Acknowledgements: with thanks to blog contributors Jennifer Armitage, Matthew Cooper and the mapping teams from LAMP Development and Itad
The Global Fund’s primary goal is to eliminate the three diseases of HIV AIDS, tuberculosis and malaria. With this in mind, the Global Fund aims to help countries develop people-centred, integrated systems for health and to strengthen health systems. In 2022, Itad and LAMP Development were commissioned by the Global Fund to conduct a mapping exercise to inform how the Global Fund can align and better harmonise health systems strengthening (HSS) efforts with countries’ national priorities, and to inform how these investments could be monitored. Here we share the benefits, challenges and lessons from such a mapping exercise. We hope that it helps other evaluators and development partners considering embarking on similar exercises in resource-tracking for health.
Health systems strengthening is about improving the health system of a country, leading to improved health outcomes for its population. The World Health Organisation’s definition of HSS is “the process of identifying and implementing the changes in policy and practice in a country’s health system, so that the country can respond better to its health and health system challenges.” However, there is no standard definition of HSS and this leads to interesting challenges when conducting mapping exercises of HSS investment.
Why map National Health Accounts (NHA) to HSS investments?
Most health expenditure tracking exercises are guided by the System of Health Accounts (SHA) or other commonly used National Health Accounting approaches. We started with the assumption that National Health Accounts can be used to track government and development partner resources within a country’s health system, which means they are a useful tool to gain a better understanding of Global Fund investment in health systems strengthening.
National Health Accounts (NHAs) are an internationally recognized way of presenting a country’s health expenditure data. Typically based on the System of Health Accounts (SHA) framework, NHAs describe the flow of resources for health, from the national government, private sector and development partners/donors through to the implementers and beneficiaries. NHAs are considered important as they are one of the only ways to compare health expenditure data between countries and over time. Tracking health expenditure is also useful for accountability and can be used as a policy tool to raise funds, allocate resources and plan for health services. Globally, 192 countries track their resources with the NHA tool.
Limited health sector budgets dominate considerations of health systems strengthening investments in low- and middle-income countries (LMIC). Meanwhile, there are often numerous external donors and NGOs working to strengthen health systems and achieve Sustainable Development Goals (SDG). To ensure the efficient use of scarce resources, and to maximise the limited resources for HSS, countries receiving foreign aid develop evidence-based roadmaps and plans. Health resource tracking, using NHAs (or other mechanisms), tracks expenditure against these plans. This can provide more reliable information to influence decision-makers in the improvement of health system performance. It can help to improve the coordination of actors and avoid duplication of effort.
However, within the published NHA reports, it is not always possible to identify whether a particular contribution to the health system comes from the domestic budget or from development partners’ / foreign aid investments. This information is important to identify and measure HSS investments, to better align planning and budgeting and to track contributions to health system strengthening outcomes. HSS does not have a specific code in the SHA framework used to produce the NHA, hence the need for a mapping exercise.
Benefits of NHA mapping
NHA mapping to strategic priorities monitors resource flows in a country’s health system, linking the sources of funds to service providers and the ultimate use of the funds. It can promote dialogue on key policy issues and facilitate cross-border comparisons, which can be used to assess the impact of HSS investments when data is consistent between countries. It can also give a clearer picture of dependencies on development funding and builds a strong case for changes in the country’s budget to finance health programmes. NHA mapping facilitates triangulation and gives a snapshot of the sources and uses of all health expenditures, including the public-private mix, both on the financing and provision sides. NHAs provide internationally comparable health expenditure data, influence budget allocations, and advocate for more funds for Universal Health Coverage (UHC). NHA reports can be effective tools in advocating for budget allocations and releases. Mapping expenditure to specific areas of investment such as HSS can provide more detailed information to inform decisions.
Challenges with the NHA mapping process
Some of the general challenges with the NHA mapping process include data gaps and inconsistencies attributed to the different information systems used by different countries. Countries that do not use the Health Accounts Production Tool (HAPT) by default have reduced the scope of classifications and face inconsistencies in the various tables. Besides, data without labels such as capital and recurrent spending are difficult to process due to the need for additional information on the components.
Crucially, the HSS definition is not used in a standard way by different global health actors, thereby creating issues with the categorisation and comparability of spending on HSS. This has implications for how any analysis of HSS investments based on NHA data can be interpreted.
Additionally, retrospective and often delayed measurement time lags of 1–2 years from analysis to decision-making do not provide concurrent information on the HSS investments in a timely fashion. There is also a need for more qualitative information to tell the story behind the numbers and statistics.
Finally, the NHA tracking process is mostly led by the WHO and when country-level partners are not sufficiently engaged, insufficient resources are allocated for this important activity. Efforts to institutionalise resource tracking are often faced with the trade-off between regularly conducting resource tracking and managing the costs of conducting such an exercise. However, there are some examples of where low-cost tools have been used to map NHA classifications to prioritized policy areas and these approaches are encouraging.
Learning from the NHA mapping exercise
Overall, the NHA mapping sought to track investments in disease-specific and cross-cutting HSS modules. The team reviewed in detail the methods and tools used, identifying the key strengths and weaknesses of these approaches, as well as interviewing stakeholders in other development partners’ (DP) organizations to map similarities and differences in approaches used as well as key challenges faced. Given the definitions and categorization of HSS are unclear and unstandardised across organisations, methodological challenges were encountered. Definitions are a fundamental part of this type of mapping methodology, and without agreement between key stakeholders on these definitions, the methodology and findings may not be accepted.
Recommendations moving forward
We call on resource tracking teams to undertake the following coordinated action which are urgently needed for the effective stewardship of health systems:
- Provide timely data to NHA processes at country level
DPs should also ensure that the data they provide to the NHA team in the Ministry of Health (MOH) is comprehensive, disaggregated, and submitted promptly. They should work with MOH and the WHO to enable regular access to relevant disaggregated data from the NHA database to track investments in HSS, both in terms of what is being funded and through which channels.
- Develop a common data architecture
Given the common interest in strengthening health systems, DPs should share details of their resource tracking systems with country NHA teams to facilitate proper visibility of HSS investments. Additionally, composition of HSS investments should be made more explicit in resource tracking systems to facilitate mapping between the DPs and NHA categories.
- Increase data access and use
Considering that accounting activities are not conducted annually and acknowledging the time delay involved, it is imperative for DPs to actively participate in regular reporting processes. This entails allocating resources towards establishing financial management systems designed to facilitate reporting for the Health Accounts team.
- Meaningful engagement between DPs and government
Finally, cooperation between the DPs, resource-tracking teams at the national level, and other resource-tracking-associated organizations should be encouraged to harmonise definitions and classification of cost categories and data inputs for HSS tracking. Perhaps this could lead to the health accounts framework (SHA) including an annex defining HSS, and main categories to include facilitation of standardised monitoring by NHAs (just like the methodological note now developed for the estimation of Primary Healthcare Expenditure).
 USAID Health Governance and Finance Project 2018 How have Health Accounts data been used to influence policy? https://apps.who.int/nha/database/DocumentationCentre/GetFile/56121891/en
 Mwai, Daniel & Maina, Thomas. (2019). Tracking Health Resources Using National Health Accounts.
 Jennifer A Price et al., How to do (or not to do) … translation of national health accounts data to evidence for policy making in a low resourced setting, Health Policy and Planning, Volume 31, Issue 4, May 2016