National health insurance scheme enrolment and antenatal care among women in Ghana: is there any relationship?

Compliance towards WHO recommendations on antenatal care for a positive pregnancy experience: Timeliness and adequacy of antenatal care visit in Sub-Saharan African countries: Evidence from the most recent standard Demographic Health Survey data

BACKGROUND

Timely and adequate antenatal care (ANC) visits are known to reduce maternal mortality by 20%. Despite the World Health Organization updating its recommendations from four to eight antenatal care contacts, data reporting in the SSA region focused primarily on four visits, and evidence on the timing and adequacy of ANC based on the current recommendation was limited. Hence, this study aimed at assessing the level of timely and adequate ANC visits and their determinants in the 18 Sub-Saharan African countries with the most recent DHS report (2016-2021).

METHODS

The data for this study were pooled from the most recent standardized Demographic and Health Survey data of sub-Saharan African countries from 2016-2021. A total of 171,183 (with a weighted frequency of 171,488) women were included and analyzed by using STATA version 16. To account for data clustering, a multivariable multilevel mixed-effect logistic regression analysis was run to determine the effects of each predictor on the receipt of timely and adequate ANC. Adjusted odds ratio with its corresponding 95% confidence interval was used to declare the statistical significance of the independent variables.

RESULTS

The receipt of timely and adequate antenatal care visits was 41.2% (95% CI: 40.9, 41.4) and 10.4% (95% CI: 9.9, 10.2), respectively. Wontedness of pregnancy [AOR = 1.18; 95% CI: 1.13, 1.24], being 1st birth order [AOR = 1.48; 95% CI: 1.41, 2.54], having a mobile phone [AOR = 1.49; 95% CI: 1.26, 2.32], and enrolled in Health insurance schemes [AOR = 2.03; 95% CI: 1.95, 2.42] were significantly associated with early initiation of ANC. Living in a lower community poverty level[AOR = 2.23; 95% CI: 1.90,2.66], being in the richest wealth quintile [AOR = 1.49; 95% CI: 1.36, 1.62], higher educational level [AOR = 3.63; 95% CI: 3.33, 3.96], the timing of ANC visit [AOR = 4.26; 95% CI: 4.08, 4.44], being autonomous in decision making [AOR = 2.29; 95% CI: 1.83, 2.54] and having a mobile phone [AOR = 1.89; 95% CI: 1.76, 2.52] were identified as significant predictors of adequate ANC uptake.

CONCLUSION

The findings revealed a low coverage of timely and adequate ANC visits in SSA countries. Governments and healthcare managers in sub-Saharan African countries should leverage their efforts to prioritize and implement activities and interventions that increase women's autonomy, and economic capability, to improve their health-seeking behavior during pregnancy. More commitment is needed from governments to increase mobile phone distribution across countries, and then work on integrating mHealth into their health system. Finally, efforts should be made to increase the coverage of health insurance schemes enrolment for the citizens.

Relationship between health insurance enrolment and unintended pregnancy in Ghana

CONTEXT

The effect of health insurance coverage on sexual and reproductive health, especially unintended pregnancy, has scantly been researched. Using the 2014 Ghana Demographic and Health Survey, the study examined the links between women's health insurance enrolment on unintended pregnancy in Ghana.

METHOD

The sample consisted of 9,396 women aged 15-49 years, but the analysis was limited to the 4,544 women who were pregnant in the two years preceding the survey. The effects of health insurance enrolment on unintended pregnancy was examined with the propensity score matching. The health insurance enrolment was the treatment variable and unintended pregnancy as the outcome variable.

RESULTS

This study showed that 66.0% of all women surveyed had health insurance coverage and 31.8% of all women of childbearing age who were currently or had previously been pregnant reported having at least one unintended pregnancy. Thirty percent of insured women had an unintended pregnancy, compared to 37% of uninsured women. The results showed that education, household wealth index, religion, and type of marital union were significant predictor of health insurance coverage among Ghanaian women. The PSM split the women based on their health insurance status. After matching, the difference between the insured and uninsured women reduces significantly. Results demonstrated that, the probability of unintended pregnancy was 0.312 among insured women and 0.351 among those not insured in Ghana. This implies that having health insurance coverage will help in reducing the likelihood of women experiencing unintended pregnancy.

CONCLUSIONS

Results highlight the importance of the target of universal health coverage under the sustainable development goal 3 and demonstrate that expanding existing health insurance schemes within Ghana could contribute to reducing the number unintended pregnancies experienced each year.

Health insurance coverage and access to child and maternal health services in West Africa: a systematic scoping review

BACKGROUND

According to the United Nations, the third Sustainable Development Goal, 'Ensure Healthy Lives and Promote Well-Being at All Ages', set numerous targets on child and maternal health. Universal health insurance is broadly seen as a solution to fulfil these targets. West Africa is known to have the most severe maternal mortality and under-five mortality rates in the world. This review seeks to understand whether health insurance provides increased access to services for mothers and children in this region.

METHODS

The protocol for this review is registered in the International Prospective Register of Systematic Reviews database (CRD42020203859). A search was conducted in the MEDLINE Complete, Embase, CINAHL Complete and Global Health databases. Eligible studies were from West African countries. The population of interest was mothers and children and the outcome of interest was the impact of health insurance on access to services. Data were extracted using a standardized form. The primary outcome was the impact of health insurance on the rate of utilization and access to services. The Joanna Briggs Institute Critical Appraisal Tool was used for methodological assessment.

