National health insurance coverage and socio-economic status in a rural district of Ghana

Health insurance coverage among women of reproductive age in rural Ghana: policy and equity implications

BACKGROUND

Globally, health insurance has been identified as a key component of healthcare financing. The implementation of health insurance policies in low and middle-income countries has led to a significant increase in access to healthcare services in these countries. This study assessed health insurance coverage and its associated factors among women of reproductive age living in rural Ghana.

METHODS

This study used a nationally representative data from the 2017/2018 Ghana Multiple Indicator Cluster Survey (GMICS) and included 7340 rural women aged 15-49 years. Bivariate and multivariable logistic regression models were developed to assess the association between the explanatory and the outcome variable. Statistical significance was considered at p = 0.05.

RESULTS

The overall prevalence of health insurance coverage among rural women in Ghana was 51.9%. Women with secondary (aOR = 1.72, 95% CI: 1.38-2.14) and higher education (aOR = 4.57, 95% CI: 2.66-7.84) were more likely to have health insurance coverage than those who had no formal education. Women who frequently listened to radio (aOR = 1.146, 95% CI: 1.01-1.30) were more likely to have health insurance coverage than those who did not. Women who had a child (aOR = 1.81, 95% CI: 1.50-2.17), two children (aOR = 1.59, 95% CI: 1.27-1.98), three children (aOR = 1.41, 95% CI: 1.10-1.80), and five children (aOR = 1.36, 95% CI: 1.03-1.79) were more likely to have health insurance coverage than those who had not given birth. Women who were pregnant (aOR = 3.52, 95% CI: 2.83-4.38) at the time of the survey, and women within the richest households (aOR = 3.89, 95% CI: 2.97-5.10) were more likely to have health insurance coverage compared to their other counterparts. Women in the Volta region (aOR = 1.36, 95% CI: 1.02-1.81), Brong Ahafo region (aOR = 2.82, 95% CI: 2.20-3.60), Northern region (aOR = 1.32, 95% CI: 1.02-1.70), Upper East region (aOR = 2.13, 95% CI: 1.63-2.80) and Upper West region (aOR = 1.56, 95% CI: 1.20-2.03) were more likely to have health insurance coverage than those in the Western region.

CONCLUSION

Although more than half of women were covered by health insurance, a significant percentage of them were uninsured, highlighting the need for prompt policy actions to improve coverage levels for insurance. It was found that educational level, listening to radio, parity, pregnancy status, wealth quintile, and region of residence were factors associated with health insurance coverage. We recommend better targeting and prioritization of vulnerability in rural areas and initiate policies that improve literacy and community participation for insurance programs. Further studies to establish health policy measures and context specific barriers using experimental designs for health insurance enrolments are required.

Towards achievement of Sustainable Development Goal 3: multilevel analyses of demographic and health survey data on health insurance coverage and maternal healthcare utilisation in sub-Saharan Africa

BACKGROUND

Improving maternal health and achieving universal health coverage (UHC) are important expectations in the global Sustainable Development Goals (SDGs) agenda. While health insurance has been shown as effective in the utilisation of maternal healthcare, there is a paucity of literature on this relationship in sub-Saharan Africa (SSA). We examined the relationship between health insurance coverage and maternal healthcare utilisation using demographic and health survey data.

METHODS

This was a cross-sectional study of 195 651 women aged 15-49 y from 28 countries in SSA. We adopted bivariable and multivariable analyses comprising χ2 test and multilevel binary logistic regression in analysing the data.

RESULTS

The prevalence of maternal healthcare utilisation was 58, 70.6 and 40.7% for antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC), respectively. The prevalence of health insurance coverage was 6.4%. Women covered by health insurance were more likely to utilise ANC (adjusted OR [aOR]=1.48, 95% CI 1.41 to 1.54), SBA (aOR=1.37, 95% CI 1.30 to 1.45) and PNC (aOR=1.42, 95% CI 1.37 to 1.48).

CONCLUSION

Health insurance coverage was an important predictor of maternal healthcare utilisation in our study. To accelerate progress towards the achievement of SDG 3 targets related to the reduction of maternal mortality and achievement of UHC, countries should adopt interventions to increase maternal insurance coverage, which may lead to higher maternal healthcare access and utilisation during pregnancy.

Factors Associated with National Health Insurance Coverage in Indonesia

Background: The National Health Insurance (NHI) program is the Indonesian government's national health program. However, health insurance coverage has not been maximized. This study aims to analyze the factors associated with health insurance coverage in Indonesia.   Methods: Retrospective cross-sectional data were obtained from the Indonesian Demographic and Health Survey 2017. A total of 39,580 respondents were selected using two-stage stratified cluster sampling. The data come from the DHS Questionnaire Phase 7. In this study, we explored age, education level, wealth quintiles, residence, the number of children who are alive, marital status, current employment status, earnings, and health insurance status in relation to health insurance coverage. Then, we analyzed the data using chi-squared and binary logistic analyses.   Results: The prevalence of health insurance coverage in the Indonesian population is 62.3%. Respondent aged 15-24 years [AOR=0.88; 95% CI=0.77-1.00], secondary education level [AOR=0.44; 95% CI=0.41-0.47], poorer wealth index [AOR=0.76; 95% CI=0.71-0.82], live in rural area [AOR=0.78; 95% CI=0.75-0.82], divorced [AOR=0.72; 95% CI=0.63-0.83] were less likelihood to have health insurance. Conversely, the respondent who received earnings [AOR=1.25; 95% CI=1.18-1.32] was more likely to have health insurance.  Conclusion: This finding pointed to education level, economic status, and demographic area such as respondents who lived in rural areas should more pay attention to NHI. Intervention through the provision of appropriate information about NHI should be promoted.

An integrative review on individual determinants of enrolment in National Health Insurance Scheme among older adults in Ghana

BACKGROUND

We conducted an integrative review in an attempt to methodically and systematically understand the individual (personal factors) that influence National Health Insurance Scheme [NHIS] enrolment among older adults aged 50 years and above. The study was premised on evidence pointing to a state of little or no change in the enrolment rates [especially among older adults], which contrasts with the initial euphoria that greeted the launch of the scheme - which culminated in high enrolment rates.

METHODS

The integrative literature review was conducted to synthesise the available evidence on individual determinants of NHIS among older adults. The methodological approach of the integrative literature review follows a five-stage interdependent and interconnected procedure of problem identification, literature search, data evaluation, data analysis and results presentation. Studies that met the inclusion criteria were peer-reviewed articles published in the English Language, from January 2010 to July 2020 and have Ghana as its setting or study area. The Andersen's Behavioural Model was used to categorize the predictor variables.

RESULTS

Predisposing factors [gender, age, level of education and marital status], enabling factors [income] and need factors [health conditions or health attributes of older adults] were identified as individual predictors of NHIS enrolment among older adults. The findings support argument of Andersen's Behavioural Model [where predisposing, enabling and need factors are considered as individual determinants of health behaviour].

CONCLUSIONS

The findings call for policy reforms that take into account the aforementioned individual predictors of NHIS enrolment, especially among the aged.

