Health Policy and Planning
Volume 29 Issue 3 May 2014
http://heapol.oxfordjournals.org/content/current

Sustainability of recurrent expenditure on public social welfare programmes: expenditure analysis of the free maternal care programme of the Ghana National Health Insurance Scheme
Emmanuel Ankrah Odame1,*, Patricia Akweongo2, Ben Yankah3, Francis Asenso-Boadi3 and Irene Agyepong2
Author Affiliations
1Public Health Unit, Ridge Regional Hospital, Ghana Health Service, Box 473, Accra, Ghana, 2School of Public Health, University of Ghana, Box LG13, Legon-Accra, Ghana and 3National Health Insurance Authority, No. 36-6th Avenue, Ridge Residential Area, Private Mail Bag Ministries, Accra, Ghana
Accepted February 28, 2013.
Abstract
Objective: Sustainability of public social welfare programmes has long been of concern in development circles. An important aspect of sustainability is the ability to sustain the recurrent financial costs of programmes. A free maternal care programme (FMCP) was launched under the Ghana National Health Insurance Scheme (NHIS) in 2008 with a start-up grant from the British Government. This article examines claims expenditure under the programme and the implications for the financial sustainability of the programme, and the lessons for donor and public financing of social welfare programmes.
Methods: Records of reimbursement claims for services and medicines by women benefitting from the policy in participating facilities in one sub-metropolis in Ghana were analysed to gain an understanding of the expenditure on this programme at facility level. National level financial inflow and outflow (expenditure) data of the NHIS, related to implementation of this policy for 2008 and 2009, were reviewed to put the facility-based data in the national perspective.
Findings: A total of US$936 450.94 was spent in 2009 by the scheme on FMCP in the sub-metropolis. The NHIS expenditure on the programme for the entire country in 2009 was US$49.25 million, exceeding the British grant of US$10.00 million given for that year. Subsequently, the programme has been entirely financed by the National Health Insurance Fund. The rapidly increasing, recurrent demands on this fund from the maternal delivery exemption programme—without a commensurate growth on the amounts generated annually—is an increasing threat to the sustainability of the fund.
Conclusions: Provision of donor start-up funding for programmes with high recurrent expenditures, under the expectation that government will take over and sustain the programme, must be accompanied by clear long-term analysis and planning as to how government will sustain the programme.

10 best resources on … mixed methods research in health systems
Sachiko Ozawa1,* and Krit Pongpirul1,2,3,4
Author Affiliations
1Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205, USA, 2Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 3Thailand Research Center for Health Services System, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand and 4Chula Clinical Research Center (ChulaCRC), Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok 10600, Thailand
Accepted March 8, 2013.
Abstract
Mixed methods research has become increasingly popular in health systems. Qualitative approaches are often used to explain quantitative results and help to develop interventions or survey instruments. Mixed methods research is especially important in low- and middle-income country (LMIC) settings, where understanding social, economic and cultural contexts are essential to assess health systems performance. To provide researchers and programme managers with a guide to mixed methods research in health systems, we review the best resources with a focus on LMICs. We selected 10 best resources (eight peer-reviewed articles and two textbooks) based on their importance and frequency of use (number of citations), comprehensiveness of content, usefulness to readers and relevance to health systems research in resource-limited contexts. We start with an overview on mixed methods research and discuss resources that are useful for a better understanding of the design and conduct of mixed methods research. To illustrate its practical applications, we provide examples from various countries (China, Vietnam, Kenya, Tanzania, Zambia and India) across different health topics (tuberculosis, malaria, HIV testing and healthcare costs). We conclude with some toolkits which suggest what to do when mixed methods findings conflict and provide guidelines for evaluating the quality of mixed methods research.

Integrating family planning messages into immunization services: a cluster-randomized trial in Ghana and Zambia
Gwyneth Vance1,*, Barbara Janowitz1, Mario Chen1, Brooke Boyer1, Prisca Kasonde1, Gloria Asare2, Beatrice Kafulubiti3 and John Stanback1
Author Affiliations
1FHI 360 – Program Sciences, Durham, NC, USA, 2Ghana Health Service, Accra, Ghana and 3Zambia Ministry of Health, Kabwe, Zambia
Accepted March 15, 2013.
Abstract
Objective To determine whether integrating family planning (FP) messages and referrals into facility-based, child immunization services increase contraceptive uptake in the 9- to 12-month post-partum period.
Methods A cluster-randomized trial was used to test an intervention where vaccinators were trained to provide individualized FP messages and referrals to women presenting their child for immunization services. In each of 2 countries, Ghana and Zambia, 10 public sector health facilities were randomized to control or intervention groups. Shortly after the introduction of the intervention, exit interviews were conducted with women 9–12 months postpartum to assess contraceptive use and related factors before and after the introduction of the intervention. In total, there were 8892 participants (Control Group Ghana, 1634; Intervention Group Ghana, 1129; Control Group Zambia, 3751; Intervention Group Zambia, 2468). Intervention effects were evaluated using logistic mixed models that accounted for clustering in data. In addition, in-depth interviews were conducted with vaccinators, and a process assessment was completed mid-way through the implementation of the intervention.
Results In both countries, there was no significant effect on non-condom FP method use (Zambia, P = 0.56 and Ghana, P = 0.86). Reported referrals to FP services did not improve nor did women’s knowledge of factors related to return of fecundity. Some providers reported having made modifications to the intervention; they generally provided FP information in group talks and not individually as they had been trained to do.
Conclusion Rigorous evidence of the success of integrated immunization services in resource poor settings remains weak.