Determinants of enrollment in the NHIS for women in Ghana

Background The National Health Insurance Scheme (NHIS) was introduced in 2005 to provide equitable access to healthcare. Furthermore, concessions were made for pregnant women, yet inequities in access continue to exist. This study explores whether dimensions of social exclusion explain why some groups of women are not benefitting from the scheme. Methods Data was collected from 4050 representative households in five districts. Logistic regression is used to examine the factors that determine enrolment of women under the NHIS. Results The study sample consists of a sub-sample of 3,173 women out of whom 58% were insured. The majority (64.9%) of the women were in the reproductive age (15-45 years). The results show that wealth status, age, health status, locality, perception about the quality of care at health facilities and perception of the NHIS, are the key factors that determine enrolment into the scheme. Conclusion With women dominating the informal sector of Ghana’s economy which is often characterised by relatively low incomes, these inequities in access need to be addressed

Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem?

BACKGROUND: Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources. METHODS: The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified. RESULTS: Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS. CONCLUSION: Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage

Does the National Health Insurance Scheme provide financial protection to households in Ghana?

BACKGROUND: Excessive healthcare payments can impede access to health services and also disrupt the welfare of households with no financial protection. Health insurance is expected to offer financial protection against health shocks. Ghana began the implementation of its National Health Insurance Scheme (NHIS) in 2004. The NHIS is aimed at removing the financial barrier to healthcare by limiting direct out-of-pocket health expenditures (OOPHE). The study examines the effect of the NHIS on OOPHE and how it protects households against catastrophic health expenditures. METHODS: Data was obtained from a cross-sectional representative household survey involving 2,430 households from three districts across Ghana. All OOPHE associated with treatment seeking for reported illness in the household in the last 4 weeks preceding the survey were analysed and compared between insured and uninsured persons. The incidence and intensity of catastrophic health expenditures (CHE) among households were measured by the catastrophic health payment method. The relative effect of NHIS on the incidence of CHE in the household was estimated by multiple logistic regression analysis. RESULTS: About 36% of households reported at least one illness during the 4 weeks period. Insured patients had significantly lower direct OOPHE for out-patient and in-patient care compared to the uninsured. On financial protection, the incidence of CHE was lower among insured households (2.9%) compared to the partially insured (3.7%) and the uninsured (4.0%) at the 40% threshold. The incidence of CHE was however significantly lower among fully insured households (6.0%) which sought healthcare from NHIS accredited health facilities compared to the partially insured (10.1%) and the uninsured households (23.2%). The likelihood of a household incurring CHE was 4.2 times less likely for fully insured and 2.9 times less likely for partially insured households relative to being uninsured. The NHIS has however not completely eliminated OOPHE for the insured and their households. CONCLUSION: The NHIS has significant effect in reducing OOPHE and offers financial protection against CHE for insured individuals and their households though they still made some out-of-pocket payments. Efforts should aim at eliminating OOPHE for the insured if the objective for establishing the NHIS is to be achieved

Humoral Immune Response to Mixed PfAMA1 Alleles; Multivalent PfAMA1 Vaccines Induce Broad Specificity