Pooled coverage of community based health insurance scheme enrolment in Ethiopia, systematic review and meta-analysis, 2016-2020

BACKGROUND

Community Based Health Insurance (CBHI) is a type of health insurance program that provides financial protection against the cost of illness and improving access to health care services for communities engaged in the informal sector. In Ethiopia, the coverage of CBHI enrolment varies across regions and decision of household enrolment is affected by different factors. There are pocket studies on CBHI scheme with different coverage in Ethiopia and there is no pooled study on CBHI enrolment coverage in Ethiopia for better understanding the scheme and decision making. The aim of this systematic review and meta-analysis was to identify the pooled coverage of CBHI enrolment in Ethiopia to understand its policy implications.

METHODS

The systematic review and meta-analysis was done by adhering the PRISMA guideline with exhaustive search in PubMed/Medline, HINARI, SCOPUS and Google scholar complemented by manual search. Two authors independently selected studies, extracted data, and assessed quality of studies. The I2 test statistic was used to test heterogeneity among studies. The overall coverage of CBHI scheme was estimated by using random-effects model.

RESULT

Among 269 identified, 17 studies were included in this meta-analysis and the overall coverage of CBHI scheme was 45% (95% CI 35%, 55%) in Ethiopia. The sub-group analysis shows higher enrolment rate 55.97 (95%CI: 41.68, 69.77) in earlier (2016-2017) studies than recent 37.33 (95%CI: 24.82, 50.77) studies (2018-2020).

CONCLUSION

The pooled coverage of CBHI enrolment is low in Ethiopia compared the national target of 80% set for 2020. It is also concentrated in only major regions of the country. The finding of the study helps national decision making for CBHI scheme service improvement. Due attention to be given to improving geographic expansion of CBHI and to the declining coverages with in the CBHI implementing regions by addressing the main bottlenecks restraining coverages.

TRIAL REGISTRATION

The protocol of this systematic review and meta-analysis was published in PROSPERO with registration number: CRD42021252762 .

Equity in health insurance schemes enrollment in low and middle-income countries: A systematic review and meta-analysis

Background

Ensuring access to essential quality health services and reducing financial hardship for all individuals regardless of their ability to pay are the main goals of universal health coverage. Various health insurance schemes have been recently implemented in low- and middle-income countries (LMICs) to achieve both of these objectives. We systematically reviewed all available literature to assess the extent to which current health insurance schemes truly reach the poor and underserved populations in LMICs.

Methods

In the systematic review, we searched on PubMed, Web of Science, EconLit and Google Scholar to identify eligible studies which captured health insurance enrollment information in LMICs from 2010 up to September 2019. Two authors independently selected studies, extracted data, and appraised included studies. The primary outcome of interest was health insurance enrollment of the most vulnerable populations relative to enrollment of the best-off subgroups. We classified households both with respect to their highest educational attainment and their relative wealth and used random-effects meta-analysis to estimate average enrollment gaps.

Results

48 studies from 17 countries met the inclusion criteria. The average enrollment rate into health insurance schemes for vulnerable populations was 36% with an inter-quartile range of 26%. On average, across countries, households from the wealthiest subgroup had 61% higher odds (95% CI: 1.49 to 1.73) of insurance enrollment than households in the poorest group in the same country. Similarly, the most educated groups had 64% (95% CI: 1.32 to 1.95) higher odds of enrollment than the least educated groups.

Conclusion

The results of this study show that despite major efforts by governments, health insurance schemes in low-and middle-income countries are generally not reaching the targeted underserved populations and predominantly supporting better-off population groups. Current health insurance designs should be carefully scrutinized, and the extent to which health insurance can be used to support the most vulnerable populations carefully re-assessed by countries, which are aiming to use health insurance schemes as means to reach their UHC goals. Furthermore, studies exploring best practices to include vulnerable groups in health insurance schemes are needed.

Registration

Not available

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01608-x.

Mixed effects analysis of factors associated with health insurance coverage among women in sub-Saharan Africa

INTRODUCTION

In the pursuit of achieving the Sustainable Development Goal targets of universal health coverage and reducing maternal mortality, many countries in sub-Saharan Africa have implemented health insurance policies over the last two decades. Given that there is a paucity of empirical literature at the sub-regional level, we examined the prevalence and factors associated with health insurance coverage among women in in sub-Saharan Africa.

MATERIALS AND METHODS

We analysed cross-sectional data of 307,611 reproductive-aged women from the most recent demographic and health surveys of 24 sub-Saharan African countries. Bivariable and multivariable analyses were performed using chi-square test of independence and multi-level logistic regression respectively. Results are presented as adjusted Odds Ratios (aOR) for the multilevel logistic regression analysis. Statistical significance was set at p<0.05.

RESULTS

The overall coverage of health insurance was 8.5%, with cross-country variations. The lowest coverage was recorded in Chad (0.9%) and the highest in Ghana (62.4%). Individual-level factors significantly associated with health insurance coverage included age, place of residence, level of formal education, frequency of reading newspaper/magazine and watching television. Wealth status and place of residence were the contextual factors significantly associated with health insurance coverage. Women with no formal education were 78% less likely to be covered by health insurance (aOR = 0.22, 95% CI = 0.21-0.24), compared with those who had higher education. Urban women, however, had higher odds of being covered by health insurance, compared with those in the rural areas [aOR = 1.20, 95%CI = 1.15-1.25].

CONCLUSION

We found an overall relatively low prevalence of health insurance coverage among women of reproductive age in sub-Saharan Africa. As sub-Saharan African countries work toward achieving the Sustainable Development Goal targets of universal health coverage and lowering maternal mortality to less than 70 deaths per 100,000 live births, it is important that countries with low coverage of health insurance among women of reproductive age integrate measures such as free maternal healthcare into their respective development plans. Interventions aimed at expanding health insurance coverage should be directed at younger women of reproductive age, rural women, and women who do not read newspapers/magazines or watch television.

Food Insecurity and Micronutrient Status among Ghanaian Women Planning to Become Pregnant

We examined the association between food insecurity (FIS) and micronutrient status among Ghanaian women planning to become pregnant. A cross-sectional analysis was completed of 95 women aged 18-35 years, living in the Upper Manya Krobo District in the Eastern Region of Ghana. Questionnaires were administered to collect sociodemographic and food security data; weight and height were measured. Blood was drawn from an antecubital vein; one drop was used to assess hemoglobin via Hemocue. Zinc and copper were analyzed using flame atomic spectrophotometry while iron biomarkers, retinol and 25-hydroxyvitamin D were analyzed using ELISA, ultra-performance liquid chromatography and liquid chromatography-tandem mass spectrometry, respectively. Logistic regression models were used to determine the relationship between food insecurity (FIS) and micronutrient deficiencies. FIS was reported among 23% of the households, while micronutrient deficiencies ranged from 7-28% irrespective of FIS status. Retinol concentrations were negatively associated with FIS (p = 0.043) after controlling for covariates, although levels were within the normal range in both groups. No statistically significant associations between FIS and micronutrient deficiencies were found. Among those with FIS, 59% were deficient in at least one nutrient with 18% deficient in two nutrients. Unmarried women were at higher risk of FIS (p = 0.017) than married women. FIS was associated with retinol concentrations but not other micronutrient biomarkers in Ghanaian women expecting to become pregnant in the next 6 months.

