent to which local leaders
understand the value of NHA for policy decisions Whether at the country level the
concept is novel or not the institutionalization of NHA will always require a thorough
situational analysis to set the baseline of the countryrsquos existing gaps prior experiences
and resources A situation where NHA is a novel concept presents an opportunity for
raising awareness and building capacity on NHA and working towards its
institutionalization from the get-go In general however NHA is not a novel concept and
most countries have produced at least one round of NHA reports sponsored and
supported by ad hoc funding and consultancy teams with minimal attention to
sustainability
Data demand and use production dissemination and translation into policies
Two important principles are highlighted here
bull Sustainability of NHA is central to its institutionalization ndash For a country to sustain NHA
there must be demand and use of NHA routine production as well as capacity for its
production and dissemination and ultimately translation of the results into relevant
policies the end goal of the overall process In regard to NHA sustainability the situational
analysis will achieve two main goals
minus Map stakeholders ndash This is of utmost importance in understanding the potential
drivers of NHA institutionalization The stakeholders include government ministries
departments agencies service providers and the parliament as well as
nongovernment players such as multilateral and bilateral stakeholders civil society
academia nongovernmental organizations the private sector etc
minus Assess past NHA demand production and dissemination and the use of evidence in
policy-making and evaluation ndash The assessment will include analyses of gaps political
commitment policy-making processes fiscal context public administration public
finance management and the extent of decentralization Included also will be the
institutions and programmes in place that would support or impede NHA
institutionalization including the monitoring and evaluation infrastructure and the
human and financial resources This guide proposes steps to understand the gaps
and suggests approaches that would move countries towards successful and
sustainable NHA institutionalization
bull NHA hosting is a crucial factor for its sustainability ndash Different countries will take different
pathways to achieve the full institutionalization of NHA In general however NHA will be
housed where the most investment in data collection and analysis already exists NHA
should not be viewed as a project that will always require targeted vertical funding but
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | xii
rather as a data reporting mechanism to be mainstreamed in existing routine data
collection systems Multiple institutions can house parts or all of the NHA processes if they
have the capacity to synchronize data collection management and analysis
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 1
1 BACKGROUND
All countries are committed to the 17 Sustainable Development Goals (SDGs)3 the third of
which aims at ensuring the provision of good health and well-being for all at all ages in all
countries Just like other States African countries are working towards achieving the Goal 3
through increased health spending and investments in cost-effective interventions The
investment process cannot be conducted blindly as both governments and donors are
increasing guided by data and becoming more efficient When it comes to health financing
understanding health expenditure indicators is indispensable in decision-making
demonstrating accountability and transparency for donor and taxpayer money making global
comparisons and sharing best practices Health expenditure indicators are internationally
standardized and tracked through the system of national health accounts (NHA)
Globally NHA has been used as a way for countries to monitor health spending regardless of
the entity financing and managing that spending NHA has the advantage of disaggregating
total health expenditure by end-user provider and population subgroups These breakdowns
are critical information in scaling up health care access and improving affordability in efforts
towards achieving universal health coverage (UHC) a strong contributor to SDG 3 Whereas
countries in America Asia and Europe have institutionalized NHA African countries are yet to
do so4 Some of the strong evidence coming from NHA is the understanding that most often
government subsidies benefit mostly richer groups living in major cities shrinking the
resources available for rural clinics contrary to the ethics of a well-designed health system5
Such evidence for decision-making becomes even more important in the context of the
COVID-19 pandemic with its contraction of countriesrsquo economic growth
2 RATIONALE SCOPE AND INTENDED AUDIENCE OF THIS GUIDE
21 Rationale
UHC means ldquothat all individuals and communities receive quality affordable and accessible
health services as close to them as possible It includes the full spectrum of essential health
services from health promotion to prevention treatment rehabilitation and palliative care
3 The Sustainable Development Goals or Global Goals are a collection of 17 interlinked global goals designed to be a
blueprint to achieve a better and more sustainable future for all The SDGs were set in 2015 by the United Nations General Assembly and are intended to be achieved by 2030 (httpswwwunorgdevelopmentdesadisabilitiesenvision2030html httpsenwikipediaorgwikiSustainable_Development_Goals)
4 The Status Update of National Health Institutionalization in the African Region WHO 2020 5 Maeda et al 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the
Institutionalization of NHA httpdocuments1worldbankorgcuratedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 2
across the life courserdquo6 UHC is a path towards achieving SDG 3 and a commitment that
countries are striving to honour In this journey the goal of a countryrsquos health financing
system is to protect its citizens from financial hardship and reduce inequalities in accessing
quality and cost-effective health care services NHA is an effective tool for providing evidence
on who is covered and who is not where the uncovered are which services have low coverage
and how much more money is needed to achieve agreed targets
NHA indicators support the monitoring of health spending and critically analyse health care
financing to ensure evidence-based resource mobilization and pooling purchasing of health
care services and benefit distribution They also provide the rationale for policy options This
guide provides a standardized yet flexible process to direct countries in undertaking
successful institutionalization of NHA and enhancing health system effectiveness efficiency
accountability and best practices
22 Scope and intended audience of this guide
This guide provides practical steps to strengthen the systems structures and institutions that
ensure the timely provision of quality NHA data It is intended for the WHO African Region
Member States to be used by their ministries of health and finance parliaments academia
civil society donor organizations regional bodies and the private sector in supporting the
institutionalization7 of NHA This guide will be adapted to each countryrsquos context
3 FRAMEWORK FOR THE INSTITUTIONALIZATION OF NHA
The 2012 World Bank guideline on the institutionalization of NHA proposes a framework for
the NHA cycle with four components (1) demand and use (2) production data management
and quality assurance (3) dissemination and (4) translation of NHA data into specific policies8
(see Fig 1)
6 httpswwwwhointnews-roomfact-sheetsdetailuniversal-health-coverage-(uhc) 7 The institutionalization of the National Health Accounts has been defined as routine government-led and
