Insured clients out-of-pocket payments for health care under the national health insurance scheme in Ghana

BACKGROUND: In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) designed to promote universal health coverage and equitable access to health care. The scheme has largely been successful, yet it is confronted with many challenges threatening its sustainability. Out-of-pocket payments (OOP) by insured clients is one of such challenges of the scheme. This study sought to examine the types of services OOP charges are made for by insured clients and how much insured clients pay out-of-pocket. METHODS: This was a descriptive cross-sectional health facility survey. A total of 2066 respondents were interviewed using structured questionnaires at the point of health care exit in the Ashanti, Northern and Central regions of Ghana. Health facilities of different levels were selected from 3 districts in each of the three regions. Data were collected between April and June 2018. Using Epidata and STATA Version 13.1 data analyses were done using multiple logistic regression and simple descriptive statistics and the results presented as proportions and means. RESULTS: Of all the survey respondents 49.7% reported paying out-of-pocket for out-patient care while 46.9% of the insured clients paid out-of-pocket. Forty-two percent of the insured poorest quintile also paid out-of-pocket. Insured clients paid for consultation (75%) and drugs (63.2%) while 34.9% purchased drugs outside the health facility they visited. The unavailability of drugs (67.9%) and drugs not covered by the NHIS (20.8%) at the health facility led to out-of-pocket payments. On average, patients paid GHS33.00 (USD6.6) out-of-pocket. Compared to the Ashanti region, patients living in the Northern region were 74% less at odds to pay out-of-pocket for health care. CONCLUSION AND RECOMMENDATION: Insured clients of Ghana's NHIS seeking health care in accredited health facilities make out-of-pocket payments for consultation and drugs that are covered by the scheme. The out-of-pocket payments are largely attributed to unavailability of drugs at the facilities while the consultation fees are charged to meet the administrative costs of services. These charges occur in disadvantaged regions and in all health facilities. The high reliance on out-of-pocket payments can impede Ghana's progress towards achieving Universal Health Coverage and the Sustainable Development Goal 3, seeking to end poverty and reduce inequalities. In order to build trust and confidence in the NHIS there is the need to eliminate out-of-pocket payments for consultation and medicines by insured clients

Coping Strategies of young mothers at risk of HIV/AIDS in the Kassena-Nankana District of Northern Ghana

This qualitative study draws on interpretative principles with emphasis on understanding young mothers’ vulnerability to HIV/AIDS and explores coping strategies used to mitigate risk of infection in a poor rural setting of Ghana. Young mothers in their mid-twenties to early thirties and their male partners were purposively selected with the assistance of key informants for repeated semi-structured interviews. Respondents included those in monogamous and polygynous marriages with two or more living children, and those with and without formal education. Young mothers in this study setting are confronted with complex realities as childbearing obligations make protective sex less optional. However, more assertive women insist their husbands use condoms when they perceive themselves at risk. We conclude that the advent of HIV may advance the cause of women’s reproductive health empowerment by providing women with very strong reasons to minimize HIV risk within marriage (Afr J Reprod Health 2009; 13[1]:61-78)

Adverse drug reaction reporting by doctors in a developing country: A case study from Ghana

Background: Spontaneous adverse drug reaction reporting is the most widely used and cost effective method of monitoring the safety of drugs. This method is heavily afflicted by underreporting by healthcare professionals. The study aims at assessing adverse drug reaction (ADR) reporting rate by doctors, knowledge of the reporting system and attitudes to SADR in the Greater Accra region.Methods: This was a cross sectional survey of 259 doctors randomly  selected from 23 hospitals classified as government 199 (76.8%), quasi-governmental 43(16.6%) and private 17 (6.6%) hospitals in the Greater Accra Region of Ghana. Data collection was by self-administered  questionnaire from May 5, 2012- July 6, 2012. Descriptive statistics was used to describe the background characteristics of the doctors and the outcome measures like training and reasons for ADR reporting were summarized as frequencies and percentages.Results: One-third (27.4%) of doctors surveyed had received previous training on drug safety monitoring and ADR reporting; training and  knowledge of the reporting system was found to improve reporting. Morethan half 154 (59.5%) of the doctors had seen a patient with suspected ADR in the past one year although only 31 (20%) had reported it by completing the SADR reporting form. Doctors working in government hospitals were about 5 times more likely to report than those in private hospitals [OR=4.94, 95%CI (1.55-15.69)].Conclusion: Training and knowledge of the ADR reporting system were found to be associated with the likelihood of reporting an ADR. Most of the doctors had not previously received training on ADR reporting.Keywords: Spontaneous reporting, adverse drug reaction, underreporting, doctors, Ghan

Community perceptions of enrolment of indigents into the National Health Insurance Scheme in Ghana: a case study of the Livelihood Empowerment against Poverty Programme

BACKGROUND: The Livelihood Empowerment against Poverty (LEAP) programme in Ghana as part of its beneficiary programme, identifies the poor/indigents for exemptions from premium payments in the National Health Insurance Scheme (NHIS). This paper sought to understand community perceptions of enrolling the poor in the NHIS through LEAP in order to inform policy. METHODS: The study adopted a descriptive cross-sectional study design by using a qualitative approach. The study was conducted in three geographical regions of Ghana: Greater Accra, Brong-Ahafo and Northern region representing the three ecological zones of Ghana between October 2017 and February 2018. The study population included community members, health workers, NHIS staff and social welfare officers/social development officers. Eighty-one in-depth interviews and 23 Focus Group Discussions were conducted across the three regions. Data were analysed thematically and verbatim quotes from participants were used to support the views of participants. RESULTS: The study shows that participants were aware of the existence of LEAP and its benefits. There was, however, a general belief that the process of LEAP had been politicized and therefore favours only people who were sympathizers of the ruling government as they got enrolled into the NHIS. Participants held the view that the process of selecting beneficiaries lacked transparency, thus, they were not satisfied with the selection process. However, the study shows the ability of the community to identify the poor. The study reports varying concepts of poverty and its identification across the three ecological zones of Ghana. CONCLUSION: There is a general perception of politicization and lack of transparency of the selection of the poor into the NHIS through the LEAP programme in Ghana. Community-based approaches in the selection of the indigent are recommended to safeguard the NHIS-LEAP beneficiary process

Positioning the national health insurance for financial sustainability and universal health coverage in Ghana: a qualitative study among key stakeholders

INTRODUCTION: The National Health Insurance Scheme (NHIS) was introduced in 2003 to reduce "out-of-pocket" payments for health care in Ghana. Over a decade of its implementation, issues about the financial sustainability of this pro-poor policy remains a crippling fact despite its critical role to go towards Universal Health Coverage. We therefore conducted this study to elicit stakeholders' views on ways to improve the financial sustainability of the operations of NHIS. METHODS: Twenty (20) stakeholders were identified from Ministry of Health, Ghana Health Services, health workers groups, private medical practitioners, civil society organizations and developmental partners. They were interviewed using an interview guide developed from a NHIS policy review and analysis. All interviews were recorded and transcribed verbatim. The data were analysed thematically with the aid of NVivo 12 software. RESULTS: Stakeholders admitted that the NHIS is currently unable to meet its financial obligations. The stakeholders suggested first the adoption of capitation as a provider payment mechanism to minimize the risk of providers' fraud and protection from political interference. Secondly, they indicated that rapid releases of specific statutory deductions and taxes for NHIS providers could reduce delays in claims' reimbursement which is one of the main challenges faced by healthcare providers. Aligning the NHIS with the Community-based Health Planning and Services and including preventive and promotive health is necessary to position the Scheme for Universal Health Coverage. CONCLUSION: The Scheme will potentially achieve UHC if protected from political interference to improve the governance and transparency that affects the finances of the scheme and the expansion of services to include preventive and promotive services and cancers

Health worker transfer processes within the public health sector in Ghana : a study of three districts in the Eastern Region

The lack of appropriate policies and procedures to ensure transparent transfer practices is an important source of dissatisfaction among health workers in low- and middle-income countries. In order to alter and improve current practices, a more in-depth and context-specific understanding is needed. This study aims to (1) identify rationales behind transfer decisions in Ghana and (2) examine how transfers are managed in practice versus in policies.; The study took place in 2014 in three districts in Eastern Ghana. The study population included (1) national, regional, and district health administrators with decision-making authority in terms of transfer decisions and (2) health workers who had transferred between 2011 and 2014. Data was collected through semi-structured and structured face-to-face interviews focusing on rationales behind transfer decisions, health administrators' role in managing transfers, and health workers' experience of transfers. A data triangulation approach was applied to compare identified practices with national policies and procedures.; A total of 44 health workers and 21 administrators participated in the study. Transfers initiated by health workers were mostly based on family conditions and preferences to move away from rural areas, while transfers initiated by administrators were based on service requirements, productivity, and performance. The management of transfers was not guided by clear and explicit procedures and thus often depended on the discretion of decision-makers. Moreover, health workers frequently reported not being involved in transfer decision-making processes. We found existing staff perceptions of a non-transparent system.; Our findings suggest a need to foster incentives to attract and retain health workers in rural areas. Moreover, health worker-centered procedures and systems that effectively guide and monitor transfer practices must be developed to ensure that transfers are carried out in a timely, fair, and transparent way

A mixed methods approach to evaluating community drug distributor performance in the control of neglected tropical diseases

BACKGROUND: Trusted literate, or semi-literate, community drug distributors (CDDs) are the primary implementers in integrated preventive chemotherapy (IPC) programmes for Neglected Tropical Disease (NTD) control. The CDDs are responsible for safely distributing drugs and for galvanising communities to repeatedly, often over many years, receive annual treatment, create and update treatment registers, monitor for side-effects and compile treatment coverage reports. These individuals are 'volunteers' for the programmes and do not receive remuneration for their annual work commitment. METHODS: A mixed methods approach, which included pictorial diaries to prospectively record CDD use of time, structured interviews and focus group discussions, was used to triangulate data on how 58 CDDs allocated their time towards their routine family activities and to NTD Programme activities in Uganda. The opportunity costs of CDD time were valued, performance assessed by determining the relationship between time and programme coverage, and CDD motivation for participating in the programme was explored. RESULTS: Key findings showed approximately 2.5 working weeks (range 0.6-11.4 working weeks) were spent on NTD Programme activities per year. The amount of time on NTD control activities significantly increased between the one and three deliveries that were required within an IPC campaign. CDD time spent on NTD Programme activities significantly reduced time available for subsistence and income generating engagements. As CDDs took more time to complete NTD Programme activities, their treatment performance, in terms of validated coverage, significantly decreased. Motivation for the programme was reported as low and CDDs felt undervalued. CONCLUSIONS: CDDs contribute a considerable amount of opportunity cost to the overall economic cost of the NTD Programme in Uganda due to the commitment of their time. Nevertheless, programme coverage of at least 75 %, as required by the World Health Organisation, is not being achieved and vulnerable individuals may not have access to treatment as a consequence of sub-optimal performance by the CDDs due to workload and programmatic factors

The economic burden of meningitis to households in Kassena-Nankana District of Northern Ghana

Objective To estimate the direct and indirect costs of meningitis to households in the Kassena-Nankana District of Ghana. Methods A Cost of illness (COI) survey was conducted between 2010 and 2011. The COI was computed from a retrospective review of 80 meningitis cases answers to questions about direct medical costs, direct non-medical costs incurred and productivity losses due to recent meningitis incident. Results The average direct and indirect costs of treating meningitis in the district was GH¢152.55 (US$101.7) per household. This is equivalent to about two months minimum wage earned by Ghanaians in unskilled paid jobs in 2009. Households lost 29 days of work per meningitis case and thus those in minimum wage paid jobs lost a monthly minimum wage of GH¢76.85 (US$51.23) due to the illness. Patients who were insured spent an average of GH¢38.5 (US$25.67) in direct medical costs whiles the uninsured patients spent as much as GH¢177.9 (US$118.6) per case. Patients with sequelae incurred additional costs of GH¢22.63 (US$15.08) per case. The least poor were more exposed to meningitis than the poorest. Conclusion Meningitis is a debilitating but preventable disease that affects people living in the Sahel and in poorer conditions. The cost of meningitis treatment may further lead to impoverishment for these households. Widespread mass vaccination will save households' an equivalent of GH¢175.18 (US$117) and impairment due to meningitis

Local perceptions of intermittent screening and treatment for malaria in school children on the south coast of Kenya.

BACKGROUND: The intermittent screening and treatment (IST) of school children for malaria is one possible intervention strategy that could help reduce the burden of malaria among school children. Future implementation of IST will not only depend on its efficacy and cost-effectiveness but also on its acceptability to parents of the children who receive IST, as well as those responsible for its delivery. This study was conducted alongside a cluster-randomized trial to investigate local perceptions of school-based IST among parents and other stakeholders on the Kenyan south coast. METHODS: Six out of the 51 schools receiving the IST intervention were purposively sampled, based on the prevalence of Plasmodium infection, to participate in the qualitative study. Twenty-two focus group discussions and 17 in-depth interviews were conducted with parents and other key stakeholders involved in the implementation of school health programmes in the district. Data analysis was guided by the framework analysis method. RESULTS: High knowledge of the burden of clinical malaria on school children, the perceived benefits of preventing clinical disease through IST and previous positive experiences and interactions with other school health programmes facilitated the acceptability of IST. However, lack of understanding of the consequences of asymptomatic parasitaemia for apparently healthy school children could potentially contribute to non-adherence to treatment, and use of alternative anti-malarial drugs with simpler regimens was generally preferred. The general consensus of stakeholders was that health workers were best placed to undertake the screening and provide treatment, and although teachers' involvement in the programme is critical, most participants were opposed to teachers taking finger-prick blood samples from children. There was also a strong demand for the distribution of mosquito nets to augment IST. CONCLUSION: School-based malaria control through IST was acceptable to most parents and other stakeholders, but careful consideration of the various roles of teachers, community health workers, and health workers, and the use of anti-malarial drugs with simpler regimens are critical to its future implementation