Understanding unmet health-care need among older Ghanaians: a gendered analysis

Health insurance schemes are important for bridging gaps in health-care needs between the rich and poor, especially in contexts where poverty is higher among seniors (persons aged 65 years and above). In this study we examined (a) gender-based predictors of unmet health-care need among seniors and (b) whether access was influenced by wealth status (measured by income quintiles). Gender-specific negative log–log regression models were fitted to data from the Study on Global Ageing and Health to examine associations between unmet health-care need and health insurance status controlling for theoretically relevant covariates. Insurance status was an important determinant of men and women's unmet health-care need but the relationship was moderated by income quintile for women and not men. While occupation was important for men, religion, marital status and income quintile were significantly associated with women's unmet health-care need. Based on the observed gender differences, we recommend the implementation of programmes aimed at improving the economic situation of older people, particularly women.

Persistence of the inverse care law in maternal health service utilization: An examination of antenatal care and hospital delivery in Ghana

The gap in maternal health outcomes, access and utilization between the haves and have-nots continues to be a challenge globally despite improvements over the past decade. Though Ghana has experienced steady gains in maternal health access and utilization over the years, maternal outcomes, on the other hand, remain poor. In this regard, it is essential to know how various groups in the population achieved improvements and whether some women continue to be disproportionately disadvantaged. The paper performs an analysis of cross-sectional data from the 2017 Ghana maternal health survey to examine the existence of the inverse care law in maternal health services in Ghana. Using descriptive techniques and multivariate logistic regression models the study reveals a pro-rich and pro-urban gradient in the use of hospital facilities for delivery and antenatal care attendance — also, regions known for their high levels of poverty feature significantly lower rates of hospital deliveries. The paper concludes by stressing that unless policies are changed to accommodate these groups, overall gains in maternal health will continue to be incremental.

The state of enrollment on the National Health Insurance Scheme in rural Ghana after eight years of implementation

Background

In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations.

Methods

A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES.

Results

Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme.

Conclusions

Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.

Health insurance coverage, type of payment for health insurance, and reasons for not being insured under the National Health Insurance Scheme in Ghana

BACKGROUND

Ghana's National Health Insurance Scheme has improved access to care, although equity and sustainability issues remain. This study examined health insurance coverage, type of payment for health insurance and reasons for being uninsured under the National Health Insurance Scheme in Ghana.

METHODS

The 2014 Ghana Demographic Health Survey datasets with information for 9396 women and 3855 men were analyzed. The study employed cross-sectional national representative data. The frequency distribution of socio-demographics and health insurance coverage differentials among men and women is first presented. Further statistical analysis applies a two-stage probit Hackman selection model to determine socio-demographic factors associated with type of payment for insurance and reasons for not insured among men and women under the National Health insurance Scheme in Ghana. The selection equation in the Hackman selection model also shows the association between insurance status and socio-demographic factors.

RESULTS

About 66.0% of women and 52.6% of men were covered by health insurance. Wealth status determined insurance status, with poorest, poorer and middle-income groups being less likely to pay themselves for insurance. Women never in union and widowed women were less likely to be covered relative to married women although this group was more likely to pay NHIS premiums themselves. Wealth status (poorest, poorer and middle-income) was associated with non-affordability as a reason for being not insured. Geographic disparities were also found. Rural men and nulliparous women were also more likely to mention no need of insurance as a reason of being uninsured.

CONCLUSION

Tailored policies to reduce delays in membership enrolment, improve positive perceptions and awareness of National Health Insurance Scheme in reducing catastrophic spending and addressing financial barriers for enrolment among some groups can be positive precursors to improve trust and enrolments and address broad equity concerns regarding the National Health Insurance Scheme.

Determinants of health insurance enrolment in Ghana: evidence from three national household surveys

In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) to move towards Universal Health Coverage. NHIS enrolment is mandatory for all Ghanaians, but the most recent estimates show that coverage stands under 40%. The evidence on the relationship between socio-economic characteristics and NHIS enrolment is mixed, and comes mainly from studies conducted in a few areas. Therefore, in this study we investigate the socio-economic determinants of NHIS enrolment using three recent national household surveys. We used data from the Ghanaian Demographic and Health Survey conducted in 2014, the Multiple Indicator Cluster Survey conducted in 2011 and the sixth wave of the Ghana Living Standard Survey conducted in 2012-13. Given the multilevel nature of the three databases, we use multilevel logistic regression models to estimate the probability of enrolment for women and men separately. We used three levels of analysis: geographical clusters, household and individual units. We found that education, wealth, marital status-and to some extent-age were positively associated with enrolment. Furthermore, we found that enrolment was correlated with the type of occupation. The analyses of three national household surveys highlight the challenges of understanding the complex dynamics of factors contributing to low NHIS enrolment rates. The results indicate that current policies aimed at identifying and subsidizing underprivileged population groups might insufficiently encourage health insurance enrolment.

Ghana's Journey towards Universal Health Coverage: The Role of the National Health Insurance Scheme

Background: the main aim of the study is to find if the National Health Insurance Scheme (NHIS) in Ghana is achieving universal health coverage (UHC) or not. The study gives the trajectories of health policies in Ghana and their implications on long term health financing. NHIS in Ghana was implemented in 2004, with the aim of increasing subscribers’ access to health care services and reduce financial barriers to health care. On equity access to healthcare, it addresses two core concerns: (1) enrolling particular groups (persons exempted from annual premium payments) and (2) achieving UHC for all citizens and persons with legal residence. It utilizes a multifactor approach to the conceptualization of UHC. The research question: Is Ghana’s NHIS on course to deliver or achieve universal health coverage? Methods: we used qualitative methods. In doing so, the study engaged participants in in-depth interviews, focus group discussions and direct observations of participants in their natural settings, like hospitals, clinics, offices and homes, with purposive and snowball techniques. This data triangulation approach aims to increase the reliability and validity of findings. Results: the empirical evidence shows NHIS performed relatively well in enrolling more exempt groups (particular groups) than enrolling all persons in Ghana (UHC). The biggest challenge for the implementation of NHIS from the perspectives of health insurance officials is inadequate funding. The health insurance beneficiaries complained of delays during registrations and renewals. They also complained of poor attitude of some health insurance officials and health workers at facilities. Conclusions: both health insurance officials and beneficiaries emphasized the need for increased public education and for implementers to adopt a friendly attitude towards clients. To move towards achieving UHC, there is a need to redesign the policy, to move it from current voluntary contributions, to adopt a broad tax-based approach to cover all citizens and persons with legal residence in Ghana. Also, to adopt a flexible premium payment system (specifically ‘payments by installation’ or ‘part payments’) and widen the scope of exempt groups as a way of enrolling more into the NHIS.

Health insurance enrolment in the Upper West Region of Ghana: Does food security matter?

Toward achieving universal health coverage, Ghana's national health insurance has been acclaimed as a pro-poor scheme, yet been criticized for leaving the poor behind. Arising from this is how poverty has been operationalized and how poor people are targeted for enrolment into the scheme. We examine the role of food insecurity (not currently considered) as a multidimensional vulnerability concept on enrolment into Ghana's health insurance using binary logistics regression on cross-sectional survey of household heads (n = 1438) in the Upper West Region of Ghana. Our analyses show that heads of severely food-insecure households were significantly less likely to enroll in national health insurance scheme (NHIS) relative to households who reported being food-secure (OR = 0.36, P < .05). We also found education, occupation, and religion as significant predictors of health insurance enrolment. Based on our findings, it is crucial to incorporate food security status in the identification of vulnerable people for free enrolment in Ghana's health insurance.

