1. Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group Linking NHA and NASA: A Coordinated Approach NASA Workshop for Eastern Europe and Central Asia Bucharest, Romania December 3-7, 2007 Lisa K. Fleisher, MPH

2. 2 Objectives Review NHA (briefly) Explain crosswalk concept and practice Crosswalk exercise NHA to NASA Discussion

3. 3 What are National Health Accounts? Internationally used and tested framework Endorsed by WHO, WB, USAID, Gates Foundation, SIDA, etc., Conducted in 100+ countries Outgrowth of System of Health Accounts (SHA), adapted for use in middle- and low- income countries in 1990s Tracks spending on general health care (amount and flows) including public, private and donor contributions Intended on a regular basis (as part of the HIS)

4. 4 The Concept of NHA Uses a comprehensive approach, looks at TOTAL national health expenditures including public, private, and donor contributions Is a standard set of tables that organizes info in an easy-to-understand manner Easily understood by policymakers, including those without a background in economics Allows for cross-country comparisons

5. 5 Purpose of NHA Single most important purpose: Contribute to the health policy process Can lead to better informed health policy decisions and avoid potentially adverse policy choices Inform donor funding decisions Further international development

6. 6 Other Benefits of NHA Provides more accurate estimates to replace guesstimates NHA is country-derived (not donor-derived) NHA estimates are inclusive of all financing actors NHA is an internationally recognized methodology

7. 7 NHA in Comparison to Guesstimates

8. 8 NHA Subaccounts Total Health Expenditures THE general Subaccount areas are pieces of the total health expenditure pie

9. 9 HIV/AIDS Subaccount Tracks health expenditures related to HIV/AIDS Generally conducted by Ministries of Health in tandem with a general NHA estimation Allows for HIV expenditures to be placed in the context of overall health care e.g. % of government health spending spent on HIV/AIDS. While focused on health spending, it can also report non- health spending as addendum items, thus also helping to contribute to UNGASS reporting requirements e.g. school fees for OVC, psychosocial support

10. 10 Policy questions addressed What is the national HIV/AIDS resource envelope? Where does the money come from? What is the burden of financing on PLWHA? Which entities manage and allocate resources? What are the end uses of financiers contributions? In terms of providers and goods & services delivered Are current expenditures aligned with the goals of national strategic plans and donor targets?

11. 11 Data collection for HIV subaccounts Use actual expenditure data available from health information system (HIS) Use secondary data (expenditure records) Top-down/bottom-up estimation if necessary Link with ongoing surveys (e.g. LSMS, DHS) Conduct primary data collection

12. 12 Indicators % of government health spending on HIV/AIDS % of donor health spending on HIV/AIDS HIV/AIDS spending as a % of general THE PLWH OOP spending versus HH OOP spending on health % of funds managed by the government vs NGOs % of funds used at government facilities vs NGO and other private facilities

13. 13 Monitoring national and donor targets HIV/AIDS subaccounts can be mapped to national and international reporting indicators and targets. UNGASS declaration of commitment National AIDS strategic plan targets Global Fund principle of additionality Spending on focus areas of major donor mechanisms

14. 14 From NHA to crosswalk … NHA NASA/ UNGASS Subaccounts Reproductive health HIV/AIDS Malaria All other health spending Crosswalk

15. 15 Both NASA and NHA aim to … Address critical policy questions (for both national and international stakeholders) i.e. what are we getting for the money? What matters is not only how much is invested but … How funds are invested Whether or not funds are reaching intended targets Serve as advocacy and monitoring tools, supporting evidenced-based policy processes e.g. informing resource allocation decision-making Provide country comparable data

16. 16 Why two frameworks? Each caters to a slightly different group of stakeholders: NHA subaccount preserves the distinction between health and nonhealth – to help meet the needs of health stakeholders. NASA aims to inform the multisectoral AIDS perspective (e.g. NAC, UNAIDS etc) Also, NASA has been designed to inform the HIV/AIDS resource gap estimation process Gap estimation: provides info on financial gap between available resources and needed resources

17. 17 Neither framework is better than the other If conducted in a coordinated manner, they can help meet the needs of both HIV/AIDS and health care stakeholders - national and international. Thus informing more stakeholders and processes involved in the fight against HIV/AIDS.

