The impact of the National Health Insurance Scheme on the interactions between providers and clients in the Bolgatanga and Builsa districts of Ghana

Includes abstract.Includes bibliographical references.Prepayments and risk pooling through social health insurance has been advocated by international development organizations. Social health insurance is seen as a mechanism that helps mobilize resources for health, pool risk, and provide more access to health care services for the poor. Hence Ghana implemented the National Health Insurance Scheme (NHIS) to help promote access to health care services for Ghanaians. The study examined the influence of the NHIS on the behaviour of health care providers in their treatment of insured and uninsured clients

The free maternal health policy: acceptability and satisfaction with quality of maternal health services during pregnancy in rural Northern Ghana

Introduction: Ghana introduced a maternal health policy in July 2008 to provide free of cost health services to women. However, the utilization of services does not depend on affordability alone but acceptability as well. Acceptability includes attitudes and behaviors of providers and satisfaction with the quality of care. The study explored women’s views and perceptions about attitudes and behaviors of providers and satisfaction with the quality of services under the free maternal health policy in Ghana. In addition, the views and perceptions of providers were examined. Methods: A convergent parallel mixed-methods study was conducted. The study was carried out in the Kassena-Nankana Municipality in Ghana. A structured questionnaire was distributed among women (n=406) who utilized health facilities during pregnancy. Further, focus group discussions (FGDs) with women (n=10) and in-depth interviews with midwives and nurses (n=25) were held. Quantitative data were analyzed using descriptive statistics, while the qualitative data were recorded, transcribed, read, and coded thematically. Results: Women perceived facilities to be clean, especially the smaller ones. Ninety-eight percent of women (n=313/320) perceived providers to be respectful or friendly, and this was mostly confirmed in the FGDs. More than two-thirds of the women (74%, n=300) were also very satisfied or satisfied with the quality of care due to the respect accorded them by providers. Equally, midwives and nurses were satisfied with the quality of care they provided. Nonetheless, providers believed that the unavailability of drugs and supplies, laboratory services, accommodation, and transportation for emergencies reduced women’s satisfaction with services and the quality of care they could provide. Conclusion: The services provided to women during pregnancy were acceptable under the free maternal health policy. There remain challenges in addressing a lack of infrastructure and commodities that affects the quality of care

Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of primary health care? Perspectives of key stakeholders in northern Ghana

In 2005, the World Health Assembly (WHA) of the World Health Organization (WHO) urged member states to aim at achieving affordable universal coverage and access to key promotive, preventive, curative, rehabilitative and palliative health interventions for all their citizens on the basis of equity and solidarity. Since then, some African countries, including Ghana, have taken steps to introduce national health insurance reforms as one of the key strategies towards achieving universal health coverage (UHC). The aim of this study was to get a better understanding of how Ghana's health insurance institutions interact with stakeholders and other health sector programmes in promoting primary health care (PHC). Specifically, the study identified the key areas of misalignment between the operations of the NHIS and that of PHC.; Using qualitative and survey methods, this study involved interviews with various stakeholders in six selected districts in the Upper East region of Ghana. The key stakeholders included the National Health Insurance Authority (NHIA), district coordinators of the National Health Insurance Schemes (NHIS), the Ghana Health Service (GHS) and District Health Management Teams (DHMTs) who supervise the district hospitals, health centers/clinics and the Community-based Health and Planning Services (CHPS) compounds as well as other public and private PHC providers. A stakeholders' workshop was organized to validate the preliminary results which provided a platform for stakeholders to deliberate on the key areas of misalignment especially, and to elicit additional information, ideas and responses, comments and recommendations from respondents for the achievement of the goals of UHC and PHC.; The key areas of misalignments identified during this pilot study included: delays in reimbursements of claims for services provided by health care providers, which serves as a disincentive for service providers to support the NHIS; inadequate coordination among stakeholders in PHC delivery; and inadequate funding for PHC, particularly on preventive and promotive services. Other areas are: the bypassing of PHC facilities due to lack of basic services at the PHC level such as laboratory services, as well as proximity to the district hospitals; and finally the lack of clear understanding of the national policy on PHC.; This study suggests that despite the progress that has been made since the establishment of the NHIS in Ghana, there are still huge gaps that need urgent attention to ensure that the goals of UHC and PHC are met. The key areas of misalignment identified in this study, particularly on the delays in reimbursements need to be taken seriously. It is also important for more dialogue between the NHIA and service providers to address key concerns in the implementation of the NHIS which is key to achieving UHC

The association between health insurance status and utilization of health services in rural Northern Ghana: evidence from the introduction of the National Health Insurance Scheme

