COSTING OF SAFE MOTHERHOOD (MAKING PREGNANCY SAFER) INITIATIVE IN GHANA: A CASE STUDY OF WASSA WEST DISTRICT

COSTING OF SAFE MOTHERHOOD (MAKING PREGNANCY SAFER) INITIATIVE IN GHANA: A CASE STUDY OF WASSA WEST DISTRICT By Dr. Felix A. Asante Research Fellow Institute of Statistical, Social & Economic Research (ISSER), University of Ghana Dr.Teddy S. Avotri District Director Wassa West District/GHS Mr. Selassi A. d Almeida Health Economist WHO, Ghana A Technical Report Prepared for the World Health Organization, African Regional Office, Zimbabwe December 24

ACKNOWLEDGEMENT The authors would like to thank the World Health Organisation (WHO) for the technical and financial support for this study. Special thanks goes to Dr. Jones M. Kirigia, WHO/AFRO for his suggestions and comments, which greatly improved the study. Our gratitude also goes to the officials of the Wassa West District Health Directorate of the Ghana Health Service for their invaluable time they spent in gathering information for this study. Finally, our appreciation goes to Mr. Anthony Kusi who worked on this project as a research assistant. The authors are responsible for any opinion expressed in this report. 2

ABSTRACT Motherhood is a stage of life, which is much cherished by families due to the emotional and social joy that it brings to families. It is therefore sad that many families are often eluded by this happiness through maternal and neonatal mortality, morbidity and disability. WHO/UNICEF (1999) estimates that there are 585, maternal deaths each year globally from complications of pregnancy and childbirth. The situation in Ghana is equally gloomy with institutional maternal mortality rate of 25 per 1, live births. In Ghana, the Safe Motherhood programme of which Making Pregnancy Safer (MPS) is a major component is part of the National Reproductive Health Service delivery, which is delivered through the Primary Health Care Programme. This study was a case study in the Wassa West district of the Western Region where a pilot programme is being implemented. The study sought to estimate the current cost of Making Pregnancy Safer (MPS) in the district at different levels of the health care system (hospital, health centre and health post) and also to estimate the incremental costs (additional investment needs) for the implementation of the MPS. The study employed the Mother Baby Package (MBP) to estimate the cost of the Current and set of interventions for maternal and newborn health care. The results show that while the total cost of the standard MBP is estimated to require about $667,78 a year for implementation, the current practice cost is estimated at $735,711, which is about 1% higher than the estimate for the standard practice cost. The high cost of the current practice is attributed to the high replacement cost of the Twakwa district hospital. The health centre has the highest incremental cost of $29,185 as a result of the relatively low investment at that level currently. In terms of the distribution of the total cost by inputs, personnel cost account for 37% of the total cost of the standard practice, making it the most expensive input, compared with only 7% for the current practice with facility cost accounting for 31% of the total cost. The total direct cost by facility also revealed that the standard practice cost of $479,59 is far more than the current practice cost of $151,114. The distribution of the recurrent cost by facility type also revealed a similar pattern. While the facilities currently have a total recurrent cost of $386,455, that of the standard practice is estimated at $578,455. Finally, it was observed that the cost per intervention in the current practice at all levels is lower than those of the standard practice. The significance therefore is the impact this is likely to have on the quality of care available. The study concludes that with the above cost structure additional investments would be required to meet the standards set by the MBP to making pregnancy safer in Ghana. 3

Table of Contents Section Acknowledgement Abstract Page ii iii I Introduction 1 II Safe Motherhood (Making Pregnancy Safer) Initiative in Ghana 3 III Study Area and Methodology 5 IV Current and Treatment Practices 1 V Treatment Cost 15 VI The Mother-Baby Package Interventions 27 1. Antenatal Care 28 2. Anaemia 33 3. Abortion Complications 36 4. Eclampsia 4 5. Family Planning 42 6. Haemorrhage 48 7. Neonatal Complications 51 8. Normal Delivery 53 9. Obstructed Labour (C-Section) 57 1. Postpartum Care 58 11. Sepsis 61 12. STD-Other 64 13. STD-Syphilis 67 References 72 Appendix 73 4

SECTION I: INTRODUCTION 1.1 Background Motherhood is a stage of life, which is much cherished by families due to the emotional and social joy that it brings to families. It is therefore sad that many families are often eluded by this happiness through maternal and neonatal mortality, morbidity and disability. Motherhood related afflictions claim the lives of many mothers and /or babies annually. WHO/UNICEF (1999) estimates that there are 585, maternal deaths each year globally from complications of pregnancy and childbirth. Another 15 million experience chronic problems resulting from childbirth while estimated 64 million women suffer dangerous complications of pregnancy. About 99% of these unpleasant cases occurred in developing countries where these complications account for at least 18% of the disease burden (DALYs) among women in their reproductive age (World Bank, 1993). Having observed the hazards of unsafe motherhood in the world and especially in developing countries, there is now a global effort to increase maternal safety and reduce maternal and neonatal mortality and complications associated with pregnancy and childbirth. As part of this effort, the Safe Motherhood Initiative was launched at an international meeting in Kenya in 1987. The major focus was to reduce high maternal death rates and pregnancy related illness and complications especially in developing countries. The importance of Safe Motherhood was again given impetus during the 1994 International Conference on Population and Development in Cairo and the 1995 World summit for Social development in Copenhagen as well as during the 1995 Fourth World Conference on Women in Beijing (Goliber, 1997). These global efforts have shaped maternal and child health care delivery in developing countries since the late 198s and early 199s. Safe Motherhood is the prevention of maternal and infant death and disability through access to basic health care to ensure that all women have access to the information and care they need to go through pregnancy and childbirth safely and confidently. In Ghana, Making pregnancy Safer (MPS) is a component of National Reproductive Health Service delivery, which is delivered through the Primary Health Care Programme (PHC). 1.2 Research Questions The study will offer answers to the following questions. What is the cost of providing and obtaining Making Pregnancy Safer (MPS) in Ghana? What effect does this cost structure have on MPS service provision in Ghana for both providers and consumers? 5

