title: Sustainability of recurrent expenditure on public social welfare programmes: expenditure analysis of the free maternal care programme of the Ghana National Health Insurance Scheme.
abstract: OBJECTIVE
  Sustainability of public social welfare programmes has long been of concern in development circles. An important aspect of sustainability is the ability to sustain the recurrent financial costs of programmes. A free maternal care programme (FMCP) was launched under the Ghana National Health Insurance Scheme (NHIS) in 2008 with a start-up grant from the British Government. This article examines claims expenditure under the programme and the implications for the financial sustainability of the programme, and the lessons for donor and public financing of social welfare programmes.
  
  
  METHODS
  Records of reimbursement claims for services and medicines by women benefitting from the policy in participating facilities in one sub-metropolis in Ghana were analysed to gain an understanding of the expenditure on this programme at facility level. National level financial inflow and outflow (expenditure) data of the NHIS, related to implementation of this policy for 2008 and 2009, were reviewed to put the facility-based data in the national perspective.
  
  
  RESULTS
  A total of US$936 450.94 was spent in 2009 by the scheme on FMCP in the sub-metropolis. The NHIS expenditure on the programme for the entire country in 2009 was US$49.25 million, exceeding the British grant of US$10.00 million given for that year. Subsequently, the programme has been entirely financed by the National Health Insurance Fund. The rapidly increasing, recurrent demands on this fund from the maternal delivery exemption programme-without a commensurate growth on the amounts generated annually-is an increasing threat to the sustainability of the fund.
  
  
  CONCLUSIONS
  Provision of donor start-up funding for programmes with high recurrent expenditures, under the expectation that government will take over and sustain the programme, must be accompanied by clear long-term analysis and planning as to how government will sustain the programme.
authors.affiliation: Public Health Unit, Ridge Regional Hospital, Ghana Health Service, Box 473, Accra, Ghana. joeankra@yahoo.com.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Ankrah Odame
authors.forename: Patricia
authors.initials: P
authors.lastname: Akweongo
authors.forename: Ben
authors.initials: B
authors.lastname: Yankah
authors.forename: Francis
authors.initials: F
authors.lastname: Asenso-Boadi
authors.forename: Irene
authors.initials: I
authors.lastname: Agyepong
mesh_terms: D005260:Female; D005380:Financing, Government / Q000191:economics / Q000706:statistics & numerical data; D005869:Ghana / Q000453:epidemiology; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006801:Humans; D008427:Maternal Health Services / Q000191:economics* / Q000706:statistics & numerical data; D009313:National Health Programs / Q000191:economics* / Q000706:statistics & numerical data; D015397:Program Evaluation / Q000191:economics / Q000706:statistics & numerical data; D012189:Retrospective Studies
keywords: Ghana; Maternal health care; National Health Insurance; exemptions; financial sustainability