country-owned production and utilization of an essential set of policy relevant health expenditure data using
an internationally accepted health accounting framework
8 Maeda Akiko Harrit Margareta Mabuchi Shunsuke Siadat Banafsheh Nagpal Somil 2012 Creating Evidence for Better Health Financing Decisions A Strategic Guide for the Institutionalization of National Health Accounts Directions in Development ndash Human Development Washington DC World Bank (httpsopenknowledgeworldbankorghandle1098613141)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 3
Figure 1 World Bank framework for the institutionalization of NHA
4 STEPS FOR THE INSTITUTIONALIZATION OF NHA
41 Governing ensuring capacity and financing NHA
The steps this guide proposes are based on the World Bank framework for the
institutionalization of NHA In terms of governance capacity and finance the report from the
assessment of the institutionalization of NHA in Africa showed that some countries were more
advanced than others in the NHA institutionalization journey A few general steps are
described here based on the challenges and recommendations identified during the recent
assessment of the current status of the institutionalization of NHA in Africa and best practices
The first step is to understand each countryrsquos context and thus the need to undertake a
situational analysis
For the situational analysis which is a customization process each country will have a unique
time frame based on the local environment specifically the political will and resources
including the available infrastructure human resources and NHA implementation culture A
careful understanding of the local context will yield sustainable results even though it may
seem to take considerable time and resources at the beginning Countries with an appropriate
legal or institutional framework will have an easy start because they will already have written
commitments
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 4
411 Country situational analysis
WHO defines a situational analysis as an assessment of the current situation fundamental in
designing and updating national policies strategies and plans9 The situational analysis should
be designed and conducted in a way to provide a systematic overview of the countryrsquos health
financing system with detailed evidence on challenges and gaps In the context of NHA
institutionalization the situational analysis will consider the following key elements
bull Stakeholders in the health sector ndash These include government branches (the executive
and the legislative) and nongovernment players such as civil society the private sector
academic institutions parliament etc Stakeholder analysis is critical to the understanding
of policy drivers and whether stakeholders are or are not potential NHA supporters The
purpose is either to capitalize on their support or design strategies to win them over to
the NHA cause This is also critical in understanding whether policies are designed in a
participatory process an important element for NHA to thrive
bull Previous efforts to produce or institutionalize NHA ndash It is important to be familiar with
the successes and failures of previous work on NHA in a given country to build on positive
experiences or to put strategies in place to mitigate previous failures In addition it is
important to assess the policy-making planning and budgeting processes including
monitoring and evaluation programmes and platforms within which NHA must be
mainstreamed
bull Major contextual factors ndash These include (1) the fiscal context of the governmentrsquos ability
to mobilize public revenues (2) public administration particularly the extent of
decentralization within the government and the decision-making responsibilities held at
different levels(3) public finance management and (4) the extent of private sector
involvement in health care
4111 Stakeholder analysis
Mapping of stakeholders
There are players inside and outside the government that based on their mission will
encourage the institutionalization of NHA First among these is the executive branch
constituting the ministry of health whose mission is to provide quality equitable and
affordable health care services Second is the ministry of finance whose goal is to improve
the populationrsquos living standards though it operates within an environment of competing
demands for resources Both these ministries have a core obligation to advocate for more
resources for health and to work at achieving the governmentrsquos health goals In some
countries the functions of finance economic development budget and planning are all rolled
into one ministry with different departments In other countries they are held by different
9 WHO AFR Status Update of the Institutionalization of NHA in Africa December 2020
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 5
ministries that work separately but in close collaboration In this document the term ministry
of finance embodies all the government functions of finance planning and budgeting
Whereas the ministry of health seeks adequate resources to implement health programmes
the ministry of finance faces budget constraints with multiple and competing demands for
resources from different sectors including education agriculture infrastructure defence etc
The ministry of finance will have a tendency to be conservative in allocating the limited
resources as it faces growing demands NHA generates triple benefits for the ministry of
health in particular and for the government as a whole by showing accountability for
government money at all levels supporting the ministry of health to advocate for increased
resources through linking expenditure to outcome indicators and (3) supporting the ministry
of finance in showing where and how much more funding is needed to achieve government
targets
Other government institutions with interest in NHA are the ministry of local government
which manages local services including health services and the office of the auditor-general
which has for instance the mandate to improve accounting and financial reporting and
promote effectiveness efficiency by holding to account all persons entrusted with
management of public funds and resources10 The auditor-generalrsquos annual audits
demonstrate the parliamentrsquos ultimate authority supervision and control over all aspects of
public finance In this context the legislative branch also is an important stakeholder because
it votes on laws and budgets Together with the ministry of local government the legislative
branch has the mandate to understand how much money is spent on the population under
its leadership who is covered and who is not covered and whether funding change will have
an impact on vulnerable populations under its responsibility
The national institute of statistics also is a key government institution in regard to NHA Its
mandate is to collect analyse archive and disseminate national statistical data with the
objective of aiding the government in making timely evidence-based national decisions This
institute can impact the production of NHA significantly by mainstreaming NHA data
requirements in existing tools such as population-based surveys The availability of data on
health expenditure patterns has the potential of enriching the recommendations from
analyses of demographic and health survey data
NHA generates benefits for nongovernment players such as civil society which is ldquothe
ecosystem that influences social change outside of the family market or government Often
referred to as the space where we act for the common good civil society aims to connect
10 Office of the Auditor General Michigan State USA (httpsaudgenmichigangovabout~text=The