Women's overall satisfaction with health facility delivery services in Ghana: a mixed-methods study

Background

Skilled birth delivery has increased up to nearly 74% in Ghana, but its quality has been questioned over the years. As understanding women's satisfaction could be important to improving service quality, this study aimed to determine what factors were associated with women's overall satisfaction with delivery services quantitatively and qualitatively in rural Ghanaian health facilities.

Results

This cross-sectional, mixed methods study used an explanatory sequential design across three Ghana Health Service research areas in 2013. Participants were women who had delivered in the preceding 2 years. Two-stage random sampling was used to recruit women for the quantitative survey. Relationships between women's socio-demographic characteristics and their overall satisfaction with health facility delivery services were examined using univariate and multiple logistic regression analyses. For qualitative analyses, women who completed the quantitative survey were purposively selected to participate in focus group discussions. Data from the focus group discussions were analyzed based on predefined and emerging themes. Overall, 1130 women were included in the quantitative analyses and 136 women participated in 15 focus group discussions. Women's mean age was 29 years. Nearly all women (94%) were satisfied with the overall services received during delivery. Women with middle level/junior high school education [adjusted odds ratio (AOR) = 0.50, 95% confidence interval (CI) = (0.26-0.98)] were less likely to be satisfied with overall delivery services compared to women with no education. Qualitatively, women were not satisfied with the unconventional demands, negative attitude, and unavailability of healthcare workers, as well as the long wait time.

Conclusions

Although most women were satisfied with the overall service they received during delivery, they were not satisfied with specific aspects of the health services; therefore, higher quality service delivery is necessary to improve women's satisfaction. Additional sensitivity training and a reduction in work hours may also improve the experience of clients.

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study

BACKGROUND

Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers' ability to serve poorer patient populations with quality health services?

METHODS

In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials' experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically.

RESULTS

Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers' abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.

CONCLUSIONS

Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study

Background

Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers’ ability to serve poorer patient populations with quality health services?

Methods

In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials’ experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically.

Results

Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers’ abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.

Conclusions

Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.

Hypertension prevalence, awareness, treatment and control in Ghanaian population: Evidence from the Ghana demographic and health survey

Hypertension is a major cause of cardiovascular disease morbidity and mortality in Ghana. This study examines the prevalence, awareness, treatment and control of hypertension among Ghanaian aged 15–49 years. This cross-sectional study retrieved data from the 2014 Ghana Demographic and Health Survey (GDHS). The sample, comprising of 13,247 respondents aged 15–49 years, was analysed using descriptive statistics, Chi-Square tests, independent sample t-tests and binary logistic regressions. The overall prevalence of hypertension was 13.0% (12.1% for males and 13.4% for females). Among respondents who had hypertension, 45.6% were aware of their hypertension status; 40.5% were treating the condition while 23.8% had their blood pressure controlled (BP <140/90 mmHg). Socio-economic and demographic factors, health insurance coverage and recent visit to health facilities played significant roles in hypertension prevalence and awareness. While region of residence and health facility visits were predictors of hypertension treatment, age and region of residence predicted hypertension control in this population. This study suggests that in order to address the increasing burden of hypertension in Ghana, there should be an expansion of the National Health Insurance Scheme and development of measures to reduce health inequities. Also, some of the determining factors such as age, gender, marital status are similar to other cultures; therefore, existing interventions from those cultures could be adapted in addressing hypertension prevalence, awareness, treatment and control in Ghana.

Predictors of Enrolment in the National Health Insurance Scheme Among Women of Reproductive Age in Nigeria

Background: Despite the implementation of the National Health Insurance Scheme (NHIS) since 2005 in Nigeria, the level of health insurance coverage remains low. The study aims to examine the predictors of enrolment in the NHIS among women of reproductive age in Nigeria.

Methods: Secondary data from the 2013 Nigeria Demographic and Health Survey (NDHS) were utilized to examine factors influencing enrolment in the NHIS among women of reproductive age (n=38 948) in Nigeria. Demographic and socio-economic characteristics of women were determined using univariate, bivariate and multivariate analyses. Data analysis was performed using STATA version 12 software.

Results: We found that 97.9% of women were not covered by health insurance. Multivariate analysis indicated that factors such as age, education, geo-political zone, socio-economic status (SES), and employment status were significant predictors of enrolment in the NHIS among women of reproductive age.

Conclusion: This study concludes that health insurance coverage among women of reproductive age in Nigeria is very low. Additionally, demographic and socio-economic factors were associated with enrolment in the NHIS among women. Therefore, policy-makers need to establish a tax-based health financing mechanism targeted at women who are young, uneducated, from poorest households, unemployed and working in the informal sector of the economy. Extending health insurance coverage to women from poor households and those who work in the informal sector through a tax-financed non-contributory health insurance scheme would accelerate progress towards universal health coverage (UHC).

Uptake of health insurance by the rural poor in Ghana: determinants and implications for policy

Introduction

Financing access to healthcare services in developing countries remains a major challenge despite recent advances towards implementation of various health insurance policies in many low and middle-income countries. The use of health insurance is considered an important means to achieve universal health coverage. However, uptake of health insurance in most developing countries remains low as a result of several challenges. Empirical evidence of factors restraining enrolment is rare in many developing countries including Ghana. This paper therefore sought to investigate the factors associated with the uptake of health insurance products and the implications thereof for policy, using Awutu Senya West District of Ghana as case study.

Methods

A logit model was used to analyze data from 178 respondents randomly selected from two microfinance groups operating in the study area.

Results

The results indicate that insurance uptake is higher among younger people, but lower among women. Older women are however more likely to take up health insurance compared to older men. In addition, the study reveals that insurance uptake increases with level of education but decreases with household size.

Conclusion

The study concludes that even though the premium on health insurance coverage in Ghana is arguably low, socio-demographic characteristics such as age, sex, literacy level and household size affect the decision to enroll. Adequate public sensitization on the benefits of the scheme and decreasing the statutory age for exemption from premium payment, especially in rural localities, are some of the measures suggested to enhance health insurance uptake in Ghana and other developing countries.

Effect of informal financial support for health care on health Insurance uptake: Evidence from a mixed-methods study in Tamale metropolis of northern Ghana

Attempts to study the determinants of health insurance enrollment in resource-poor settings have often given less consideration to the potential influence of informal risk-sharing systems on individuals and households' decisions about health insurance. This paper contributes to existing discussions in this area by examining the effect of informal financial support for health care, an example of informal risk-sharing arrangement, on enrollment in the Ghana National Health Insurance Scheme (NHIS). It is based on a mixed-methods research in Tamale metropolis of northern Ghana. The study found widespread availability and reliance on informal support among low-income households to finance out-of-pocket health-care expenditure. Informal financial support for enrollment into the NHIS was noted to be less available. The study further found less strong but suggestive evidence that the perceived availability of informal financial support for health care by individuals diminishes their enrollment in the NHIS. The paper emphasizes the need for theory and policy on health insurance uptake in resource-constrained settings to consider existing informal risk-sharing arrangements as much as other known determinants of enrollment.

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.