Apical Membrane Antigen 1 (AMA1), a merozoite protein essential for red cell invasion, is a candidate malaria vaccine component. Immune responses to AMA1 can protect in experimental animal models and antibodies isolated from AMA1-vaccinated or malaria-exposed humans can inhibit parasite multiplication in vitro. The parasite is haploid in the vertebrate host and the genome contains a single copy of AMA1, yet on a population basis a number of AMA1 molecular surface residues are polymorphic, a property thought to be primarily as a result of selective immune pressure. After immunisation with AMA1, antibodies more effectively inhibit strains carrying homologous AMA1 genes, suggesting that polymorphism may compromise vaccine efficacy. Here, we analyse induction of broad strain inhibitory antibodies with a multi-allele Plasmodium falciparum AMA1 (PfAMA1) vaccine, and determine the relative importance of cross-reactive and strain-specific IgG fractions by competition ELISA and in vitro parasite growth inhibition assays. Immunisation of rabbits with a PfAMA1 allele mixture yielded an increased proportion of antibodies to epitopes common to all vaccine alleles, compared to single allele immunisation. Competition ELISA with the anti-PfAMA1 antibody fraction that is cross-reactive between FVO and 3D7 AMA1 alleles showed that over 80% of these common antibodies were shared with other PfAMA1 alleles. Furthermore, growth inhibition assays revealed that for any PfAMA1 allele (FVO or 3D7), the cross-reactive fraction alone, on basis of weight, had the same functional capacity on homologous parasites as the total affinity-purified IgGs (cross-reactive+strain-specific). By contrast, the strain-specific IgG fraction of either PfAMA1 allele showed slightly less inhibition of red cell invasion by homologous strains. Thus multi-allele immunisation relatively increases the levels of antibodies to common allele epitopes. This explains the broadened cross inhibition of diverse malaria parasites, and suggests multi-allele approaches warrant further clinical investigation

The Effect of Educational Strategies Targeted for Nurses on Pain Assessment and Management in Children: An Integrative Review

Background: Nurses play an important role in children's pain assessment and management because they spend the majority of the time with them and provide care on a 24-hour basis. However, research studies continue to report on nurses' inadequate assessment and management of children's pain, which may be partly attributed to their insufficient education in this area.Objectives: This integrative review sought to examine the effect of strategies used in educating nurses on pediatric pain assessment and management.Design: An integrative review.Data Sources: Cumulative Index to Nursing and Allied Health Literature, Cochrane, PubMed/ Medline and Scopus.Review/Analysis Methods: Four databases were searched up to February 2018 based on a prescribed eligibility criteria. The review included 37 studies with varied methodologic quality.Results: Our findings revealed that various types of educational strategies improve nurses’ knowledge, attitudes, and practice of pain assessment, management, and/or documentation.Conclusions: Developing a responsive program that includes expectations of beneficiaries, integrating it into existing facility training systems and delivering it through multidisciplinary collaboration, offers the benefit of securing sustainability of the educational gains.</p

Working practices and incomes of health workers : evidence from an evaluation of a delivery fee exemption scheme in Ghana

Background: This article describes a survey of health workers and traditional birth attendants (TBAs) which was carried out in 2005 in two regions of Ghana. The objective of the survey was to ascertain the impact of the introduction of a delivery fee exemption scheme on both health workers and those providers who were excluded from the scheme (TBAs). This formed part of an overall evaluation of the delivery fee exemption scheme. The results shed light not only on the scheme itself but also on the general productivity of a range of health workers in Ghana. Methods: A structured questionnaire was developed, covering individual and household characteristics, working hours and practices, sources of income, and views of the exemptions scheme and general motivation. After field testing, this was administered to 374 respondents in 12 districts of Central and Volta regions. The respondents included doctors, medical assistants (MAs), public and private midwives, nurses, community health nurses (CHNs), and traditional birth attendants, both trained and untrained. Results: Health workers were well informed about the delivery fee exemptions scheme and their responses on its impact suggest a realistic view that it was a good scheme, but one that faces serious challenges regarding financial sustainability. Concerning its impact on their morale and working conditions, the responses were broadly neutral. Most public sector workers have seen an increased workload, but counterbalanced by increased pay. TBAs have suffered, in terms of client numbers and income, while the picture for private midwives is mixed. The survey also sheds light on pay and productivity. The respondents report long working hours, with a mean of 54 hours per week for community nurses and up to 129 hours per week for MAs. Weekly reported client loads in the public sector range from a mean of 86 for nurses to 269 for doctors. Over the past two years, reported working hours have been increasing, but so have pay and allowances (for doctors, allowances now make up 66% of their total pay). The lowest paid public health worker now earns almost ten times the average gross national income (GNI) per capita, while the doctors earn 38.5 times GNI per capita. This compares well with average government pay of four times GNI per capita. Comparing pay with outputs, the relatively high number of clients reported by doctors reduces their pay differential, so that the cost per client – $1.09 – is similar to a nurse's (and lower than a private midwife's). Conclusion: These findings show that a scheme which increases demand for public health services while also sustaining health worker income and morale, is workable, if well managed, even within the relatively constrained human resources environment of countries like Ghana. This may be linked to the fact that internal comparisons reveal Ghana's health workers to be well paid from public sector sources.This work was undertaken as part of an international research programme – IMMPACT (Initiative for Maternal Mortality Programme Assessment) – funded by the Bill & Melinda Gates Foundation, the Department for International Development, the European Commission and USAID