RESULTS

Following screening, we retained 49 studies representing 51 study settings. In most study settings, health insurance increased access to child and maternal health services. Other determinants of access were socio-economic factors such as wealth and education.

CONCLUSIONS

Our findings suggest that health insurance may be a viable long-term strategy to alleviate West Africa's burden of high maternal and child mortality rates. An equity lens must guide future policy developments and significant research is needed to determine how to provide access reliably and sustainably to services for mothers and children in the near and long term.

The effect of health insurance coverage on antenatal care utilizations in Ethiopia: evidence from national survey

Background

About three-fourths of maternal near-miss events and two-fifths of the risk of neonatal mortality can be reduced by having at least one antenatal visit. Several studies have identified potential factors related to maternal health seeking behavior. However, the association between health insurance membership and antenatal care utilization was not well investigated in Ethiopia. Therefore, this study was aimed at assessing the effect of health insurance coverage on antenatal care use in Ethiopia.

Methods

The study utilized data from the 2019 Ethiopia Mini Demographic and Health Survey (EMDHS). The analysis included a weighted sample of 3,919 women who gave birth in the last five years. A logistic regression model was employed to assess the association between antenatal care use and health insurance coverage and other covariates. The results were presented as adjusted odds ratios (AOR) at a 95% confidence interval (CI). Statistical significance was declared at a p-value <0.05 in all analyses.

Results

Antenatal care was used by 43% (95% CI: 41.46 to 44.56%) of Ethiopian women. Those with health insurance coverage had higher odds of antenatal care use than those without health insurance coverage. Women were 33% more likely to use antenatal care (ANC) if they were covered by health insurance. Age, Media access, marital status, education status, wealth index, and economic regions were also factors associated with antenatal care utilizations.

Conclusions

According to our findings, less than half of Ethiopian women had four or more antenatal care visits. Health insurance membership, respondent age, media access, marital status, education status, wealth index, and economic region were factors associated with antenatal care utilization. Improving health insurance, women's economic empowerment, and education coverage are critical determinants of antenatal care utilization.

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.

The uptake of WHO-recommended birth preparedness and complication readiness messages during pregnancy and its determinants among Ethiopian women: A multilevel mixed-effect analyses of 2016 demographic health survey

Background

Birth preparedness and complication readiness (BPCR) is a package of interventions recommended by the World Health Organization to improve maternal and newborn health and it is provided and implemented through a focused antenatal care program. This study aimed at assessing the uptake of birth preparedness and complication readiness messages, and compliance with each key message, among Ethiopian women during their recent pregnancies using the 2016 demographic health survey report.

Methods

The data for this study was taken from the Ethiopian Demographic and Health Survey, which was conducted from January to June 2016 and covered all administrative regions. STATA version 16 was used to analyze a total of 4,712 (with a weighted frequency of 4,771.49) women. A multilevel mixed-effects logistic, and multilevel mixed-effect negative binomial regressions were fitted, respectively. Adjusted odds ratio (AOR) and Incidence rate ratio (IRR) with their corresponding 95% confidence interval (CI) were used to report significant determinants.

Results

More than half, 56.02% [95% CI: 54.58, 57.41] of women received at least one birth preparedness and complication readiness message. Being in the richest wealth quintiles (AOR = 2.33; 95% CI: 1.43, 3.73), having two birth/s in the last five years (AOR = 1.54; 95% CI: 1.13, 2.10), receiving four or more antenatal visits(AOR = 3.33; 95% CI: 2.49, 4.45), and reading a newspaper at least once a week (AOR = 1.27; 95% CI: 1.07, 1.65) were the individual‑level factors, whereas regions and residence(AOR = 1.54; 95% CI: 1.11, 1.96) were the community-level factors associated with the uptake of at least one BPCR message. On the other hand, receiving four or more antenatal visits (IRR = 2.78; 95% CI: 2.09, 3.71), getting permission to go to a health facility (IRR = 1.29; 95% CI: 1.028, 1.38), and not covered by health insurance schemes (IRR = 0.76; 95% CI: 0.68, 0.95) were identified as significant predictors of receiving key birth preparedness and complication readiness messages.

Conclusion

The overall uptake of the WHO-recommended birth readiness and complication readiness message and compliance with each message in Ethiopia was found to be low. Managers and healthcare providers in the health sector must work to increase the number of antenatal visits. Policymakers should prioritize the implementation of activities and interventions that increase women’s autonomy in decision-making, job opportunity, and economic capability to enhance their health-seeking behavior. The local administrative bodies should also work to enhance household enrollment in health insurance schemes.

Inequalities in the prevalence of skilled birth attendance in Ghana between 1993 and 2014

BACKGROUND

Globally, maternal and neonatal health remains a public health priority, particularly for resource-constrained regions like sub-Saharan Africa (SSA). Skilled birth attendance (SBA) is essential in promoting maternal and neonatal health. This study investigated the inequalities in the prevalence of SBA in Ghana using data from the Ghana Demographic and Health Survey (GDHS) between 1993 and 2014.