What is the gap between the current situation and the ideal (standard) situation, using the Mother-Baby Package as a guide? 1.3 Study Objectives The principal objective of this study is to estimate the cost of Making Pregnancy Safer (MPS) in Ghana. The specific objectives however include; To estimate the current cost of Making Pregnancy Safer (MPS) in Ghana at different levels of the health care system. To estimate the incremental costs (additional investment needs) for the implementation of the MPS. 1.4 Study Rationale/Purpose The study will be very useful to the MoH/GHS which are the major stakeholders in the efforts to achieve Safe Motherhood in Ghana in terms of their policy directions, resource mobilization and allocation activities. Health partners and donors will also benefit from the study by having data to make informed decisions on their priorities and resource allocations to the area. It is hoped that the evidence provided by the study will expose the current level of service delivery. This, it is believed will attract political commitment to provide the necessary inputs for the implementation of an effective MPS programme to make motherhood less risky in Ghana. The study will also provide the cost of providing each of the major interventions under the package. This will make it possible to identify the major areas, which contribute substantially to the cost of MPS in Ghana as well as those that are under-funded. This will help in resource allocation by the Ministry of Health/Ghana Health Service and health partners. Finally, knowing the cost of providing maternal health services can help health administrators to price such services. This will be necessary in view of the emerging major government policies relating to Community Health Planning and Service (CHPS) for service provision, and district-wide Mutual Health Insurance. It will also be possible to determine how much resources could be saved if service providers operate more efficient MPS programmes. 6

SECTION II: SAFE MOTHERHOOD (MAKING PREGNANCY SAFER) INITIATIVE IN GHANA 2.1 Safe Motherhood Initiative In Ghana, Safe Motherhood programme of which Making Pregnancy Safer (MPS) is a major component is part of the National Reproductive Health Service delivery, which is delivered through the Primary Health Care Programme. The Maternal and Child Health (MCH) was launched in Ghana as a major component of the Primary Health Care (PHC) system in 1978. Among other things, the MCH initiative is mandated to promote and maintain the health of women and children in Ghana. This has become necessary given the high rate of maternal and infant mortality rates in the country. The maternal death estimation based on institutional data (MoH) placed the figure at 25/1, live births (GHS, 23) while a United Nations estimate put it at 54/1, (http://millenniumindicators.un.org) but it is believed that the best estimate will be between 14 39 / 1 live births (http://www.policyproject.com/pubs/mnpi/ghana_mnpi.pdf) since not all cases are reported. In 1992, the Ministry of Health, having observed the numerous health problems affecting women and children in particular, set a number of priorities for itself. Among other things, there was the need to intensify maternal and child health services and family planning activities as part of the strategies within the framework of the national population policy (GSS, 1995). The idea of giving special attention to MCH/FP as part of the PHC was again justified in 1992 because of the fact that women and children are seen as the most vulnerable to ill-heath and death in Ghana (MoH, 1992). Consequently specific actions were taken to achieve Safe Motherhood including the process of instituting a Life-Saving skills programme and forming the National Safe Motherhood Task Force in 1993 (Levin, et al. 1999). In line with this, a number of health care centres were empowered to provide MCH/FP services through out the country. Since 1998, the focus of the MoH/GHS has shifted from MCH/FP to Reproductive and Child Health (RCH). The Safe Motherhood initiative however continues to receive much attention.the major components of the Safe Motherhood programme include the following interventions; Antenatal Care Labour and Delivery Care Postnatal Care Family Planning Prevention and Management of unsafe abortions Health education These major interventions are mostly carried out within the context of the PHC system. Services are taken closer to the communities while at the same time encouraging community participation. The interventions for making pregnancy safer in Ghana are 7

mostly provided at the grassroot level by the various district hospitals, clinics, health centres and posts. 2.2 Making Pregnancy Safer (MPS) The main goal of the MPS programme in Ghana has been to improve women s health in general and to reduce maternal mortality and morbidity in particular. Despite all the various programmes launched in Ghana, maternal mortality rate continue to be high. In Wassa West District where a pilot MPS programme is currently going on 7% of the urban population has access to formal health services as opposed to 45% in the rural areas. Ethno-medical practice and health seeking is high particularly in the hard to reach rural areas with traditional healers and spiritual gardens catering for the health needs of the people. In Ghana in order to accelerate the reduction in maternal mortality, the MPS programme is being adopted to focus on the specific areas shown in Table 2.1. Table 2.1 A B C D 1 2 3 4 5 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 1 2 3 Interventions for Making Pregnancy Safer in Ghana Interventions CARE DURING PREGNANCY Antenatal Care Treatment of Severe anaemia Treatment of syphilis Treatment of other STDs such as gonorrhea, Chlamydia Treatment of malaria CARE DURING AND AFTER DELIVERY Delivery by skilled birth attendant including routine newborn care Management of eclampsia Management of postpartum haemorrhage Management of obstructed labour/caesarean delivery Management of sepsis Management of basic of newborn complications Postpartum care Management of abortion complication Management of post surgical care POSTPARTUM FAMILY PLANNING Condom Depo-Provera IUD Norplant Oral contraception Sterilisation COMMUNITY COMPONENT Community Health Compounds (CHPS) Traditional Birth Attendants (TBA) Community Empowerment Programme for MPS 8