Prevalence, incidence and severity of a new root rot disease of cowpea caused by Macrophomina phaseolina (Tassi) Goid in Northern Ghana

Cowpea is an important economic crop in northern Ghana. Following reports of a new cowpea root rot, disease in northern Ghana (Northern, Upper East and Upper West regions), surveys were conducted in 2016 and 2017 with the aim of determining the causal organism, prevalence, incidence and severity of the disease across northern Ghana under rain fed and irrigated conditions. Seventeen locations were surveyed and symptomatic plants were taken to the Plant Pathology laboratory in CSIR- Savanna Agricultural Research Institute (SARI), Nyankpala for pathogen identification. The disease was prevalent in all the locations surveyed. There was no significant difference (P &gt; 0.05) between disease incidence and severity (1‒9 scale) under rain fed and irrigated conditions for each year. Disease incidence and severity were however significantly different (P &lt; 0.05) amongst locations surveyed under both rain fed and irrigated production for 2016 and 2017. Under rain fed conditions for 2016, Nyankpala recorded the highest incidence (43.8%), with Feo recording the lowest (17.8%). For the same period, Manga recorded the highest severity (4.3) with Silbelle recording the least (2.1). Under dry season cultivation for 2016, Asumsapeliga recorded the highest disease incidence (44.5%) with Silbelle recording the lowest (11.4%). Sakpari, however, recorded the highest disease severity (3.8) with Feo recording the lowest for the same period. Under rain fed conditions for 2017, disease incidence was highest in Nyankpala (47.7%) and lowest in Lawra (8.7%). For the same period, however, Manga and Yendi recorded the highest severity (4.3) with Lawra recording the lowest (1.6). Under dry season cowpea production for 2017, Sakpari (64.8%) recorded the highest incidence and Silbelle (7.0%) recording the least. Disease severity for the same period was highest in Nafkluga (4.2) and lowest in Silbelle (2.3). Morphocultural characteristics and pathogenicity test confirmed Macrophomina phaseolina as the causal organism of the cowpea root rot disease

Safety and immunogenicity of multi-antigen AMA1-based vaccines formulated with CoVaccine HT™ and Montanide ISA 51 in rhesus macaques

<p>Abstract</p> <p>Background</p> <p>Increasing the breadth of the functional antibody response through immunization with <it>Plasmodium falciparum </it>apical membrane antigen 1 (<it>Pf</it>AMA1) multi-allele vaccine formulations has been demonstrated in several rodent and rabbit studies. This study assesses the safety and immunogenicity of three <it>Pf</it>AMA1 Diversity-Covering (DiCo) vaccine candidates formulated as an equimolar mixture (DiCo mix) in CoVaccine HT™ or Montanide ISA 51, as well as that of a <it>Pf</it>AMA1-MSP1₁₉fusion protein formulated in Montanide ISA 51.</p> <p>Methods</p> <p>Vaccine safety in rhesus macaques was monitored by animal behaviour observation and assessment of organ and systemic functions through clinical chemistry and haematology measurements. The immunogenicity of vaccine formulations was assessed by enzyme-linked immunosorbent assays and <it>in vitro </it>parasite growth inhibition assays with three culture-adapted <it>P. falciparum </it>strains.</p> <p>Results</p> <p>These data show that both adjuvants were well tolerated with only transient changes in a few of the chemical and haematological parameters measured. DiCo mix formulated in CoVaccine HT™ proved immunologically and functionally superior to the same candidate formulated in Montanide ISA 51. Immunological data from the fusion protein candidate was however difficult to interpret as four out of six immunized animals were non-responsive for unknown reasons.</p> <p>Conclusions</p> <p>The study highlights the safety and immunological benefits of DiCo mix as a potential human vaccine against blood stage malaria, especially when formulated in CoVaccine HT™, and adds to the accumulating data on the specificity broadening effects of DiCo mix.</p