METHODS

Data were analysed using the World Health Organization's Health Equity Assessment Toolkit software. In analysing the data, we first disaggregated SBA by four inequality stratifiers: wealth index, education, residence, and region. Second, we measured the inequality through summary measures, namely difference, population attributable risk, ratio, and population attributable fraction. A 95% confidence interval was constructed for point estimates to measure statistical significance.

RESULTS

Throughout the period, SBA was highest among women in the highest wealth quintile and those with a secondary or higher level of education. The analysis also indicated that SBA was highly concentrated among urban residents in 1993 (80.78 [95% uncertainty interval {UI} 76.20-84.66]) and persisted to 2014 (91.55 [95% UI 88.80-93.68]). In 1993, Northern region recorded the lowest prevalence of SBA in Ghana (15.69 [95% UI 11.20-21.54]) and the region consistently recorded the lowest SBA prevalence even into 2014 (38.21 [95% UI 27.44-50.27]).

CONCLUSIONS

There are significant inequalities in SBA across education, wealth, residence, and region in Ghana. To enhance SBA, there is the need for policymakers and interventionists to design and develop targeted policies and programs that are tailored to the needs of the subpopulations at risk of low SBA: women with no formal education, those within the poorest wealth quintile, rural-dwelling women and women in the Northern region. This will facilitate the uptake of SBA and ultimately translate into the realization of Sustainable Development Goals 3.1 and 3.2.

An assessment of out of pocket payments in public sector health facilities under the free maternal healthcare policy in Ghana

BACKGROUND

The free maternal healthcare policy was introduced in Ghana in 2008 under the national health insurance scheme as a social intervention to improve access to maternal health services. This study investigated the prevalence of out of pocket (OOP) payment among pregnant women with valid national health insurance who sought skilled delivery services at public sector health facilities in Ghana. The study also assessed the health system factors associated with OOP payment.

METHODS

We used data from the Ghana Maternal Health Survey (GMHS), which was conducted in 2017. The study comprised 7681 women who delivered at a public sector health facility and had valid national health insurance at the time of delivery. We used multivariable logistic regression analysis to assess factors associated with OOP payment, whiles accounting for clustering, stratification, and sampling weights.

RESULTS

The prevalence of OOP payment for skilled delivery services was 19.0%. After adjustment at multivariable level, hospital delivery services (adjusted Odds Ratio [aOR] = 1.23, 95% Confidence Interval [CI] = 1.00, 1.52), caesarean section (aOR = 1.73, 95% CI = 1.36, 2.20), and receiving intravenous infusion during delivery (aOR = 1.31, 95% CI = 1.08, 1.60) were associated with higher odds of OOP payment. Women who were discharged home 2 to 7 days after delivery had 19% lower odds of OOP payment compared to those who were discharged within 24 hours after delivery.

CONCLUSION

This study provides evidence of high prevalence of OOP payment among women who had skilled delivery services in public sector health facilities although such women had valid national health insurance. Government may need to institute measures to reduce OOP payment in public sector facilities especially at the hospitals and for women undergoing caesarean sections.

The impact of maternal health insurance coverage and adequate healthcare services utilisation on the risk of under-five mortality in Nigeria: a cross-sectional study

Background

Despite the progress in reducing under-five mortality (U-5 M) in recent years, these deaths remain considerably high in Nigeria. This could be attributed to poor health policies including inequality of health insurance coverage and access to adequate healthcare services utilisations which has remained inimical to achieving sustainable development goals (SDGs). Therefore, this study examined the impact of maternal health insurance coverage and adequate healthcare services utilisation on the risk of U-5 M in Nigeria.

Methods

The data for the study were derived from the 2018 Nigeria Demographic and Health Survey and comprised a weighted sample of 127,545 birth histories of childbearing women. Descriptive and analytical analyses were carried out, including frequency tables and multivariate using Cox proportional regression. The results were presented as hazard ratios (HR) with 95% confidence intervals (CIs). Data were analyzed using Stata software version 15.1.

Results

The results showed that 14.3% of the sampled birth histories of the childbearing women were children who died before age 5. The results further showed that 97.7% of the children were of mothers who have health insurance and over one-half (56.5%) were children whose mothers had adequate healthcare services utilisation. The risk of under-five death was significantly lower among the children of mothers who were covered by health insurance (HR: 0.66, CI: 0.42–1.02) and those whose mothers utilised adequate healthcare services (HR: 0.78, CI: 0.68–0.90). A similar result was observed among children whose mothers reported that distance to the health facility was not a problem (HR: 0.81, CI: 0.72–0.86). Some mothers’ characteristics including educational attainment, wealth quintile and region of residence significantly influenced the risk of U-5 M.

Conclusions

The study established that maternal health insurance coverage and adequate healthcare services utilisation were found to be protective factors against the risk of U-5 M. Also, the revealed low health insurance coverage of mothers calls for more pragmatic policy and intervention programmes through health insurance to achieve SDGs targets of ending preventable deaths of children under 5 years of age and ensuring quality, as well as universal access to maternal and child healthcare services.