Differences in the determinants of health insurance enrolment among working-age adults in two regions in Ghana

Background

Ghana’s National Health Insurance Scheme (NHIS) has achieved varying levels of enrolment within the regions with different rural-urban populations with associated income inequalities. This study sought to investigate the differences in the determinants of enrolment between the Greater Accra (GAR) and Western (WR) regions of Ghana to inform the NHIS reforms.

Method

Data from 4214 adults, 18 years and above from a household survey conducted in the two regions was analyzed. Bivariate analysis (t-test for continuous and Pearson chi-square for categorical) was performed to examine differences in respondents characteristics (socio-economic and insurance enrolment) between the two regions for the total, urban and rural samples. Logistic regression estimation was performed to establish differences in determinant of enrolment between the regions.

Results

Age, sex, educational level, marital status, health status and travel time to nearest health facility were identified as determinants of enrolment in both regions and among the rural and urban residents within the regions. Although the rich and richest in both regions are more likely to enroll than the poor and poorest, the odds of enrolment for the urban richest in the WR is about twice that of GAR whiles the odds of enrolment for the rural richest in the GAR is also about twice that of the WR. Those who visit public facilities in the GAR are more likely to enroll than those in WR for the total and urban samples. However, those who visit private facilities in rural communities in both regions are more likely to enroll.

Conclusion

Differences in the NHIS enrolment between the regions is as a result of differences in socio-economic factors that are intrinsic in the regions and impact on the inhabitants’ ability to afford insurance premium. Policymakers should determine NHIS premium differently at the district level based on socio-economic activities and income levels within the districts.

Mundane? Demographic characteristics as predictors of enrolment onto the National Health Insurance Scheme in two districts of Ghana

Background

In 2003, Ghana passed a law to establish a National Health Insurance Scheme (NHIS) to serve as the main vehicle for achieving universal health coverage. Over 60% of the population had registered by 2009. Current active membership is however 40%. The stagnation in growth has been recorded across all the membership categories. Clearly, the Scheme is falling short of its core objective. This analysis is a critical thematic contextual examination of the effects of demographic factors on enrolment onto the Scheme.

Methods

Demographic secondary data for 625 respondents collected (using a structured questionnaire) during a cross-sectional household survey in an urban, Ashaiman, and rural, Adaklu, districts was analyzed in univariate and multivariate logistic regression models using Statistical Package for Social Scientists (SPSS). Statistical significance was set at P-value < 0.05. Variables included in the analysis were age, gender, education, occupation and knowledge about the NHIS.

Results

Seventy-nine percent of the survey respondents have ever enrolled onto the NHIS with three-fifths being females. Of the ever enrolled, 63% had valid cards. Age, gender and educational level were significant predictors of enrolment in the multivariate analysis. Respondents between the ages 41–60 years were twice (p = 0.05) more likely to be enrolled onto a district Scheme compared with respondents between the ages 21–40 years. Females were thrice (p = 0.00) more likely to enroll compared with males. Respondents educated to the tertiary, five times (p = 0.02), and post-graduate, four times (p = 0.05), levels were more likely to enroll compared with non-educated respondents. No significant association was observed between occupation and enrolment.

Conclusion

Uptake of the scheme is declining despite high awareness and knowledge. Leadership, innovation and collaboration are required at the district Scheme level to curtail issues of low self-enrolment and to grow membership. Otherwise, the goal of universal coverage under the NHIS will become merely a slogan and equity in financial access to health care for all Ghanaians will remain elusive.

Factors That Influence Enrolment and Retention in Ghana' National Health Insurance Scheme

Background: The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2004 with the goal of achieving universal coverage within 5 years. Evidence, however, shows that expanding NHIS coverage and especially retaining members have remained a challenge. A multilevel perspective was employed as a conceptual framework and methodological tool to examine why enrolment and retention in the NHIS remains low.

Methods: A household survey was conducted after 20 months educational and promotional activities aimed at improving enrolment and retention rates in 15 communities in the Central and Eastern Regions (ERs) of Ghana. Observation, indepth interviews and informal conversations were used to collect qualitative data. Forty key informants (community members, health providers and district health insurance schemes’ [DHISs] staff) purposely selected from two casestudy communities in the Central Region (CR) were interviewed. Several community members, health providers and DHISs’ staff were also engaged in informal conversations in the other five communities in the region. Also, four staff of the Ministry of Health (MoH), Ghana Health Service (GHS) and National Health Insurance Authority (NHIA) were engaged in in-depth interviews. Descriptive statistics was used to analyse quantitative data. Qualitative data was analysed using thematic content analysis.

Results: The results show that factors that influence enrolment and retention in the NHIS are multi-dimensional and cut across all stakeholders. People enrolled and renewed their membership because of NHIS’ benefits and health providers’ positive behaviour. Barriers to enrolment and retention included: poverty, traditional risk-sharing arrangements influence people to enrol or renew their membership only when they need healthcare, dissatisfaction about health providers’ behaviour and service delivery challenges.

Conclusion: Given the multi-dimensional nature of barriers to enrolment and retention, we suggest that the NHIA should engage DHISs, health providers and other stakeholders to develop and implement intervention activities to eliminate corruption, shortage of drugs in health facilities and enforce the compulsory enrolment stated in the NHIS policy to move the scheme towards universal coverage.

Porous safety net: catastrophic health expenditure and its determinants among insured households in Togo

BACKGROUND

In Togo, about half of health care costs are paid at the point of service, which reduces access to health care and exposes households to catastrophic health expenditure (CHE). To address this situation, the Togolese government introduced a National Health Insurance Scheme (NHIS) in 2011. This insurance currently covers only employees and retirees of the State as well as their dependents, although plans for extension exist. This study is the first attempt to examine the extent to which Togo's NHIS protects its members financially against the consequences of ill-health.

METHODS

Data was obtained from a cross-sectional representative households' survey involving 1180 insured households that had reported illness in the household in the 4 weeks preceding the survey or hospitalization in the 12 months preceding the survey. The incidence and intensity of CHE were measured by the catastrophic health payment method. A logistic regression was used to analyse determinants of CHE.

RESULTS

The results indicate that the proportion of insured households with CHE varies widely between 3.94% and 75.60%, depending on the method and the threshold used. At the 40% threshold, health care cost represents 60.95% of insured households' total monthly non-food expenditure. This study showed that the socioeconomic status, the type of health facility used, hospitalization and household size were the highest predictors of CHE. Whatever the chosen threshold, care in referral and district hospitals significantly increases the likelihood of CHE. In addition, the proportion of households facing CHE is higher in the lowest income groups. The behaviour of health care providers, poor quality of care and long waiting time were the main factors leading to CHE.

CONCLUSION

A sizable proportion of insured households face CHE, suggesting gaps in the coverage. To limit the impoverishment of insured households with low income, policies for free or heavily subsidized hospital services should be considered. The results call for an equitable health insurance scheme, which is affordable for all insured households.

Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya

Background

Incorporating private healthcare providers into social health insurance schemes is an important means towards achieving universal health coverage in low and middle income countries. However, little research has been conducted about why private providers choose to participate in social health insurance systems in such contexts, or their experiences with these systems. We explored private providers’ perceptions of and experiences with participation in two different social health insurance schemes in Sub-Saharan Africa—the National Health Insurance Scheme (NHIS) in Ghana and the National Hospital Insurance Fund (NHIF) in Kenya.

