1. Sustainability of recurrent expenditure on public social welfare programs: expenditure analysis of the free maternal care programme of the Ghana NHIS Presentation by: DR EMMANUEL ANKRAH ODAME PPME-MOH

2. Outline of Presentation Background Methods Results Discussion Conclusion Acknowledgement

3. Acknowledgements Prof. Irene Agyepong Dr Afisah Zakariah Mr Sylvester Mensah Mr. Nathaniel Otoo Mr Ben Yankah Dr Patricia Akweongo Dr Francis Asenso-Boadi Mr Emmanuel Owusu-Ansah

4. Background Sustainability of public social welfare programs has been of concern in development circles Free maternal care programme(FMCP) launched with a start up grant in 2008 form British Government The NHIS received US$20 million in 2008 and US$10million in 2009, afterwards NHIS was expected to fund it

5. Methods Retrospective and descriptive Relied on secondary data from a review of routine health records of provider facilities and the NHIS Study period January to December,2009 in one sub metro It had all 3 levels of provider facilities(B,C,D) Data analysed with Stata version 9

6. Results 62% of all claim was for Antenatal care(ANC) 60% of claims was from regional specialist hospital(RSH) Regional specialist hospital average claim expenditure was higher than the overall average Average ANC claim expenditure was lower at the RSH than at the Government polyclinic(GP) Average spontaneous vaginal delivery (SVD) claim expenditure was higher at the Government Maternity Home(GMH) than at GP and RSH

7. Results Total claims expenditure showed ANC as the component with the highest claims expenditure SVD was the component with the highest claim expenditure at the RSH British Government grant in 2009 was about half the expenditure incurred in 2008 for maternal health services In 2009,FMCP expenditure was 23% of the total claims expenditure NHIA expenditure exceeded income in 2009, giving a deficit

8. Discussion Impossible to create a health system free of all tensions relating to financial sustainability Financial sustainability are coming from several fronts  Failure from onset to look at long term financial sustainability  International development partners should also be responsible in promising financial guarantees  Inadequate attention to claims expenditure cost containment  Lack of adequate attention to provider payment mechanism

9. Discussion Gatekeeper system not being adhered too Medicines can be a major cost driver Levels of care and gatekeeper systems are important cost containment mechanisms

10. Conclusion Avoid a dependency on donor promises to replace careful long term fiscal evaluation and planning Critical attention should be paid to issues of strategic purchasing of the services There are incentives an disincentives inherent in different provider payment mechanisms Careful attention must be paid to design with this in mind