Is the National Health Insurance Scheme helping pregnant women in accessing health services? Analysis of the 2014 Ghana demographic and Health survey

BACKGROUND

Increasing the use of healthcare is a significant step in improving health outcomes in both the short and long term. However, the degree of the relationship between utilization of health services and health outcomes is affected by the quality of the services rendered, the timeliness of treatment and follow-up care. In this study, we investigated whether the National Health Insurance Scheme (NHIS) is helping pregnant women in accessing health services in Ghana.

METHODS

Data for the study were obtained from the women's file of the 2014 Ghana Demographic and Health Survey. All women with birth history and aged 15-49  constituted our sample (n = 4271). We employed binary logistic regression analysis in investigating whether the NHIS was helping pregnant women in accessing health service. Statistical significance was set at <0.05.

RESULTS

Most women had subscribed to the NHIS [67.0%]. Of the subscribed women, 78.2% indicated that the NHIS is helping pregnant women in accessing healthcare. Women who had subscribed to the NHIS were more likely to report that it is helping pregnant women in accessing health service [aOR = 1.70, CI = 1.38-2.10]. We further noted that women who had at least four antenatal visits were more likely to indicate that NHIS is helping pregnant women in accessing health services [aOR = 3.01, CI = 2.20-4.14]. Women with secondary level of education [aOR= 1.42; CI: 1.04-1.92] and those in the richest wealth quintile [aOR = 3.51; CI = 1.94-6.34] had higher odds of indicating that NHIS is helping pregnant women in accessing healthcare. However, women aged 45-49 [aOR = 0.49; CI = 0.26-0.94], women in the Greater Accra [aOR = 0.29; CI = 0.16-0.53], Eastern [aOR = 0.12; CI = 0.07-0.21], Northern [aOR = 0.29; CI = 0.12-0.66] and Upper East [aOR = 0.17; CI = 0.09-0.31] regions had lower odds of reporting that NHIS is helping pregnant women in accessing health services.

CONCLUSION

To enhance positive perception towards the use of health services among pregnant women, non-subscribers need to be encouraged to enrol on the NHIS. Together with non-governmental organizations dedicated to maternal and child health issues, the Ghana Health Service's Maternal and Child Health Unit could strengthen efforts to educate pregnant women on the importance of NHIS in maternity care.

The Impact of Ghana's National Health Insurance on Psychological Distress

BACKGROUND

Poor mental health is among the growing number of noncommunicable diseases in low- and middle-income countries. Despite poor mental health accounting for an already considerable and growing burden of disease in many low- and middle-income countries, policy action to confront the challenge has been limited, at both international and national levels. Recently, several low- and middle-income countries have embarked on the journey toward universal health coverage by expanding their public health insurance provision, with the ultimate objective of improving population health, in addition to other health system objectives. Mental health interventions typically may not have been specifically covered in the publicly funded benefit package, and this raises the question of whether, and if so, by how much, the expansion of public health insurance may have directly or indirectly contributed to improved mental health.

OBJECTIVE

We assessed the impact of Ghana's implementation of national health insurance on psychological distress.

METHODS

Our study used the first wave of the 2009-2010 Ghana Social Economic Panel survey, including 10,007 respondents. We employed instrumental variable and propensity score matching methods to estimate the causal impact of health insurance on psychological distress, measured by the Kessler Psychological Distress Scale (K10). Higher K10 values indicate greater psychological distress.

RESULTS

The median K10 score in Ghana was 16 (P < 0.001), with a minimum of 10 (P < 0.001) and a maximum of 45 (P < 0.001). The results from the instrumental variable estimations, without matching, indicated that the K10 score for the insured was 11.8% lower (P < 0.001) than that of the uninsured. After running the instrumental variable regression on the matched sample, the K10 score for the insured was 10.6% (P < 0.001) lower than that of the uninsured. Similarly, the estimates based on propensity score matching indicated that the insured had a lower K10 score (- 0.023; P < 0.05). Furthermore, the beneficial impact of health insurance on psychological distress is larger for wealthier than poorer insurance members and varies across regions in Ghana. The findings were robust to the various estimation methods.

CONCLUSION

This study suggests that having health insurance is associated with reduced psychological distress and hence improved mental health, even though mental illness treatment or prevention were at best only partially covered by the National Health Insurance Scheme in Ghana.

Factors Associated with Enrolment of Households in Nepal's National Health Insurance Program

BACKGROUND

Nepal has made remarkable efforts towards social health protection over the past several years. In 2016, the Government of Nepal introduced a National Health Insurance Program (NHIP) with an aim to ensure equitable and universal access to healthcare by all Nepalese citizens. Following the first year of operation, the scheme has covered 5 percent of its target population. There are wider concerns regarding the capacity of NHIP to achieve adequate population coverage and remain viable. In this context, this study aimed to identify the factors associated with enrolment of households in the NHIP.

