Impact of National Health Insurance on health seeking behavior in the Kassena-Nankana district of Northern Ghana

Includes bibliographical references.The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003 with the aim of mobilizing additional funds for health care, promoting equal access to reasonable health care, pool health risks, prevent impoverishment, and improve the efficiency and quality of health care. The success of the NHIS in improving access to health care since its implementation and the extent to which it has impacted on health seeking behaviour has not been extensively investigated. This study examines health-seeking behaviours of insured and uninsured households on the mutual health insurance scheme on health care access in the Kassena-Nankana District (KND) of northern Ghana and to determine the factors that influence household decision to enrol into the NHIS. The study is a cross sectional survey of 422 household heads randomly selected to represent rural, peri-urban and urban zones of KND. Data was analysed using STATA version 8.0. A binary logit model was used to determine factors that predict household enrolment into the NHIS. The choice of a particular type of provider with multiple outcomes was analysed using a multinomial logit model. Results showed that 72% of household heads were males and the average age was 51 years. Out of the 422 respondents, 64% were insured. Household heads of age 40 years and above, being a female household head, being married, and economic wealth positively influenced enrolment into the national health insurance scheme. Seventy four percent (74%) of the ill among the insured and 48% among uninsured sought care from public facilities while 14% among the insured and 8% among uninsured sought care from private facility. Also, self treatment among the insured was 13% and 44% among uninsured households. Results also showed that being a member of NHIS and being moderately or severely ill were associated with public health facility utilization. Household heads of 60 years or older was negatively associated with use of public health facilities. Similarly, a household that was insured, being a Muslim and the severity of illness of household member were positively associated with the use of private health care. The findings showed that the insured were more likely to use formal care providers than the uninsured. This implies that the NHI in the KND has improved the health seeking behaviour from the hitherto use of informal providers and self treatment to preferred use of formal providers

"I would have to sell things in order to get the money":A qualitative exploration of willingness to pay for the RTS,S/AS01 malaria vaccine in the Volta region, Ghana

BACKGROUND: Malaria morbidity and mortality remain a challenge in Ghana. A promising childhood vaccine is being piloted in Ghana, however with the loss of its low-income status, Ghana is losing associated donor co-funding. User fees have been considered an alternative financing method, so this study utilised qualitative methods and explored caregivers’ willingness to pay for the malaria vaccine (RTS,S/AS01) to inform future service provision. METHODS: The study design was cross-sectional. Twenty in-depth interviews were conducted between February 2020 and March 2020 amongst a purposive sample of caregivers of RTS,S/AS01 eligible children, in the Volta region, Ghana. Interviews were audio-recorded and transcribed into English Language. Thematic analysis followed, using NVIVO12 to organise this data. RESULTS: Caregivers could distinguish between RTS,S/AS01 and routine vaccines and were willing to pay median GH₵5 (US$0.94), interquartile range GH₵3.75–5 (US$0.71–0.94) per dose of RTS,S/AS01. The maximum amount participants were willing to pay per dose was GH₵10 (US$1.88), interquartile range GH₵6–10 (US$1.13–1.88). Caregivers mentioned that they would work more to cover this cost because they were happy with services rendered to them during the RTS,S/AS01 pilot phase, and preferred vaccines over vector control measures. The results suggest that a willingness to pay was based on beliefs that the vaccine is fully effective. Although no participant declared that they would be unwilling to pay hypothetical user fees, there were still widespread concerns about affordability, with the majority feeling that the government should be responsible to pay for RTS,S/AS01. CONCLUSIONS: Participants expressed a willingness to pay due to an appreciation of vaccines, shaped by personal experiences with immunisations and disease. Participants’ average income was lower than the national average, potentially affecting the perceived affordability of RTS,S/AS01. Because of the belief that RTS,S/AS01 is fully effective, caregivers may pay less attention to other preventative measures, thus unintentionally undermining malaria vector control

Efficiency of antenatal care and childbirth services in selected primary health care facilities in rural Tanzania : a cross-sectional study

Background: Cost studies are paramount for demonstrating how resources have been spent and identifying opportunities for more efficient use of resources. The main objective of this study was to assess the actual dimension and distribution of the costs of providing antenatal care (ANC) and childbirth services in selected rural primary health care facilities in Tanzania. In addition, the study analyzed determining factors of service provision efficiency in order to inform health policy and planning. Methods: This was a retrospective quantitative cross-sectional study conducted in 11 health centers and dispensaries in Lindi and Mtwara rural districts. Cost analysis was carried out using step down cost accounting technique. Unit costs reflected efficiency of service provision. Multivariate regression analysis on the drivers of observed relative efficiency in service provision between the study facilities was conducted. Reported personnel workload was also described. Results: The health facilities spent on average 7 USD per capita in 2009. As expected, fewer resources were spent for service provision at dispensaries than at health centers. Personnel costs contributed a high approximate 44% to total costs. ANC and childbirth consumed approximately 11% and 12% of total costs; and 8% and 10% of reported service provision time respectively. On average, unit costs were rather high, 16 USD per ANC visit and 79.4 USD per childbirth. The unit costs showed variation in relative efficiency in providing the services between the health facilities. The results showed that efficiency in ANC depended on the number of staff, structural quality of care, process quality of care and perceived quality of care. Population-staff ratio and structural quality of basic emergency obstetric care services highly influenced childbirth efficiency. Conclusions: Differences in the efficiency of service provision present an opportunity for efficiency improvement. Taking into consideration client heterogeneity, quality improvements are possible and necessary. This will stimulate utilization of ANC and childbirth services in resource-constrained health facilities. Efficiency analyses through simple techniques such as measurement of unit costs should be made standard in health care provision, health managers can then use the performance results to gauge progress and reward efficiency through performance based incentives

Cost of installing and operating an electronic clinical decision support system for maternal health care: case of Tanzania rural primary health centres

Background: Poor quality of care is among the causes of high maternal and newborn disease burden in Tanzania. Potential reason for poor quality of care is the existence of a “know-do gap” where by health workers do not perform to the best of their knowledge. An electronic clinical decision support system (CDSS) for maternal health care was piloted in six rural primary health centers of Tanzania to improve performance of health workers by facilitating adherence to World Health Organization (WHO) guidelines and ultimately improve quality of maternal health care. This study aimed at assessing the cost of installing and operating the system in the health centers. Methods: This retrospective study was conducted in Lindi, Tanzania. Costs incurred by the project were analyzed using Ingredients approach. These costs broadly included vehicle, computers, furniture, facility, CDSS software, transport, personnel, training, supplies and communication. These were grouped into installation and operation cost; recurrent and capital cost; and fixed and variable cost. We assessed the CDSS in terms of its financial and economic cost implications. We also conducted a sensitivity analysis on the estimations. Results: Total financial cost of CDSS intervention amounted to 185,927.78 USD. 77% of these costs were incurred in the installation phase and included all the activities in preparation for the actual operation of the system for client care. Generally, training made the largest share of costs (33% of total cost and more than half of the recurrent cost) followed by CDSS software- 32% of total cost. There was a difference of 31.4% between the economic and financial costs. 92.5% of economic costs were fixed costs consisting of inputs whose costs do not vary with the volume of activity within a given range. Economic cost per CDSS contact was 52.7 USD but sensitive to discount rate, asset useful life and input cost variations. Conclusions: Our study presents financial and economic cost estimates of installing and operating an electronic CDSS for maternal health care in six rural health centres. From these findings one can understand exactly what goes into a similar investment and thus determine sorts of input modification needed to fit their context

Cost-effectiveness of an electronic clinical decision support system for improving quality of antenatal and childbirth care in rural Tanzania: an intervention study

Background: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. Methods: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider’s perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. Results: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. Conclusions: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. Trial registration: Registered clinical trial at www.clinicaltrials.gov (NCT01409824). Registered May 2009

A qualitative analysis of the effect of a community-based primary health care programme on reproductive preferences and contraceptive use among the Kassena-Nankana of northern Ghana

Background In 2000, Ghana launched the Community-based Health Planning and Services (CHPS) initiative to improve access to health and family planning services. This initiative was based in part on research, known as the Navrongo Project, conducted in the Kassena-Nankana district (KND) between 1994 to 2003 which demonstrated significant impact on fertility and child mortality. This paper examines current contraceptive perceptions in communities that were exposed to the Project’s service models over the 1994 to 2003 period, and the post-experimental policies of the CHPS era. Methods Qualitative study was conducted in the KND of Ghana from June to September, 2012, by convening 8 male and 8 female FGD panels as well as 8 in-depth interviews of community leaders. Data collection was stratified by original experimental cell of the Navrongo Project to permit appraisal of social effects of contrasting experimental conditions. Inductive content analysis was performed with QSR Nvivo 10 to identify predominant themes. Results While findings show that exposure to community-based services was associated with enhanced approval of birth spacing and limitation, this view is grounded in perceptions that childhood survival has improved. Nonetheless, concerns were expressed about contraceptive side effects, prominently permanent sterility. Strategies for male outreach and community engagement originally introduced during the Navrongo Project have not been sustained with CHPS scale-up. The apparent atrophy of attention to the needs of men may explain the resistance of some males to the notion of female reproductive autonomy and the practice of some women to adopt contraception in secret. Despite this apparent programmatic dearth of male engagement, there is evidence to suggest that social impact of the original male engagement strategy persists in communities where male mobilization was combined with doorstep provision of family planning care during the Navrongo Project. Conclusion Community-based services fostered attitudinal change towards family planning in a traditional sub-Saharan African setting. Sustained exposure to primary health care that have improved the survival of children has made the use of contraception more acceptable. Efforts should be embedded in primary health care programmes that address concerns about child survival while also consigning sustained priority to the information needs of men

Kitchen Area Air Quality Measurements in Northern Ghana: Evaluating the Performance of a Low-Cost Particulate Sensor within a Household Energy Study

Household air pollution from the combustion of solid fuels is a leading global health and human rights concern, affecting billions every day. Instrumentation to assess potential solutions to this problem faces challenges-especially related to cost. A low-cost ($159) particulate matter tool called the Household Air Pollution Exposure (HAPEx) Nano was evaluated in the field as part of the Prices, Peers, and Perceptions cookstove study in northern Ghana. Measurements of temperature, relative humidity, absolute humidity, and carbon dioxide and carbon monoxide concentrations made at 1-min temporal resolution were integrated with 1-min particulate matter less than 2.5 microns in diameter (PM2.5) measurements from the HAPEx, within 62 kitchens, across urban and rural households and four seasons totaling 71 48-h deployments. Gravimetric filter sampling was undertaken to ground-truth and evaluate the low-cost measurements. HAPEx baseline drift and relative humidity corrections were investigated and evaluated using signals from paired HAPEx, finding significant improvements. Resulting particle coefficients and integrated gravimetric PM2.5 concentrations were modeled to explore drivers of variability; urban/rural, season, kitchen characteristics, and dust (a major PM2.5 mass constituent) were significant predictors. The high correlation (R2 = 0.79) between 48-h mean HAPEx readings and gravimetric PM2.5 mass (including other covariates) indicates that the HAPEx can be a useful tool in household energy studies.</p

A glimpse into real-world kitchens: Improving our understanding of cookstove usage through in-field photo-observations and improved cooking event detection (CookED) analytics

The combustion of solid fuels in residential cookstoves is a global health and climate issue, and expanded use ofimproved cookstoves could have significant benefits locally and globally. Evaluating impacts of improved cookstove programs requires more accurately measuring stove use patterns. This work builds on and improves existing stove use monitoring methods. First, we introduce and describe a novel, in-field photo-observation sampling method designed to capture near-continuous, real-world, ground-truth stove usage information. These measurements are used to validate predictions made by electronic stove use monitors (SUMs). Second, we present Cooking Event Detector (CookED), a SUM algorithm that translates stove-temperature measurements into classifications of cooking or not-cooking. The predictive performance of the new algorithm is evaluated using results from the photo-observations and compared to existing algorithms. CookED demonstrates considerable improvement over some methods for all five types of improved and traditional stoves monitored in the study. Overall minute-level predictive accuracy of CookED ranges from 95.6% to 98.4%, depending on the stove type, while Matthews correlation coefficients range from 72.8% to 88.3%. Comparisons between predicted and observed average cooking event durations show high correlation (Pearson&rsquo;s r = 0.85). These methods can be applied in a wide variety of applications, including research studies linking behavior, technology, exposure, and human and environmental health, as well as operational programs that aim to scale up improved cookstove adoption and quantify benefits.</p

Cost of delivering health care services at primary health facilities in Ghana

Abstract Background There is limited knowledge on the cost of delivering health services at primary health care facilities in Ghana which is posing a challenge in resource allocations. This study therefore estimated the cost of providing health care in primary health care facilities such as Health Centres (HCs) and Community-based Health Planning and Services (CHPS) in Ghana. Methods The study was cross-sectional and quantitative data was collected from the health provider perspective. Data was collected between July and August, 2016 at nine primary health facilities (six CHPS and three HCs) from the Upper West region of Ghana. All health related costs for the year 2015 and revenue generated for the period were collected. Data were captured and analysed using Microsoft excel. Costs of delivery health services were estimated. In addition, unit costs such as cost per Outpatient Department (OPD) attendance were estimated. Results The average annual cost of delivering health services through CHPS and HCs was US$10,923 and US$44,638 respectively. Personnel cost accounted for the largest proportion of cost (61% for CHPS and 59% for HC). The cost per OPD attendance was higher at CHPS (US$8.79) than at HCs (US$5.16). The average Internally Generated Funds (IGF) recorded for the period at CHPS and HCs were US$2327 and US$ 15,795 respectively. At all the facilities, IGFs were greatly lower than costs of running the health facilities. Also, at both the CHPS and HCs, the National Health Insurance Scheme (NHIS) reimbursement was the main source of revenue accounting for over 90% total IGF. Conclusions The average annual cost of delivering primary health services through CHPS and HCs is US$10,923 and US$44,638 respectively and personnel cost accounts for the major cost. The government should be guided by these findings in their financial planning, decision making and resource allocation in order to improve primary health care in the country. However, more similar studies involving large numbers of primary health facilities in different parts of the country are needed to assess the cost of providing primary health care

Additional file 1: of Cost of delivering health care services at primary health facilities in Ghana

Questionnaire for health facility data collection. (DOC 475 kb