Supporting a review of the benefits package of the National Health Insurance Scheme in Ghana

BACKGROUND

Although Ghana is lauded for its National Health Insurance Scheme (NHIS), concerns exist about the scheme's functioning and sustainability. An often-cited issue-contributing to the scheme's decreasing membership, long-standing financial deficit, and frequent out-of-pocket payments among members-is the large benefits package (BP). While, on paper, the BP covers over 95% of the conditions occurring in Ghana, its design was not informed by any budget analysis, nor any systematic prioritization of interventions. This paper aims to provide evidence-based input into ongoing discussions regarding a review of the NHIS benefits package.

METHODS

An existing analytic framework is used to calculate net health benefit (NHB) for a range of interventions in order to assess their cost-effectiveness and enable the prioritization of 'best buys'. The framework is expanded upon by incorporating concerns for financial protection, and practical feasibility, as well as the political economy challenges of disinvesting in currently funded activities. Five different options for the benefits package, each based on policy discourse in Ghana's health sector, are presented and evaluated.

RESULTS

Implementing all interventions for which data was available to 100% of the population in need was estimated to cost GH₵4323 million (US$994 million), while the available NHIS budget was only GH₵970 million (US$223 million). Options for the benefits package that focussed on cost-effectiveness and primary care provision achieved the best health outcomes, while options reflecting the status quo and allowing for co-payments included a higher number of healthcare interventions. Apart from the package option focussing on primary care, all packages were faced with physician shortages.

CONCLUSIONS

Current funding to the NHIS is insufficient to provide the historical benefits package, which promises to cover over 95% of disease conditions occurring in Ghana, to the total population. Shifting the NHIS focus from intervention coverage to population coverage is likely to lead to better health outcomes. A primary care package may be most feasible in the short-term, though additional physicians should be trained to provide higher-level care that is highly cost-effective, such as emergency neonatal care.

Comparative prevalence of hepatitis B virus infection among pregnant women accessing free maternal care in a tertiary hospital in Ghana

Hepatitis B virus infection is endemic in sub-Saharan Africa, and accounts for a significant proportion of morbidities and mortalities in Ghana. Infection with HBV during pregnancy can result in life-threatening complications to both mother and child. To improve their quality of life, the free maternal care was introduced to grant pregnant women cost-free access to antenatal and postnatal services. The study analysed the prevalence of HBV infection among pregnant women receiving free antenatal care in a tertiary hospital in Ghana. This was a retrospective cross-sectional study, where secondary data of pregnant women who accessed free antenatal services at the Trafalga hospital, Ho, from 2016 to 2017 were retrieved from the hospital's database. Data on hepatitis B surface antigen reactivity test, age and period of turnout were analysed with Microsoft Excel and Graph pad prism version 6. A total of 2,634 pregnant women assessed free antenatal care from January 2016 -December 2017, with 10% rise in turnout in 2017. The age of the study population was fairly young, ranging from 13-52 years and mean of 29.87±5.83. The prevalence of HBV infection among pregnant women in the entire study was estimated to be 6.0%, while that of 2016 and 2017 were 5.3% and 6.7% respectively. Turnout for antenatal services peaked in July, which also recorded the highest prevalence of HBV infection among the pregnant women. Our study, first of its kind show an HBV prevalence of 6.0% among a large population of pregnant women who accessed free antenatal services at a tertiary hospital in Ghana. The study evaluates the influence of the free maternal care policy on antenatal attendance and HBV infection rates among pregnant women.

Comparative study of the effect of National Health Insurance Scheme on use of delivery and antenatal care services between rural and urban women in Ghana

BACKGROUND

Despite the focus of the National Health Insurance Scheme (NHIS) to bridge healthcare utilisation gap among women in Ghana, recent evidence indicates that most maternal deaths still occur from rural Ghana. The objective of this study was to examine the rural-urban differences in the effects of NHIS enrolment on delivery care utilisation (place of delivery and assistance at delivery) and antenatal care services among Ghanaian women.

METHODS

A nationally representative sample of 4169 women from the 2014 Ghana Demographic and Health Survey was used. Out of this sample, 2880 women are enrolled in the NHIS with 1229 and 1651 being urban and rural dwellers, respectively. Multivariate logistic and negative binomial models were fitted as the main estimation techniques. In addition, the Propensity Score Matching technique was used to verify rural-urban differences.

RESULTS

At the national level, enrolment in NHIS was observed to increase delivery care utilisation and the number of ANC visits in Ghana. However, rural-urban differences in effects were pronounced: whereas rural women who are enrolled in the NHIS were more likely to utilise delivery care [delivery in a health facility (OR = 1.870; CI = 1.533-2.281) and assisted delivery by a medical professional (OR = 1.994; CI = 1.631-2.438)], and have a higher number of ANC visits (IRR = 1.158; CI = 1.110-1.208) than their counterparts who are not enrolled, urban women who are enrolled in the NHIS on the other hand, recorded statistically insignificant results compared to their counterparts not enrolled. The PSM results corroborated the rural-urban differences in effects.

CONCLUSION

The rural-urban differences in delivery and antenatal care utilisation are in favour of rural women enrolled in the NHIS. Given that poverty is endemic in rural Ghana, this positions the NHIS as a potential social equaliser in maternal health care utilisation especially in the context of developing countries by increasing access to delivery care services and the number of ANC visits.