20OAGs20overall20goal20isand20economy20in20State20government)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 6
poor or marginalized people with groups that can mobilize support to helprdquo11 Civil society
can track the use of taxpayer money and advocate for underserved services or populations
NHA has benefits also for the private sector as it can use NHA data to make informed
decisions on where to allocate its investments for example in underserved wealthy
communities
The scientific and academic worlds need NHA to generate evidence on what works or does
not work through economic impact studies or efficiency and cost-effectiveness analyses of
health programmes This is critical in informing policy and programmes and in stimulating
innovation
For both government and nongovernment players NHA serves as an accountability tool to
show how available funding contributes to achieving key development goals In each country
stakeholder mapping will include a complete list of stakeholders contributing to the health
sector (see Table 1 for an example)
Table 1 Illustrative list of stakeholders in the health sector in African countries
Sector Branch Institution
Government Executive branch Ministry of health
Ministries of budget finance planning local government etc
National institute of statistics
Office of the auditor-general
Legislative branch Senate parliament
Academia
Schools of public health economics business
Stakeholder organizations
Multilateral agencies United Nations agencies (WHO UNAIDS UNFPA UNICEF UNDP) World Bank IMF Global Fund
Philanthropies Bill and Melinda Gates Foundation etc
Regional bodies African Union European Union East African Community East Central and Southern Africa Health Community etc
Bilateral agencies USAID Belgian Cooperation French Cooperation SIDA
Nongovernment institutions
Action Aid
Civil society Health Development Performance
Consulting organizations Abt Associates Management Sciences for Health
Note This list is illustrative and will be adapted based on countriesrsquo contexts
Assessment of stakeholder interest and influence for National Health Accounts
Once the list of stakeholders has been made it is important to undertake an analysis of their
interest and power to either positively or negatively impact the institutionalization of the NHA
process The interest or influence of stakeholders allows those entrusted with pushing
forward the NHA agenda to assess the next steps and take appropriate decisions Powerful
stakeholders are those with the interest and power to significantly impact NHA
institutionalization The most common among these on the government side are the
11 Mission Box Global Networks (httpswwwmissionboxcomarticle418social-change-whats-the-role-of-civil-society)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 7
ministries of health and finance including the ministries of budget and planning in some
countries the parliamentary committee on health and the national institute of statistics
When leaders and technocrats from these key stakeholders support NHA institutionalization
the process can be smooth
The powerful nongovernment stakeholders are those capable of providing substantial
funding and technical support for NHA institutionalization These include United Nations
agencies and specifically WHO and the World Bank foundations such as the Bill and Melinda
Gates Foundation and civil society organizations Nongovernment stakeholders in support of
NHA institutionalization will be identified for engagement right away while awareness efforts
and training sessions will be undertaken for uninterested stakeholders to get them involved
because of their importance for funding resource mobilization and NHA data collection
analyses dissemination and interpretation
Semi-structured interviews can be useful to establish stakeholder awareness of and interest
in NHA institutionalization and specifically to understand
bull their knowledge on NHA demand and use production and dissemination and the
potential benefits for policy decisions
bull challenges and gaps related to NHA and factors that may impede its institutionalization
and
bull their suggestions for improving the demand and use production and dissemination of
NHA data and their translation into policies
The situational analysis results should lead to concrete actions in the form of
bull engagement with stakeholders who are unaware or unsupportive of NHA for example
through consultative meetings where their important role in the countryrsquos health and
development will be highlighted
bull assessment of each individual stakeholderrsquos organization and its potential benefits for
NHA
bull supporting the mainstreaming of NHA data in stakeholder routine activities through
involving the stakeholders in the collection sharing analysis interpretation and
dissemination of NHA data and their translation into specific policies
4112 Assessment of existing policies and programmes for National Health Accounts
NHA institutionalization requires the development of pertinent legal and institutional
frameworks Legal frameworks include ministerial orders policies laws memorandums of
understanding and collaboration instruments in support of NHA These frameworks should
be explicit and should provide specific institutions the mandate and resources for the
functions under their charge The goal is to move from the consultant-based approach that
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 8
has so far been the modus operandi for NHA production in all the countries Institutional
frameworks will encompass newly set up programmes and modifications or upgrades of
existing institutions or programmes to include NHA as a part of their deliverables Policies and
programmes supporting NHA already in existence are an important factor in charting the way
forward If an existing institution housing NHA is not delivering for some reason its policies
and institutional framework including its resources will need to be reviewed NHA
sustainability requires ownership and leadership and adequate policies programmes and
resources
412 Lead plan and finance National Health Accounts
4121 Leadership structure for National Health Accounts
There is need to create a country NHA leadership mechanism in coordination with the
stakeholders Three levels of leadership are proposed an NHA champion a role that will cease
with the successful institutionalization of NHA and steering and technical committees
Countries can contextualize the proposed leadership structure as needed including the
number of committee members Strategic selection of members will ensure that those in non-
technical roles will not exceed a dozen for efficiency in discussions (see Table 2 for an example
of the constitution of NHA institutionalization leadership teams)
National Health Accounts champion
The primary function of this role is advocacy for NHA institutionalization This role should be
entrusted to a person of influence who could be the prime minister minister of health or
finance or the chairperson of the health committee in parliament The champion will be the
face of NHA institutionalization efforts will ensure NHA gains political attention and will
support resource mobilization for NHA policy and programme implementation making sure
that there is evidence that resources are earmarked for NHA institutionalization This role has
a timeline and will end after the complete and successful NHA institutionalization has been
objectively demonstrated through an evaluation Being drawn from the existing leadership in
the country the champion will not earn an income for the role but will receive facilitation
support
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 9
Table 2 Country leadership for National Health Accounts in Africa
Leadership level Representation Institutions from which NHA team will be drawn
