Challenges and experiences in linking community level reported out-of-pocket health expenditures to health provider recorded health expenditures: experience from the iHOPE project in Northern Ghana

Out of pocket health payment (OOPs) has been identified by the System of Health Accounts (SHA) as the largest source of health care financing in most low and middle-income countries. This means that most low and middle-income countries will rely on user fees and co-payments to generate revenue, rationalize the use of services, contain health systems costs or improve health system efficiency and service quality. However, the accurate measurement of OOPs has been challenged by several limitations which are attributed to both sampling and non-sampling errors when OOPs are estimated from household surveys, the primary source of information in LICs and LMICs. The incorrect measurement of OOP health payments can undermine the credibility of current health spending estimates, an otherwise important indicator for tracking UHC, hence there is the need to address these limitations and improve the measurement of OOPs. In an attempt to improve the measurement of OOPs in surveys, the INDEPTH-Network Household out-of-pocket expenditure project (iHOPE) developed new modules on household health utilization and expenditure by repurposing the existing Ghana Living Standards Survey instrument and validating these new tools with a 'gold standard' (provider data) with the aim of proposing alternative approaches capable of producing reliable data for estimating OOPs in the context of National Health Accounts and for the purpose of monitoring financial protection in health. This paper reports on the challenges and opportunities in using and linking household reported out-of-pocket health expenditures to their corresponding provider records for the purpose of validating household reported out-of-pocket health expenditure in the iHOPE project

Factors affecting antenatal care attendance: results from qualitative studies in Ghana, Kenya and Malawi.

BACKGROUND: Antenatal care (ANC) is a key strategy to improve maternal and infant health. However, survey data from sub-Saharan Africa indicate that women often only initiate ANC after the first trimester and do not achieve the recommended number of ANC visits. Drawing on qualitative data, this article comparatively explores the factors that influence ANC attendance across four sub-Saharan African sites in three countries (Ghana, Kenya and Malawi) with varying levels of ANC attendance. METHODS: Data were collected as part of a programme of qualitative research investigating the social and cultural context of malaria in pregnancy. A range of methods was employed interviews, focus groups with diverse respondents and observations in local communities and health facilities. RESULTS: Across the sites, women attended ANC at least once. However, their descriptions of ANC were often vague. General ideas about pregnancy care - checking the foetus' position or monitoring its progress - motivated women to attend ANC; as did, especially in Kenya, obtaining the ANC card to avoid reprimands from health workers. Women's timing of ANC initiation was influenced by reproductive concerns and pregnancy uncertainties, particularly during the first trimester, and how ANC services responded to this uncertainty; age, parity and the associated implications for pregnancy disclosure; interactions with healthcare workers, particularly messages about timing of ANC; and the cost of ANC, including charges levied for ANC procedures - in spite of policies of free ANC - combined with ideas about the compulsory nature of follow-up appointments. CONCLUSION: In these socially and culturally diverse sites, the findings suggest that 'supply' side factors have an important influence on ANC attendance: the design of ANC and particularly how ANC deals with the needs and concerns of women during the first trimester has implications for timing of initiation