Trends in antenatal care visits and associated factors in Ghana from 2006 to 2018

Introduction

Given that maternal mortality is a major global health concern, multiple measures including antenatal care visits have been promoted by the global community. However, most pregnant women in Ghana and other sub-Saharan African countries do not attain the recommended timelines, in addition to a slower progress towards meeting the required minimum of eight visits stipulated by the World Health Organization. Therefore, this study explored the trends in antenatal care visits and the associated factors in Ghana from 2006 to 2018 using the Multiple Indicator Cluster Surveys.

Methods

The study used women datasets (N = 7795) aged 15 to 49 years from three waves (2006, 2011, and 2017-2018) of the Ghana Multiple Indicator Cluster Surveys (GMICS). STATA version 14 was used for data analyses. Univariable analyses, bivariable analyses with chi-square test of independence, and multivariable analyses with robust multinomial logistic regression models were fitted.

Results

The study found a consistent increase in the proportion of women having adequate and optimal antenatal attendance from 2006 to 2018 across the women’s sociodemographic segments. For instance, the proportion of mothers achieving adequate antenatal care (4 to 7 antenatal care visits) increased from 49.3% in 2006 to 49.98% in 2011 to 58.61% in 2017-2018. In the multivariable model, women with upward attainment of formal education, health insurance coverage, increasing household wealth, and residing in the Upper East Region were consistently associated with a higher likelihood of adequate and/or optimal antenatal care attendance from 2006 to 2018.

Conclusion

Women who are less likely to achieve optimal antenatal care visits should be targeted by policies towards reducing maternal mortalities and other birth complications. Poverty-reduction policies, promoting maternal and girl-child education, improving general livelihood in rural settings, expanding health insurance coverage and infrastructural access, harnessing community-level structures, and innovative measures such as telehealth and telemedicine are required to increase antenatal care utilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04404-9.

Perceptions and Experiences of Orthodox Health Practitioners and Hospital Administrators towards Integrating Traditional Medicine into the Ghanaian Health System

The government of Ghana has been piloting traditional medicine (TM) integration in 17 health facilities across the country. However, the nature of current practice of integrated healthcare has not been thoroughly explored. This paper sought to explore the experiences and recommendations of orthodox health practitioners and hospital administrators in the Ashanti region regarding the practice of integrated healthcare in Ghana. The study adopted a qualitative, phenomenological approach involving 22 interviews. Purposive sampling technique was used in selecting study participants. Framework analysis was used to draw on the experiences of participants relating to TM integration. Participants were knowledgeable about the existence of integrated health facilities and stated that TM integration has created options in health services. However, participants deemed the integrated system ineffective and attributed the inefficiency to poor processing and certification of TM products, opposition of medical doctors to TM usage, absence of a protocol to guide the integration process, and inadequate publicity. Professional training of TM practitioners and inclusion of TM in medical school curriculum could improve collaboration between the health practitioners. Future research should focus on assessing the opinions and involvements of TM practitioners regarding the integration of traditional therapies into national health systems.

Prevalence of Eight or More Antenatal Care Contacts: Findings From Multi-Country Nationally Representative Data

Optimal antenatal care is an important service required by women and babies. To promote healthy motherhood and for positive pregnancy outcomes, World Health Organization recently recommended a minimum of 8 ANC contacts. We aim to explore the prevalence of 8 or more ANC contacts using multi-country data. Urban dwellers, mothers with secondary or higher education, women from high household wealth, early birth order, and older mothers at childbirth had higher prevalence of 8 or more ANC contacts respectively. The pooled prevalence of 8 or more ANC contacts was 13.0%. Jordan had the leading prevalence of 8 or more ANC contacts (74.0%), followed by Ghana (43.0%) and Albania (30.0%). On the other hand, Senegal, Uganda, and Zambia had very low prevalence of 8 or more ANC contacts. There was heterogeneity in the prevalence of 8 or more ANC contacts across countries. There was low prevalence of 8 or more ANC contacts.

Socioeconomic inequality in premiums for a community-based health insurance scheme in Rwanda

Community-based health insurance (CBHI) has gained popularity in many low- and middle-income countries, partly as a policy response to calls for low-cost, pro-poor health financing solutions. In Africa, Rwanda has successfully implemented two types of CBHI systems since 2005, one of which with a flat rate premium (2005-10) and the other with a stratified premium (2011-present). Existing CBHI evaluations have, however, tended to ignore the potential distributional aspects of the household contributions made towards CBHI. In this paper, we investigate the pattern of socioeconomic inequality in CBHI household premium contributions in Rwanda within the implementation periods. We also assess gender differences in CBHI contributions. Using the 2010/11 and 2013/14 rounds of national survey data, we quantify the magnitude of inequality in CBHI payments, decompose the concentration index of inequality, calculate Kakwani indices and implement unconditional quantile regression decomposition to assess gender differences in CBHI expenditure. We find that the CBHI with stratified premiums is less regressive than CBHI with a flat rate premium system. Decomposition analysis indicates that income and CBHI stratification explain a large share of the inequality in CBHI payments. With respect to gender, female-headed households make lower contributions towards CBHI expenditure, compared with male-headed households. In terms of policy implications, the results suggest that there may be a need for increasing the premium bracket for the wealthier households, as well as for the provision of more subsidies to vulnerable households.