SECTION III: STUDY AREA AND METHODOLOGY 3.1 Profile of Study Area Wassa West District The Wassa West district is one of the eleven districts in the Western Region of Ghana. The district occupies a land area of about 3,5 square kilometres and has an estimated population of 241,175 in 23. Though majority of the population are peasant farmers, other economic activities are very vibrant in the district. Major economic activities in the district include food and cash crop production (cocoa, coffee and oil palm). Other activities include rubber production, lumbering and most importantly gold mining. These economic activities especially the mining of gold attracts many migrants to the district thereby contributing to the rapid increase of the population. The district has five hospitals - two government hospitals at Prestea and Tarkwa, and three private hospitals. In addition to these, the district has eight (8) public health centres, many of which are located in semi-urban towns spread across the district. There are also 11 maternity homes, 25 Traditional Birth Attendants (TBAs) and 4 community clinics or health posts. These facilities especially the district hospital does not only serve the population of the district but also receive referral cases from some of the neighbouring districts. Sometimes, very difficult medical cases in the district are also referred to the Regional hospital at Effia Nkwanta, the Komfo Anokye Teaching hospital in Kumasi and the Korle-Bu Teaching hospital in Accra. Accessibility of the population to formal institutional health care services is estimated to be less than 6% (MoH/GPMMN, 22). Apart from the high incidence of diseases such as malaria and U.R.T.I, pregnancy related complications are also high. Institutional records indicate that MMR are high. The institutional MMR was estimated at 54 per 1, live births (MoH /GPMMN, 22), compared with the national average of 24 per 1, life births. It is also estimated that women in fertility age (WIFA) stood at 55,47, constituting about 23% of the total population of the district. 3.2 Conceptual Framework The general framework for costing the MPS programme in Ghana is shown in Figure 1. The cost of MPS could be categorized into direct and indirect. The direct costs are the costs directly associated with the provision of maternal health services borne by the government and the service provider as well as the consumer. This cost component includes personnel cost, drugs, supplies, materials, utilities, and overhead expenses 9

among others. The consumer costs include transport fees, service user fees as well as cost of prescribed drugs and supplies bought from outside. The indirect costs are made up of costs of travel time and waiting time in Making Pregnancy Safer (MPS) activities. Under the direct cost category, this study considered only the cost borne by health facilities. The actual cost of current MPS interventions and the cost of providing a standard WHO package of Mother Baby Package were estimated. The difference between the two constitutes the resource gap that needs to be filled if standard is to be achieved in the country. 3.3 Method of Analysis The study employed the WHO s Excel Spreadsheet based Mother Baby Package to estimate the cost of the Current and set of interventions for maternal and newborn health care. 3.3.1 Data Requirements / Data Collection The relevant data required from the district for the operation of the model included the population, birth rate, antenatal coverage rate, institutional supervised delivery rate and modern contraceptive prevalence rate. Others include the prevalence or incidence rates of pregnancy and delivery complications. In addition, morbidity data and treatment protocols for the various interventions as well as the staff time spent per client were gathered from selected health facilities. The prices of drugs and supplies were obtained from the suppliers lists obtained from the District Government Hospital. Where these prices were not available on the suppliers lists, the UNICEF Supply catalogue for 1996/97 was consulted. Salary data was also obtained from the District Health Service Directorate. The data for the filling of the demographic sheet was obtained from the District Health Service Directorate. This consisted of summary data contained in the various return sheets from the health facilities in the district. From this compilation, the various coverage rates as well as the prevalence rates were estimated for year 23. To estimate the cost of the current treatment practice, site visits and interviews were conducted in 11 health institutions across the district. In addition, three TBAs were also interviewed. Each health institution and TBA filled out a questionnaire - Facilities Data Collection Form. The distribution of the health facilities visited is presented in table 3.1. These facilities were selected based on a number of considerations. The District Government hospital and the ABA hospital (private) were purposively selected because they provide many of the interventions and also have higher patronage from clients. Five 1

of the eight public health centers representing different sub-districts for health administration in the districts were randomly sampled. For the health posts and maternity homes, they were purposively selected based on their strategic locations and the number of clients they receive per month (current performance). Table 3.1 Health facilities Visited for Field Survey Type of facility Name of Facility Location Status Hospital Tarkwa Government Hospital ABA Hospital Tarkwa Tarkwa (Mines) Public Private Health Centre Nsuem Health Centre Simpa Health Centre Dompim Health Centre Bogoso Health Centre Heman Health Centre Nsuem Simpa Dompim Bogoso Heman Public Public Public Public Public Health Post or Community Clinic New Atuabo Community Clinic New Atuabo Public Maternity Home AMI Maternity Home Bosomtwe Maternity Home Adom Maternity Home Tarkwa Tarkwa Aboaso Private Private Private In each of the facilities visited, the administrator, the nursing officer (matron) as well as principal staff (doctors, midwives, nurses, laboratory technicians, etc.) in charge of the various relevant departments were interviewed, guided by a questionnaire (Facilities Data Collection Form). The data gathered from each of the facilities covered information on the following: Number of both clinical and support staff by position History of the Facility and stock of major equipment available at the institutions. Clinical staff time spent on maternal health care according to each intervention provided by the facility. Facility specific maternal morbidity data for 23. Current treatment protocol under each of the interventions with specific interest in type and quantity of drugs administered and other supplies used per client under each of the interventions. Cost Estimation To get the estimated cost of Safe Motherhood through the Mother Baby Package, the major cost components were organized into Direct Cost, Overhead cost and Capital cost. The total cost under each component was estimated based on the data available from which the various average costs were computed. The average costs computed included 11

direct cost by intervention and input, recurrent cost by intervention and input and total cost by intervention and input. Average costs by facility levels were also computed. Direct Cost The estimated direct cost was made up of all recurrent costs that could be directly attributed to one intervention. Major cost inputs under this cost component included: Blood products Hospital bed and food Laboratory supplies cost Consumable supplies Emergency transportation Overhead Cost This cost included all recurrent costs that were not directly attributed to one specific intervention. Major cost items included annual maintenance and utility costs for each facility, salaries of support personnel, Information, Education and Communication (IEC) and social marketing programme cost, supervision and management. Capital Cost This included the cost of major capital items including buildings, land, equipment and vehicles among others. The capital costs were estimated based on their replacement cost. Annual operating cost of these capital items were computed by depreciating each type of item over its estimated useful years of life. While buildings were amortized over 25 years, vehicles and refrigerators were amortized over 1 years and 7 years respectively. Examination and surgery equipment were amortized over 5 years. Communication equipment was also amortized over 2 years. The selection of these periods was guided by a recent study for the health ministry of Ghana (Huff-Rousselle et al. 2). The cost of furniture and bed for each facility was estimated at 1% of the total facility cost as suggested by the MBP model. The total facility cost of the selected health centres were based on the construction cost of the Begoso health centre as well as the New Atuabo Community clinic, which were constructed not long ago. The maternity clinics operate mostly in rented facilities and therefore the annual rental charges paid were used for the estimation. The Tarkwa Government Hospital is about 122 years while the ABA hospital is over 5 years. To estimate the capital cost at this level, the replacement cost of the Tarkwa Government hospital was used. The proposed new district hospital is estimated to cost $ 6,1, to be funded by the African Development Bank (ADB III project). This cost far exceeds the $1,, estimate in the standard MBP for a hospital. 12

Data Consolidation To facilitate the entry of the collected data into the model, the data from the different facilities were consolidated according to the types of health facilities hospital, health center and health post. Averages were then computed from the consolidated data form based on facility type. The averages were then entered into the Excel spreadsheet model provided for the purpose. 13

SECTION IV: CURRENT AND STANDARD TREATMENT PRACTICES Almost all the interventions are currently being provided in the district. Some differences were observed between the current and the standard treatment practices. This is due to the quality and quantity of personnel, health infrastructure and medical supplies currently available in the health institutions. It could also be as a result of the country s policy on maternal health. The current practice among facilities at each level was however observed not to be quite different. The interventions available at each level are presented in table 4.1. Health Post Though the Mother Baby Package describes a health post as a facility staffed by one or two auxiliary workers and has no bed, the public facility visited was staffed by a nurse while the private facilities were either staffed by private midwives or retired public midwives and have one or two beds. They provide services for three of the five interventions that are prescribed by the package to be provided at this level. In addition, delivery services are also provided by some health post/maternity clinics though not prescribed for this level. Currently, about half of the clients requiring normal delivery services are referred to the hospitals. Since the health post do not have laboratory facilities, all clients who come for antenatal care are required to perform the required initial laboratory tests elsewhere and bring the results. Subsequent minor tests such as haemoglobin test and urinary protein test are however performed at this level. Family Planning services are available at this level but they are limited to condoms, depo-provera and oral contraceptives. Though women with abnormal vaginal discharges are treated with antibiotics and vaginal tablets, none of the STDs mentioned in the package was identified for specific treatment at this level. Currently, the percentage of women who first seek care at health posts is estimated at 18% with maternal-health related care accounting for 23% of all facility contacts at this level. This is however estimated to rise to 2% and 25% respectively for the standard model. Health Centre Current treatment practices were quite similar in all the facilities visited. Though the facilities are staffed by nurses and midwives and auxiliaries, none had a doctor as specified by the package. Each of them however had a nurse or midwife trained as a medical assistant who head the facility. Currently, the health centres provide services for seven out of the ten interventions prescribed in the Mother-Baby package for health centres. 14

The health centres generally provide antenatal care, normal delivery care and some family planning services (Condom, Depo-Provera, Oral Contraceptive). IUD and Norplant are currently not provided at this level as specified by the package. They are also not equipped to treat severe Anaemia cases. All the health centres have the ability to address only minor abortion complications and postpartum haemorrhage (PPH) cases. All severe cases are referred to the nearest hospital in and outside the district. Normal delivery care and postpartum care are available at this level. Though they can handle minor sepsis cases, none of the health centres visited had recorded any sepsis case during the year. None of the facilities visited could confirm the treatment of any of the STDs during the year though treatment is offered to women with abnormal vaginal discharges. Currently, none of the health centres has a laboratory and therefore refer women for laboratory test to serve as a basis for subsequent minor routine tests during the antenatal period. The percentage of women who first seek care at health centres is estimated at 35% with maternal-health related care accounting for 33% of all facility contacts at this level. This is however estimated at 45% and 3% respectively for the standard model. Hospital All the hospitals visited could provide all the interventions but not up to the standard practice. Though none of the facilities had an Obstetrician nor a Paediatrician, some of the General Physicians have had the necessary post-graduate training to provide the required services. They have laboratories but RPR test and test for malaria are not conducted. The syndromic approach is employed for the treatment of suspected STDs. No cases of Severe Anaemia, Sepsis, Eclampsia and Syphilis were recorded at the facilities though they could be handled. As a result, the cost estimate for the current treatment practice could not be ascertained. With regards to Family Planning, Condoms were least patronized while Norplant had just been introduced in the District. Currently, the Hospitals receive about 47% of the women who seek maternal health from the health institutions for the first time but only 18% of all hospital contacts are maternal health related. The estimates for the standard model are 35% and 2% respectively. The fall from 47% to 35% is anticipated because the health centres are to receive more clients than they are doing now. Malaria in Pregnancy In addition to the Malaria prophylaxis that are required as part of the antenatal care, there seemed not to be a uniform practice among the facilities visited. Not all clients are given this care. Even for those who receive this preventive service, the drug given as prophylaxis often alternative between Chloroquine (mostly in public facilities) and Daraprim (mostly in private facilities). Malaria test is not regarded as a routine antenatal requirement. 15

Table 4.1 Current and Interventions at Different Health Facilities Current Practice Practice Antenatal Care Antenatal Care Family Planning Family Planning Health Post -Condom, Depo-Provera -Oral Contraceptive -Condom, Depo-Provera -Oral Contraceptive Normal Delivery Care Postpartum Care Postpartum Care STD Other Health Centre Hospital Abortion Complications Antenatal Care Family Planning -Condom, Depo-Provera, -Oral Contraception Haemorrhage Normal Delivery Care Postpartum Care Sepsis Abortion Complications Antenatal Care Eclampsia Family Planning -Condom, Depo-Provera, -Oral Contraception, IUD, Sterilization, +Haemorrhage Neonatal Complications Normal Delivery Care Obstructed Labour Postpartum Care STD Other STD syphilis Abortion Complications Anaemia, severe Antenatal Care Family Planning -Condom, Depo-Provera, -Oral Contraception, IUD, -Norplant Haemorrhage Normal Delivery Care Postpartum Care Sepsis STD Other STD Syphilis Abortion Complications Antenatal Care Eclampsia Family Planning -Condom, Depo-Provera, -Oral Contraception, IUD, -Sterilization, Norplant Haemorrhage Neonatal Complications Normal Delivery Care Obstructed Labour Postpartum Care STD Other STD Syphilis Though Malaria treatment is not regarded as one of the interventions in the mother-baby package, it was observed as one of the major causes of illness among pregnant women in Ghana. The common antemalarial drugs mentioned included Chloroquine, (which could be under different brand names) and artesunate. Pregnant women who are suspected to have malaria may be made to have a laboratory test to confirm it. 16

Traditional Birth Attendants (TBAs) Again, although the Mother-Baby Package does not include the services provided by TBAs, they are recognized as partners in Ghana s Safe Motherhood programme. Trained TBAs mostly conduct home deliveries and limited ANC in the district. Number of Clients The district currently has no planned targets based on projected population in the future. Thus using the current population of the district and its crude birth rate, the numbers of pregnancies and births have been estimated at 8,755 and 7,959 respectively. Guided by the current and targeted ANC coverage rates, institutional delivery rate and contraceptive prevalence rate as well as the prevalence/incidence of the various complications, the estimated number of clients for each intervention is presented in table 4.1 and further shown in figure 4.1. Table 4.1 Estimated Number of Clients requiring various Interventions under the Current and Treatment Practices Intervention Current Difference % Difference Abortion complications 46 438 32 7.9 Anaemia, Severe 23 35 147 72 Antenatal Care 578 8755 3677 72.4 Eclampsia 4 14 1 25 Family Planning 151 4377 3326 316.5 Haemorrhage (PPH) 4 72 32 8 Neonatal Complications 446 1433 987 221.3 Normal Delivery Care 2228 7163 4935 221.5 Obstructed Labour 16 358 198 123.8 Postpartum Care 4616 7959 3343 72.4 Sepsis 16 5 34 212.5 STD _ Other 162 88-74 -45.7 STD _ Syphilis - - - - Total 14412 3158 16646 115.5 Currently, it is estimated that a total of 14,412 clients require the various interventions. Without taking population growth into consideration, it is expected that the increases in projected coverage rate for ANC is from 58% to 1%, institutional delivery rate from 28% to 9% and family planning prevalence rate from 12% to 5%. The estimated number of clients for the standard treatment practice thus increases to 31,58, resulting in a difference of 16,646. With reference to individual interventions, ANC is expected to be required by many of the clients though the percentage change is 72.4% over the current number of clients. This is to be followed by postpartum care, normal delivery and family planning in that 17

order. The largest increase in the number of clients (316%) is however expected in the demand for family planning services. Health facilities are expected to record massive increases in the number of clients for eclampsia, normal delivery, neonatal complications and sepsis. It is however anticipated that there will be a decline in clients with STDother. Figure 4.1 Total Numbers of Clients 35 3 Total Number of Clients Current 31,56 25 NUMBER OF CLIENT 2 14,412 15 1 8,755 7,959 7,163 5,78 4,377 4,616 5 2,228 438 1,51 1,433 35 88 46 23 4 4 72 446 16 358 16 5 162 14 Abortion Complications Anaemia, Severe Antenatal Care Eclampsia Family Planning Haemorrhage Neonatal Complications Normal Delivery Care Obstructed Labour INTERVENTION Postpartum Care Sepsis STD - Other STD - syphilis Total 18

SECTION V: TREATMENT COST This section discusses the total direct costs of the current safe motherhood programme and the standard WHO Mother-Baby Package (MBP). The cost is presented by facility level and then by input at different facility levels as well as the total recurrent cost by facility levels. 5.1 Total Cost by Facility Table 5.1 below summarizes the total costs of the current safe motherhood care practice and the standard WHO MBP, and the incremental cost. Table 5.1 Current, and Incremental Cost by Facility Level (US$) Total Cost by Facility Level in Wassa West District (US$) Health Post Health Centre Hospital Total Cost Current Safe Motherhood 28,642 56,719 65,35 Care Practice (A) WHO/MBP Option (B) (3.9%) 65,915 (9.9%) (7.7%) 265,94 (39.8%) Cost per Capita 1 (88.4%) 735,711 3.1 335,96 (5.3%) 667,78 2.8 Incremental Cost [(B) (A)] 37,273 29,185-314,39-67,931 1 It is estimated that the district will require about $667,78 a year to implement the standard Mother-Baby Package. This is equivalent to per capita cost of $2.8. The current practice is estimated to cost $735,711, which is 1.1% ($67,931) higher than the estimate for the standard MBP. This is due to the higher replacement cost for the district hospital. Comparatively, the hospital accounts for about 5.% of the total cost for the standard practice while the health centre and the health post account for almost 4.% and 1.% respectively. Currently, while the hospital account for 88.4% of the estimated total cost, the health centre and the health post account for almost 8.% and 4.% respectively (Table 5.1 & Figure 5.1). For the health post, the current total cost of $28,642 represents 43.5% of the estimated total cost of the standard MBP practice. The health centre has the highest incremental cost of $29,185, with the current practice cost representing only 21.3% of the estimate for the standard MBP option. The estimate for the current practice cost for the hospital is however 93.6% higher than the estimate for the standard MBP at the hospital level. 1 The cost per capita was estimated by dividing the Total cost by the total population of the district. 19

Figure 5.1 Total Cost by Facility Total Cost by Facility Level Current Total Cost ( $ ) 8, 7, 6, 5, 4, 3, 2, 1, 65,35 735,711 667,78 335,96 265,94 65,915 28,642 56,719 Health Post Health Centre Hospital Total Health Facility Level Total Cost (CURRENT PRACTICE) BY Facility Level Total Cost (STANDARD PRACTICE) by Facility Level Health Post Health 4% Centre 8% Health Post 1% Hospital 88% Hospital 5% Health Centre 4% 5.2 Total Cost by Input The distribution of the total cost of the standard practice by input indicates that personnel time cost represents the most important cost item accounting for 37% of the total cost. This is followed by the cost of consumable supplies (12%) and cost of drugs (1%). Facility cost accounts for 6% while hospital bed+food and examination and surgery equipment account for 8% and 2% of the total cost respectively (Fig.5.3a). Compared with the distribution of the total cost of the current practice, personnel time cost accounts for only 7.%. Facility cost represents 31%, making it the most important cost item. This is followed by cost of maintenance and utility (27%) and furniture and bed (11%). Cost of drugs and support salaries represent 5% and 4% respectively. Examination and surgery equipment cost represents only 3% while the cost of laboratory supplies accounts for less than 1% of the total cost (Figure 5.3b). 2

Figure 5.3a Total Cost by Input [ Practice] Support Salaries 6% Communications Equipment 1% Exam. & Surgery Equipment Refrigerators Furniture and Beds 2%.3% 2% Facilities IEC and Social 6% Marketing 2% Supervision 1% Vehicles 2% Blood Products Other %.4% 1% Hospital Bed + Food 8% Lab Supplies 3.1% Maintenance and Utility 6% Transportation.3% Consumable Supplies 12% 37% Figure 5.3b Total Cost by Input [Current Practice] Refrigerators Communications Equipment.2% 1% Furniture and Beds 11% Exam. & Surgery Equipment 3% Vehicles 1% Blood Products.4% 5% Hospital Bed + Food 3% Lab Supplies.4% 7% Consumable Supplies 4% Transportation % Other % Facilities 31% Maintenance and Utility 27% IEC and Social Marketing 1% Support Salaries 4% Supervision % 21

5.3 Total Cost by Intervention The distribution of the total cost by the various interventions is based on the coverage rates of the various programmes and the prevalence rate as well as the number of clients earmarked for the various facility levels by the MBP. The average cost per intervention is discussed in detail in Section VI. Health Post The Health Post is assumed by the MBP to provide only three of the interventions, namely: ANC, family planning and postpartum care. ANC to clients is estimated to cost $47,321, which represents 72.1% of the total cost. Family planning account for 16.1% of the total cost ($1,562) while postpartum care represents almost 12% ($7,72). In the current practice, however, ANC costs $16,97, (6.2% of total cost), which is 35.9% of the estimated cost of ANC under the standard practice. Family planning at the health post costs $3,49 (67.7% less than the estimate for the standard MBP) while postpartum care currently costs $6,415. Though normal delivery care is not recommended by the MBP at this level, health posts do provide this service and currently costs $1,41 (Figure 5.4). Figure 5.4 Total Cost by Intervention at Health Post Total Cost by Intervention - Health Post TOTAL COST ($) 5 45 4 35 3 25 2 15 1 5 Abortion Complications Aneamia, severe 16,97 Antenatal Care 47,321 Eclampsia 1,562 3,49 Family Planning Haemorrhage Neonatal complications 1,41 Obstructed Labour Normal Delivery Care INTERVENTION Postpartum Care 7,72 6,415 Current Sepsis STD - Other STD-syphilis Health Centre Under MBP, the normal delivery would cost a total of $119,176 and ANC, $1,928. Other interventions such as family planning and postpartum care would cost $26,842 and $11,444 respectively. The largest incremental costs are recorded for ANC (equivalent to 72.5% of the standard practice cost for ANC), family planning (82%) and normal delivery care (9.7%). The current cost of abortion complication is $2,977, which is 22

61.3% of the standard practice cost. These percentages indicate that the current practice costs are far below the estimated requirement for the implementation of the standard practice (Figure 5.5). Figure 5.5 Total Cost by Intervention at Health Centre Total Cost by Intervention - Health Centre TOTAL COST ($) 14, Current 119,176 12, 1,928 1, 8, 6, 4, 27,79 26,842 2, 11,14 9,322 11,444 4,853 2,977 1,263 4,823 16 423 54 15 573 473 Abortion Complications Aneamia, severe Antenatal Care Eclampsia Family Planning Haemorrhage Neonatal complications Normal Delivery Care INTERVENTION Obstructed Labour Postpartum Care Sepsis STD - Other STD-syphilis Hospital Given the estimate that 2% of all newborns suffer from complications and the fact that care is only available at the hospital, it is expected to cost $87,879 in the standard practice, making it the most expensive intervention in the MBP. This is followed by ANC and normal delivery care at $76,718 and $62,48 respectively due to the large numbers of clients for these interventions. With the exception of eclampsia, haemorrhage, normal delivery care, and obstructed labour, where the standard practice costs are higher than those of the current practice costs, the opposite holds true for all the other interventions. Currently, ANC is the most expensive intervention at $236,465 (28% higher than the standard practice cost), which is followed by neonatal complications ($14,453), normal delivery care ($52,51) and family planning (Figure 5.6). It should be noted that the higher cost of interventions at the facility level is in part attributed to the high replacement cost of the district hospital at Tarkwa. Figure 5.6 Total Cost by Intervention at Hospital 23

Total Cost by Intervention - Hospital TOTAL COST ($) 25, 2, 15, 1, 48,748 5, 19,715 13,84 2,212 Abortion Complications Aneamia, severe Antenatal Care Current 236,465 14,453 76,718 87,879 62,48 51,176 52,51 32,911 37,355 32,689 5,245 21,87 1,877 2,473 635 4,653 6,88 3,61 2,63 286 Eclampsia Family Planning Haemorrhage Neonatal complications Normal Delivery Care INTERVENTION Obstructed Labour Postpartum Care Sepsis STD - Other STD-syphilis 5.4 Direct Treatment Cost The total direct cost of the standard practice is estimated at $479,59 compared with $151,144 for the total direct cost of the current practice. This represents 32% of the direct standard practice cost. While the hospital account for 75% of the total cost of the current practice cost, the health centre and the health post account for 19% and 6% respectively. The trend is the same for the standard practice with the hospital taking more than half of the total direct cost. The incremental cost for the health post represents 76% of the standard practice cost while that of the hospital is 57%. The health centre however has the largest incremental cost of $15,629, which represents 84% of the estimated standard practice cost (Table 5.2 and Figure 5.7). Table 5.2 Current and Direct Treatment Cost by Facility Level (US$) Direct Cost by Facility Level Health Health Hospital Total Cost Post Centre Current Direct Treatment Practice 8,332 (6%) 28,97 (19%) 113,812 (75%) 151,114 (1) Treatment According WHO/MBP 34,935 (7%) 179,599 (37%) 265,55 (56%) 479,59 (1%) Difference (Incremental Cost) 26,63 15,629 151,243 328,476 24

Figure 5.7 Direct Cost by Facility Level 6, Direct Cost by Facility Level Current 5, 479,59 4, Total Direct Cost ($) 3, 265,55 2, 179,599 151,114 113,812 1, 34,935 28,97 8,332 Health Post Health Centre Hospital Total Health Facility (Level) 5.5 Direct Treatment Cost by Input Health Post The cost of personnel time of $23,341 represent 67% of the standard practice cost compared with $3,48 in the current practice (37% of the direct treatment cost). The cost of drugs and consumable supplies are the other major cost inputs at this level though their percentage shares in the two practices differ (Figure 5.8). The cost of drugs at $3,157 in the current practice amounts to only 38% of the drug cost in the standard practice. The cost of consumable supplies in the standard practice is $1,578 higher than in the current practice. Since the health post is assumed in the standard practice not to have beds, it has no input cost but in the current practice, hospital beds amount to $17. The cost of laboratory supplies in the current practice of $451 is far higher than the $58 in the standard practice. 25

Figure 5.8 Current and Treatment Cost by Input at Health Post Direct Treatment Cost by Input at Health Post 25 23341 Current 2 COST ($) 15 1 8299 5 Blood Products 3157 17 451 58 Hospital Bed Lab. Supplies 348 1659 3237 Consumable Supplies Emergency Transportation CURRENT Direct Treatment Cost by Input - Health Post STANDARD Direct Treatment Cost by Input - Health Post Consumable Supplies 2% 38% Consumable Supplies 9% 24% Lab. Supplies.2% 37% Hospital Bed + Food % Lab. Supplies 5% 67% Health Centre All the direct input cost in the standard practice at health centre is higher than those of the current practice (Figure 5.9). The personnel cost of $14,13 in the current practice represent only 12% of that of the standard practice cost of $119,47. Though drug cost account for 3% of the current direct treatment cost and 16% of the standard direct treatment cost, the incremental cost of drugs amounts to $16,573, representing 65% of the drug cost in the standard practice. The incremental cost of laboratory supplies is also estimated at $1,367 while that of consumable supplies amount to $16,113. The health centre does not provide blood products and emergency transport to its clients and therefore does not record any cost for them. 26