Background: Many households in low- and middle-income countries face financial hardships due to payments for health care, while others are pushed into poverty. Risk pooling and prepayment mechanisms help to lessen the impact of the costs of care as well as assisting to achieve universal health coverage (UHC). Ghana implemented the National Health Insurance Scheme (NHIS) for the promotion of access to health services for all Ghanaians. In this paper, we examined the association between health insurance status and utilization of outpatient and inpatient health services in rural poor communities. Methods: The study was a cross-sectional household survey conducted in the Kassena-Nankana districts of Northern Ghana. We conducted interviews in 11,175 households and collected data on 55,992 household members. Multiple logistic regression models were used to identify factors associated with the utilization of outpatient and inpatient health services. The dependent variables were the utilization of outpatient and inpatient health services. We adjusted for several potential socio-demographic factors associated with utilization and health insurance status. Results: Significantly, the insured had 2.51 (95% CI 2.3\u20132.8) and 2.78 (95% CI 2.2\u20133.6) increased odds of utilizing outpatient and inpatient health services respectively. Respondents with a history of recent illness or injury [32.4 (95% CI 29.4\u201335.8) and 5.72 (95% CI 4.6\u20137.1)] and poor or very poor self-reported health status [2.08 (95% CI 1.7\u20132.5) and 2.52 (95% CI 1.9\u20133.4)] and those on chronic medication [2.79 (95% CI 2.2\u20133.5) and 3.48 (95% CI 2.5\u20134.8)] also had increased odds of utilizing both outpatient and inpatient health services respectively. Among the insured, the poorest use the Community-based Health Planning and Services (CHPS) compounds, while the least poor use private clinics and public hospitals for outpatient health services. The uninsured predominately use pharmacies or licensed chemical shops (LCSs). For inpatient health services, the insured largely use public hospitals, with the uninsured using private clinics or public health centres. Conclusion: The findings suggest that being insured with the NHIS is associated with increased utilization of outpatient and inpatient health services in the study area. Overall, the NHIS can be an effective tool for achieving UHC and hence pragmatic efforts should be made to sustain it

Prevalence and correlates of current tobacco use and non-user susceptibility to using tobacco products among school-going adolescents in 22 African countries: A secondary analysis of the 2013-2018 global youth tobacco surveys

From Springer Nature via Jisc Publications RouterBackground: Our study examined the prevalence and associated factors of tobacco product use and non-users’ susceptibility to using tobacco products among school-going adolescents in 22 African countries. Methods: We analyzed the cross-sectional 2013-2018 Global Youth Tobacco Survey (GYTS) data from 22 African countries. We conducted complex sampling descriptive and logistic regression analyses. Results: The overall prevalence of current use of any tobacco product among adolescents was 19.1%, with more males (23.7%) than females (13.7%) being current users. Zimbabwe and Morocco were the highest (47.1%) and least (12.6%) reported prevalence, respectively. Being male (AOR = 1.93;95%CI:1.61-2.32), being 16 and older(AOR = 1.37;95%CI:1.01-1.86), exposure to secondhand smoke within (AOR = 1.98;95%CI:1.69-2.32) and outside (AOR = 1.37;95%CI:1.13-1.65) the home, not knowledgeable about the harmful effect of secondhand smoke (AOR = 1.44;95%CI:1.20-1.74), exposure to tobacco industry promotion (AOR = 3.05;95%CI:2.68-3.47) and not in favour of banning smoking in enclosed places (AOR = 1.32;95%CI:1.08-1.60) were associated with current use of any tobacco product. The prevalence of the susceptibility to using tobacco products among never users of tobacco products was 12.2%, with no significant gender difference. Mozambique (24.6%) and Algeria (4.5%) had the highest and least prevalence of susceptibility to using tobacco products among never users, respectively. Exposure to tobacco industry promotion (AOR = 1.54;95%CI:1.31-1.82), those not in favour of banning smoking in enclosed places (AOR = 1.29;95%CI:1.14-1.45) and those not exposed to anti-smoking school education (AOR = 1.24;95%CI:1.06-1.46) were associated with susceptibility to using any tobacco product among never users of tobacco products. Conclusion: Our study reports that tobacco use and non-user susceptibility to using tobacco products among school-going adolescents in the 22 African countries is high. As part of public health efforts, governments and other stakeholders need to fully implement anti-tobacco use campaigns, enforce a complete ban on tobacco promotion and advertising, institute educational programs for families, and anti-tobacco use education for the general public and in schools in line with WHO Framework Convention on Tobacco Control guidelines.80pubpu

Access to maternal health services under the free maternal health policy in the Kassena-Nankana municipality of Northern Ghana