Prevalence and Socioeconomic Inequalities in Eight or More Antenatal Care Contacts in Ghana: Findings from 2019 Population-Based Data

Background

For the prevention of complications and death during pregnancy, adequate antenatal care (ANC) contacts are important. To achieve optimal obstetric care, the latest ANC guidance recommends eight or more ANC contacts. The aim of this analysis is to investigate the prevalence and socio-economic differences of eight or more Ghanaian ANC contacts.

Methods

A total sample of 1404 women of reproductive age who had given birth after eight or more ANC contacts had been initiated, taking into account 9 months of gestation, was studied. The Ghana Malaria Indicator Survey of 2019 (GMIS) was used. In the univariate analysis, percentage was used. The curve and concentration index of Lorenz were used to assess socio-economic disparities for eight or more ANC contacts. Statistical significance was set at 5%.

Results

The weighted prevalence of eight or more ANC contacts was 41.9% (95% CI: 37.9–45.9%). The prevalence of eight or more ANC contacts among the poorest, poorer, middle, richer and richest households was 34.0%, 36.1%, 35.8%, 42.4% and 59.6%, respectively. Similarly, 33.0%, 37.7% and 42.6% prevalence of eight or more ANC contacts were estimated among women with no formal education, primary, secondary or higher, respectively. In addition, women from rich household had greater coverage of eight or more ANC contacts (Conc. Index= 0.089; SE= 0.019) and educated women had greater coverage of eight or more ANC contacts in Ghana (Conc. Index= 0.053; SE= 0.017) (all p<0.001).

Conclusion

Eight or more ANC contacts from the WHO in 2016 have yet to be fully institutionalized in Ghana. In order to increase access to the recommended prenatal care and for a healthy pregnancy experience, measures that resolve disparities in healthcare usage need to be prioritized for the country. Efforts should be made to expand the health insurance services available, as well as to enact policies that will increase free health care particularly among the poor and uneducated women.

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.

Inequalities in out-of-pocket health expenditure among women of reproductive age: after-effects of national health insurance scheme initiation in Ghana

Background

Improvement in maternal healthcare is a public health priority. Unfortunately, in spite of the efforts made over time regarding universal coverage, there remain issues with accessibility and use of healthcare services up to now. In this study, we examined inequalities in out-of-pocket health expenditure among women of reproductive age in Ghana. We analyzed secondary data collected in Ghana Demographic and Health Survey (GDHS) - 2014. A total of 9,002 women of reproductive age were included in this study. Lorenz curves and the concentration index were used to examine neighborhood socioeconomic disadvantage inequalities in out-of-pocket expenditure for maternal healthcare utilization

Results

About two thirds (66.0%) of women of reproductive age in Ghana were covered by health insurance. In sum, women of high neighborhood socioeconomic disadvantage status had the least out-of-pocket expenditure for total healthcare utilization, laboratory investigations, antenatal care visits, post-natal care visits, care for new born for up to 3 months, and other healthcare services. The converse was however true for family planning service utilization. Using Concentration Index, we quantified the degree of neighborhood socioeconomic disadvantage inequalities in healthcare service utilizations.

Conclusion

This study showed a gap in health insurance coverage among women of reproductive age. There were also inequalities in out-of-pocket expenditure for healthcare services utilization. It is expedient for stakeholders in the healthcare system to make policies targeted at bridging the neighborhood socioeconomic differences in maternal healthcare use and develop programs to improve women’s financial protection. Moreover, enlightenment on health insurance availability and coverage should focus on women at risk of out-of-pocket expenditure.

National health insurance and the choice of delivery facility among expectant mothers in Ghana

The effectiveness of health insurance in removing barriers to the utilisation of maternal healthcare in order to curb maternal mortality especially in developing countries is gaining ground. However, in assessing the effects of health insurance on choice of delivery facilities, previous studies either put all delivery services together and used binary techniques or failed to address endogeneity problem. Moreover, the age of data used for such analysis in Ghana may not tell a convincing story. This study used data from the 2014 to 2008 Ghana Demographic and Health Surveys with a sample of 6319 women and employed multinomial endogenous treatment effects models with Conditional Mixed Process estimator to examine the effects of national health insurance scheme (NHIS) on the choice delivery facility in Ghana. We found that NHIS has varied effects on the use of delivery services across service providers in the health system. Relative to home delivery services, being insured increases the probability of using public hospitals, public clinics and private health facilities for delivery by 20.3 percent, 9.1 percent and 2.3 percent respectively. Moreover, relative to an insured woman who gave birth before 2008, her counterpart who gave birth after 2008 is 6.3 percent, 4.9 percent and 0.77 percent more likely to use public hospitals, public clinics and private health facilities respectively for delivery.

The shared experiences of insured members and the uninsured in health care access and utilization under Ghana's national health insurance scheme: Evidence from the Hohoe Municipality

Background

The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003 to remove financial barriers and to promote equitable access to health care services. Post implementation has been characterized by increases in access and utilization of services among the insured. The uninsured have been less likely to utilize services due to unaffordability of health care costs. In this study, we explored the experiences of the insured members of the NHIS, the uninsured and health professionals in accessing and utilizing health care services under the NHIS in the Hohoe Municipality of Ghana.