18. 18 Need for coordination To avoid duplicative efforts in resource tracking, particularly for the area of overlap e.g. may face respondent fatigue and frustration from donors, NGOs if two sets of survey questionnaires are administered - one for NASA and one for NHA To eliminate production of conflicting estimates i.e. one estimate from the National AIDS Commission and another from the MoH Maximize efficiency in the use of resources - both human and financial - for resource tracking. Reducing the administrative and managerial burden on country governments.

19. 19 Coordination complies with the UNAIDS three ones principle For coordination of national HIV/AIDS responses ONE agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners, ONE National AIDS coordinating authority, with a broad- based multisectoral mandate, and ONE agreed country level monitoring and evaluation system.

20. 20 How can coordination be realized? At international level- Crosswalking the overlapping areas – through production of equivalency tables Effort led by UNAIDS, WHO, and USAID At country level- Bringing both HIV and health stakeholders together for one coordinated resource tracking effort that results in two outputs.

21. 21 Crosswalking between NASA and NHA Forthcoming NHA-NASA equivalency table shows how NHA can be mapped to NASA (and vice versa) for the areas of overlap Namely, health and health related HIV/AIDS activities

22. 22 HIV/AIDS Expenditure Totals Total HIV/AIDS Health Expenditure (THE HIV/AIDS ) = Core HIV/AIDS health expenditures + Capital Formation for HIV/AIDS Total National HIV/AIDS Health Expenditure (NHE HIV/AIDS ) = THE HIV/AIDS + Health Care Related HIV/AIDS Activities Total HIV/AIDS Expenditure = Total National HIV/AIDS Expenditure + Non-health HIV/AIDS expenditure = Total for UNGASS reporting matrix

23. 23 NHA and NASA classification schemes - corresponding categories NASANHA Financing Sources (FS) Financing Agents (FA)Financing Agents (HF) Production Factors (PF)Resource Costs (RC) Providers (PS)Providers (HP) AIDS Spending Categories (ASC)Functions (HC) Beneficiaries (BP) Both use alphanumerical codes followed by a descriptive name

24. 24 Glimpse of the equivalency table NASA AIDS Spending Categories (ASC) CodesNHA Financing Functions (HC) Codes ASC.1.1.1 Mass media programmes targeting the health risks of HIV and AIDS prevention campaigns HC.6.3.yIEC (subcategory of prevention and public health services; prevention of communicable diseases) ASC.1.1.2 Mass media programmes targeting the non- health risks of HIV and AIDS prevention campaigns ASC.1.2 Community mobilizationHC.6.3.y Community mobilization ASC.1.3 Voluntary counseling and testingHC.6.3.y VCT program (excluding that given to pregnant women) + HC.1.3.y VCT services rendered as part of outpatient care (excluding that given to pregnant women) ASC.1.4 Programs involving vulnerable and special populations HC.6.3.y Programs involving vulnerable and special populations excluding OVCs, youth, MSM, sex workers, drug users, and other groups targeted by other HC categories ASC.1.5 Prevention - Youth in schoolHC.6.2 School health services.

25. 25 How can NASA be produced from NHA? 1. Helpful to have NASA team members on NHA team 2. Design NHA data collection to include items needed for NASA to facilitate crosswalk. 3. When analyzing each dataset, map each expenditure line item to NHA categories (and to addendum items for nonhealth), maintaining sufficient disaggregation needed for NASA. 4. Create a Financing Source x Financing Function (FS x HC) table for targeted and untargeted spending for HIV/AIDS

26. 26 How can UNGASS table be produced from NHA? 1. Helpful to have NASA team members on NHA team 2. When analyzing each dataset, map each expenditure line item to NHA categories (and to addendum items for nonhealth), maintaining sufficient disaggregation needed for NASA. 3. Create a Financing Source x Financing Function (FS x HC) table for targeted and untargeted spending for HIV/AIDS Start with HF (agent) x HC (function) targeted table. For every HF cell that has a value, disaggregate the amount by its contributing financing source - using the % distribution shown in the FSxHF table. Repeat process for untargeted tables Merge into one table (adding the amounts together)

27. 27 How can an UNGASS table be produced from NHA? (2) 4. Using the forthcoming NASA-NHA linkages document, develop a specific mapping from your country-specific HIV/AIDS subaccount categories to the FS and ASC categories 5. Pull up NHA HIV subaccount FS x HC table next to UNGASS table Simply copy and paste link from NHA to UNGASS using your specific mapping of cells.

