Cost of Family Planning Services in Ghana

Publication date: 2013

COST OF FAMILY PLANNING SERVICES IN GHANA September 2013 This publication was prepared by Felix Ankomah Asante for the Health Policy Project. A technical report prepared for the National Population Council with support from the U.S. Agency for International Development (USAID)-supported Health Policy Project and the Department for International Development (DFID), U.K. HEALTH POL ICY P R O J E C T Suggested citation: Asante, F. A. 2013. Cost of Family Planning Services in Ghana. Washington, DC: Futures Group, Health Policy Project. ISBN: 978-1-59560-104-9 The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). Cost of Family Planning Services in Ghana SEPTEMBER 2013 This publication was prepared by Felix Ankomah Asante for the Health Policy Project. A Technical Report Prepared for the National Population Council with Support from the U.S. Agency for International Development (USAID)-supported Health Policy Project and the Department for International Development (DFID), U.K. The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development or the U.K Department for International Development. iii TABLE OF CONTENTS Table of Contents . iii List of Tables . v List of Figures . v Abbreviations . vi Executive Summary .viii Methodology . viii Results . viii Background . 1 Introduction . 1 Family Planning in Ghana . 1 Study Objectives . 5 Family Planning Service Interventions Costed . 6 Target Audiences for the Study . 7 Scope of the Study . 8 Timeframe and Analytic Horizon . 8 Methodology . 8 Costing Approach . 8 Study Sites . 8 Types of Inputs Costed . 12 Data Collection and Analysis . 12 Limitations of the Study . 13 Results . 14 Unit Cost of Family Planning Services . 14 Indirect and Direct Costs . 15 Components of Direct Cost . 15 Projected Cost of Family Planning Services in Ghana, 2012–2016 . 16 Total Cost . 16 Components of Direct Cost . 16 Conclusion . 26 References . 27 Appendix 1: Details of How the Costs were Estimated . 28 Appendix 2: Questionnaire—Estimating the Unit Cost of Delivering Family Planning Services . 31 Costs per Facility: Hospital . 31 Costs per Facility: Health Centres and Community Health Practitioners . 32 Costs per Facility: Health Centres and Community Health Practitioners . 33 iv Costs per Facility: Polyclinics . 34 Costs per Facility: Maternity Home . 35 v LIST OF TABLES Table 1: Number of Users of Family Planning Service Methods, 2010–2012 . 3 Table 2: Site Selection for Cost of Family Planning Services . 10 Table 3: Unit Cost of Family Planning Services in Ghana . 14 Table 4: Projected Total Cost of Family Planning Services in Ghana, 2012–2016 (US$) . 18 Table 5: Projected Direct Cost of Family Planning Services in Ghana, 2012–2016 (US$). 21 LIST OF FIGURES Figure 1: Trend in Family Planning Method Preference, 2010–2012. 4 Figure 2: Direct and Indirect Cost of Family Planning Services . 15 Figure 3: Components of Direct Cost of Family Planning Services (Percentage) . 16 vi ABBREVIATIONS AIDS acquired immune deficiency syndrome CHPS Community-Based Health Planning Services CIC combined injectable contraceptive COC combined oral contraceptive CPR contraceptive prevalence rate DMPA Depot Metroxyprogesterone Acetate FHU family health unit FP family planning GDHS Ghana Demographic and Health Survey GHS Ghana Health Service GSS Ghana Statistical Service HIV human immunodeficiency virus HPP Health Policy Project IUD intrauterine device LAM lactational amenorrhoea method MDGs Millennium Development Goals NET-EN Norethisterone Enanthate NFP natural family planning NGOs nongovernmental organisations NHIA National Health Insurance Authority NHIS National Health Insurance Scheme NPC National Population Council POI progestin-only injectable POP progestin-only pills STI sexually transmitted infection TFR total fertility rate vii UNFPA United Nations Population Fund USAID United States Agency for International Development VSC voluntary surgical contraception viii EXECUTIVE SUMMARY Family planning (FP) is a major component of reproductive health, one of the pillars of safe motherhood, and an entry point to other reproductive health services such as prevention and management of sexually transmitted infections (STIs) and HIV and AIDS, comprehensive abortion care, management of infertility, screening for reproductive tract cancers, and prevention of gender-based violence (GHS, 2007). In 2012, the government of Ghana included FP commodities and services in the benefit package of the National Health Insurance Scheme (NHIS), creating a need to assess the cost of family planning. This activity focused on costing the FP services included in the National Family Planning Protocols of 2007, which are currently being delivered in health facilities and by nongovernmental organisations (NGOs) in Ghana. The objectives of the study were to determine the unit cost (direct and indirect) of providing FP services in Ghana and to project the resource requirements for scaling up FP services from 2012 to 2016. Methodology The study was carried out between March and July 2013. A bottom-up ingredients approach to costing, in which all inputs were listed and their contribution to the overall cost tallied, was combined with a step- down approach to allocate direct and indirect costs to each FP service on the basis of utilisation or workload. Nineteen purposefully selected sites were studied: five hospitals, two polyclinics, three health centres, three Community-based Health Planning Services (CHPS), two maternity homes, and four NGO service points. The sites reflect the key characteristics thought to influence unit cost estimation, including the level of health facility; location within the country; and ownership and utilisation of FP services. The study used 2012 service statistics in the 19 selected sites and 2012 prices to value the inputs’ economic cost. Results The study found that on average the cost per client per year for the provision of FP services ranged from 135.29 Ghanaian cedi (GH¢) (US$75.16) and GH¢82.60 (US$45.89) for female condoms and combined injectable contraceptive (CIC) to GH¢11.75 (US$6.53) and GH¢11.25 (US$6.25) for natural family planning (NFP) and lactational amenorrhoea method (LAM), respectively. The unit cost for other FP services were as follows: male condoms, GH¢20.43 (US$11.35); combined oral contraceptive (COC), GH¢26.87 (US$14.93); progestin-only or mini-pills (POP), GH¢19.46 (US$10.81); progestin-only injectable (POI), GH¢45.72 (US$25.40); implants, GH¢63.11 (US$35.06); intrauterine devices (IUDs), GH¢19.39 (US$10.77); tubal ligation, GH¢52.20 (US$29.00); and vasectomy, GH¢46.36 (US$25.76). Projecting the cost of providing all FP services in the country shows a rise from US$40,480,136.02 in 2014 to US$43,634,330.54 in 2015 and US$46,922,214.96 in 2016, an increase of 15.91 percent between 2014 and 2016. The cost of FP commodities is expected to grow from US$8,074,816 in 2014 to US$8,628,121 in 2015 and US$9,204,240 in 2016, representing an increase of 13.99 percent between 2014 and 2016. 