Methods

In-depth interviews were held with providers working at 79 facilities of varying sizes in three regions of Kenya (N = 52) and three regions of Ghana (N = 27). Most providers were members of a social franchise network. Interviews covered providers’ reasons for (non) enrollment in the health insurance system, their experiences with the accreditation process, and benefits and challenges with the system. Interviews were coded in Atlas.ti using an open coding approach and analyzed thematically.

Results

Most providers in Ghana were NHIS-accredited and perceived accreditation to be essential to their businesses, despite challenges they encountered due to long delays in claims reimbursement. In Kenya, fewer than half of providers were NHIF-accredited and several said that their clientele were not NHIF enrolled. Understanding of how the NHIF functioned was generally low. The lengthy and cumbersome accreditation process also emerged as a major barrier to providers’ participation in the NHIF in Kenya, but the NHIS accreditation process was not a major concern for providers in Ghana.

Conclusions

In expanding social health insurance, coordinated efforts are needed to increase coverage rates among underserved populations while also accrediting the private providers who serve those populations. Market pressure was a key force driving providers to gain and maintain accreditation in both countries. Developing mechanisms to engage private providers as stakeholders in social health insurance schemes is important to incentivizing their participation and addressing their concerns.

Migrant female head porters' enrolment in and utilisation and renewal of the National Health Insurance Scheme in Kumasi, Ghana

PURPOSE

As a social protection policy, Ghana's National Health Insurance Scheme (NHIS) aims to improve access to healthcare, especially for the vulnerable. Migrant female head porters (kayayoo), who are part of the informal economic workforce, are underscored as an ethnic minority and vulnerable group in Ghana. This study aimed to analyse the factors associated with enrolment in and renewal and utilisation of the NHIS among migrant female head porters in the Kumasi Metropolis.

METHOD

We purposively sampled 392 migrant female head porters in the Kejetia, Asafo and Bantama markets. We used a binary logit regression model to estimate associations among baseline characteristics, convenience and benefit factors and enrolment in and renewal and utilisation of the NHIS.

RESULT

Age and income significantly increased the probability of NHIS enrolment, renewal and utilisation. Long waiting times at NHIS offices significantly reduced the likelihood of renewal, while provision of drugs highly significantly increased the tendency for migrant female head porters to enrol in, renew and use the NHIS. Consulting and surgery also significantly increased renewal and utilisation of the NHIS.

CONCLUSION

Political commitment is imperative for effective implementation of the decentralisation policy of the NHIS through the National Health Insurance Authority in Kumasi. We argue that retail offices should be well equipped with logistic facilities to ensure convenience in NHIS initial enrolment and renewal processes by citizenry, and by vulnerable groups in particular.

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.

Oh, as for the Health Insurance…it’s good, but…: rural elders in Agate, Ghana, discuss the National Healthcare Insurance Scheme

This paper investigates the Ghanaian National Healthcare Insurance Scheme (NHIS) through interviews with 28 elders over 50 years old with pre-existing illnesses in Agate, a rural village in Ghana. Our goals were to obtain snapshot views of the lives, in relation to health, wellness, and NHIS, of participants. Elders possessed reasonable information about NHIS. For most enrollees, NHIS provided peace of mind against financially-related health challenges, however, inability to afford non-covered medicines sometimes interfered with treatment. Most interviewees, insured or not, reported continuing chronic health problems. Based on qualitative data, we describe possibilities to improve elder experiences including: transportation to medical care, increased drug coverage, and faith-based health partnerships.

A quantitative study on factors influencing enrolment of dairy farmers in a community health insurance scheme

BACKGROUND

Access to affordable and effective health care is a challenge in low- and middle- income countries. Out-of-pocket expenditure for health care is a major cause of impoverishment. One way to facilitate access and overcome catastrophic expenditure is through a health insurance mechanism, whereby risks are shared and financial inputs pooled by way of contributions. This study examined factors that influenced the enrolment status of dairy farmers in Western Kenya to a community health insurance (CHI) scheme.

METHODS

Quantitative, cross-sectional research was used to describe factors influencing the enrolment in the CHI scheme. Quota and convenience sampling was used, recruiting a sample of 135 farmers who supply milk to a dairy cooperation. Data were collected using a structured interview schedule and analysed using Stata SE, Data Analysis and Statistical Software, Version 12.

RESULTS

Factors influencing non-enrolment were identified as affordability (40%; n = 47), unfamiliarity with the management of the scheme (37%; n = 44) and a lack of understanding about the scheme (41%; n = 48). An exploratory factor analysis was used to reduce the variables to two factors: information provision and understanding community health insurance (CHI). Logistic regression identified factors associated with enrolment in the Tanykina Community Healthcare Plan (TCHP). Supplies of less than six litres of milk per day (OR: 0.22; 95% CI: 0.06-0.84) and information provision (OR: 8.77; 95% CI: 2.25-34.16) were significantly associated with enrolment in the TCHP. Nearly 30% (29.6%; n = 40) of the respondents remarked that TCHP is expensive and 17% (n = 23) asked for more education on CHI and TCHP in an open-ended question.

CONCLUSION

Recommendations related to marketing strategies, financial approach, information provision and further research were outlined to be made to the management of the TCHP as well as to those involved in public health.

Health insurance subscription among women in reproductive age in Ghana: do socio-demographics matter?

BACKGROUND

Premised that health insurance schemes in Africa have only been introduced recently and continue evolving, various concerns have been raised regarding their effectiveness in improving utilisation of orthodox health care and the reduction of out-of-pocket expenditures for their population, particularly women.

OBJECTIVE

To examine the effects of socio-demographics on health insurance subscription among women in Ghana.

METHODS

The study draws on the 2014 Ghana Demographic and Health Survey. Bivariate descriptive analysis and binary logistic regression were used to analyse the data.

RESULTS

Wealth status, age, religion, birth parity, marriage and ecological zone were found to have significantly predicted health insurance subscription among women in reproductive age in Ghana. Urban dwellers, women who are nulliparous, those with no or low levels of education, African traditionalists and the poor were those who largely did not subscribe to the scheme.

CONCLUSION

The findings underscore the need for the National Health Insurance Authority to carry out more education in association with the National Commission for Civic Education and the Information Services Department to recruit more urban dwellers, nulliparous women, those with no or low levels of education, African traditionalists and the poor unto the scheme.

"Perspectives on financing population-based health care towards Universal Health Coverage among employed individuals in Ghanzi district, Botswana: A qualitative study"

BACKGROUND

Globally, about 150 million people experience catastrophic healthcare expenditure services annually. Among low and middle income countries, out-of-pocket expenditure pushes about 100 million people into poverty annually. In Botswana, 83 % of the general population and 58 % of employed individuals do not have medical aid coverage. Moreover, inequity allocation of financial resources between health services suggests marginalization of population-based health care services (i.e. diseases prevention and health promotion). The purpose of the study is to explore perspectives on employed individuals regarding financing population based health care interventions towards Universal Health Coverage (UHC) in order to make recommendations to the Ministry of Health on health financing options to cover population-based health services.

METHODS

A qualitative design grounded in interpretivist epistemology through social constructivism lens was critical for exploring perspectives of employed individuals. Through purposive and snowballing sampling techniques, a total of 15 respondents including 8 males and 7 females were recruited and interviewed using a semi-structured format. Their age ranged from 23 to 59 years with a median of 36 years. Data was analyzed using Thematic Content Analysis technique.