METHODS

A cross-sectional household survey using face to face interview was carried out in 2 Palikas (municipalities) of Ilam district. 570 households were studied by recruiting equal number of NHIP enrolled and non-enrolled households. We used Pearson's chi-square test and binary logistic regression to identify the factors associated with household's enrolment in NHIP. All statistical analyses were performed using IBM SPSS version 23 software.

RESULTS

Enrolment of households in NHIP was found to be associated with ethnicity, socio-economic status, past experience of acute illness in family and presence of chronic illness. The households that belonged to higher socio-economic status were about 4 times more likely to enrol in the scheme. It was also observed that households from privileged ethnic groups such as Brahmin, Chhetri, Gurung, and Newar were 1.7 times more likely to enrol in NHIP compared to those from underprivileged ethnic groups such as janajatis (indigenous people) and dalits (the oppressed). The households with illness experience in 3 months preceding the survey were about 1.5 times more likely to enrol in NHIP compared to households that did not have such experience. Similarly, households in which at least one of the members was chronically ill were 1.8 times more likely to enrol compared to households with no chronic illness.

CONCLUSION

Belonging to the privileged ethnic group, having a higher socio-economic status, experiencing an acute illness and presence of chronically ill member in the family are the factors associated with enrolment of households in NHIP. This study revealed gaps in enrolment between rich-poor households and privileged-underprivileged ethnic groups. Extension of health insurance coverage to poor and marginalized households is therefore needed to increase equity and accelerate the pace towards achieving universal health coverage.

Examining equity in health insurance coverage: an analysis of Ghana's National Health Insurance Scheme

Background

Following years of out-of-pocket payment for healthcare, some countries in Africa including Ghana, Kenya and Rwanda have instituted social health protection programs through health insurance to provide access to quality and affordable healthcare especially for the poor. This paper examines equity in coverage under Ghana’s National Health Insurance Scheme (NHIS).

Methods

Secondary data from the 2008 Ghana Demographic and Health Survey based on an analytical sample of 4821 females (15–49 years) and 4568 males (15–59 years) were analysed using descriptive, bivariate and multivariate methods. Concentration curves and indices were used to examine equity in coverage on the NHIS.

Results

As at 2008, more than 60% of Ghanaians aged 15–59 years were not covered under the NHIS with slightly more females (38.9%) than males (29.7%) covered. Coverage was highest among the highly educated, professionals, those from households in the richest wealth quintile and urban residents. Lack of coverage was most concentrated among the poor.

Conclusions

Universal coverage under the NHIS is far from being achieved with marked exclusion of the poor. There is the need for deliberate action to enrol the poor under the NHIS.

Social health insurance in Nepal: A health system departure toward the universal health coverage

The World Health Organization has identified universal health coverage (UHC) as a key approach in reducing equity gaps in a country, and the social health insurance (SHI) has been recommended as an important strategy toward it. This article aims to analyze the design, expected benefits and challenges of realizing the goals of UHC through the recently launched SHI in Nepal. On top of the earlier free health-care policy and several other vertical schemes, the SHI scheme was implemented in 2016 and has reached population coverage of 5% in the implemented districts in just within a year of implementation. However, to achieve UHC in Nepal, in addition to operationalizing the scheme, several other requirements must be dealt simultaneously such as efficient health-care delivery system, adequate human resources for health, a strong information system, improved transparency and accountability, and a balanced mix of the preventive, health promotion, curative, and rehabilitative services including actions to address the social determinants of health. The article notes that strong political commitment and persistent efforts are the key lessons learnt from countries achieving progressive UHC through SHI.

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.

Utilization of healthcare services and renewal of health insurance membership: evidence of adverse selection in Ghana

BACKGROUND

Utilization of healthcare in Ghana's novel National Health Insurance Scheme (NHIS) has been increasing since inception with associated high claims bill which threatens the scheme's financial sustainability. This paper investigates the presence of adverse selection by assessing the effect of healthcare utilization and frequency of use on NHIS renewal.

METHOD

Routine enrolment and utilization data from 2008 to 2013 in two regions in Ghana was analyzed. Pearson Chi-square test was performed to test if the proportion of insured who utilize healthcare in a particular year and renew membership the following year is significantly different from those who utilize healthcare and drop-out. Logistic regressions were estimated to examine the relationship between healthcare utilization and frequency of use in previous year and NHIS renewal in current year.

RESULTS

We found evidence suggestive of the presence of adverse selection in the NHIS. Majority of insured who utilized healthcare renewed their membership whiles most of those who did not utilize healthcare dropped out. The likelihood of renewal was significantly higher for those who utilize healthcare than those who did not and also higher for those who make more health facility visits.

CONCLUSION

The NHIS claims bill is high because high risk individuals who self-select into the scheme makes more health facility visits and creates financial sustainability problems. Policy makers should adopt pragmatic ways of enforcing mandatory enrolment so that low risk individuals remain enrolled; and sustainable ways of increasing revenue whiles ensuring that the societal objectives of the scheme are not compromised.