University of Technology Sydney. Faculty of Health.Introduction: Ghana implemented the National Health Insurance Scheme (NHIS) in 2005 to improve access to health services, for the achievement of universal health coverage. A free maternal health policy was implemented under the NHIS to enhance access for pregnant women. It is unknown if the policy has reduced access barriers regarding affordability, availability, acceptability and quality of care. Therefore the aim of the study was to explore factors affecting access in the form of affordability, availability, acceptability and quality of care under the NHIS policy. Methods: A cross-sectional survey was conducted in the Kassena-Nankana municipality of the Upper East region of Ghana. The study used parallel mixed methods; it collected and combined quantitative and qualitative data. Questionnaires were administered to women (n=406) who gave birth in facilities (n=353) and at home (n=53). In-depth interviews (IDIs) were carried out with health providers (n=25) and insurance managers (n=3), while focus group discussions (FGDs) were held with women (n=10). Descriptive statistics were used for the quantitative data. The qualitative data were analysed using a thematic analysis process. Results: Affordability – Women made out of pocket payments (OOP) under the policy, averaging GH¢17.50 (US$8.90) and GH¢33.50 (US$17.00) respectively, during pregnancy and childbirth. About 36% (n=145/406) of women incurred what was classified as ‘catastrophic’ OOP payments over 10% threshold of household income, affecting their welfare. Availability – Distance and time were barriers to care seeking. Infrastructure, laboratory services, accommodation, equipment, basic drugs and supplies were limited and often inadequate. The community-based health planning and services compounds were particularly challenged. Of the 14 study facilities, only two (14%) had a source of clean water, and five (36%) had a regular power supply. Emergency transport for referral was also unavailable. Acceptability – Women perceived facilities to be clean despite the limitations in infrastructure. Providers were perceived to be respectful and friendly. Eighty-nine percent (n=314/353) of women revealed a lack of privacy at childbirth, which was confirmed in IDIs. Quality of care – Overall, 74% (n=300/406) and 77% (n=272/353) of women were very satisfied or satisfied with quality of care during pregnancy and at childbirth respectively, which was supported in FGDs. Providers reported being dissatisfied, due to the challenges associated with service provision. Conclusion: Despite the policy, findings showed that out of pocket payments still existed and one third of women were significantly disadvantaged by the payments. Nevertheless, most women were satisfied with their care, although this could be because they were unaware of what high quality care might include. Providers were aware of the limitations of care provision and many reported being dissatisfied with the service they could provide. The government of Ghana, the National Health Insurance Scheme and other stakeholders should embark on resourcing facilities as well as infrastructural improvements. These would improve access to services and staff satisfaction, for the achievement of universal health coverage

The operations of the free maternal care policy and out of pocket payments during childbirth in rural Northern Ghana

Abstract Background To promote skilled attendance at births and reduce maternal deaths, the government of Ghana introduced the free maternal care policy under the National Health Insurance Scheme (NHIS) in 2008. The objective is to eliminate financial barriers associated with the use of services. But studies elsewhere showed that out of pocket (OOP) payments still exist in the midst of fee exemptions. The aim of this study was to estimate OOP payments and the financial impact on women during childbirth in one rural and poor area of Northern Ghana; the Kassena-Nankana municipality. Costs were taken from the perspective of women. Methods Quantitative and qualitative data collection techniques were used in a convergent parallel mixed methods study. The study used structured questionnaire (n = 353) and focus group discussions (FGDs =7) to collect data from women who gave birth in health facilities. Quantitative data from the questionnaire were analysed, using descriptive statistics. Qualitative data from the FGDs were recorded, transcribed and analysed to determine common themes. Results The overall mean OOP payments during childbirth was GH¢33.50 (US$17), constituting 5.6% of the average monthly household income. Over one-third (36%, n = 145) of women incurred OOP payments which exceeded 10% of average monthly household income (potentially catastrophic). Sixty-nine percent (n = 245) of the women perceived that the NHIS did not cover all expenses incurred during childbirth; which was confirmed in the FGDs. Both survey and FGDs demonstrated that women made OOP payments for drugs and other supplies. The FGDs showed women bought disinfectants, soaps, rubber pads and clothing for newborns as well. Seventy-five percent (n = 264) of the women used savings, but 19% had to sell assets to finance the payments; this was supported in the FGDs. Conclusion The NHIS policy has not eliminated financial barriers associated with childbirth which impacts the welfare of some women. Women continued to make OOP payments, largely as a result of a delay in reimbursement by the NHIS. There is need to re-examine the reimbursement system in order to prevent shortage of funding to health facilities and thus encourage skilled attendance for the reduction of maternal deaths as well as the achievement of universal health coverage

Has the free maternal health policy eliminated out of pocket payments for maternal health services? Views of women, health providers and insurance managers in Northern Ghana.