Champion High government level Minister of health finance and parliamentary health committee chairperson
Steering committee
Government
Secretary-general ministry of health
Secretary(ies) general ministries of financebudgetplanning
Director general institute of statistics
Head health committeeparliament
Academia Schools of finance public health or economics
Civil society
President of private health care providersrsquo federation
President of private health insurance federation
President of private pharmaciesrsquo federation
President of traditional healers and alternative medicine association
Representatives of NGOs working in health
Stakeholders Deputy directors at WHO
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation
Technical team
Coordinator National planning institute of statistics or IFMIS at the ministry of finance
Data collection and analysis teams
IFMIS 2 IT experts and 2 analysts EMR 2 IT experts and 2 analysts
4 staff (2 IT experts and analysts) from the institute of statistics
2 staff NHA focal person at MoH and ministry of finance
1 staff from MoH in charge of public hospitals
1 staff from private sector in charge of private hospitals
1 staff from the office in charge of traditional healers and alternative medicine
In countries where IFMIS teams do not exist any public finance team will work
Steering committee
This will be a political leadership structure giving legitimacy to the technical committee It will
provide political attention and resources for NHA institutionalization through its life cycle
from NHA demand and use to translation of the data analyses into policies It will contribute
to the interpretation of NHA results and validate own and translate them into actionable
policies that will be evaluated as part of the health sectorrsquos performance The steering
committee will be led by a chairperson who will be drawn from a government institution
and a co-chairperson who will come from a nongovernment institution
The steering committee should include permanent secretaries from the ministries of health
and the ministries of finance and their directors-general and the director in charge of health
financing and planning and equivalent in these ministries Additional members will be the
head of the institute of statistics leaders of the parliamentary health committee and
directors-general of the public social health protection schemes From outside the
government will be leaders of regional or provincial public hospitals the president of the
private health care providersrsquo federation heads of private pharmacies and health insurance
associations local nongovernmental organizations in health and the presidents of traditional
healers and alternative medicine associations
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 10
Technical committee
This committee will comprise technical teams working towards NHA institutionalization The
technical staff will be located in the different institutions collecting and analysing data and
whenever needed will be brought on board to focus on NHA or to support the overall
institution in which specific NHA data will be collected
The technical committee will be made up of a coordinator and staff working on a daily basis
in existing institutions and handling data Technical teams will not be located in the same
institution to avoid the NHA institutionalization becoming a vertical programme the goal
being to mainstream NHA in existing data systems The coordinator may be housed at any of
the key institutions handling data such as planning departments IFMIS or the institute of
statistics or she or he may be from academia The technical committee will include IT experts
health economists and data analysts from IFMIS electronic medical records or the institute
of statistics and the institution responsible for the integrated household living conditions
surveys and demographic and health surveys Other members will come from the directorate
in charge of public hospitals staff in charge of accounting in the private health insurance
federation technicalfinance staff from the office of traditional healersalternative medicine
etc The technical committee will include senior technical officers and directors at WHO the
World Bank UNAIDS USAID UK Aid Belgian Technical Cooperation etc
Steering and technical committee members will be drawn from the government civil society
academia the private sector and development partners The leaders from these institutions
who join the NHA team will be part of the steering committee whereas the technical staff
will be in the technical committee The technical committee will be the implementing team
in charge of institutionalizing data collection and analysis but in data interpretation they will
work in conjunction with the steering committee
413 Planning for National Health Accounts
The planning strategies and activities for institutionalizing NHA presented in this guide are
based on the World Bank NHA institutionalization framework They will need to be adapted
to countriesrsquo contexts Table 3 focuses on governance capacity and financing strategies and
activities while Table 4 deals with aspects relating to NHA demand and use and dissemination
and translation of data into policies
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 11
Table 3 Planning for National Health Accounts governance capacity and financing
Steps Activities
Step 1 Define governance of National Health Accounts capacity and financing
Step 11 Identify leadership and stakeholders
Step 111 Identify the NHA champion
Step 112 Appoint the steering committee
Step 113 Appoint the technical committee
Step 12 Conduct a situational analysis identify gaps and provide recommendations
Step 121 Agree on initial budget and source of funds for early work (meetings consultants etc)
Step 122 Hire consultant(s)
Step 123 Produce the situational analysis draft report circulate and revise it and share the final draft
Step 124 Organize report dissemination and validation
Step 125 Use the validation meeting to define the next steps objectives and priorities
Step 13 Develop a national strategy for the institutionalization of NHA
Step 131 Develop a national strategy for institutionalizing NHA (preferably as part of the health financing strategy MampE framework) including key indicators of progress
Step 132 In the process of setting up the strategy assign roles responsibilities and funding sources
Step 133 Produce the draft and circulate it
Step 134 Launch the costed national strategy with indicators roles and resources
Step 14 Mobilize resources
Step 141 Organize a stakeholder meeting for resource mobilization
Step 142 Agree on short-term mid-term and long-term funding and its integration in existing institutionsrsquo budget lines
Step 143 Develop MOUs and written commitments
Step 15 Implement and monitor
Step 151 Raise institutional and public awareness on NHA (through television radio print media)
Step 152 Ensure teams working on the demand and use production dissemination and translation of data into policies are doing their job or getting ready to do it
Step 153 Coordinator to organize monthly meetings of technical committee members
Step 154 Hold quarterly meetings of the steering committee to monitor the set milestones
Step 155 Integrate reviews of NHA institutionalization within the health financing reviews and annual health sector reviews
Step 156 Include the budget for the institutionalization of NHA in the budget of relevant institutions
These are drawn from existing identified stakeholder institutions
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 12
Table 4 Meeting National Health Accounts needs in terms of institutionalization
Steps Activities
Step 2 Improve the demand use and dissemination of NHA
Step 21 Ensure that all funding (initial short-term medium-term and long-term) is committedagreed upon
Step 22 Ensure that NHA data demand use and dissemination strategies and activities are included in the health sector strategic plan aligned with the evidence from the initial countryrsquos own needs assessment
Step 23 Map stakeholders understand their mandate and data needs and tailor the dissemination strategy accordingly
Step 24 Identify opportunities and best timing to share NHA data (eg national policy dialogues or retreats etc)
Step 25 Work with academia and designers to provide expertise in designing templates for short user-friendly regular reports on available data on spending Templates should be targeted at different audiences and revised regularly to include new knowledge and stakeholders
Step 27 Develop different dissemination products (formal and informal dissemination of NHA findings)
Focus on policy-makers hospitals and high-level leaders and publish articles policy briefs cost-effective analyses for the ministry of finance parliament etc
Step 28 Focus on civil society ndash organize radio and television shows on health financing and get inputs
Step 29 Focus on regional learning ndash encourage scientific studies innovative improvements in policy and programmes
Step 210 Use social media to highlight indicators needing public attention
Step 211 Integrate NHA dissemination in national MampE systems surveys reports government reviews etc
Step 212 Organize quarterly meetings of government institutions on NHA and define the needed policy improvements
Step 213 Organize quarterly meetings of private sector institutions on NHA and define needed policy improvements
Step 214 Organize quarterly meetings of the steering committee to agree on policy improvements
Step 215 Design a scoring system to motivate public and private sectors to publish NHA data Reward best performers with additional grants to support further research
Step 3 Improve the production and translation of specific analyses into policies
Step 31 IT tools
Step 311 List IT gaps and design or re-design tools and pathways for harmonized and interoperable systems for data collection sharing and analysis
Step 312 Create a national health financing dashboard located at the ministry of health
Step 313 Design a scaling plan and implement it (training installing new solutions in decentralized structures) Evaluate these as you go and create new solutions
Step 32 Enforce data submission and collection
Step 321 Train public and private sector entities in understanding the NHA data required
Step 322 Include submission of NHA data as part of government unitsrsquo performance assessments
Step 323 Bind renewal of licenses for private sector entities and tax submission to NHA data submission
Step 324 Design a scoring system for the public and private sectors to submit data Reward best performers through grants for research in support of data submission improvements
Step 33 Data production solutions
Step 331 List train and sustain human resource capacity (training of existing human resources mainstreaming data production in curricula in schools and public health economics public policy journalism institutions etc)
Step 332 Produce detailed and targeted analyses for all stakeholders (including subregional equity allocative and technical efficiency analyses etc)
Step 333 Monitor technologies to improve data production based on current science
Step 34 Translate specific analyses into policies
Step 341 Identify the list of policies and strategies concerned with NHA findings and monitor them
Step 342 Incorporate NHA in health financing working groups to inform policies after implementation
Step 343 Design a scoring system to motivate the public and private sectors to use data and inform programme and implementation Reward best performers eg with grants for improvements in data processes
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 13
414 Financing National Health Accounts Planning and budgeting for NHA institutionalization will be based on the overall country
situational analysis and will be part of the health sectorrsquos strategic plansrsquo costing exercises Some
countries will need more resources than others based on their local human resources and existing
IT infrastructure The steps below are proposed as guidelines for planning and budgeting purposes
and will need to be adapted to each countryrsquos context We categorize the funding for the
institutionalization of NHA into four types
bull The initial budget will start the functioning of the championrsquos role It is limited funding meant
to support the early stages of NHA institutionalization
bull The short-term budget will support the steering and technical committees and enable the
undertaking of a situational analysis and the subsequent development of a costed strategic
plan to respond to the gaps identified by the situational analysis
bull The mid-term budget or investment fund will ensure the implementation of the strategic plan
through for example building the governmentrsquos or the private sectorrsquos information
technology recruiting technical consultants in IT health financing or economics and
acquiring digital solutions servers and internet capability etc When NHA institutionalization
is complete the investment fund will cover the first two years of its monitoring and
evaluation
bull The long-term or routine budget will be disbursed as part of the regular budgets of the
institutions involved in collecting analysing and disseminating data and translating data into
policies The long-term budgetrsquos disbursement will not be vertical but will be mainstreamed
in existing budgets
Country teams will need to develop financial estimates and time frames for their activities
and Table 5 can serve as a template they can fill to capture the values for their budgets
Table 5 Situation analysis results and resources needed
Resources Funders Amount Time
1 Initial budget support NHA champion with initial discussions Activities will involve
meetings and travel to engage with stakeholders and potential supporters
2 Short-term budget The steering committee chairpersons (representing the
government) and co-chairpersons (representing nongovernment stakeholders) will
designate members of the steering and the technical committees This budget will
support these committees but not the salaries of members as they will be staff of
existing institutions The technical team will be covered by this budget including
recruitment of new IT staff to support existing institutions if required
3 Mid-term budget or investment fund This will cover infrastructure and technical
consultancy resources needed to upgrade IT systems and databases The consultants
may be existing staff of government or nongovernment institutions but working
outside their regular hours
4 Long-term budget or routine fund This budget will be dedicated to finalizing NHA
institutionalization once everything has been put in place and to ensure the system is
functioning well before exiting NHA efforts are implemented vertically
The money and time needed column will be filled by each country based on local needs
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 14
415 Hosting National Health Accounts for sustainability NHA institutionalization activities will be best hosted in an institution with a strong capacity
for data production for their maximum routinization in existing data systems The institution
should also have authority over the data to enforce data submission NHA would also benefit
from being accommodated by a host with the highest IT capabilities The situational analysis
report will propose the primary NHA host institution Several other institutions can be
considered secondary hosts based on the data they produce Ideally the coordinator should
be located in the primary host institution The host institution will be confirmed and
designated during the reportrsquos validation Below are the proposals for potential NHA host
institutions
4151 Ministry of health
The ministry of health is the first beneficiary of NHA data However it is mainly a political
institution and may not have the internal capacity to undertake the institutionalization of NHA
owing to funding and expertise limitations but also in terms of scope because NHA involves
data beyond those generated within this ministry The 2020 assessment of institutionalization
of NHA showed that most ministries of health in Africa were short of staff in general and IT
experts and economists in particular to coordinate data collection and analyses processes
It is expected that under the overall leadership of the minister of Health the process will be
accelerated
4152 Ministry of finance
In all countries the ministries of finance are the hosts of IFMIS In countries where IFMIS is
decentralized it becomes a precious tool to provide key government data for NHA IFMIS
teams are composed of economists finance officers and IT programmers and are a unique
resource to tap into to advance NHA as part of a regular report submission process such as
the reports submitted to the International Monetary Fund the World Bank UNDP National
AIDS Spending Assessment (NASA) etc Each countryrsquos ministry of finance has a set of
indicators that it generates monthly quarterly semi-annually or yearly Within the ministry
of finance NHA has the potential to thrive and benefit from the resources allocated to other
data systems The downside is that IFMIS focuses exclusively on public funds missing data
from the private sector However as part of a government institution IFMIS can find ways to
enforce submission of data from that sector Considering it require coordination between two
ministries the leadership of minister of finance along with minister of health will be vital for
success of this endeavour
4153 National institute of statistics
According to the UNstats national statistical agencies compile official statistics to provide
information to the general public governments business and research communities on the
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 15
economic demographic social and environmental fields12 Their mission include the
production and dissemination official statistics to support evidence-based decision making
and planning processes and to coordinate the statistical activities of the National Statistical
System including statistical capacity building initiatives helliprdquo13 They generate health non-
health financial non-financial and household demographic and health survey data etc There
are multiple advantages in housing NHA at the institutes of statistics (1) they are mandated
to produce data and are staffed and equipped to deliver on their mission (2) there are
economies of scale in entrusting them to mainstream NHA in the general data collection
systems and (3) they have a culture of enforcing data submission by both public and private
agencies The national institute of statistics should collaborate with the ministries of health
and finance on the one hand and academia on another hand to ensure the translation of data
analyses into policies As the National Institutes of Statistics have role in collection and
coordination of the data their leadership will ensure availability of health and financing data
in timely manner which meets the quality standards This would be essential for
institutionalization of the process and development of high quality NHA reports
4154 Academia
Universities and institutes of higher learning have the skills and mission to provide human
resources The schools of economics public health and public policy are mandated to train
and equip students with critical and independent analysis skills They provide the best setting
to sustain NHA human resources Students could major in health financing and use datasets
from the national statistics institute for training and research However academic institutions
do not have a mandate to generate data and hence may not serve as the primary but a
secondary host for NHA focusing on human resources The academia may be involved in the
capacity building of human resources who can be trained in working on development of
NHAs The selected academic institutions may be designated to conducti regular trainings in
NHA and related tools This would ensure that even if some of the staff responsible in various
concerned departments are transferred out there would be sufficient availability of
additional workforce to continue such activities This would strengthen the
institutionalization process
Table 6 shows the NHA hosting options available to the countries and their advantages and
disadvantages Each country will decide which among them best suits its setting
12 httpsunstatsunorgunsddnssgpImplementation_Guidelines_FINAL_without_editpdf 13 Institute of Statistics Rwanda httpswwwstatisticsgovrwpresspress-releasepress-release-nisr-signs-partnership-
aims
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 16
Table 6 Analysis of potential National Health Accounts hosts for sustainability
Potential host Advantages Inconveniences
Ministry of health
1 Health policy is a priority here and advocacy for more funding is a permanent activity
2 A clear advantage is the rapidity of translating the data into policies if NHA was hosted in this ministry
1 May not be equipped with enough personnel and skills to delve into data analyses and interpretation
Ministry of finance
1 The strong oversight and close monitoring of the performance of the health sector can serve to improve the efficiency of the health ministry This ministry can enforce the requirement for adequate improvement of NHA
2 NHA sustainability is guaranteed as this ministry is the budget holder
3 NHA will benefit from building on IFMIS infrastructure and human resources
4 It can easily enforce data submission from the private sector
1 Data activities are not a primary function
2 As the funds holder this ministry might use NHA as a tool of pressure requiring submission of data as a precondition for disbursing of funds
Institute of statistics
1 NHA will benefit from the primarily data collection and analysis function
2 Building on other data resources will be an advantage 3 Sustainability will be guaranteed due to the
investments in all national data collection infrastructure and human resources
4 This institute serves as the best intermediary between ministries by focusing on its role of production and providing evidence
1 NHA estimation is not a primary function
2 No control over development partners implementing partners and private sector reporting especially by hospitals
Schools of economics public health
1 NHA will benefit from supervision from professors and senior lecturers close by who will motivate studies and deeper analysis of data and interpretation of findings
1 Does not have a function of continuous data collection so NHA would be a vertical project with targeted funding
42 Meeting the needs for the demand and use production and dissemination of
NHA and translation of data into policies
421 Assessing country status on the demand and use of National Health Accounts
To ensure that NHA is fully institutionalized the situational analysis will provide responses to
the questions presented in Table 7
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 17
Table 7 Assessing country status on the demand and use of National Health Accounts
Assessment area
Question Text
Assessing the demand and use of National Health Accounts data
Q11 Is there an established governance structure for undertaking and coordinating NHA work Where is it housed
Q12 Who predominantly finances NHA work-related activities Is there a long-term financing strategy for the production of NHA
Q13
Who demands NHA data in the country What triggers the demand Who has direct interest in its demand and use Please present the context related to the expression of the need for NHA data from government (was it from the ministry of health or finance) the private sector and donor perspectives
Q14 Who are the stakeholders interested in the documentation and use of NHA data This would enrich the understanding of the willingness and readiness to use NHA data
Q15 What is the extent to which reference is made to NHA data in policy dialogues (joint annual reviews health sector assessments) in which decision-makers discuss and express the need for the availability of health expenditure data for planning and implementation
Q16 Is there any reference to NHA data in making resource allocations negotiations with the ministry of finance or monitoring of implementation equity or efficiency
Q17
Are there future plans to further improve the demand for and use of NHA data Documentation of the challenges and suggestions for the improvement of the demand and use of NHA data will be undertaken including best practices that have pushed the country forward in demanding and using NHA data
Q18 Is there additional information we may have forgotten on the demand and use of NHA data Please add as much information as needed to clarify this topic within your country context
The country-level assessment will provide details on data production including a description
of the policies and programmes related to data collection the human and financial resources
involved and the methods and tools used A clear understanding of data analyses the
discussions around the findings and data validation processes before their dissemination will
be assessed The challenges to achieving real-time submission of indicators using current
technologies will be described and potential solutions proposed Table 8 gives more details
on the minimum descriptions expected However more information is always better
422 Assessing country status on data production
If NHA reports are produced it is key to understand the level at which they are shared
whether the ministry of healthrsquos policy-makers and government stakeholders and especially
the ministry of finance are informed and whether public and private hospitals health
insurance partners academia and development partners have all been engaged Table 8
provides guidance on the questions to be asked to find out more about data production but
each country can customize this guide
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 18
Table 8 Assessing country status on data production
Assessment area Questions
Production data management and quality assurance of National Health Accounts data
Q21 Are policy priorities to be addressed by NHA determined before the exercise Who decides on them
Q22 Is there a team or institution with appropriate knowledge and skills charged with undertaking and coordinating NHA in the country
Q23 Who funds the production data management and quality assurance for NHA data Is there sustainable financing for these activities
Q24
To what extent are NHA data requirements incorporated into routine information systems Is there routinization of NHA indicators in the national financial and health information systems and population-based surveys (income and expenditure surveys) through adequate adjustments of the systems or inclusion of relevant questions in surveys to provide the data required to produce NHA
Q25 Is the undertaking of NHA included in the monitoring and evaluation plans with planned or existing data collection tools Please provide details
Q26 What are the existing tools and national data systems to sustainably produce NHA data These will include all IT tools such as the health management information systems (HMIS) and the integrated financial management information system (IFMIS)
Q27
What are the challenges in NHA reporting What is the degree of annualization of NHA and the degree of institutionalization in terms of the scope of NHA dimensions including existing roadmaps in the countries for effective NHA institutionalization An identification of the gaps and limitations will be provided with a view to identifying existing opportunities for integration of NHA indicators into existing data collection systems
Q28 What are the areas for potential upgrade or customization of existing tools to align with the System of Health Accounts (SHA) 2011 requirements and achieve NHA institutionalization The processes of quality assurance should be clearly described to show that the criterion of reliability is met for NHA data at the country level
Q29 Are there future plans to further improve the production data management and quality assurance of NHA data
Q210 What best practices can be applied in the context of synchronizing data tools and systems in the production and management of NHA data
Q211 Is there any additional information in relation to the production data management and quality assurance for NHA data Please add as much information as needed to clarify this topic
423 Assessing country NHA dissemination and data translation into policies
Table 9 provides a set of questions to help in gathering material for the production of a report on the status of NHA dissemination and data translation into policies
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 19
Table 9 Assessment of country National Health Accounts dissemination data translation
Assessment area Question
Dissemination
Q31 What are the different forums or meetings in which NHA data are presented in the country Which institutions are involved How often are NHA data dissemination forums or meetings organized
Q32 Are NHA results disseminated using soft and hard copies Are national websites publishing NHA data Are there printed summary reports of NHA data and their interpretation into policies and decisions
Q33 How are the NHA results disseminated to the different audiences Are there tailored approaches to reach different audiences
Q34 Who funds the dissemination activities for NHA results Is there any sustainable financing for the dissemination of NHA results
Q35 Are there future plans to further improve the dissemination of NHA data
Q36 What are the challenges and possible solutions to improve the dissemination of NHA results This applies to national subnational and local levels in addition to regional and international levels
Q37 What best practices have improved NHA data or results dissemination in your country that can be used by other countries
Q38 Is there additional information we may have forgotten on the dissemination of NHA data Please add as much information as needed to clarify this topic
Translation of data and dissemination of specific analyses
Q41 Ownership in data production and analysis
Q411 Who are the stakeholders involved in the translation of data and specific analyses These may be the ministries of health or finance members of parliament civil society or the donor community
Q412 Who are the funding organizations taking part in the activities related to the translation of data and specific analyses
Q42 Ownership of the processes of translating data into concrete decisions and actions that follow
Q421 Is the health sector leadership aware of and taking action based on the NHA analyses results
Q422 Who leads the translation of data into concrete decisions and the implementation of those decisions Who is involved government ministries donor organizations civil society List any other
Q423 How is the translation of data and specific analyses done Describe the processes involved
Q43 Are there future plans to further improve the translation of data and dissemination of specific analyses of NHA data
Q44 What are the challenges and suggestions in translating NHA data into specific policies NHA data interpretation and country ownership of their processes