Methods

Qualitative in-depth interviews were held with twenty-five NHIS insured, twenty-five uninsured, and five health care professionals, who were randomly sampled from the Hohoe Municipality to collect data for this study. Data was analyzed using thematic analysis.

Results

Participants identified both enablers or motivating factors and barriers to health care services of the insured and uninsured. The major factors motivating members to access and use health care services were illness severity and symptom persistence. On the other hand, barriers identified included perceived poor service quality and lack of health insurance among the insured and uninsured respectively. Other barriers participants identified included financial constraints, poor attitudes of service providers, and prolonged waiting time. However, the level of care received were reportedly about the same among the insured and uninsured with access to quality health care much dependent on ability to pay, which favors the rich and thereby creating inequity in accessing the needed quality care services.

Conclusion

The implication of the financial barriers to health care access identified is that the poor and uninsured still suffer from health care access challenges, which questions the efficiency and core goal of the NHIS in removing financial barrier to health care access. This has the potential of undermining Ghana’s ability to meet the Sustainable Development Goal 3.8 of universal health coverage by the year 2030.

Health Insurance in Sub-Saharan Africa: A Scoping Review of the Methods Used to Evaluate its Impact

We conducted a scoping review with the objective of synthesizing available literature and mapping what designs and methods have been used to evaluate health insurance reforms in sub-Saharan Africa. We systematically searched for scientific and grey literature in English and French published between 1980 and 2017 using a combination of three key concepts: "Insurance" and "Impact evaluation" and "sub-Saharan Africa". The search led to the inclusion of 66 articles with half of the studies pertaining to the evaluation of National Health Insurance schemes, especially the Ghanaian one, and one quarter pertaining to Community-Based Health Insurance and Mutual Health Organization schemes. Sixty-one out of the 66 studies (92%) included were quantitative studies, while only five (8%) were defined as mixed methods. Most studies included applied an observational design (n = 37; 56%), followed by a quasi-experimental (n = 27; 41%) design; only two studies (3%) applied an experimental design. The findings of our scoping review are in line with the observation emerging from prior reviews focused on content in pointing at the fact that evidence on the impact of health insurance is still relatively weak as it is derived primarily from studies relying on observational designs. Our review did identify an increase in the use of quasi-experimental designs in more recent studies, suggesting that we could observe a broadening and deepening of the evidence base on health insurance in Africa over the next few years.

The Role of a Health Protection Scheme in Health Services Utilization Among Community-Dwelling Older Persons in Ghana

OBJECTIVES

This study examines the relationships between National Health Insurance Scheme (NHIS) enrollment and the frequency and "timing" of health services utilization among community-dwelling older Ghanaians. It also investigates whether the NHIS policy has improved equity in access to health care in later life.

METHODS

Cross-sectional data were derived from an Ageing, Health, Psychological Wellbeing and Health-seeking Behavior Study collected between August 2016 and January 2017 (N = 1,200). Descriptive and bivariate analyses described the sample. Generalized Poisson and logit regression models, respectively estimated the predictors of frequency of health services utilization and time from onset of illness to health facility use and during last illness episode.

RESULTS

Older persons with active NHIS membership frequently used health facilities (β = 0.237, standard error [SE] = 0.0957, p ˂ .005), but the association was largely a function of health-related factors. The NHIS enrollees were more likely to attend health facility earlier (β = 1.347, SE = 0.3437, p ˂ .001) compared with nonenrollees, after adjusting for theoretically relevant covariates. Moreover, given the NHIS enrollment, the rich (eβ = 2.149, SE = 0.240, p ˂ .005), social support recipients (eβ = 1.366, SE = 0.162, p ˂ .05) and those living with relevant others (eβ = 2.699, SE = 0.175, p ˂ .001) were more likely to consume health services.

DISCUSSION

Ghana's NHIS policy generally increases health services utilization but at present lacks the capability to improve equitable access to health care, especially between poor and nonpoor older adults. This may hamper the progress toward universal health coverage (UHC), indicating the need for further refinements in the policy including ways to improve the health status of older persons.

Maternal health services utilisation among primigravidas in Uganda: what did the MDGs deliver?

BACKGROUND

Achieving maternal health outcomes in the SDGs requires the implementation of more targeted policies and strategies. While the MDGs may have deepened our understanding in this regard, we know little about the trends in maternal health services utilisation among primigravidas, and how age and geographical regions could have influenced these trends. In this study, we examined utilisation of antenatal and skilled delivery services among primigravidas in Uganda, a country with one of the highest maternal mortality ratios, and where early childbearing and its attendant challenges are common.

METHODS

Guided by Andersen's Behavioural Model, we fitted multivariate regression models to a pooled dataset of the 2006, 2011 and 2016 Ugandan Demographic and Health Survey (n = 3477) to understand the dynamics in Antenatal Care (ANC) and Skilled Birth Attendance (SBAs) utilisation among primigravidas. Post-estimation margins were employed to further highlight the effect of age and geographical regions.