The free maternal health policy was implemented in Ghana in 2008 under the National Health Insurance Scheme (NHIS). The policy sought to eliminate out of pocket (OOP) payments and enhance the utilisation of maternal health services. It is unclear whether the policy had altered OOP payments for services. The study explored views on costs and actual OOP payments during pregnancy. The source of funding for payments was also explored.A convergent parallel mixed methods design, involving quantitative and qualitative data collection approaches. The study was set in the Kassena-Nankana municipality, a rural area in Ghana. Women (n = 406) who utilised services during pregnancy were surveyed. Also, 10 focus groups discussions (FGDs) were held with women who used services during pregnancy as well as 28 in-depth interviews (IDIs) with midwives/nurses (n = 25) and insurance managers/directors (n = 3). The survey was analysed using descriptive statistics, focussing on costs from the women's perspective. Qualitative data were audio recorded, transcribed and translated verbatim into English where necessary. The transcripts were read and coded into themes and sub-themes.The NHIS did not cover all expenses in relation to maternal health services. The overall mean for OOP cost during pregnancy was GH¢17.50 (US$8.60). Both FGDs and IDIs showed that women especially paid for drugs and ultrasound scan services. Sixty-five percent of the women used savings, whilst twenty-two percent sold assets to meet the OOP cost. Some women were unable to afford payments due to poverty and had to forgo treatment. Participants called for payments to be eliminated and for the NHIS to absorb the cost of emergency referrals. All participants admitted the benefits of the policy.Women needed to make payments despite the policy. Measures should be put in place to eliminate payments to enable all women to receive services and promote universal health coverage

Are health facilities well equipped to provide basic quality childbirth services under the free maternal health policy? Findings from rural Northern Ghana

Abstract Background Basic inputs and infrastructure including drugs, supplies, equipment, water and electricity are required for the provision of quality care. In the era of the free maternal health policy in Ghana, it is unclear if such basic inputs are readily accessible in health facilities. The study aimed to assess the availability of basic inputs including drugs, supplies, equipment and emergency transport in health facilities. Women and health providers’ views on privacy and satisfaction with quality of care were also assessed. Methods The study used a convergent parallel mixed methods in one rural municipality in Ghana, Kassena-Nankana. A survey among facilities (n = 14) was done. Another survey was carried out among women who gave birth in health facilities only (n = 353). A qualitative component involved focus group discussions (FGDs) with women (n = 10) and in-depth interviews (IDIs) with midwives and nurses (n = 25). Data were analysed using descriptive statistics for the quantitative study, while the qualitative data were recorded, transcribed, read and coded using themes. Results The survey showed that only two (14%) out of fourteen facilities had clean water, and five (36%) had electricity. Emergency transport for referrals was available in only one (7%) facility. Basic drugs, supplies, equipment and infrastructure especially physical space were inadequate. Rooms used for childbirth in some facilities were small and used for multiple purposes. Eighty-nine percent (n = 314) of women reported lack of privacy during childbirth and this was confirmed in the IDIs. Despite this, 77% of women (n = 272) were very satisfied or satisfied with quality of care for childbirth which was supported in the FGDs. Reasons for women’s satisfaction included the availability of midwives to provide childbirth services and to have follow-up homes visits. Some midwives were seen to be patient and empathetic. Providers were not satisfied due to health system challenges. Conclusion Government should dedicate more resources to the provision of essential inputs for CHPS compounds providing maternal health services. Health management committees should also endeavour to play an active role in the management of health facilities to ensure efficiency and accountability. These would improve quality service provision and usage, helping to achieve universal health coverage

The implementation of the free maternal health policy in rural Northern Ghana: synthesised results and lessons learnt

Abstract Objective A free maternal health policy was implemented under Ghana’s National Health Insurance Scheme to promote the use of maternal health services. Under the policy, women are entitled to free services throughout pregnancy and at childbirth. A mixed methods study involving women, providers and insurance managers was carried out in the Kassena-Nankana municipality of Ghana. It explored the affordability, availability, acceptability and quality of services. In this manuscript, we present synthesised results categorised as facilitators and barriers to access as well as lessons learnt (implications). Results Reasonable waiting times, cleanliness of facilities as well as good interpersonal relationships with providers were the facilitators to access. Barriers included out of pocket payments, lack of, or inadequate supply of drugs and commodities, equipment, water, electricity and emergency transport. Four lessons (implications) were identified. Firstly, out of pocket payments persisted. Secondly, the health system was not strengthened before implementing the free maternal health policy. Thirdly, lower level facilities were poorly resourced. Finally, the lack of essential inputs and infrastructure affected quality of care and therefore, access to care. It is suggested that the Government of Ghana, the Health Insurance Scheme and other stakeholders improve the provision of resources to facilities