Q45 What best practices did the country use in improving data and translating NHA data into specific policy decisions and its assumption of the ownership of the overall processes
Q46 Is there additional information we may have forgotten on the translation of NHA data and dissemination of specific analyses Please explain to clarify this topic
43 Monitoring National Health Accounts institutionalization progress
It is necessary to monitor progress through a set of indicators that can trigger adjustments for
success Based on the World Bank framework on the institutionalization of NHA a dozen
indicators are proposed in Table 10 The time frame will be considered from the time the
decision to institutionalize NHA will be made
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 20
Table 10 Progress indicators towards National Health Accounts institutionalization
Activities Numbered indicators
Governance capacity and funding
Identify leadership stakeholders and organizationsrsquo focal persons
1 Leadership and members of committees designated
Agree on initial budget to support early meetings as needed and consultants
2 A budget for institutionalization secured and disbursement conditions defined
Conduct a situational analysis identify gaps and provide recommendations
3 A situational analysis report
Cost the national plan of action 4 A costed NHA institutionalization strategy produced
Mobilize resources for the short medium and long terms
5 MOUs and written commitments from stakeholders
Demand and use and dissemination
Sustainably improve NHA demand disseminate findings and translate specific analyses into policies
6 NHA working group (government and partners) for the first year Locate it in the health financing working group after institutionalization is secured
7 Health sector reviews include NHA data
8 Annual NHA impact assessments on national policies
Production of NHA and translation of data into specific policies
Sustainably improve NHA production and translation of data into specific policies
9 Redesigned tools and pathways for data collection sharing and analysis
10 Health financing dashboard at the ministry of health
11 IT tools are scaled in public and private sectors
12 NHA curriculum accepted as part of existing health financing curriculum in the schools of public health economics and journalism
13 Reward mechanisms designed for timely submission of data and NHA data used for policy and programme reform
Full institutionalization 14 Funding and personnel for NHA are mainstreamed in relevant sector budget
44 Gantt Chart for National Health Accounts institutionalization
To ensure timely implementation of the NHA institutionalization strategic plan establishing
and agreeing on a time frame are critical to keep up the momentum and for the efficient use
of political capital and the resources available All stakeholders will need to keep track of time
and the champion will monitor the progress The work of both the steering and technical
committees will be time bound In the scenario where the budget appears to be insufficiently
planned and more resources are needed the steering committee and the champion should
be proactive in securing new funding to successfully institutionalize NHA in the country
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 21
Table 11 Gantt chart for National Health Accounts institutionalization
5 CONCLUSION
NHA is a powerful tool in understanding the health expenditure breakdown in a given country
It helps to comprehend the health expenditure trends and what influences them to inform
resource allocation Africa lags behind in institutionalizing NHA A few countries have made
steps that require support to keep up the momentum but more is needed to initiate the full
institutionalization of NHA in most countries For this to happen there is need for a well-
designed leadership structure for NHA with the functions clearly defined The most highly
recommended leadership structure includes political and technical teams Sufficient
resources also are necessary to build solid information technology infrastructure and recruit
capable human resources for the timely submission of NHA data and generation of real-time
dashboard information on performance indicators to report on health expenditure With the
current technologies and internet capabilities along with the provision of the necessary
technical and financial support and time African countries can potentially effectively
institutionalize NHA This guide is a step forward in inspiring the countries expectation is that
its customization will be necessary to fit individual country contexts
Indicators Time frame (months)
1 2 3 4 5 6 7 8 9 10 11 12 18 24 30 36 42 48
Governance capacity and funding
Leadership designated
Budget secured
Situational analysis report
Costed NHA institutionalization strategy
Funding MOUs signed
Demand and use and dissemination
NHA working group
NHA mainstreamed in health sector reviews
Annual NHA impact assessments
2 publications on health expenditure every semester
Production of NHA and translation of data into specific policies
Redesigned IT tools
Health financing dashboard
IT tools scaled in public and private sectors
NHA mainstreamed in schools
Rewards mechanisms designed
Full institutionalization
Funding and personnel are mainstreamed
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Page | 22
RECOMMENDED LITERATURE
1 WHO AFR Status update of the institutionalization of NHA in Africa December 2020
2 Xu Ke Soucat A amp Kutzin J et al Public spending on health a closer look at global trends Geneva World Health Organization 2018
3 Nkhoma D Institutionalization of the national health accounts (NHA) production in Malawi 2018
4 Rwiyereka KA Improvement of Rwandarsquos health expenditure information systems Report to PHCPI amp WHO 2019
5 WHO Health accounts (httpswwwwhointhealth-topicshealth-accountstab=tab_1)
6 WHO What are national health accounts (httpappswhointnhawhatenindexhtml)
7 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
8 PHRplus Project Using NHA to inform the policy process NHA Regional Policy Brief Eastern Central and Southern Africa
9 Fetter B Origins and elaboration of the national health accounts 1926-2006 Health Care Financing Review 2006 28(1)53ndash67 (wwwncbinlmnihgovpmcarticlesPMC4194972)
10 A system of health accounts Version of 2011 (httpswwwoecdorghealthhealth-systems 21160591pdf)
11 A system of health accounts Version of 2011 (httpswwwwhointhealth-accounts methodologysha2011pdfua=1)
12 Global Health Expenditure Database (GHED)
13 Organization for Economic Co-operation and Development (OECD) Creating an evidence base for better health financing and greater accountability - A Strategic Guide for the Institutionalization of National Health Accounts
14 WHO National health accounts (httpappswhointnhaen)
15 USAID National health accounts Global Policy Brief (httppdfusaidgovpdf_docs Pnacs960pdf)
16 WHO National health accounts in policy formulation (httpappswhointnhauseen)
17 African Union African Heads of State and Government define the future direction for AIDS TB and malaria responses (httpwwwauint)
18 Robert Yin Case studies design and methods 2013
19 Vaismoradi et al Theme development in qualitative content analysis and thematic analysis Journal of Nursing Education and Practice 2016 (httpscoreacukdownloadpdf52132811pdf)
20 Maeda et al Creating evidence for better health financing decisions a strategic guide for the institutionalization of national health accounts 2012 (httpdocuments1worldbankorg curatedar410301468323088938pdf689660PUB0publ07926B009780821394694pdf )
21 httpswwwwhointhealthsystemspublicationsabuja_declarationen
22 World Bank (httpswwwworldbankorgentopicgovernancebrieffinancial-management-information-systems-fmis)
Recommended