RESULTS

Use of social constructivism lens enabled to classify emerging themes into population coverage, health services coverage and financial protection issues. Despite broad understanding of health coverage schemes among participants, knowledge appears insignificant in increasing enrolment. Participants indicated limited understanding of UHC concepts, however showed willingness to embrace UHC upon brief description. Main thematic issues raised include: exclusion of population-based health services from coverage scheme; disparity in financial protection and health services coverage among enrollees; inability to sustain contracted employees; and systematic exclusion of unemployed individuals and informal sector employees.

CONCLUSION

Increasing enrolment in health coverage schemes requires targeted campaign for information dissemination through use of myriads mass media including: social networks, TV, Radio and others. Moreover, re-designing health insurance schemes is critical in order to include population-based interventions; expand uptake of unemployed and informal sector employees; flexibility in monthly premiums payment plan and use of technology to increase access to payment points. Further study need to evaluate the content of health financing policy in Botswana measured against the World Health Organization Universal Health Coverage conceptual requirements for Low and Middle Income Countries.

Perception of quality of health delivery and health insurance subscription in Ghana

Background

National health insurance schemes (NHIS) in developing countries and perhaps in developed countries as well is a considered a pro-poor intervention by helping to bridge the financial burden of access to quality health care. Perceptions of quality of health service could have immense impacts on enrolment. This paper shows how perception of service quality under Ghana’s insurance programme contributes to health insurance subscription.

Methods

The study used the 2014 Ghana Demographic and Health Survey (GDHS) dataset. Both descriptive proportions and binary logistic regression techniques were applied to generate results that informed the discussion.

Results

Our results show that a high proportion of females (33 %) and males (35 %) felt that the quality of health provided to holders of the NHIS card was worse. As a result, approximately 30 % of females and 22%who perceived health care as worse by holding an insurance card did not own an insurance policy. While perceptions of differences in quality among females were significantly different (AOR = 0.453 [95 % CI = 0.375, 0.555], among males, the differences in perceptions of quality of health services under the NHIS were independent in the multivariable analysis. Beyond perceptions of quality, being resident in the Upper West region was an important predictor of health insurance ownership for both males and females.

Conclusion

For such a social and pro-poor intervention, investing in quality of services to subscribers, especially women who experience enormous health risks in the reproductive period can offer important gains to sustaining the scheme as well as offering affordable health services.

Perceptions and uptake of health insurance for maternal care in rural Kenya: a cross sectional study

INTRODUCTION

In Kenya, maternal and child health accounts for a large proportion of the expenditures made towards healthcare. It is estimated that one in every five Kenyans has some form of health insurance. Availability of health insurance may protect families from catastrophic spending on health. The study intended to determine the factors affecting the uptake of health insurance among pregnant women in a rural Kenyan district.

METHODS

This was cross-sectional study that sampled 139 pregnant women attending the antenatal clinic at a level 5 hospital in a Kenyan district. The information was collected through a pretested interview schedule.

RESULTS

The median age of the study participants was 28 years. Out of the 139 respondents, 86(62%) planned to pay for their deliveries through insurance. There was a significant relationship between insurance uptake and marital status Adjusted odds ratio (AOR) 6.4(1.4-28.8). Those with tertiary education were more likely to take up insurance AOR 5.1 (1.3-19.2). Knowing the benefits of insurance and the limits the insurance would settle in claims was associated with an increase in the uptake of insurance AOR 7.6(2.3-25.1), AOR 6.4(1.5-28.3) respectively. Monthly income and number of children did not affect insurance uptake.

RESULTS

Being married, tertiary education and having some knowledge on how insurance premiums are paid are associated with uptake of medical insurance. Information generated from this study if utilized will bring a better understanding as to why insurance coverage may be low and may provide a basis for policy changes among the insurance companies to increase the uptake.

The Association Between Health Insurance Coverage and Skilled Birth Attendance in Ghana: A National Study

OBJECTIVES

Skilled birth attendance (SBA) is a key health intervention used by roughly two-thirds of women in Ghana. The National Health Insurance Scheme provided by the Government of Ghana is widely expected to improve maternal health outcomes by removing financial barriers to health services. In this paper, we examine if indeed health insurance is able to improve SBA, a key maternal outcome.

METHODS

We use data from the 2011 Ghana Multiple Indicator Cluster Survey implemented by the Ghana Statistical Services with support from the United Nations Children's Fund (UNICEF). We use a multivariate logistic model controlling for a number of enabling and predisposing factors and past experience with the health system to examine the effect of health insurance on skilled birth attendance. The sample is 2528 women.

RESULTS

Our results show that women with health insurance are 47 % more likely to use SBA than women without health insurance. Results also underscore that women with repetitive contact with the health system (such as antenatal care) are more likely to have a skilled delivery (OR 3.00, p value 0.000). We also find that higher parity, rural and poor women are much less likely to use SBA.

CONCLUSIONS

Health insurance may indeed be a useful mechanism to improve coverage of SBA, though many barriers to delivery care still exist for women. Further work to understand the effect of health insurance on other maternal outcomes is also warranted.

Why are the poor less covered in Ghana's national health insurance? A critical analysis of policy and practice

Background

The National Health Insurance Scheme (NHIS) was introduced in Ghana to ensure equity in healthcare access. Presently, some low and middle income countries including Ghana are using social health insurance schemes to reduce inequity in access to healthcare. In Ghana, the NHIS was introduced to address the problem of inequity in healthcare access in a period that was characterised by user-fee regimes. The premium is heavily subsidised and exemption provided for the poorest, yet studies reveal that they are least enrolled in the scheme. We used a multi-level perspective as conceptual and methodological tool to examine why the NHIS is not reaching the poor as envisaged.

Methods

Fifteen communities in the Central and Eastern Regions of Ghana were surveyed after implementing a 20 months intervention programme aimed at ensuring that community members have adequate knowledge of the NHIS’ principles and benefits and improve enrolment and retention rates. Observation and in-depth interviews were used to gather information about the effects of the intervention in seven selected communities, health facilities and District Health Insurance Schemes in the Central Region.

Results

The results showed a distinct rise in the NHIS’ enrolment among the general population but the poor were less covered. Of the 6790 individuals covered in the survey, less than half (40.3 %) of the population were currently insured in the NHIS and 22.4 % were previously insured. The poorest had the lowest enrolment rate: poorest 17.6 %, poor 31.3 %, rich 46.4 % and richest 44.4 % (p = 0.000). Previous enrolment rates were: poorest (15.4 %) and richest (23.8 %), (p = 0.000). Ironically, the poor’s low enrolment was widely attributed to their poverty. The underlying structural cause, however, was policy makers’ and implementers’ lack of commitment to pursue NHIS’ equity goal.

Conclusion

Inequity in healthcare access persists because of the social and institutional environment in which the NHIS operates. There is a need to effectively engage stakeholders to develop interventions to ensure that the poor are included in the NHIS.

Social Factors Influencing Child Health in Ghana

Objectives

Social factors have profound effects on health. Children are especially vulnerable to social influences, particularly in their early years. Adverse social exposures in childhood can lead to chronic disorders later in life. Here, we sought to identify and evaluate the impact of social factors on child health in Ghana. As Ghana is unlikely to achieve the Millennium Development Goals’ target of reducing child mortality by two-thirds between 1990 and 2015, we deemed it necessary to identify social determinants that might have contributed to the non-realisation of this goal.

