Equitable access to health insurance for socially excluded children? The case of the National Health Insurance Scheme (NHIS) in Ghana

To help reduce child mortality and reach universal health coverage, Ghana extended free membership of the National Health Insurance Scheme (NHIS) to children (under-18s) in 2008. However, despite the introduction of premium waivers, a substantial proportion of children remain uninsured. Thus far, few studies have explored why enrolment of children in NHIS may remain low, despite the absence of significant financial barriers to membership. In this paper we therefore look beyond economic explanations of access to health insurance to explore additional wider determinants of enrolment in the NHIS. In particular, we investigate whether social exclusion, as measured through a sociocultural, political and economic lens, can explain poor enrolment rates of children. Data were collected from a cross-sectional survey of 4050 representative households conducted in Ghana in 2012. Household indices were created to measure sociocultural, political and economic exclusion, and logistic regressions were conducted to study determinants of enrolment at the individual and household levels. Our results indicate that socioculturally, economically and politically excluded children are less likely to enrol in the NHIS. Furthermore, households excluded in all dimensions were more likely to be non-enrolled or partially-enrolled (i.e. not all children enrolled within the household) than fully-enrolled. These results suggest that equity in access for socially excluded children has not yet been achieved. Efforts should be taken to improve coverage by removing the remaining small, annually renewable registration fee, implementing and publicising the new clause that de-links premium waivers from parental membership, establishing additional scheme administrative offices in remote areas, holding regular registration sessions in schools and conducting outreach sessions and providing registration support to female guardians of children. Ensuring equitable access to NHIS will contribute substantially to improving child health and reducing child mortality in Ghana

Hospital based maternity care in Ghana - findings of a confidential enquiry into maternal deaths

Background: In Ghana, a universal free delivery policy was implemented to improve access to delivery care in health facilities, thereby improving access to skilled attendance and reducing maternalmortality. Objective: A confidential enquiry was conducted to ascertain if changes had occurred in the care provided by reviewing the care given to a sample of maternal deaths before and after introduction of the policy. Method: Twenty women who died as a result of pregnancy-related complications (maternal deaths) in selected hospitals in two regions were assessed by a clinical panel, guided by a maternal deathassessment form. Unlike the traditional confidential enquiry process, both adverse and favourable factors were identified. Findings: Clinical care provided before and after the introduction of the fee exemption policy did not change, though women with complications were arriving in hospital earlier after the introduction of the policy. On admission, however, they received very poor care and this, the clinical paneldeduced could have resulted in many avoidable deaths; as was the case before the implementation of the policy. Consumables, basic equipment and midwifery staff for providing comprehensive emergency obstetric care were however found to be usually available. Conclusion: Our findings suggest that the already poor delivery care services women received remained unchanged after introduction of the policy

Assessment of Heavy Metal Contamination and Distribution in Surface Soils and Plants along the West Coast of Ghana

Onshore oil drilling activity is ongoing at Jubilee oil fields, Ghana. This activity could lead to heavy metal exposure with consequential adverse effects on public health in nearby coastal communities. Therefore, we assessed heavy metal levels and spatial distribution in soils and plants from the west coast of Ghana to obtain baseline values for monitoring heavy metal exposure. Surface soils were collected from six coastal communities, and analyzed for arsenic, cadmium, copper, mercury, lead, selenium and zinc using atomic absorption spectrophotometer. Mean heavy metal concentrations in soil samples were 2.06, 6.55, 0.016, 21.59, 0.18 and 39.49mg/kg for arsenic, copper, mercury, lead, selenium and zinc, respectively. Mean heavy metal concentrations in plants were 2.70, 17.47, 3.17, 91.74, 1.51 and 9.88mg/kg for arsenic, cadmium, copper, lead, selenium and zinc, respectively. Concentrations of arsenic, cadmium and lead in plants exceeded WHO/FAO permissible limits. Enrichment factor for arsenic was significant and extremely high for selenium, while geoaccumulation index showed moderate pollution for selenium. Soil contamination factors for arsenic, lead, and selenium indicated considerable contamination. In view of these findings remediation methods must be adopted to safeguard the communities. The data will be useful for future monitoring of heavy metal exposure in the communities and to assess the impact of the ongoing crude oil drilling activity on the environment

Who uses outpatient healthcare services under Ghana’s health protection scheme and why?

Background: The National Health Insurance Scheme (NHIS) was launched in Ghana in 2003 with the main objective of increasing utilisation to healthcare by making healthcare more affordable. Previous studies on the NHIS have repeatedly highlighted that cost of premiums is one of the major barriers for enrollment. However, despite introducing premium exemptions for pregnant women, older people, children and indigents, many Ghanaians are still not active members of the NHIS. In this paper we investigate why there is limited success of the NHIS in improving access to healthcare in Ghana and whether social exclusion could be one of the limiting barriers. The study explores this by looking at the Social, Political, Economic and Cultural (SPEC) dimensions of social exclusion. Methods: Using logistic regression, the study investigates the determinants of health service utilisation using SPEC variables including other variables. Data was collected from 4050 representative households in five districts in Ghana covering the 3 ecological zones (coastal, forest and savannah) in Ghana. Results: Among 16,200 individuals who responded to the survey, 54 % were insured. Out of the 1349 who sought health care, 64 % were insured and 65 % of them had basic education and 60 % were women. The results from the logistic regressions show health insurance status, education and gender to be the three main determinants of health care utilisation. Overall, a large proportion of the insured who reported ill, sought care from formal health care providers compared to those who had never insured in the scheme. Conclusion: The paper demonstrates that the NHIS presents a workable policy tool for increasing access to healthcare through an emphasis on social health protection. However, affordability is not the only barrier for access to health services. Geographical, social, cultural, informational, political, and other barriers also come into play

Efficiency of private and public primary health facilities accredited by the National Health Insurance Authority in Ghana

BACKGROUND: Despite improvements in a number of health outcome indicators partly due to the National Health Insurance Scheme (NHIS), Ghana is unlikely to attain all its health-related millennium development goals before the end of 2015. Inefficient use of available limited resources has been cited as a contributory factor for this predicament. This study sought to explore efficiency levels of NHIS-accredited private and public health facilities; ascertain factors that account for differences in efficiency and determine the association between quality care and efficiency levels. METHODS: The study is a cross-sectional survey of NHIS-accredited primary health facilities (n = 64) in two regions in southern Ghana. Data Envelopment Analysis was used to estimate technical efficiency of sampled health facilities while Tobit regression was employed to predict factors associated with efficiency levels. Spearman correlation test was performed to determine the association between quality care and efficiency. RESULTS: Overall, 20 out of the 64 health facilities (31 %) were optimally efficient relative to their peers. Out of the 20 efficient facilities, 10 (50 %) were Public/government owned facilities; 8 (40 %) were Private-for-profit facilities and 2 (10 %) were Private-not-for-profit/Mission facilities. Mission (Coef. = 52.1; p = 0.000) and Public (Coef. = 42.9; p = 0.002) facilities located in the Western region (predominantly rural) had higher odds of attaining the 100 % technical efficiency benchmark than those located in the Greater Accra region (largely urban). No significant association was found between technical efficiency scores of health facilities and many technical quality care proxies, except in overall quality score per the NHIS accreditation data (Coef. = −0.3158; p < 0.05) and SafeCare Essentials quality score on environmental safety for staff and patients (Coef. = −0.2764; p < 0.05) where the association was negative. CONCLUSIONS: The findings suggest some level of wastage of health resources in many healthcare facilities, especially those located in urban areas. The Ministry of Health and relevant stakeholders should undertake more effective need analysis to inform resource allocation, distribution and capacity building to promote efficient utilization of limited resources without compromising quality care standards