1 BACKGROUND Introduction Family planning (FP) plays a pivotal role in the attainment of many of the Millennium Development Goals (MDGs) in Ghana. It is a major component of reproductive health, one of the pillars of safe motherhood, and an entry point for other reproductive health services such as prevention and management of sexually transmitted infections (STIs) and HIV and AIDS, comprehensive abortion care, management of infertility and gender-based violence cases, and screening for reproductive tract cancers (GHS, 2007). In Ghana, the National Family Planning Protocols of 2007 provide standard guidance for FP service provision at all levels and for both the public and private sectors, including nongovernmental organisations (NGOs). Recognizing the link between rapid population growth and social and economic development, the government of Ghana has worked to build a positive policy environment for family planning, an effort spearheaded by the National Population Council (NPC). Article 3, clause 4 of the 1992 Fourth Republican Constitution of Ghana enjoins the government to maintain a population policy that is consistent with the aspirations and development needs of the country. The NPC was established in 1992 and given legal backing by the 1994 National Population Council Act 485. It is responsible for coordinating all population-related programmes in the country, setting targets for programme performance, interpreting and reviewing the population policies, undertaking and commissioning research to inform policy making, and ensuring the integration of population variables into development planning in Ghana. In 2011, the NPC and its partners initiated a process to cost FP commodities and services in Ghana in support of its advocacy and coordination of FP programme implementation. The aim of this exercise was to assist the council in making a case for the inclusion of FP commodities and services in the benefits package of the National Health Insurance Scheme (NHIS). The government subsequently made pronouncements to do so (NHIA Act 852 of 2012); there is a need to assess the cost of FP commodities and services and combine these cost data with demographic data and coverage goals to generate the resources required for scaling up family planning nationally. Family Planning in Ghana Ghana’s Population Policy of 1969 was one of the first on the African continent. However, a 1989 assessment by the national Population Policy Technical Advisory Committee documented the lack of progress in achieving the goals the policy had set out, as a result of a lack of grassroots involvement in the development of the policy and a strategic plan for implementation. In 1994, the policy was revised to take these factors into account. The National Population Policy (Revised Edition, 1994) set clear targets regarding fertility and contraceptive use and addressed emerging issues such as HIV and AIDS, population and the environment, concerns about the elderly and children, and the development of new strategies to ensure achievement of the revised policy objectives. The revision also entailed a concerted effort to systematically integrate population variables into all areas of development planning. Cost of Family Planning Services in Ghana 2 Selected Major Goals of the Revised Population Policy (NPC, 1994) • To reduce the total fertility rate (TFR) from 5.5 in 1993 to 5.0 by year 2000, 4.0 by 2010, and 3.0 by 2020. Accordingly, the policy aims to achieve a contraceptive prevalence rate (CPR) of 15 percent for use of modern methods by year 2000, 28 percent by 2010, and 50 percent by 2020. • To make family planning services available, accessible and affordable to at least half of all adults by the year 2020. • To reduce the proportion of women below 20 years and above 34 years having births to 50 percent by the year 2010 and to 80 percent by 2020. • To reduce the population growth rate from 3 percent to 1.5 percent by 2020 while increasing life expectancy from the current level of 58 years to 65 years by 2010, and 70 years by 2020. The attainment of these population goals is recognised as an integral component of the national strategy to accelerate economic development, eradicate poverty, and enhance the quality of life for all Ghanaians. These policies are further supported by the current national blueprint for development, the Ghana Shared Growth and Development Agenda (2010–2013), which recognizes family planning as a top priority for inclusion in national development plans and activities at all levels. In collaboration with the United Nations Population Fund (UNFPA), the United States Agency for International Development (USAID), the World Bank, and other development partners, Ghana has implemented several family planning and reproductive health projects. Support from these agencies has targeted policy coordination, implementation, and service delivery. Since the revised policy was implemented in 1994, improvements in family planning have accelerated. Data from the 1993 to 2008 Ghana Demographic and Health Surveys (GDHS) showed a decrease in the country’s TFR—to an average of four children per woman in 2008—and a CPR increase for modern methods to 19 percent in 2003, followed by a decline to 17 percent in 2008. Although the TFR has declined and contraceptive prevalence has increased, unmet need for family planning among married women remained high (50% in 1988 and 42% in 2008) and women continue to have more children than they desire. The Ghana Health Services/Family Health Unit (FHU) has made the availability and appropriate use of FP services a priority. Data from the five consecutive GDHS (1988–2008) showed marked increases in knowledge about family planning and use of FP services and methods available in Ghana. Between 1993 and 1996, the FHU expanded access to permanent (mini-laparotomy and vasectomy) and long-acting (IUDs and implants) methods and introduced the monthly (combined) injectable and female condom in both the public and private sectors. Current use of contraception varies by residence (urban or rural, and regional) and levels of education and wealth. The 2008 GDHS showed that women in urban areas were more likely to use modern methods of contraception than women in rural areas (24.2% vs. 14.9%). Use of both male and female condoms, IUDs, and female sterilisation is two to three times higher in urban areas than in rural Ghana. The prevalence of modern method use ranges from 7.7 percent and 9.7 percent in Northern and Upper East regions to 24.8 percent and 26.0 percent in Brong Ahafo and Greater Accra regions, respectively. The order of preferred methods has changed since the 1998 GDHS. The proportion of non-users who prefer injectables for future use increased from 36 percent in 1998 to 43 percent in 2003, and declined to 39 percent in 2008. The proportion of non-users who prefer pills decreased from 21 percent in 1998 to 15 percent in 2003, and increased to 21 percent in 2008. Preference for implants increased from 4 percent in Background 3 1998 to 11 percent in 2003, and remained steady for five years (10% in 2008). Intention to use the IUD also increased from 2 percent in 1998 to 4 percent in 2003, and declined to 1 percent in 2008. In 1998, 4 percent of non-users said that they preferred to use female sterilisation in the future compared with just 2 percent in 2008. Short-term contraceptive methods include oral contraceptive pills, condoms, and injectables. Long-term contraceptive methods provided include IUDs, female sterilisation, vasectomy, implants, and natural methods. A total of 2,084,686 individuals used some FP service methods in 2010 while 2011 and 2012 recorded 1,699,128 and 1,548,293 users, respectively (Table 1). Table 1: Number of Users of Family Planning Service Methods, 2010–2012 Family Planning Methods Number of Users 2010 2011 2012 Fertility awareness-based methods NFP 66,890 10,299 9,987 LAM 4,678 106,757 108,188 Barrier methods Male condom 809,840 442,915 250,894 Female condom 6,227 4,226 7,104 Spermicide (foaming tablet) 554 - - Hormonal Methods Combined pill (COC) 240,286 153,940 161,041 Mini pill (POP) 25,996 30,536 30,067 Norigynon inject (CIC) 124,368 186,282 84,229 Depo injectable (POI) 733,182 649,924 789,524 Implant 35,740 62,326 80,968 Reversible FP methods IUD 21,503 27,313 17,969 Permanent FP methods Vasectomy 536 282 995 Tubal ligation 15,440 24,328 7,327 Total users 2,084,686 1,699,128 1,548,293 Source: Ghana Health Service, 2010–2012 Annual Reproductive and Child Health Reports, Accra, Ghana. Injectables accounted for the highest use in all three years, increasing proportionally from 41 percent in 2010 to 50 percent in 2011 and 56 percent in 2012. This is followed by condom use, which formed about 39 percent of total use in 2010, but declined to 27 percent in 2011 and 17 percent in 2012. The pill (both the combined oral contraceptive and mini pill) ranked third in all three years, accounting for 12 percent of total use on average. The use of LAM has increased from 3 percent in 2010 to 6 percent in 2011 and 7 percent in 2012. In 2010, there was some use of spermicidal foaming (contraceptive) tablets (0.03% of total use) but none in 2011 or 2012. Long-term contraceptive methods such as IUDs and vasectomy also received minimal patronage. NFP methods, apart from LAM, accounted for less than 