Immunization with different PfAMA1 alleles in sequence induces clonal imprint humoral responses that are similar to responses induced by the same alleles as a vaccine cocktail in rabbits

<p>Abstract</p> <p>Background</p> <p>Antibodies to key <it>Plasmodium falciparum </it>surface antigens have been shown to be important effectors that mediate clinical immunity to malaria. The cross-strain fraction of anti-malarial antibodies may however be required to achieve</p> <p>strain-transcending immunity. Such antibody responses against <it>Plasmodium falciparum </it>apical membrane antigen 1 (<it>Pf</it>AMA1), a vaccine target molecule that is expressed in both liver and blood stages of the parasite, can be elicited through immunization with a mixture of allelic variants of the parasite molecule. Cross-strain antibodies are most likely elicited against epitopes that are shared by the allelic antigens in the vaccine cocktail.</p> <p>Methods</p> <p>A standard competition ELISA was used to address whether the antibody response can be further focused on shared epitopes by exclusively boosting these common determinants through immunization of rabbits with different <it>Pf</it>AMA1 alleles in sequence. Th<it>e in vitro </it>parasite growth inhibition assay was used to further evaluate the functional effects of the broadened antibody response that is characteristic of multi-allele vaccine strategies.</p> <p>Results</p> <p>A mixed antigen immunization protocol elicited humoral responses that were functionally similar to those elicited by a sequential immunization protocol (p > 0.05). Sequential exposure to the different <it>Pf</it>AMA1 allelic variants induced immunological recall of responses to previous alleles and yielded functional cross-strain antibodies that would be capable of optimal growth inhibition of variant parasites at high enough concentrations.</p> <p>Conclusions</p> <p>These findings may have implications for the current understanding of the natural acquisition of clinical immunity to malaria as well as for rational vaccine design.</p

Evaluating the content validity of two versions of an instrument used in measuring pediatric pain knowledge and attitudes in the Ghanaian context

In this article, we compared the content validity of two instruments used in measuring pediatric pain knowledge and attitudes. This was considered necessary due to the universal differences in culture, semantics and healthcare resources in different parts of the globe. Thirteen (13) pediatric experts in Ghana assessed the content validity of two instruments: the 42-item Pediatric Nurses' Knowledge and Attitudes Survey Regarding Pain (PNKAS) and the 41-item Pediatric Healthcare Providers' Knowledge and Attitudes Survey Regarding Pain (PHPKASRP). The relevance and clarity of each item on these instruments were rated on a four-point likert scaled options from 1 (not relevant/ not clear) to 4 (very relevant/ very clear). The item-level content validity index (I-CVI) was calculated by dividing the number of experts who rated an item with 3 or 4 by the total number of experts. The average scale-level content validity index (S-CVI/Ave) was also estimated by summing up the I-CVIs of all items and dividing them by the total number of items. The I-CVIs on the PNKAS ranged from 0.62 to 1.00 for the relevance component and 0.69 to 1.00 for the clarity component. The I-CVIs on the PHPKASRP ranged from 0.62 to 1.00 for both the relevance and clarity components. The S-CVI/Ave were 0.87 and 0.89 for the relevance and clarity aspects on the PNKAS respectively. The S-CVI/Ave for the PHPKASRP instrument were 0.86 and 0.89 for the relevance and clarity aspects correspondingly. At the end of the validation process, 5 items were revised on both instruments whilst 37 and 36 items were maintained on the PNKAS and PHPKASRP instruments respectively. The PNKAS and PHPKASRP have an acceptable level of content validity in the Ghanaian context and recommended for educational and research purposes. Other forms of validity and reliability of these instruments should also be examined in future studies.</p