Cost of MEBCI national and regional level activities
Cost expenditure data were categorized into fixed cost and recurrent cost. Fixed cost comprised of purchase of project vehicles, project office rent and sunk cost on equipment and sub-agreements with intervention regions. Recurrent cost components included staff salaries, international and local travels for staff of GHS and consultants, consultative/sub-committee meetings, advertisements, bills and utilities, stationery, repairs and maintenance.
It was found that a cumulative amount of GH₵ 24,555,370.41 (US$ 5,518,061[i]) was recorded as expenditure for fixed and recurrent cost activities between September 2013 and August 2017. Out of this amount, fixed cost expenditure constituted 71% while recurrent cost represented 29% of the total expenditure. Fiscal year one recorded the least expenditure of GH₵ 1,379,013.12 (equivalent to US$ 429,599.10, using the 2014 end of year exchange rate[1]). The highest cost was recorded in fiscal year four (4) with an expenditure of GH₵ 10,817,985.59 (equivalent to US$ 2,367,174.09, using the 2017 end of year exchange rate[2]) (see Figure 2).
Cost of strengthening national leadership
Greater proportion of the expenditure on the local government implementing partner was on recurrent cost activities. Out of the cumulative amount of GH₵ 1,658,633.00 (US$ 372,727) reported as expenditure incurred on best practices for newborn care, GH₵ 1,141,735.00 (US$ 256,570) was spent on workshops and training-related activities which represented approximately 69% of the total cost. These costs also include development of guidelines on newborn standards, and KMC guidelines.
Additionally, the cumulative expenditure on national leadership for newborn care activities was GH₵ 1,666,827.44 (US$ 374,568) out of which 76% was spent on workshops and training followed by “other project cost” (14%), consultancy (4%), travel (4%), support for seconded staff (2%) and printing (1%).
Project support and advisory activities for the local government implementing partner accounted for 21% of the total expenditure as at the time of the data collection. Expenditures related to travel and consultancy services accounted for 2% and 8% of the total expenditures respectively. It was also observed that expenditure at the GHS National level increased over time with the majority of expenditures occurring in the fourth year and lowest expenditure occurring in the first year.
Cost of strengthening capacity in four Regional hospitals
Cost data from Kybele showed that a total amount of US$ 1,030,679.86 was recorded as cost for strengthening capacity of health staff from 1st Dec, 2015 – 31st May, 2018. Out of this amount, approximately US$ 936,981.69 was reported as direct cost expenditure, representing 91% of the total cost while indirect cost constituted 9%. Out of the direct cost expenditure, cost of consultants and contract staff (US$446,026.88) was the major cost component constituting 48%; cost of MEBCI core training and Observed Structured Clinical Examination (OSCE) sessions and clinical observations was the second highest cost component amounting to US$ 394,849.74, representing 42%.
The least cost components were expenditures associated with computers and telecommunication (US$ 1,276.04); MEBCI core training and supplies (US$ 3,113.12), incidentals (US$ 3,315.15), training, equipment and supplies (US$ 340.76). Each of these cost components constituted less than 1% of the total direct cost expenditure. Indirect cost was US$ 93,698.17, representing 9% of the total cost. Direct cost peaked from US$ 144,545.23 in “fiscal year 3 quarter 2” to US$ 182,330.47 in “fiscal year 3 quarter 4” then gradually dipped in “fiscal 5 quarter 2” (US$ 39,876.68) and rose marginally to US$ 81,231.46 in “fiscal year 5 quarter 3”. Figures 3 shows the trend of direct and indirect cost over the fiscal years and quarters.
It was also found that aggregate cost per capita was highest (US$ 9,477.06) in “fiscal year 3 quarter 4” (1st June 2016 – 31st August 2016) and least cost of per capita (US$ 3,028.52) was in “fiscal year 5 quarter 2” (Figure 4).