1 percent of total Cost of Family Planning Services in Ghana 4 use in all three years. Figure 1 shows the national shifts in short- and long-term methods between 2010 and 2012. Figure 1: Trend in Family Planning Method Preference, 2010–2012 NFP LAM Condoms Pills Injectables Implants IUDs Sterilisation 2010 NFP LAM Condoms Pills Injectables Implants IUDs Sterilisation 2011 NFP LAM Condoms Pills Injectables Implants IUDs Sterilisation 2012 Source: Ghana Health Service, 2010–2012 Annual Reproductive and Child Health Reports, Accra, Ghana. Background 5 As shown on Figure 1, more women are choosing long-term methods, and the government will need to ensure the availability of commodities and trained personnel to meet this increased demand (GSS et al., 2008). As the government takes over a greater share of responsibility for financing FP programmes with domestic resources, it requires up-to-date information about the cost of FP services. Such information will feed into future strategic planning and coordination and resource mobilisation for family planning, whether integrated into the NHIS or otherwise. Study Objectives The objectives of the FP costing study are primarily to provide the GHS/FHU in the Ministry of Health, as well as other programs into which family planning is integrated, a better understanding of the costs of delivering FP services. The specific objectives of the costing study are to • Calculate unit cost estimates for a range of FP service delivery methods and commodities • Identify the cost drivers (direct and indirect) of the specific unit costs for each FP service delivery modality • Provide estimates of FP costs from 2014 to 2016 The study results provide information on unit costs of delivering FP services through a variety of methods, at different levels of the healthcare system and in different locations throughout the country. Additional analyses should be able to use this data to assess the most efficient ways of delivering FP services, and to identify the best allocation of resources to minimise costs of the FP component of NHIS. 6 FAMILY PLANNING SERVICE INTERVENTIONS COSTED The FP services costed in this study are provided at all levels by the public or private sector, including NGOs. In all, 12 service delivery methods in the 2007 National Family Planning Protocols were included in the study. Fertility Awareness–based Methods .1. Natural Family NFP can be used to either avoid or achieve pregnancy. The service can be provided Planning (NFP) separately or as a part of an established health and family planning or community agency programme. Delivery of NFP services is not dependent on medically qualified personnel. The NFP methods used include basal body temperature (BBT), calendar (rhythm), and symptothermal. .2. Lactational LAM is a short-term contraceptive method which can be initiated at the moment of Amenorrhoea birth or early in the postpartum period and used for up to six months if the mother (LAM) remains amenorrhoeic and practices exclusive breastfeeding. Suckling at the breast causes suppression of ovulation. Barrier Methods .3. Condoms (male Condoms are thin sheaths made of latex rubber, vinyl, or polyurethane, which may and female) be treated with spermicides for added protection against pregnancy and sexually transmitted diseases such as HIV. There are two types of condoms: the male condom and the female condom. Worn by the man, a male condom is a thin covering made of latex, plastic, or animal membrane to prevent sperm from entering a woman’s body. Worn by the woman, the female condom is a tube of soft plastic (polyurethane) that helps keep sperm from getting into her body. .4. Diaphragm or Each of these barrier methods is placed inside the vagina to cover the cervix to Cervical Cap block sperm. The diaphragm is a dome-shaped (rubber) shallow cup. The cervical cap is a thimble-shaped (soft rubber) deep cup with a firm, round rim. It fits around the base of the cervix. They are inserted into the vagina with spermicide before sexual intercourse to block or kill sperm. .5. Spermicides Spermicides are chemicals that deactivate or kill sperm cells and provide lubrication and additional barrier effect. They come in several forms: gel, foam, tablet, cream, suppository, or film. Spermicides can be used alone or in combination with a condom, diaphragm, or cervical cap. Reversible Hormonal Methods .6. Combined Oral COC, also called “the pill,” consists of a course of 21 synthetic hormone pills Contraceptive (oestrogen and progestin, similar to hormones naturally present in a woman’s body) (COC) and seven iron pills per cycle. .7. Progestin-Only Pill POP, also called “the mini pill” contains only one hormone (progestin) instead of (POP) both oestrogen and progestin. POP is a good choice for breastfeeding women who want to use oral contraceptives or those who cannot take oestrogen. It is not a good option for women who have breast cancer or liver disease, or tuberculosis patients on Rifampicin. .8. Combined CIC, or “the shot,” is a combination of natural oestrogen and progestin administered Injectable at four-week intervals by deep intramuscular injection in a woman’s buttocks or arm. Contraceptive The formulation currently available in Ghana is Norigyon. (CIC) 1 1 1 1 1 1 1 1 Family Planning Service Interventions Costed 7 1.9. Progestin-Only POI, or “the mini shot,” contains only the hormone progestin that is administered via Injectable (POI) injection in a woman’s buttocks or arm. There are two preparations currently available in Ghana: depot medroxyprogesterone acetate (DMPA), or Depo Provera; and norethisterone enanthate (NET-EN), or Noristerat. A single injection of DMPA or NET-EN provides safe and highly effective contraception for three or two months, respectively. 1.10. Implant Implant is a single, thin, flexible rod (capsule) that is inserted under the skin of a woman’s upper arm. The rod contains progestin (Levonorgestrel) that is released into the body over three years. There are two types of implants in Ghana: Jadelle, consisting of two small plastic capsules, and Norplant, consisting of six small plastic capsules. Reversible Non-Hormonal Methods 1.11. Intrauterine The IUD is a small, flexible T-shaped plastic device that is inserted into a woman’s Devices (IUDs) uterine cavity. It releases a small amount of progestin each day to prevent pregnancy. An applicator is used to insert and remove the IUD through the opening of the cervical canal. The most commonly used IUDs in FP programmes in Ghana are the copper-bearing CUT 380 IUD (effective for up to 10–12 years) and Multiload (MLCu250 and 375) and the NOVAT (both effective for up to 5 years). Permanent Methods 1.12. Voluntary Surgical VSC is a minor surgical procedure—vasectomy for men and tubal ligation for Contraception women—to prevent the patient from having any more children. (VSC) • Male sterilisation: A vasectomy keeps a man’s sperm from going to his penis, so his ejaculation never has any sperm that can fertilize an egg. • Female sterilization: Tubal ligation (or “tying tubes”) and transcervical sterilisation prevent the sperm and eggs from meeting for fertilization. The woman can have her fallopian tubes tied (or closed) or a tiny device threaded into each fallopian tube. TARGET AUDIENCES FOR THE STUDY Many stakeholders in Ghana have an interest in the cost of FP services. The target audiences for this study are 1. The government of Ghana, including the NPC, GHS, Ministry of Health, Ministry of Finance, and the National Health Insurance Authority (NHIA) 2. International donor and technical assistance agencies 3. Civil society organisations in Ghana that provide FP services and for advocate family planning 8 SCOPE OF THE STUDY The FP costing exercise built on previous work undertaken by the NPC and its partners. It used a combination of normative approaches listed in the 2007 Family Planning Protocols and collection of data from a number of health facilities in each of the three ecological zones of Ghana: coastal, forest, and savannah. The sampling was based on the magnitude of utilisation of FP services (high, medium, low) and ownership (government, mission, private, NGO). Selection of the health facilities took into consideration the structure of health delivery systems in Ghana (teaching hospitals, regional hospitals, district hospitals, polyclinics, health centres, CHPS). The data collection was based on service statistics for 2012 to ensure complete statistics in all facilities. TIMEFRAME AND ANALYTIC HORIZON For any study, the timeframe (period over which the service is carried out) and analytic horizon (period over which the cost and outcome of the intervention or service occurred) should be long enough to capture all relevant positive and negative programme effects. For this study, we defined both the timeframe and analytic horizon as one year. METHODOLOGY Costing Approach The study focused on unit cost analysis, defined as the cost of providing FP service for one client for one year. An ingredients approach to the costing analysis was used whereby quantities of each input are identified and prices are then attached to estimate their contribution to the overall cost. The approach considered FP services as a system in which direct and indirect inputs are transformed into outputs through processes or actions. The system approach helps to ensure that the analysis captures the full range of inputs, defined as anything the service needs to function and produce the desired outputs. Inputs include recurrent items such as labour (health workers, administrative staff, volunteers); supplies (family planning commodities, medical consumables, office materials, promotional materials); and fixed capital items (medical and office equipment, buildings, land, vehicles). Valuing these inputs (putting a cost or price on them) is the focus of the study. Study Sites Ghana’s FP service delivery environment is complex and multifaceted. The sample selection of facilities for the FP costing study had to reflect that complexity by including FP service delivery sites from the public, private, and NGO sectors. Additionally, all service delivery modalities had to be represented, as well as geographic disparities, rural/urban areas, and volume of service delivery. In choosing where to collect data, the team used the GHS-accredited FP sites as a starting point. After consultation with GHS/FHU and its partners, facilities were selected to ensure adequate representation of all variables under consideration in the study. The team chose regions first and then identified associated regional and district hospitals, polyclinics, health centres, and maternity homes within each region, and determined whether they were urban or rural; public, private, or NGO. From the site mapping and breakdowns, a purposive sample was selected according to the following criteria: Methodology 9 • Level of health facility (from highest to lowest): teaching, regional, district hospital, health centre, or CHPS • Ownership: government, mission, maternity home, or NGO • Location within the country: including the three main agro-ecological zones (coastal, forest, savannah) • Utilisation of FP services: high, medium, or low ased on these criteria, 19 sites were selected: 5 hospitals, 2 polyclinics, 3 health centres, 3 CHPS, 2 aternity homes, and 4 NGO service sites (see Table 2 for the list of selected sites/facilities). B m Cost of Family Planning Services in Ghana 10 Table 2: Site Selection for Cost of Family Planning Services Facility Region Service Utilisation Ownership of Facility Type of Facility Agro-ecology Zone Low Medium High GOV CHAG PRIV HOSP POLY HC CHPS MH Coastal Forest Savannah GAR 1. X X X X 2. X X X X 3. X X X X 4. X X X X ASH 5. X X X X 6. X X X X 7. X X X X X BAR 8. X X X X 9. X X X 10. X X X X NR 11. X X X X 12. X X X X 13. X X X X 14. X X X X 15. X X X X NGO 16. GAR X Methodology 11 Facility Region Service Utilisation Ownership of Facility Type of Facility Agro-ecology Zone Low Medium High GOV CHAG PRIV HOSP POLY HC CHPS MH Coastal Forest Savannah 17. BAR X 18. X 19 NR X Note: GAR Greater Accra Region CHAG Christian Health Association of Ghana Ash Ashanti Region HOSP Hospital BAR Brong Ahafo Region POL Polyclinic NR Northern Region HC Health centre GOV Government MH Maternity home Cost of Family Planning Services in Ghana 12 Types of Inputs Costed A full costing of all inputs gives decisionmakers the best sense of the real unit cost of the programme/service. Thus, any input determined to be critical to the successful provision of FP services was included in the costing. For each FP service level, all resources were grouped into direct programme- related items and indirect costs (see Appendix 1 for details of how the costs were estimated). Direct Costs Indirect Costs at the Facility Level • Staff time for providing FP services—counselling and clinic visits • FP commodities • Medical consumables • Other consumables, mainly medical supplies • Laboratory testing • Administrative staff time • Supervision from regional or central level • Office equipment • Medical equipment • Vehicles used for programme administration • Physical infrastructure for administering the programme/service • Transport costs for administration • Public utilities (electricity, water, etc.) • Maintenance and repair • Staff training • Other administrative costs (office supplies, legal costs, audit) The direct programme-related costs were classified into specific FP methods or delivery services. Costs were then grouped by resource inputs (salaries and allowances, supplies, transport, and capital), and by activity related to each FP method using the classification and framework listed in the Family Planning Protocol (GHS, 2007). Only the costs of activities that were clearly related to the provision of FP services were included. Certain activities were not specific to family planning and were not included in the study. For example, general administrative support from national health authorities and technical assistance from external donor agencies involve activities that would be done in the absence of the family planning. The analysis was undertaken from the perspective of service providers (i.e., health facilities). This implies that out-of-pocket costs incurred by FP clients (e.g., travel costs, opportunity cost of travel time, user fees for services or drugs, and other social costs) were excluded from the analysis. Data Collection and Analysis A standard questionnaire to collect data from the 19 selected sites was developed by the research team, pretested, and used to train the data collection team (see Appendix 2 for the final questionnaire). The data collection team travelled to the 19 study sites between April and May 2013 to apply the questionnaire. Site visits included a review of the FP activities run by the facility, collection of financial information, and interviews with key facility service providers/officials to establish costs incurred for specific FP methods. Central sources of data on resource use and prices were collected from the USAID-supported DELIVER Project in Ghana, Ghana Health Services, programme documents, and financial records. As a general rule, the value of an input should reflect its economic (opportunity) cost. In most cases, the economic cost was the same as the financial cost (the amount paid for it). However, the cost sometimes Methodology 13 differed if the input was not purchased at market price (e.g., donated drugs or volunteer labour). The study aimed to identify both the financial and market cost of inputs (where a difference may exist). For donated or subsidised inputs, market prices were estimated. Data were entered into an Excel-based costing tool developed as part of this project. The template includes one workbook for each facility, a workbook that summarises the facility data collected, and a workbook that consolidates the data for analysis. Data were then analysed to identify the key cost drivers of each FP service delivery method. The analysis of the unit cost was based on the total annual cost of inputs and the number of FP clients at each of the delivery sites. Where appropriate, the data are presented as national average costs and direct and indirect costs attributable to specific FP services. Costs were calculated in Ghanaian cedi (GH¢) and converted to U.S. dollars using an average 2012 exchange rate of GH¢1.80 to US$1. Limitations of the Study One overarching limitation of the study was the nonrandomised selection of study sites, which introduced an element of uncertainty when extrapolating the results nationally. Another limitation was the relatively small size of the sample, which precluded carrying out tests of statistical significance when comparing groups of sites (e.g., hospitals and health centres). The data collection teams applied a standard questionnaire at each site, but the quality and completeness of the data were not uniform across sites. Teams attempted to contact and interview those persons who were most knowledgeable about a programme’s functioning. However, responsibility for programmes is typically scattered across various persons and departments within sites. The limited amount of time available at each site meant teams were not always able to locate and interview all key informants. This particularly hampered the team’s ability to collect data on some of the facility-wide indirect costs shared by the FP service, such as the costs of public utilities, maintenance and repair, and transportation. However, these inputs were minor contributors to overall unit cost, so any underestimate of unit cost arising from this lack of information is probably minimal. Another limitation was recall bias, because many of the data on resource use were estimated based on providers’ recall. The most important of these were the amount of staff time consumed in a typical client visit, and the average number of visits the typical client makes during a year. Although all sites had information on the number of clients, very few providing FP services kept accurate data on the number of visits clients made during the year. Basing the calculations on these estimates could introduce errors into the cost results. Finally, all indirect costs for general programme support—for family planning and from national health authorities on FP services—were not included in the costing because they are centrally managed and not available at the site/facility level. 14 RESULTS The results focus on the unit cost of providing FP services for one year (cost per client per year). Where appropriate, results are shown by national averages, direct, and indirect cost. Unit Cost of Family Planning Services The most representative indicator of national-level FP service cost is an average across the 19 sites/facilities weighted by the number of clients served at each site. Using this weighted average, the average cost per client per year for the various family planning services in Ghana is shown in Table 3. Cost per client per year for the provision of FP services ranges from GH¢135.29 (US$75.16) and GH¢82.60 (US$45.89) for female condoms and CIC to GH¢11.75 (US$6.53) and GH¢11.25 (US$6.25) for NFP and LAM, respectively. The unit cost for VSC (vasectomy) was based on providing the service to only one client in all 19 study sites/facilities; thus, unit cost may be under- or overestimated. In 2012, diaphragms/cervical caps and spermicides were not provided at any of the 19 sites/facilities visited for data collection. Table 3: Unit Cost of Family Planning Services in Ghana Family Planning Service Unit Cost GH¢ US$ Natural family planning (NFP) method 11.75 6.53 Lactational amenorrhoea method (LAM) 11.25 6.25 Female condoms 135.29 75.16 Male condoms 20.43 11.35 Diaphragm/cervical cap N/A N/A Spermicides N/A N/A Combined cral contraceptive (COC) 26.87 14.93 Combined injectable contraceptive (CIC) 82.60 45.89 Progestin-only pills (POP) 19.46 10.81 Progestin-only injectable (POI) 45.72 25.40 Implants 63.11 35.06 Intrauterine devices (IUDs) 19.39 10.77 Voluntary surgical contraception (tubal ligation) 52.20 29.00 Voluntary surgical contraception (vasectomy) 46.36 25.76 N/A—service was not provided in 2012 by the sites/facilities visited for data collection. Results 15 Indirect and Direct Costs Figure 2 shows the direct and indirect cost (in percent) components in the unit cost of FP services. The study revealed that LAM, male condoms, COC, and NFP had the highest indirect costs: 44.9 percent, 38.5 percent, 36.0 percent, and 32.3 percent of unit cost, respectively. One reason for this is the frequency with which a client can or will visit the site or facility for the service in a year. The FP service with the lowest percentage of indirect cost was VSC (vasectomy) (3.0%), followed by female condoms (7.1%) and CIC (7.8 %). The highest percentage of direct cost was for VSC (vasectomy) (97.0%), followed by condoms (89.8%) and VSC (tubal ligation) (78.3%). The FP service with the lowest percentage of direct cost was LAM (55.1%), followed by COC (64.0%) and NFP (67.8%). Figure 2: Direct and Indirect Cost of Family Planning Services 67.8 55.1 61.5 92.9 64.0 92.2 68.9 77.0 87.3 69.3 78.3 97.0 32.2 44.9 38.5 7.1 36.0 7.8 31.1 23.0 12.7 30.7 21.7 3.0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NFP LAM Male condoms Female condoms COC CIC POP POI Implants IUDs VSC (tubal ligation) VSC (vasectomy) Direct Indirect Components of Direct Cost The direct cost of FP services consisted of five components: counselling, FP commodities, laboratory, medical consumables, and other consumables. Figure 3 shows the components of the direct cost (in percentage) of all the services costed in the study. The data reveal the importance of personnel time for counselling in the direct cost of FP service provision. This ranged from 77.4 percent for NFP to 7.1 percent for condoms. Another important factor in the direct cost composition is the FP commodity. This ranges from 90.3 percent of total direct cost for condoms, to 80.1 percent for VSC (vasectomy), and no use of family planning commodities in NFP and LAM. Cost of Family Planning Services in Ghana 16 Figure 3: Components of Direct Cost of Family Planning Services (Percentage) 77.4 71.0 28.9 4.1 31.3 7.5 38.3 15.7 10.5 47.2 45.7 15.1 56.8 94.5 35.2 24.3 48.3 16.0 58.8 7.2 0.0 80.1 23.1 5.2 11.3 6.0 30.8 16.1 60.7 43.8 21.4 2.7 33.9 0.8 22.6 29.0 14.3 1.4 10.5 2.4 13.4 13.2 3.3 12.1 4.4 4.0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Counselling FP commodities Lab Medical consumables Other consumable Projected Cost of Family Planning Services in Ghana, 2012–2016 The projected cost of FP services in Ghana was obtained by multiplying the projected population for each FP service for a year (obtained from the NPC projection) by the unit cost per client per year for delivering the service. Total Cost The total projected cost of providing all family planning services in Ghana in 2012 was US$34,021,632.19. Direct cost constituted 77 percent (US$26,218,004.51) of total cost, and indirect cost 23 percent (US$7,803,627.68). The total cost of all FP services in 2013 rose to US$37,455,149.36, with direct cost again constituting 77 percent (US$28,784,255.86) and indirect cost 23 percent (US$8,670,893.50). The total cost of all family planning services in Ghana were projected to increase in 2014 to US$40,480,136.02. From 2014 to 2016, total cost was projected to increase by about 7.6 percent per annum, with direct cost averaging 76 percent and indirect cost 24 percent for all FP services. By 2016, total cost is expected to reach US$46,922,214.96 (Table 4). Components of Direct Cost The projected total direct cost of all family planning services in Ghana in 2012 was US$26,218,004.51. Medical consumables accounted for 36 percent (US$9,513,368.36) of this direct cost and FP commodities 26 percent (US$6,922,736.50). Laboratory services made up only 10 percent (US$2,499,684.78) of total direct cost. In 2013, the total direct cost increased to US$28,784,255.86. Medical consumables remained the most important cost item, again accounting for 36 percent (US$10,366,552.09) of total direct cost. Results 17 Similar to 2012, laboratory services constituted only 9 percent (US$2,723,859.99) of total direct cost. Total direct cost of all FP services was projected to increase to US$31,029,039.43 in 2014. Medical consumables were again expected to account for about 36 percent (US$11,096,577.14) of direct cost, and laboratory services about 9 percent (US$2,915,680.09). Projections for 2015 and 2016 indicate increases similar to those in 2014. The cost of FP commodities is expected to increase 32.96 percent, from US$6,922,736 in 2012 to US$9,204,240 in 2016. Thus, total direct cost of all FP services in Ghana is estimated to reach US$33,369,071.64 in 2015 and US$35,807,648.73 by 2016 (Table 5). Cost of Family Planning Services in Ghana 18 Table 4: Projected Total Cost of Family Planning Services in Ghana, 2012–2016 (US$) Family Planning Service Year 2012 2013 2014 2015 2016 atural FamN ily Planning NFP) Method( Number of users 9,987 16,034 22,380 29,038 36,018 Unit cost 6.53 6.53 6.53 6.53 6.53 Total cost of FP service 65,215.11 104,702.02 146,141.40 189,618.14 235,197.54 Direct cost (67.8) 44,215.84 70,987.97 99,083.87 128,561.10 159,463.93 Indirect cost (32.2) 20,999.27 33,714.05 47,057.53 61,057.04 75,733.61 Lactational menorrhoea Method A LAM)( Population 108,188 173,692 242,443 314,564 390,181 Unit cost 6.25 6.25 6.25 6.25 6.25 Total cost of FP service 676,175 1,085,575 1,515,268.75 1,966,025 2,438,631.25 Direct cost (55.1) 372,572.43 598,151.83 834,913.08 1,083,279.78 1,343,685.82 Indirect cost (44.9) 303,602.58 487,423.18 680,355.67 882,745.23 1,094,945.43 emaF le Condoms Population 7,104 7,741 8,286 8,854 9,445 Unit cost 75.16 75.16 75.16 75.16 75.16 Total cost of FP service 533,936.64 581,813.56 622,775.76 665,466.64 709,886.20 Direct cost (92.9) 496,027.14 540,504.80 578,558.68 618,218.51 659,484.28 Indirect cost (7.1) 37,909.50 41,308.76 44,217.08 47,248.13 50,401.92 Male Condoms Population 250,894 273,395 292,648 312,701 333,581 Unit cost 11.35 11.35 11.35 11.35 11.35 Total cost of FP service 2,847,646.9 3,103,033.25 3,321,554.8 3,549,156.35 3,786,144.35 Results 19 Family Planning Service Year 2012 2013 2014 2015 2016 Direct cost (61.5) 1,751,302.84 1,908,365.45 2,042,756.20 2,182,731.16 2,328,478.78 Indirect cost (38.5) 1,096,344.06 1,194,667.80 1,278,798.60 1,366,425.19 1,457,665.57 Combined Oral Contraceptive (COC) Population 161,041 175,483 187,841 200,713 214,115 Unit cost 14.93 14.93 14.93 14.93 14.93 Total cost of FP service 2,404,342.13 2,619,961.19 2,804,466.13 2,996,645.09 3,196,736.95 Direct cost (64.0) 1,538,778.96 1,676,775.16 1,794,858.32 1,917,852.86 2,045,911.65 Indirect cost (36.0) 865,563.17 943,186.03 1,009,607.81 1,078,792.23 1,150,825.30 Combined Injectable Contraceptive (CIC) Population 84,229 91,783 98,246 104,978 111,988 Unit cost 45.89 45.89 45.89 45.89 45.89 Total cost of FP service 3,865,268.81 4,211,921.87 4,508,508.94 4,817,440.42 5,139,129.32 Direct cost (92.2) 3,563,777.84 3,883,391.96 4,156,845.24 4,441,680.07 4,738,277.23 Indirect cost (7.8) 301,490.97 328,529.91 351,663.70 375,760.35 400,852.09 Progestin-Only Pills (POPs) Population 30,067 32,763 35,071 37,474 39,976 Unit cost 10.81 10.81 10.81 10.81 10.81 Total cost of FP service 325,024.27 354,168.03 379,117.51 405,093.94 432,140.56 Direct cost (68.9) 223,941.72 244,021.77 261,211.96 279,109.72 297,744.85 Indirect cost (31.1) 101,082.55 110,146.26 117,905.55 125,984.22 134,395.71 Progestin-Only Injectable (POI) Population 789,524 860,330 920,917 984,020 1,049,728 Unit cost 25.40 25.40 25.40 25.40 25.40 Cost of Family Planning Services in Ghana 20 Family Planning Service Year 2012 2013 2014 2015 2016 Total cost of FP service 20,053,909.60 21,852,382 23,391,291.80 24,994,108 26,663,091.20 Direct cost (77.0) 15,441,510.39 16,826,334.14 18,011,294.69 19,245,463.16 20,530,580.22 Indirect cost (23.0) 4,612,399.21 5,026,047.86 5,379,997.11 5,748,644.84 6,132,510.98 Implants Population 80,390 87,600 93,769 100,194 106,884 Unit cost 35.06 35.06 35.06 35.06 35.06 Total cost of FP service 2,818,473.40 3,071,256 3,287,541.14 3,512,801.64 3,747,353.04 Direct cost (87.3) 2,460,527.28 2,681,206.49 2,870,023.42 3,066,675.83 3,271,439.20 Indirect cost (12.7) 357,946.12 390,049.51 417,517.72 446,125.81 475,913.84 Intrauterine (IUDs) Devices Population 17,969 19,580 20,959 22,396 23,891 Unit cost 10.77 10.77 10.77 10.77 10.77 Total cost of FP service 193,526.13 210,876.6 225,728.43 241,204.92 257,306.07 Direct cost (69.3) 134,113.61 146,137.48 156,429.80 167,155.01 178,313.11 Indirect cost (30.7) 59,412.52 64,739.12 69,298.63 74,049.91 78,992.96 Voluntary Surgical Contraception (tubal ligation) Population 7,327 7,984 8,546 9,132 9,742 Unit cost 29.00 29.00 29.00 29.00 29.00 Total cost of FP service 212,483 231,536 247,834 264,828 282,518 Direct cost (78.3) 166,374.19 181,292.69 194,054.02 207,360.32 221,211.59 Indirect cost (21.7) 46,108.81 50,243.31 53,779.98 57,467.68 61,306.41 Voluntary Surgical Population 995 1,084 1,161 1,240 1,323 Results 21 Family Planning Service Year 2012 2013 2014 2015 2016 Contraception (vasectomy) Unit cost 25.76 25.76 25.76 25.76 25.76 Total cost of FP service 25,631.20 27,923.84 29,907.36 31,942.40 34,080.48 Direct cost (97.0) 24,862.26 27,086.12 29,010.14 30,984.13 33,058.07 Indirect cost (3.0) 768.94 837.72 897.22 958.27 1,022.41 All FP Services Total cost 34,021,632.19 37,455,149.36 40,480,136.02 43,634,330.54 46,922,214.96 Direct cost 26,218,004.51 28,784,255.86 31,029,039.43 33,369,071.64 35,807,648.73 Indirect cost 7,803,627.68 8,670,893.50 9,451,096.59 10,265,258.90 11,114,566.23 Note: In 2012, diaphragm/cervical cap and spermicide services were not provided by the sites/facilities visited for data collection. ( ): Figures in parentheses are the percentage of total cost. Table 5: Projected Direct Cost of Family Planning Services in Ghana, 2012–2016 (US$) Family Planning Service Year 2012 2013 2014 2015 2016 Natural Family Planning (NFP) Method Total direct cost 44,215.84 70,987.97 99,083.87 128,561.10 159,463.93 Counselling (77.4) 34,223.06 54,944.69 76,690.91 99,506.29 123,425.08 FP commodity (0.0) 0.0 0.0 0.0 0.0 0.0 Laboratory (0.0) 0.0 0.0 0.0 0.0 0.0 Medical consumables (0.0) 0.0 0.0 0.0 0.0 0.0 Cost of Family Planning Services in Ghana 22 Family Planning Service Year 2012 2013 2014 2015 2016 Other consumables (22.6) 9,992.78 16,043.28 22,392.95 29,054.81 36,038.85 Lactational Amenorrhoea Method (LAM) Total direct cost 372,572.43 598,151.83 834,913.08 1,083,279.78 1,343,685.82 Counselling (71.0) 264,526.43 424,687.80 592,788.29 769,128.64 954,016.93 FP commodity (0.0) 0.0 0.0 0.0 0.0 0.0 Laboratory (0.0) 0.0 0.0 0.0 0.0 0.0 Medical consumables (0.0) 0.0 0.0 0.0 0.0 0.0 Other consumables (29.0) 108,046.00 173,464.03 242,124.79 314,151.13 389,668.89 Female Condoms Total direct cost 496,027.14 540,504.80 578,558.68 618,218.51 659,484.28 Counselling (4.1) 20,337.11 22,160.70 23,720.91 25,346.96 27,038.86 FP commodity (94.5) 468,745.65 510,777.03 546,737.95 584,216.49 623,212.64 Laboratory (0.0) 0.0 0.0 0.0 0.0 0.0 Medical consumables (0.0) 0.0 0.0 0.0 0.0 0.0 Other consumables (1.4) 6,944.38 7,567.07 8,099.82 8,655.06 9,232.78 Male Condoms Total direct cost 1,751,302.84 1,908,365.45 2,042,756.20 2,182,731.16 2,328,478.78 Counselling (28.9) 506,126.52 551,517.61 590,356.54 630,809.30 672,930.37 FP commodity (56.8) 994,740.02 1,083,951.57 1,160,285.52 1,239,791.30 1,322,575.94 Laboratory (0.0) 0.0 0.0 0.0 0.0 0.0 Medical consumables (0.0) 0.0 0.0 0.0 0.0 0.0 Other consumables (14.3) 250,436.31 272,896.26 292,114.14 312,130.56 332,972.46 Results 23 Family Planning Service Year 2012 2013 2014 2015 2016 Combined Oral Contraceptive (COC) Total direct cost 1,538,778.96 1,676,775.16 1,794,858.32 1,917,852.86 2,045,911.65 Counselling (31.3) 481,637.82 524,830.63 561,790.66 600,287.94 640,370.35 FP commodity (35.2) 541,650.20 590,224.86 631,790.13 675,084.21 720,160.90 Laboratory (23.0) 353,919.16 385,658.29 412,817.41 441,106.16 470,559.68 Medical consumables (0.0) 0.0 0.0 0.0 0.0 0.0 Other consumables (10.5) 161,571.79 176,061.39 188,460.12 201,374.55 214,820.72 Combined Injectables Contraceptive (CIC) Total direct cost 3,563,777.84 3,883,391.96 4,156,845.24 4,441,680.07 4,738,277.23 Counselling (7.5) 267,283.34 291,254.40 311,763.39 333,126.01 355,370.79 FP commodity (24.2) 862,434.24 939,780.86 1,005,956.55 1,074,886.58 1,146,663.09 Laboratory (5.2) 185,316.45 201,936.38 216,155.95 230,967.36 246,390.42 Medical consumables (60.7) 2,163,213.15 2,357,218.92 2,523,205.06 2,696,099.80 2,876,134.28 Other consumables (2.4) 85,530.67 93,201.41 99,764.29 106,600.32 113,718.65 Progestin-Only Pills (POPs) Total direct cost 223,941.72 244,021.77 261,211.96 279,109.72 297,744.85 Counselling (38.3) 85,769.68 93,460.34 100,044.18 106,899.02 114,036.28 FP commodity (48.3) 108,163.85 117,862.52 126,165.38 134,810.00 143,810.76 Laboratory (0.0) 0.0 0.0 0.0 0.0 0.0 Medical consumables (0.0) 0.0 0.0 0.0 0.0 0.0 Other consumables (13.4) 30,008.19 32,698.92 35,002.40 37,400.70 39,897.81 Progestin-Only Total direct cost 15,441,510.39 16,826,334.14 18,011,294.69 19,245,463.16 20,530,580.22 Cost of Family Planning Services in Ghana 24 Family Planning Service Year 2012 2013 2014 2015 2016 Injectable (POI) Counselling (15.7) 2,424,317.13 2,641,734.46 2,827,773.27 3,021,537.72 3,223,301.10 FP commodity (16.0) 2,470,641.66 2,692,213.46 2,881,807.15 3,079,274.11 3,284,892.84 Laboratory (11.3) 1,744,890.67 1,901,375.76 2,035,276.30 2,174,737.34 2,319,955.57 Medical consumables (43.8) 6,763,381.55 7,369,934.35 7,888,947.07 8,429,512.86 8,992,394.14 Other consumables (13.2) 2,038,279.37 2,221,076.11 2,377,490.90 2,540,401.14 2,710,036.59 Implants Total direct cost 2,460,527.28 2,681,206.49 2,870,023.42 3,066,675.83 3,271,439.20 Counselling (10.5) 258,355.36 281,526.68 301,352.46 322,000.96 343,501.12 FP commodity (58.8) 1,446,790.04 1,576,549.41 1,687,573.77 1,803,205.39 1,923,606.25 Laboratory (6.0) 147,631.64 160,872.39 172,201.40 184,000.55 196,286.35 Medical consumables (21.4) 526,552.84 573,778.19 614,185.01 656,268.63 700,087.99 Other consumables (3.3) 81,197.40 88,479.81 94,710.77 101,200.30 107,957.49 Intrauterine Devices (IUDs) Total direct cost 134,113.61 146,137.48 156,429.80 167,155.01 178,313.11 Counselling (47.2) 63,301.62 68,976.89 73,834.87 78,897.16 84,163.79 FP commodity (7.2) 9,656.18 10,521.90 11,262.95 12,035.16 12,838.54 Laboratory (30.8) 41,306.99 45,010.35 48,180.38 51,483.74 54,920.44 Medical consumables (2.7) 3,621.07 3,945.71 4,223.60 4,513.19 4,814.45 Other consumables (12.1) 16,227.75 17,682.64 18,928.01 20,225.76 21,575.89 Voluntary Surgical Contraception (tubal ligation) Total direct cost 166,374.19 181,292.69 194,054.02 207,360.32 221,211.59 Counselling (45.7) 76,033.00 82,850.76 88,682.69 94,763.67 101,093.70 Results 25 Family Planning Service Year 2012 2013 2014 2015 2016 FP commodity (0.0) 0.0 0.0 0.0 0.0 0.0 Laboratory (16.0) 26,619.87 29,006.83 31,048.64 33,177.65 35,393.86 Medical consumables (33.9) 56,400.85 61,458.22 65,784.31 70,295.15 74,990.73 Other consumables (4.4) 7,320.46 7,976.88 8,538.38 9,123.85 9,733.31 Voluntary Surgical Contraception (vasectomy) Total direct cost 24,862.26 27,086.12 29,010.14 30,984.13 33,058.07 Counselling (15.1) 3,754.20 4,090.00 4,380.53 4,678.60 4,991.77 FP commodity (80.1) 19,914.67 21,695.99 23,237.12 24,818.29 26,479.51 Laboratory (0.0) 0.0 0.0 0.0 0.0 0.0 Medical consumables (0.8) 198.90 216.69 232.08 247.87 264.46 Other consumables (4.0) 994.49 1,083.44 1,160.41 1,239.37 1,322.32 All FP Services Total direct cost 26,218,004.51 28,784,255.86 31,029,039.43 33,369,071.64 35,807,648.73 Counselling 4,485,665.28 5,042,034.95 5,553,178.69 6,086,982.28 6,644,240.11 FP commodity 6,922,736.50 7,543,577.60 8,074,816.52 8,628,121.51 9,204,240.48 Laboratory 2,499,684.78 2,723,859.99 2,915,680.09 3,115,472.80 3,323,506.30 Medical consumables 9,513,368.36 10,366,552.09 11,096,577.14 11,856,937.50 12,648,686.06 Other consumables 2,796,549.60 3,108,231.23 3,388,786.98 3,681,557.55 3,986,975.77 Note: In 2012, diaphragm/cervical cap and spermicide services were not provided by the sites/facilities visited for data collection. ( ): Figures in parentheses are the percentage of total direct cost 26 CONCLUSION This study aimed to provide key stakeholders—particularly the government of Ghana, the NPC, and the NHIA—with information on the yearly cost of providing FP services to a client. This study is one of the first attempts to conduct a comprehensive analysis of the provision of FP services in Ghana and will hopefully inform national planning, budgeting, and programme efforts. In estimating the costs of providing FP services in Ghana as stated in the National Family Planning Protocols of 2007, the study focused on full-cost service provision to one client/person for one year. Using a combination of data from 19 sites/facilities and information on normative use of resources, the study team was able to estimate the cost per client per year for various FP services. Understanding the composition and unit cost of the different FP services is important given the decision to cover FP services under the National Health Insurance Scheme. Expansion of the client base under the NHIS will likely bring down the unit cost, especially if most of the scale-up occurs at lower-level health facilities such as polyclinics and health centres. The study reveals that long-term FP services such as IUDs are the most efficient, while short-term services like use of condoms, injectables, and pills are less efficient and expensive in the long-term. The results from the costing exercise indicate that the average unit costs of FP services provided through the public, private, and NGO sectors throughout the country range from a high of US$75.16 (GH¢135.29) through female condoms to a low of US$6.25 (GH¢11.25) through LAM in 2012. The projected cost of providing all FP services shows that it will increase from US$82,919,301 in 2014 to US$90,610,045 in 2016: a 9.27 percent change. The cost of FP commodities is expected to increase from US$8,074,816 in 2014 to US$9,204,240 in 2016, or 13.99 percent. The major cost component of the total cost of FP services is the direct cost, which comprises FP commodities, medical consumables, other consumables, and laboratory services. 27 REFERENCES Ghana Health Service (GHS). 2007. National Family Planning Protocols. Accra: Ghana Health Service. Ghana Statistical Service (GSS) and Macro International Inc. 1994. Demographic and Health Survey, 1993. Calverton, MD: Macro International Inc. GSS and Macro International Inc. 1999. Demographic and Health Survey, 1998. Calverton, MD: Macro International Inc. GSS, Noguchi Memorial Institute for Medical Research, and ORC Macro. 2004. Demographic and Health Survey, 2003. Calverton, MD: ORC Macro. GSS, Ghana Health Service, and ICF Macro. 2009. Demographic and Health Survey, 2008. Calverton, MD: ICF Macro. National Population Council (NPC). 1994. National Population Policy, Rev. Ed. Accra: NPC. 28 APPENDIX 1: DETAILS OF HOW THE COSTS WERE ESTIMATED For each type of input, the table describes the methods and sources for estimating quantities of the input, prices, and unit cost (per client per year). The inputs are grouped into (i) direct cost and (ii) indirect cost. Direct Cost Staff time for providing FP services—counselling and clinic visits Quantities Average number of minutes each health worker directly provides to the client, by type of visit for each FP service Interviews with facility/site staff Prices Calculated per minute of salary for selected categories of staff based on 2012 Ghana Health Service central-level data on compensation/salary Ghana Health Service 2012 salary structure Interviews with facility/site staff Unit Cost For staff compensation: Average total number of minutes per worker multiplied by cost per minute, summed across type of worker by different FP services Family planning commodities Quantity Quantity required for one person for one year based on national protocol National Family Planning Protocol of 2007 and Family Health Unit, Ghana Health Service Prices International rate, prices to port Central-level information on import prices of FP commodities Unit Cost Quantity needed for one year multiplied by price for each FP commodity Medical consumables and other consumables Quantity Average quantity used per visit by type of visit for each FP service Facility staff interviews Prices Price of item used for each FP service Based on international prices and local market prices Unit Cost Price per item multiplied by average quantity of items used in each FP service visit Laboratory Testing Quantity For each test, quantity needed for one patient for one year Interviews with facility staff Appendix 1: Details of How the Costs were Estimated 29 Prices Cost per laboratory test NHIS diagnostic tariffs Unit Cost For each test, price per