Benefit incidence of health services in Ghana and access factors influencing benefit distribution

Includes bibliographical references (leaves 204-214).Universal coverage is built around financial protection and access to needed care for all members of the society. The main focus in many countries, including Ghana, has been on financial protection. However removing financial barriers does not necessarily remove other access barriers to the use of health care services. The extent to which a population gains access to health care depends on a multiplicity of factors. The study investigated the distribution of health care benefits across socioeconomic groups, assessed if these benefits are distributed according to need and identified health system and community access factors that influence the distribution of benefits from using health care services in Ghana, in order to identify policy options for promoting equitable access to and use of health services in Ghana

Something old or something new? Social health insurance in Ghana.

Background There is considerable interest at present in exploring the potential of social health insurance to increase access to and affordability of health care in Africa. A number of countries are currently experimenting with different approaches. Ghana's National Health Insurance Scheme (NHIS) was passed into law in 2003 but fully implemented from late 2005. It has already reached impressive coverage levels. This article aims to provide a preliminary assessment of the NHIS to date. This can inform the development of the NHIS itself but also other innovations in the region. Methods This article is based on analysis of routine data, on secondary literature and on key informant interviews conducted by the authors with stakeholders at national, regional and district levels over the period of 2005 to 2009. Results In relation to its financing sources, the NHIS is heavily reliant on tax funding for 70-75% of its revenue. This has permitted quick expansion of coverage, partly through the inclusion of large exempted population groups. Card holders increased from 7% of the population in 2005 to 45% in 2008. However, only around a third of these are contributing to the scheme financially. This presents a sustainability problem, in that revenue is de-coupled from the growing membership. In addition, the NHIS offers a broad benefits package, with no co-payments and limited gate-keeping, and also faces cost escalation related to its new payment system and the growing utilisation of members. These features contributed to a growth in distressed schemes and failure to pay outstanding facility claims in 2008. The NHIS has had a considerable impact on the health system as a whole, taking on a growing role in funding curative care. In 2009, it is expected to contribute 41% of the overall resource envelope. However there is evidence that this funding is not additional but has been switched from other funding channels. There are some equity concerns about this, as the new funding source (a VAT-based tax) may be more regressive. In addition, membership of the NHIS at present has a pro-rich bias, and a pro-urban bias in relation to renewals. Only a very small proportion is registered as indigent, and there is some evidence of 'squeezing out' of non-members from health care utilisation. Finally, considerable challenges remain in relation to strengthening the purchasing role of the NHIS, and also settling debates about its structure and accountability. Conclusion Some trade-offs will be necessary between the existing wide benefits package of the NHIS and the laudable desire to reach universal coverage. The overall resource envelope for health is likely to be stable rather than increasing over the medium-term. In the longer term, the investment costs in the NHIS will only be justified if it is able to increase the cost-effectiveness of purchasing and the responsiveness of the system as a whole.It is estimated that in 2000 almost 175 million people, or 2.9% of the world's population, were livingoutside their country of birth, compared to 100 million, or 1.8% of the total population, in 1995.As the global labour market strengthens, it is increasingly highly skilled professionals who aremigrating. Medical practitioners and nurses represent a small proportion of highly skilled workerswho migrate, but the loss of health human resources for developing countries can mean that thecapacity of the health system to deliver health care equitably is compromised. However, data tosupport claims on both the extent and the impact of migration in developing countries is patchyand often anecdotal, based on limited databases with highly inconsistent categories of educationand skills.The aim of this paper is to examine some key issues related to the international migration of healthworkers in order to better understand its impact and to find entry points to developing policyoptions with which migration can be managed.The paper is divided into six sections. In the first, the different types of migration are reviewed.Some global trends are depicted in the second section. Scarcity of data on health worker migrationis one major challenge and this is addressed in section three, which reviews and discusses differentdata sources. The consequences of health worker migration and the financial flows associated withit are presented in section four and five, respectively. To illustrate the main issues addressed in theprevious sections, a case study based mainly on the United Kingdom is presented in section six.This section includes a discussion on policies and ends by addressing the policy options from abroader perspective.sch_iih9pub2704pub2

Identification of poor households for premium exemptions in Ghana’s National Health Insurance Scheme: empirical analysis of three strategies

OBJECTIVES: To evaluate the effectiveness of three alternative strategies to identify poor households: means testing (MT), proxy means testing (PMT) and participatory wealth ranking (PWR) in urban, rural and semi-urban settings in Ghana. The primary motivation was to inform implementation of the National Health Insurance policy of premium exemptions for the poorest households. METHODS: Survey of 145-147 households per setting to collect data on consumption expenditure to estimate MT measures and of household assets to estimate PMT measures. We organized focus group discussions to derive PWR measures. We compared errors of inclusion and exclusion of PMT and PWR relative to MT, the latter being considered the gold standard measure to identify poor households. RESULTS: Compared to MT, the errors of exclusion and inclusion of PMT ranged between 0.46-0.63 and 0.21-0.36, respectively, and of PWR between 0.03-0.73 and 0.17-0.60, respectively, depending on the setting. CONCLUSION: Proxy means testing and PWR have considerable errors of exclusion and inclusion in comparison with MT. PWR is a subjective measure of poverty and has appeal because it reflects community's perceptions on poverty. However, as its definition of the poor varies across settings, its acceptability as a uniform strategy to identify the poor in Ghana may be questionable. PMT and MT are potential strategies to identify the poor, and their relative societal attractiveness should be judged in a broader economic analysis. This study also holds relevance to other programmes that require identification of the poor in low-income countries

Role of topographic corridors and small mammals in facilitating the spread of Lyme disease from southwestern Virginia to northwestern North Carolina

Lyme disease is the most important vector-borne disease in the United States. It is caused by the bacterium, Borrelia burgdorferi and transmitted by blacklegged ticks, Ixodes scapularis. An estimated 30,000 cases are reported to the CDC yearly from across the United States. Lyme disease cases in the Appalachian and western Piedmont foothills in northwestern North Carolina are rising, suggesting that there is an invasion of the disease in northwestern North Carolina. This study therefore set out to (1) evaluate if there are evidence for an invasion, and (2) understand how the invasion works and if northwestern North Carolina is a permissive area for Lyme disease establishment. Specifically, we do not know (1) how certain geographic features along the route of invasion may be influencing the spread of the disease, (2) whether the host community structure, and (3) seasonal tick lifecycle, are suitable for the establishment of Lyme disease enzootic cycle in northwestern NC. Hence, my specific goals were to: (1) determine the role of the New River as a potential route facilitating the spread of the pathogen and vector. (2) characterize the local and regional rodent community within northwestern North Carolina region, and (3) investigate the phenology of the life stages of the blacklegged tick vector within the region. For aim 1, I determined the role of the New River as a putative corridor for the spread of I. scapularis and B. burgdorferi by sampling ticks along a north-to-south gradient from southwestern Virginia to northwestern North Carolina using two 10-12 site flagging transects: one along the New River and a parallel one in the western NC Piedmont. My results showed (1) about thrice more I. scapularis density and 8% higher B. burgdorferi infection along the New River compared with the western Piedmont, (2) a more southern extent of the tick and pathogen along the New River compared with the western Piedmont, although the tick extended further southern than the pathogen in both the New River and western Piedmont. These results suggested that the New River is acting as a corridor that is facilitating the spread of Lyme disease from southwestern Virginia into northwestern North Carolina. The mechanism of invasion can be (1) tick-first (when the tick precedes the pathogen), (2) dual-invasion (when the tick and pathogen invade simultaneously), or (3) spirochete-first (when the pathogen already exists, awaiting the invasion of the tick). My result was indicative of the tick-first hypothesis. In aim 2, I trapped rodents in selected sites along the New River and the Western Piedmont, inspected them for attached ticks, and collected ear tissue samples for B. burgdorferi screening. Out of the 174 rodents captured, 89.14% of them were P. leucopus, the competent reservoir host of B. burgdorferi, with 74% more individuals in the western Piedmont than the New River. Out of the 172 rodents tested, 38 of them were positive for B. burgdorferi of which 63.2% were from the New River. Of the 38 rodents that tested positive, two were not P. leucopus (one eastern gray squirrel and one pine vole) All the 98 I. scapularis ticks on rodents were collected from P. leucopus with 91.8% of them from the New River. Ninety-two of the I. scapularis ticks from the rodents were tested with 26 out of the 30 of them that tested positive for B. burgdorferi coming from the New River sites. These results provide a further support for the role of the New River as a potential spread corridor and showed that the rodent community structure in the mountains and western Piedmont area is suitable for the establishment of an effective enzootic transmission system of B. burgdorferi. To evaluate the phenology of the tick and of the transmission cycles, in aim 3, I flagged the two sites that showed highest tick densities in my first aim (i.e., the Alleghany and Ashe County sites), each month for 12 months to obtain seasonal information on the life cycle of the I. scapularis ticks. The results showed a phenology pattern that was typical to that of the Lyme disease hyper-endemic regions in northeastern US. In this phenology pattern, the adults have two peaks (a lower one in early spring and a higher one in fall), and nymphs emerge in early spring before the emergence of larvae in mid-summer. Such a phenology is suited for an effective transmission of the pathogen among the wild rodents and humans, indicating that northwestern North Carolina is a suitable geographic region for the establishment of Lyme disease. Put together, these findings indicated that western North Carolina, specifically the New River valley area, is a hotspot for the establishment of Lyme disease and could serve as a focus from where the disease can further spread to neighboring counties. To control the spread of the B. burgdorferi from wild animals to susceptible hosts such as humans, there is the need for state regulated programs that will ensure that regular monitoring through enhanced active surveillance for I. scapularis within the region (and possibly statewide) and their control using acaricides, and periodic P. leucopus vaccinations in the northwestern North Carolina area. This control measure will ensure that the prevalence of the pathogen in wild rodents is kept low to reduce Lyme disease risk. Public health officials also need to educate people who live and visit areas in and around northwestern North Carolina on proper tick control such as the wearing of permethrin treated clothes when conducting outdoor activities, frequent checking of self for attached ticks when out in the woods and staying on demarcated paths when hiking in the woods. Information on what the early symptoms of Lyme disease are may also help to reduce the risk of Lyme disease becoming chronic in affected individuals. Future studies should include sampling ticks on hunter-harvested deer since this approach is the easier way to locate the ticks and usually show high I. scapularis detectability rate even when their densities are low. Also, other adjoining counties around the New River and its tributaries require investigation. It may also be important to aim at identifying other possible natural and artificial events around the northwestern North Carolina that may be influencing the disease invasion

Improving the Ghanaian Safe Motherhood Programme

Prior to the Ghana Ministry of Health scaling up the country’s Safe Motherhood program, they requested support from the Population Council’s USAID-funded Frontiers in Reproductive Health program to undertake an operations research study to evaluate and compare the cost-effectiveness of two training approaches and other performance improvement interventions. The study measured and compared changes in provider knowledge and skills and the costs of implementing a three-week residential vs. self-paced learning (SPL) approach. The SPL approach costs more per trainer than the traditional residential approach, both in financial costs alone and when opportunity costs are added, however, a cost-effectiveness analysis showed that for improving provider knowledge, the SPL approach was clearly more cost-effective. At a dissemination meeting, stakeholders agreed that the SPL and residential approaches are not mutually exclusive—both approaches have their strengths and weaknesses. Training for safe motherhood should be developed based on the strengths of the two approaches

Treatment choices for fevers in children under-five years in a rural Ghanaian district

<p>Abstract</p> <p>Background</p> <p>Health care demand studies help to examine the behaviour of individuals and households during illnesses. Few of existing health care demand studies examine the choice of treatment services for childhood illnesses. Besides, in their analyses, many of the existing studies compare alternative treatment options to a single option, usually self-medication. This study aims at examining the factors that influence the choices that caregivers of children under-five years make regarding treatment of fevers due to malaria and pneumonia in a rural setting. The study also examines how the choice of alternative treatment options compare with each other.</p> <p>Methods</p> <p>The study uses data from a 2006 household socio-economic survey and health and demographic surveillance covering caregivers of 529 children under-five years of age in the Dangme West District and applies a multinomial probit technique to model the choice of treatment services for fevers in under-fives in rural Ghana. Four health care options are considered: self-medication, over-the-counter providers, public providers and private providers.</p> <p>Results</p> <p>The findings indicate that longer travel, waiting and treatment times encourage people to use self-medication and over-the-counter providers compared to public and private providers. Caregivers with health insurance coverage also use care from public providers compared to over-the-counter or private providers. Caregivers with higher incomes use public and private providers over self-medication while higher treatment charges and longer times at public facilities encourage caregivers to resort to private providers. Besides, caregivers of female under-fives use self-care while caregivers of male under-fives use public providers instead of self-care, implying gender disparity in the choice of treatment.</p> <p>Conclusions</p> <p>The results of this study imply that efforts at curbing under-five mortality due to malaria and pneumonia need to take into account care-seeking behaviour of caregivers of under-fives as well as implementation of strategies.</p

Pharmaceutical availability across levels of care: evidence from facility surveys in Ghana, Kenya, and Uganda.

OBJECTIVE: In this study we use facility-level data from nationally representative surveys conducted in Ghana, Kenya, and Uganda to understand pharmaceutical availability within the three countries. METHODS: In 2012, we conducted a survey to capture information on pharmaceuticals and other facility indicators from over 200 facilities in each country. We analyze data on the availability of pharmaceuticals and quantify its association with various facility-level indicators. We analyze both availability of essential medicines, as defined by the various essential medicine lists (EMLs) of each respective country, and availability of all surveyed pharmaceuticals deemed important for treatment of various high-burden diseases, including those on the EMLs. RESULTS: We find that there is heterogeneity with respect to availability across the three countries with Ghana generally having better availability than Uganda and Kenya. To analyze the relationship between facility-level factors and pharmaceutical stock-out we use a binomial regression model. We find that the factors associated with stock-out vary by country, but across all countries both presence of a laboratory at the facility and presence of a vehicle at the facility are significantly associated with reduced stock-out. CONCLUSION: The results of this study highlight the poor availability of essential medicines across these three countries and suggest more needs to be done to strengthen the supply system so that stock remains uninterrupted

Feasibility and acceptability of artemisinin-based combination therapy for the home management of malaria in four African sites

BACKGROUND: The Home Management of Malaria (HMM) strategy was developed using chloroquine, a now obsolete drug, which has been replaced by artemisinin-based combination therapy (ACT) in health facility settings. Incorporation of ACT in HMM would greatly expand access to effective antimalarial therapy by the populations living in underserved areas in malaria endemic countries. The feasibility and acceptability of incorporating ACT in HMM needs to be evaluated. METHODS: A multi-country study was performed in four district-size sites in Ghana (two sites), Nigeria and Uganda, with populations ranging between 38,000 and 60,000. Community medicine distributors (CMDs) were trained in each village to dispense pre-packaged ACT to febrile children aged 6-59 months, after exclusion of danger signs. A community mobilization campaign accompanied the programme. Artesunate-amodiaquine (AA) was used in Ghana and artemether-lumefantrine (AL) in Nigeria and Uganda. Harmonized qualitative and quantitative data collection methods were used to evaluate CMD performance, caregiver adherence and treatment coverage of febrile children with ACTs obtained from CMDs. RESULTS: Some 20,000 fever episodes in young children were treated with ACT by CMDs across the four study sites. Cross-sectional surveys identified 2,190 children with fever in the two preceding weeks, of whom 1,289 (59%) were reported to have received ACT from a CMD. Coverage varied from 52% in Nigeria to 75% in Ho District, Ghana. Coverage rates did not appear to vary greatly with the age of the child or with the educational level of the caregiver. A very high proportion of children were reported to have received the first dose on the day of onset or the next day in all four sites (range 86-97%, average 90%). The proportion of children correctly treated in terms of dose and duration was also high (range 74-97%, average 85%). Overall, the proportion of febrile children who received prompt treatment and the correct dose for the assigned duration of treatment ranged from 71% to 87% (average 77%). Almost all caregivers perceived ACT to be effective, and no severe adverse events were reported. CONCLUSION: ACTs can be successfully integrated into the HMM strategy

Pharmaceutical Availability across Levels of Care: Evidence from Facility Surveys in Ghana, Kenya, and Uganda

In this study we use facility-level data from nationally representative surveys conducted in Ghana, Kenya, and Uganda to understand pharmaceutical availability within the three countries

Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial

Evelyn Ansah and colleagues report on whether removing user fees has an impact on health care-seeking behavior and health outcomes in households with children in Ghana