Cost of RHD Sub-agreements implementation
Cost data from the four RHDs were analyzed to ascertain the cost of strengthening capacity in the district hospitals and selected health centres. In terms of regional percentage share of the total cost of MEBCI interventions, approximately 34% (GH₵ 5,997,952.06) Overall, it was observed that the direct cost component constituted 98% of the total MEBCI interventions in the four RHDs; the remaining 2% of the expenditure was on indirect activities including supportive/technical visits, funding agent local office refurbishment.
Cost of MEBCI district provider trainings
According to provider training records retrieved from funding agent, a total of 4,027 individuals were involved in the MEBCI training activities. This number includes key clinical staff (n=3,453) and non-clinical personnel (n=574). For the purposes of this evaluation, only data related to key clinical staff were further explored and analyzed.
As shown in Table 2, beneficiaries of the MEBCI training interventions at the district hospitals, polyclinics and health centres were generally youthful with a mean age of 32 years and average of 6 years work experience. Out of the total number of 3,453 clinical providers trained, 85% were females; midwives constituted 61% with the least being physician assistants (1%). Approximately 90% of the staff trained were from district hospitals while staff from polyclinics and health centres constituted 2% and 8% respectively.
In terms of regional percentage share of the number of district clinical care providers trained, 40% of the staff trained were from Ashanti region while Volta region had the least percentage share of 14%; two thirds of the total number of trained clinical staff were from public (government and quasi-government) facilities and the remaining from faith-based health facilities (see Table 2).
Insert Table 2: Summary statistics on district providers trained and followed-up
Source: MEBCI training data (2018)
Legend: Helping Babies Breathe First Assessment (HBB0, the first OSCE score immediately after the training) and Essential Care for Every Baby First Assessment (ECEB0, the first OSCE score immediately after the training)
*Includes specialist doctors such as pediatricians, obstetrics and gynecology
**Includes health assistants, perioperative nurses, enrolled nurses, pediatric nurses, community health nurses, critical and emergency care nurses, ward assistants
***One provider each was drawn from the four regional hospitals which constitutes less than 1% of the total number of providers trained
+Facilities owned by faith-based organizations
++Facilities owned by Ghana Health Service or Quasi-government organizations
Cost per capita estimation
It was observed that even though Region A recorded the highest cost of training, cost of training per capita appeared to be the lowest (GH₵ 4,384.47 approximately US$ 985).
For those trained to be followed up, Region D had the highest cost of training per capita (GH₵ 5,864.89 approximately US$ 1,318), followed by Region C region (GH₵ 5,635.00 approximately US$ 1,266) and Region B (GH₵ 5,341.84 approximately US$ 1,200). The overall average cost of training per capita was GH₵ 5,104.98 (approximately US$ 1,147) (see Figure 4).
Training cost per capita (all category of staff versus core clinical staff)
Training cost per capita was explored first based on the composite direct and indirect cost. It was found that the average cost per capita for all staff was GHC4, 377 (US$ 982.05) compared to GHC3, 554 (US$ 798.65) per capita for the core clinical staff. Secondly, the cost per capita was estimated using only the direct of training and it was found that the average cost per capita for all regions was GHC 4, 294 (US$ 964.94) for all cadre of staff compared to GHC 3, 457 (US$ 776.85) per capita for only clinical staff (see Figures 5&6).
[1]2014 end of year exchange rate of 1 US$ = GHS 3.21. Source: www.oanda.com/currency/converter Accessed on 27/09/2018
[2]2017 end of year exchange rate of 1 US$ = GHS 4.57. Source: www.oanda.com/currency/converter Accessed on 27/09/2018
[i]There were no readily available uniform US$ equivalence of all recorded expenditures in the four regions hence, the US$ equivalence as quoted in this report are based on the current prevailing exchange rate of 1 US$ = 4.45 GHC. US$ 4.45 Source: www.oanda.com/currency/converter Accessed on 27/09/2018. Accessed on 24/09/2018