Figure 5.9 14 Direct Treatment Cost by input at Health Centre Direct Treatment Cost by Input at Health Centre Current 12 119,47 1 COST ($) 8 6 4 2 8,782 25,355 Blood Products Hospital Bed + Food 11,248 422 2,47 881 14,13 4,781 2,894 Lab. Supplies Consumable Supplies 225 Emergency Transportation CURRENT Direct Treatment Cost by Input, Health Centre Consumable Supplies 17% 49% 3% Hospital Bed + Food 1% Lab. Supplies 3% STANDARD Direct Treatment Cost by Input, Health Centre Emergency.1% Transportation Blood Hospital Bed Consumable Products % + Food Supplies 12% Drug 14% 1% Lab. Supplies 6% 67% Hospital At the Hospital, personnel cost continues to be the most important cost input accounting for 4% ($17,7) and 32% ($36,453) of the direct treatment cost in the standard and current direct treatment costs respectively. The cost of consumable supplies at $58,66 in the standard practice and $25,7 in the current practice represent 22% of the direct cost in each of the practices. While the cost of drugs at $53,521 represents 13% of the total standard direct cost, it represents 22% in the current direct cost at $25,213. Comparatively, the incremental cost for the various inputs as percentages of the standard direct treatment cost by inputs are 29% for drugs, 55% for hospital bed+food, 82% for laboratory supplies, 66% for personnel and 57% for consumable supplies. 27

Figure 5.1 Direct Treatment Cost by input at Hospital 12 Direct Treatment Cost by Input - HOSPITAL 17,7 Current 1 8 COST ($) 6 49,765 58,66 4 35,521 36,453 2 25,213 2223 25,7 9,283 31922,973 Blood Products Hospital Bed + Food 1681 Lab. Supplies Consumable Supplies 1,91 Emergency Transportation CURRENT Direct Treatment Cost by Input - HOSPITAL Consumable Supplies 22% Blood Products 3% 22% STANDARD Direct Treatment Cost by Input - HOSPITAL Consumable Supplies 22% Emergency Transportation 1% Blood Products 1% 13% Hospital Bed + Food 19% 32% Lab. Supplies 1% Hospital Bed + Food 2% 4% Lab. Supplies 4% 5. 5 Recurrent Cost 5.5.1 Recurrent Cost by Facility Level The recurrent cost for the implementation of the standard WHO/MBP is estimated at $578,455. Almost 52% of this amount is accounted for by the hospital while 38.3% and 1.1% go to the health centre and health post respectively. The current treatment practice is estimated at $386,133 in recurrent cost with the hospital accounting for almost 83%. The total incremental cost of $192,22 represents almost 33.2% of the standard practice cost. The health centre has the largest incremental cost (in terms of percentages) of 79.9% compared with 63.% for the health post. The hospital on the other hand has a negative 28

incremental cost of $21,44. The reason for the high incremental cost for the health centre is that the current state of the health centres in the district is far below what is assumed in the MBP as the standard. The differences are clearly shown in Figure 5.11. Table 5.3 Current and Recurrent Cost by Facility Level (US$) Recurrent Cost by Facility Level Health Post Health Centre Hospital Current safe motherhood 21,536 44,413 32,133 care [A] (5.6%) (11.5%) (82.9%) WHO/MBP 58,273 221,454 298,729 Practice [B} (1.1%) (38.3%) (51.6%) Total Cost 386,455 (1%) 578,455 (1%) Incremental Cost [(B A)] 36,737 177,41-21,44 192,22 Figure 5.11 Recurrent Cost by Facility Level Recurrent Cost by Facility Level 7, 6, Current 578,455 Recurrent Cost ($) 5, 4, 3, 2, 221,454 32,133 298,729 386,84 1, 58,273 21,536 44,413 Health Post Health Centre Hospital Total Facility Level 5.5.2 Total Recurrent Cost by Input The most important input in terms of recurrent cost for the standard treatment practice is personnel cost, which accounts for 42% of the total recurrent cost of the standard practice compared with only 14% for the current practice. Some of the important inputs in the standard practice include consumable supplies (14%), drugs (12%), hospital bed+food (9%), support salaries (7%) and maintenance and utility (7%). The sequence however changes in the current practice with the cost of maintenance and utility alone accounting for 5% of the total recurrent cost. Others include cost of drugs (1%), consumable 29

supplies (8%) and support salaries (8%). The cost of IEC and social marketing as well as laboratory supplies account for only 2% and.8% respectively. The details are presented in figures 5.12a and 5.12b below. Figure 5.12a Total Recurrent Cost by Input for the Practice M aintenance and Utility 7% Transportation.4% Supervision Blood 1% IEC and Social M arketing Products Support Salaries 3% 1% 7% 12% Hospital Bed + Food 9% Consumable Supplies 14% Lab Supplies 3.6% 42% Figure 5.12b Total Recurrent Cost by Input for the Current Practice Support Salaries 8% Blood Products 1% IEC and Social Marketing 2% 1% Hospital Bed + Food 6% Supervision % Lab Supplies.8% 14% Maintenance and Utility 5% Consumable Supplies 8% Transportation % 3