test multiplied average number of tests per client and percentage of clients getting the test Indirect Costs Other administrative staff time (including volunteers’ time) Quantity Number of administrative staff and percentage of time spent on family planning in a year Interviews with facility/site staff Prices Calculated per minute of salary for selected categories of staff based on 2012 Ghana Health Service central-level data on compensation/salary Ghana Health Service 2012 salary structure Interview with facility/site staff Unit Cost Yearly administrative personnel cost divided by yearly number of FP clients served by facility, multiplied by the ratio of clients for each FP service in yearly number of FP clients Office equipment Quantity Number and type of equipment used for administration of FP services Facility inventory record from questionnaire Prices Replacement cost of item, straight-line depreciation by useful life Estimate based on local prices Useful life for each equipment type provided by facility Unit Cost Yearly depreciated replacement cost multiplied by use in family planning as a percentage of total use in facility divided by yearly number of FP clients served by the facility and multiplied by the ratio of clients for each FP service in yearly number of FP clients Medical equipment Quantity Number and type of equipment used in FP services Interviews with facility staff Prices Replacement cost of item, straight-line depreciation by useful life Estimate based on international and local prices Cost of Family Planning Services in Ghana 30 Unit Cost Yearly depreciated replacement cost multiplied by use in family planning as percentage of total use in facility divided by yearly number of FP clients served by facility and multiplied by the ratio of clients for each FP service in yearly number of FP clients Vehicles used for programme administration No vehicle was used in the provision of FP services Transportation costs for administration Quantity None Prices Annual transportation cost for FP services Interviews with facility staff, review of facility records Unit Cost Total yearly transportation cost for FP services multiplied by ratio of clients for each FP service in yearly number of FP clients Public utilities (water, electricity, and telephone) Quantity None Prices Annual costs for facility as a whole Interviews with facility staff, review of facility records Unit Cost Total yearly cost multiplied by FP programme as a proportion of all outpatient visits to the facility multiplied by outpatient visits as a proportion of all facility services divided by the yearly number of FP service clients served by the facility Maintenance and repair Quantity None Prices Annual costs for the facility as a whole Interviews with facility staff, review of facility records Unit Cost Total yearly cost multiplied by FP programme as a proportion of all outpatient visits to the facility multiplied by outpatient visits as a proportion of all facility services divided by the yearly number of FP clients served by facility 31 APPENDIX 2: QUESTIONNAIRE—ESTIMATING THE UNIT COST OF DELIVERING FAMILY PLANNING SERVICES Costs per Facility: Hospital KOMFO ANOKYE- KUMASI RIDGE HOSPITAL TAMALE CENTRAL HOSPITAL MANNA MISSION HOSPITAL SAVELUGU HOSPITAL AVERAGE Am ount A ssum ptions A m ount A ssum ptions A m ount A ssum ptions A m ount A ssum ptions A m ount A ssum ptions INDIRECT COSTS PER FACILITY Vehicles Used for FP Services (including Administration) Other Equipment Physical Infrastructure Personnel 7004.48 4867.29 2688.22 984.67 1679.01 3444.73 Office Equipment Administrative Physical Infrastructure Other Administrative Costs Volunteer Costs Monetary Incentive 250.00 250.00 Local Medical Supply Cost 75.00 327288 Local Travel and Transport Costs Public Utilities Buildings Cost Maintenance and Repair Cost of Family Planning Services in Ghana 32 7,329 4,867 6098.39 INDIRECT COSTS FROM CENTRAL LEVEL Training Supervision Costs per Facility: Health Centres and Community Health ractitioners P APPOLONIA CHPS INDIRECT COSTS PER FACILITY Vehicles Used for FP Services (including Administration) A ssum ption A m ount BUIPE HEALTH CENTRE A ssum ption A m ount KARAGA CH A ssum ption A m ount MAMPONTENG HEALTH CENTRE A ssum ption A m ount A ssum ption A m ount OBENEMASE CHPS A ssum ption A m ount YAMFO HEALTH CENTRE AVERAGE Other Equipment Physical Infrastructure 1846. 20 1846.20 Personnel 368.37 529.3 3 4705.70 1155.05 3400.3 8 2031.77 Office Equipment Administrative Physical Infrastructure Other Administrative Costs Volunteer Costs 120.00 120.00 Monetary Incentive Local Medical Supply Cost 56.15 56.15 Local Travel and Transport Costs Public Utilities Buildings Cost Appendix 2: Questionnaire—Estimating the Unit Cost of Delivering Family Planning Services 33 Maintenance and Repair 425 425 529 INDIRECT COSTS FROM CENTRAL LEVEL Training Supervision Costs per Facility: Health Centres and Community Health Practitioners PPAG ACCRA PPAG SUNYAN A ssum ption INDIRECT COSTS PER FACILITY A m ount Vehicles Used for FP Services (including Administration) A ssum ptions Other Equipment Physical A m ount Infrastructure Personnel 3074.88 1144.52 Office Equipment Administrative Physical Infrastructure Other Administrative Costs Volunteer Costs Monetary 520.00 Incentive Local Medical Supply Cost Local Travel and Transport Costs Public Utilities A ssum ption PPAG TECHIMAN A m ount 1291.68 A ssum ption A m ount PPAG KPARIGU_NR 560.38 AVERAGE 1517.86 520.00 Cost of Family Planning Services in Ghana 34 Buildings Cost Maintenance and Repair 3,075 1,665 2369.70 INDIRECT COSTS FROM CENTRAL LEVEL Training Supervision Costs per Facility: Polyclinics JANGA POLY CLINIC MADINA POLYCLINIC AVERAGE Amount Assumptions Amount Assumptions INDIRECT COSTS PER FACILITY Vehicles Used for FP Services (including Administration) Other Equipment Physical Infrastructure Personnel 703.67 1936.14 1319.91 Office Equipment Administrative Physical Infrastructure Other Administrative Costs Volunteer Costs Monetary Incentive Local Medical Supply Cost Local Travel and Transport Costs Public Utilities Buildings Cost Maintenance and Repair INDIRECT COSTS FROM CENTRAL LEVEL Training Supervision Appendix 2: Questionnaire—Estimating the Unit Cost of Delivering Family Planning Services 35 Costs per Facility: Maternity Home ADJEI MENSAH MATERNITY GOASO MONICA'S MATERNITY HOME-SUNYANI AVERAGE Amount Assumptions Amount Assumption INDIRECT COSTS PER FACILITY Vehicles Used for FP Services (including Administration) Other Equipment Physical Infrastructure Personnel 538.72 318.72 428.72 Office Equipment Administrative Physical Infrastructure Other Administrative Costs Volunteer Costs Monetary Incentive Local Medical Supply Cost 4500.00 46595.00 25547.50 Local Travel and Transport Costs Public Utilities Buildings Cost Maintenance and Repair 5,039 46,914 25976.22 INDIRECT COSTS FROM CENTRAL LEVEL Training Supervision For more information, contact: Health Policy Project Futures Group 1331 Pennsylvania Ave NW, Suite 600 Washington, DC 20004 Tel: (202) 775-9680 Fax: (202) 775-9694 Email: policyinfo@futuresgroup.com www.healthpolicyproject.com Table of Contents List of Tables List of Figures Abbreviations Executive Summary Methodology Results Background Introduction Family Planning in Ghana Study Objectives Family Planning Service Interventions Costed Target Audiences for the Study Scope of the Study Timeframe and Analytic Horizon Methodology Costing Approach Study Sites Types of Inputs Costed Data Collection and Analysis Limitations of the Study Results Unit Cost of Family Planning Services Indirect and Direct Costs Components of Direct Cost Projected Cost of Family Planning Services in Ghana, 2012–2016 Total Cost Components of Direct Cost Conclusion References Appendix 1: Details of How the Costs were Estimated Appendix 2: Questionnaire—Estimating the Unit Cost of Delivering Family Planning Services Costs per Facility: Hospital Costs per Facility: Health Centres and Community Health Practitioners Costs per Facility: Health Centres and Community Health Practitioners Costs per Facility: Polyclinics Costs per Facility: Maternity Home Blank Page

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