28. 28 Suggestion 1: Linking once NHA tables are done FS.1.1.1.1 Ministry of Finance FS.1.1.2 Local Authorities FS.3. Rest of the world HC.1.1 Inpatient curative care WZ HC.1.3.1 Out patient curative care- VCT Y HC.6.3.1 VCT Programs X FS.1.1 Territorial government: central FS.1..2 Territorial government: state/provincial FS.3. International funds ASC 2.2. Inpatient care WZ ASC 1.3. VCT( incl. (programmatic and personal) XY NHA HIV/AIDS subaccount NASA – UNGASS table

29. 29 Computing UNGASS from HIV/AIDS subaccount - cell by cell

30. 30

31. 31 Process for harmonization in-country Planning: Involve representatives from both NAC and MoH (or institution housing NHA) on RT team Be strategic when approaching stakeholders Keep UNAIDS country office informed Training: should include cross-walk presentation Data collection: target health and non-health HIV spending E.g. for NGO NHA questionnaire that asks HIV/AIDS health questions, add rider questions on non-health expenditures.

32. 32 Process for harmonization in-country Analysis : populate both NHA and NASA tables (at minimum UNGASS reporting matrix) Report writing : include both sets of tables in report In Rwanda, one chapter will house both NHA and NASA data. Dissemination: to HIV/AIDS stakeholders, incl. MoH, NAC, UNAIDS.

33. 33 Exercise: Map NHA to UNGASS table Step 1: Review selection of NASA classifications. Step 2: Review list of NHA HIV subaccount classifications. Step 3: Identify appropriate NHA HIV subaccount classification that crosswalks to UNGASS. Example: UNGASS classification: ASC 1.18 (blood safety) NHA HIV subact. match = HC 6.3.1.2 (blood supply) Hint: For a few UNGASS classifications, there might be more than one NHA HIV subact. match.

34. 34 Crosswalk: NHA to UNGASS (1) NASA Sub-categoryNASA ASCNHA code PREVENTION Prevention of Mother to Child Transmission (PMTCT) ASC 1.17 Blood safetyASC 1.18 Voluntary counseling and testingASC 1.03 HC.6.1.1 PMTCT HC 6.3.1.2 blood supply HC.6.3.1.1 VCT Programmes + HC.1.3.11 VCT as part of OP care

35. 35 NASA Sub-categoryNASA ASCNHA code CARE and TREATMENT Home-based careASC 2.1.09 Opportunistic infection (OI) treatment ASC 2.2.1 Antiretroviral therapyASC 2.1.03 Crosswalk: NHA to UNGASS (2) HC.1.4 Services of curative home care (HIV/AIDS) HC.1.1.2 IP OI Treatment + HC.1.3.6 OP OI treatment and monitoring HC.1.1.1 ARV IP care + HC.1.3.7 OP ARV treatment + HC.5.1.1.1 ARV drugs+ HC.6.3.1.8 ART programmes

36. 36 Crosswalk: NHA to UNGASS (3) NASA Sub-categoryNASA ASCNHA code Orphans and Vulnerable Children EducationASC.3.1 Family/home supportASC.3.3 AD.1.2.3 School fees for OVC AD.1.2.2 Inkind benefits to OVC + AD.1.2.2 Monetary benefits to OVC

37. 37 Discussion What do you think the experience would be in your country of attempting a crosswalk between NHA and NASA? Coordination with health and HIV stakeholders? Data collection?

38. 38 Take-away messages NASA and NHA can be crosswalked Planning is important! Engage stakeholders strategically Plan data collection efforts Be transparent about assumptions Coordination allows for one resource tracking process with two outputs to satisfy stakeholders

39. Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group Thank you Reports related to this presentation are available at www.HS2020.org