Methods

ScienceDirect, PubMed, MEDLINE via EBSCO and Google Scholar were searched for published articles reporting on the influence of social factors on child health in Ghana. After screening the 98 articles identified, 34 of them that met our inclusion criteria were selected for qualitative review.

Results

Major social factors influencing child health in the country include maternal education, rural-urban disparities (place of residence), family income (wealth/poverty) and high dependency (multiparousity). These factors are associated with child mortality, nutritional status of children, completion of immunisation programmes, health-seeking behaviour and hygiene practices.

Conclusions

Several social factors influence child health outcomes in Ghana. Developing more effective responses to these social determinants would require sustainable efforts from all stakeholders including the Government, healthcare providers and families. We recommend the development of interventions that would support families through direct social support initiatives aimed at alleviating poverty and inequality, and indirect approaches targeted at eliminating the dependence of poor health outcomes on social factors. Importantly, the expansion of quality free education interventions to improve would-be-mother’s health knowledge is emphasised.

The Politics of Universal Health Coverage in Low- and Middle-Income Countries: A Framework for Evaluation and Action

Universal health coverage has recently become a top item on the global health agenda pressed by multilateral and donor organizations, as disenchantment grows with vertical, disease-specific health programs. This increasing focus on universal health coverage has brought renewed attention to the role of domestic politics and the interaction between domestic and international relations in the health reform process. This article proposes a theory-based framework for analyzing the politics of health reform for universal health coverage, according to four stages in the policy cycle (agenda setting, design, adoption, and implementation) and four variables that affect reform (interests, institutions, ideas, and ideology). This framework can assist global health policy researchers, multilateral organization officials, and national policy makers in navigating the complex political waters of health reforms aimed at achieving universal health coverage. To derive the framework, we critically review the theoretical and applied literature on health policy reform in developing countries and illustrate the framework with examples of health reforms moving toward universal coverage in low- and middle-income countries. We offer a series of lessons stemming from these experiences to date.

Prevalence of malaria parasitaemia in school children from two districts of Ghana earmarked for indoor residual spraying: a cross-sectional study

BACKGROUND

Indoor residual spraying (IRS) is considered a valuable transmission control measure against malaria but exact efficacy data are not available for many epidemiological settings. This study was conducted to determine indicators for malaria epidemiology and transmission among school children as baseline assessment before IRS implementation in Ghana.

METHODS

A cross-sectional study was conducted in Adansi South District of the Ashanti Region and Wa West District of the Upper West Region of Ghana. Malarial parasitaemia and anaemia were determined in pupils between the ages of 2 and 14 years from Early Childhood Development Centres and primary schools. Plasmodium falciparum parasitaemia was detected by light microscopy.

RESULTS

Out of 1,649 pupils who were enrolled at participating schools, 684 were positive for plasmodia resulting in a baseline parasitaemia prevalence of 41.5%. Parasite rate was similar in the two districts (42.0% in Adansi South and 40.7% in Wa West), but differed across the nine sentinel schools ranging from 21 to 63% (p < 0.001). The mean haemoglobin concentration was 11.3 g/dl [standard deviation (SD) ±2.1]. Pupils who had moderate to mild anaemia (7.0-10.9 g/dl) constituted 41.7% of the study sample.

CONCLUSION

The burden of parasitaemia, malaria and anaemia is a major public health problem among school children in rural Ghana with extensive heterogeneity between schools and warrants further investment in intervention measures.

Clinical indicators for bacterial co-infection in Ghanaian children with P. falciparum infection

Differentiation of infectious causes in severely ill children is essential but challenging in sub- Saharan Africa. The aim of the study was to determine clinical indicators that are able to identify bacterial co-infections in P. falciparum infected children in rural Ghana. In total, 1,915 severely ill children below the age of 15 years were recruited at Agogo Presbyterian Hospital in Ghana between May 2007 and February 2011. In 771 (40%) of the children malaria parasites were detected. This group was analyzed for indicators of bacterial co-infections using bivariate and multivariate regression analyses with 24 socio-economic variables, 16 terms describing medical history and anthropometrical information and 68 variables describing clinical symptoms. The variables were tested for sensitivity, specificity, positive predictive value and negative predictive value. In 46 (6.0%) of the children with malaria infection, bacterial co-infection was detected. The most frequent pathogens were non-typhoid salmonellae (45.7%), followed by Streptococcus spp. (13.0%). Coughing, dehydration, splenomegaly, severe anemia and leukocytosis were positively associated with bacteremia. Domestic hygiene and exclusive breastfeeding is negatively associated with bacteremia. In cases of high parasitemia (>10,000/μl), a significant association with bacteremia was found for splenomegaly (OR 8.8; CI 1.6–48.9), dehydration (OR 18.2; CI 2.0–166.0) and coughing (OR 9.0; CI 0.7–118.6). In children with low parasitemia, associations with bacteremia were found for vomiting (OR 4.7; CI 1.4–15.8), severe anemia (OR 3.3; CI 1.0–11.1) and leukocytosis (OR 6.8 CI 1.9–24.2). Clinical signs of impaired microcirculation were negatively associated with bacteremia. Ceftriaxone achieved best coverage of isolated pathogens. The results demonstrate the limitation of clinical symptoms to determine bacterial co-infections in P. falciparum infected children. Best clinical indicators are dependent on the parasitemia level. Even with a moderate sensitivity of >60%, only low positive predictive values can be obtained due to low prevalence of bacteremia. Rapid testing for distinguishing parasitemia and bacteremia is essential.

Historical account of the national health insurance formulation in Kenya: experiences from the past decade

BACKGROUND

Many Low-and-Middle-Income countries are considering reviewing their health financing systems to meet the principles of Universal Health Coverage (UHC). One financing mechanism, which has dominated UHC reforms, is the development of health insurance schemes. We trace the historical development of the National Health Insurance (NHI) policy, illuminate stakeholders' perceptions on the design to inform future development of health financing policies in Kenya.

METHODS

We conducted a retrospective policy analysis of the development of a NHI policy in Kenya using data from document reviews and seven in depth interviews with key stakeholders involved in the NHI design. Analysis was conducted using a thematic framework.

RESULTS

The design of a NHI scheme was marked by complex interaction of the actor's understanding of the design, proposed implementation strategies and the covert opposition of the reform due to several reasons. First, actor's perception of the cost of the NHI design and its implication to the economy generated opposition. This was due to inadequate communication strategies to articulate the policy, leading to a vacuum of factual information flow to various players. Secondly, perceived fear of implications of the changes among private sector players threatened support and success gained. Thirdly, underlying mistrust associated with perceived lack of government's commitment towards transparency and good governance affected active engagement of all key players dampening the spirit of collective bargain breeding opposition. Finally, some international actors perceived a clash of their role and that of international programs based on vertical approaches that were inherent in the health system.

CONCLUSION

The thrust towards UHC using NHI schemes should not only focus on the design of a viable NHI package but should also involve stakeholder engagements, devise ways of improving the health care system, enhance transparency and develop adequate governance structures to institutions mandated to provide leadership in the reform process to overcome covert opposition.

Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem?

BACKGROUND

Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources.

METHODS

The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified.

RESULTS

Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS.

CONCLUSION

Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage.