The power of sampling: it’s not just for scientists

August 20th, 2013

Sampling is a fairly common practice among health workers and researchers—especially those interested in monitoring and evaluating the results of health interventions. Like many programs in the global health arena, Neglected Tropical Disease (NTD)  programs use sampling to help evaluate the impact of their work.

Government finance and health experts work together to improve systems behind Ghana’s NTD program.

For example when a NTD program wants to assess the effectiveness of a mass drug administration intervention (MDA) in a particular community, it may use sampling techniques to select a representative group of people living in that community, upon whom it will then run blood tests. Based on the percentage of people from that sample who test positive for the disease antigen, they can confidently say whether or not disease transmission has been stopped among the entire community.

But sampling is also important in other areas of NTD programs. It is an equally powerful tool for evaluating—and even improving—the administrative side of NTD control programs, too.

In addition to supporting MDAs in the five West African countries where it operates, the END in Africa project also strives to improve the financial transparency of national NTD control programs by reviewing the internal financial controls within each country’s ministry of health (MOH) and performing a financial sampling of MDA expenditures.

The project performs MDA sampling in the offices of project sub-grantees,[i] following the same principles and procedures that guide any basic statistical sampling framework. The typical process involves obtaining samples of MDA receipts and testing transaction appropriateness through physical evidence or confirmation by reliable sources, such as other government officials or appropriate third parties. Transaction appropriateness may also be verified through inquiries, reconciliation of documentation and other accepted methods.  After obtaining and verifying sample transactions, the project team uses analytical procedures to determine the adequacy of controls and provides observations on specific areas that may need strengthening.

More often than not, the sampling process helps NTD programs identify ways to improve their administrative controls and become more efficient. For example, a financial sampling exercise in Ghana revealed significant inconsistencies in the budget formulation and general payment voucher submission process.  It turned out that most Budget and Management Centres (BMCs) of the Ghana Health Service (GHS)—the units responsible for administering development partner fund—had not been providing a summary of vouchers, an explanation of budget against expenditures or details explaining treatment of certain expenses such as fuel.  Of the 110 districts sampled, only one had provided details on how fuel was distributed (individuals, purpose, vehicle numbers), in addition to the fuel receipts.  Minimal adherence to approved budget line items and delays in voucher submission across BMCs were also observed.

After this study, the GHS began enforcing the issuance of receipts to improve accountability and the timely submission of MDA vouchers. Delays in voucher liquidation have since fallen by 30 days.  Going forward, additional improvements in traceability and record-keeping are expected once BMCs are assigned unique identification numbers. Once implemented, standardization and proper completion of forms–including dates, activity descriptions and purpose of payments–should further improve recording and reporting mechanisms.    Budget variance analysis may also help uncover variations between current or end-of-year budget line items and initial budget projections from the beginning of the year.

Financial sampling is a useful tool for identifying weaknesses within financial management systems that can ultimately compromise NTD programs. The results of financial sampling exercises have led to subsequent capacity building efforts with the MOHs in the countries where END in Africa operates in the following areas:

• Improving management of US Government funds and providing training and support to help organizations transition to  a new implication vehicle—the fixed obligation grant (FOG).
• Improving costing, budgeting and planning of programs through the Tool for Integrated Planning and Costing (TIPAC), along with WHO and the Envision project. TIPAC implementation has occurred in Ghana and will be rolled out to additional countries in the coming months.