RESULTS

The analyses show an improvement in access to maternal health services among primigravidas from 2006 to 2016. Compared to 2006, primigravidas in 2016 were 48%, 24% and 2.98 times more likely to have early ANC, four or more ANC visits, and SBAs, respectively. Altogether, a primigravida in 2016 relative to 2006 was 42% more likely to meet all three maternal health service indicators. Post-estimation margins analyses on age and geographical disparities revealed that younger primigravidas have lower probability, while primigravidas in Eastern Region, one of the most deprived in the country, have the lowest probability of accessing maternal health services. Also, the study found education, wealth, women's household decision-making power, place of residence as important determinants of ANC visits and SBAs.

CONCLUSIONS

Based on our findings, it is important to address the vulnerabilities of primigravidas, particularly younger individuals, in accessing early ANC. Uganda should scale-up decentralisation and integration of maternal health delivery in local communities as a strategy of addressing lingering geographical disparities, and ultimately improve maternal health outcomes in the SDGs period.

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.

Does insurance protect individuals from catastrophic payments for surgical care? An analysis of Ghana's National Health Insurance Scheme at Korle-Bu teaching Hospital

BACKGROUND

According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe.

METHODS

We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017 - October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual's income.

RESULTS

Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58-87% of insured patients would face financial catastrophe, versus 83-98% of uninsured patients (all comparisons by definition were significant, p < .05).

CONCLUSION

This study-the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana-found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana's national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care.

TRIAL REGISTRATION

Registered at www.clinical trials.gov identifier NCT03604458.

Exploring the Determinants of Antenatal Care Services Uptake: A Qualitative Study among Women in a Rural Community in Northern Ghana

Background

Global evidence has shown significant contribution of Antenatal care (ANC) in the detection and treatment of pregnancy related complications. Over the years, many areas in Ghana have recorded high uptake of ANC. However, this is not the case for Binduri district in Northern Ghana where only 37.4% of pregnant women utilised the services of ANC during their period of pregnancy compared to a national figure of 87%. We therefore sought to explore the determinants of ANC uptake among women who failed to utilise ANC services during their period of pregnancy in Binduri District in Northern Ghana.

Methodology

The study was an exploratory descriptive study using purposive sampling technique. A total of 15 women who met the inclusion criteria for the study were recruited for a face-to-face interview. The data were analysed using the procedure of inductive thematic analysis.

Results

The study findings showed that several factors hindered the use of ANC among our participants. The individual factors that were responsible for nonutilisation of ANC included financial constraints hindering registration with the national health insurance scheme, excuses of being busy, perception that pregnancy was not sickness and concentration on work. Perceived poor attitude of nurses was the only health system factor that contributed to non utilisation of ANC services.

Conclusion

There is the need for establishment of registration centres of the national health insurance in all communities to make the scheme more accessible. There should also be intensive public education on importance of attending ANC.

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.

Access to primary health care among women: the role of Ghana's community-based health planning and services policy

Background:

Ghana in 1999 adopted the Community-based Health Planning and Service (CHPS) policy to enhance access to primary health care (PHC) service. After two decades of implementation, there remains a considerable proportion of the country’s population, especially women who lack access to basic health care services.

Aim:

The aim of this paper is to understand the contribution of Ghana’s CHPS policy to women’s access to PHC services in the Upper West Region (UWR) of Ghana.

Methods:

A logistic regression technique was employed to analyse cross-sectional data collected among women (805) from the UWR.

Findings:

We found that women who resided in CHPS zones (OR = 1.612; P ≤ 0.01) were more likely to have access to health care compared with their counterparts who resided in non-CHPS zones. Also, rural-urban residence, distance to health facility, household wealth status and marital status predicted access to health care among women in the region. Our findings underscore the need to expand the CHPS policy to cover many areas in the country, especially rural communities and other deprived localities in urban settings.

Does Antenatal Care Translate into Skilled Birth Attendance? Analysis of 2014 Ghana Demographic and Health Survey

Background. Despite the high antenatal care attendance rate in Ghana, skilled birth attendance is relatively low. There is limited evidence on whether antenatal care attendance translates into skilled birth attendance in the Ghanaian research discourse. This study investigates whether antenatal care attendance translates into skilled birth. Methods. We extracted data from the 2014 Ghana Demographic and Health Survey. Data were analysed using descriptive and binary logistic regression analyses at 5% confidence interval. Results. The descriptive findings indicated a vast variation between antenatal care attendance and skilled birth attendance. Skilled birth attendance was consistently low across almost all sociodemographic characteristics as compared to antenatal care attendance. The binary logistic regression analysis however indicated higher inclination toward skilled birth attendance among women who had at least four antenatal care visits [OR=5.87, CI=4.86-7.08]. The category of women noted to have higher tendencies of skilled birth attendance was those with higher/tertiary education [OR=9.13, CI=2.19-37.93], the rich [OR=4.27, CI=3.02-6.06], urban residents [OR=2.35, CI=1.88-2.93], women with maximum of four children [OR=1.36, CI=1.08-1.72], and those using modern contraceptives [OR=1.24, CI=1.03-1.50]. Conclusion. We recommend that interventions to enhance skilled birth attendance must target women who do not achieve at least four antenatal visits, those with low wealth standing, those not using contraceptives, and women without formal education. Again, an in-depth qualitative study is envisaged to deepen the understanding of these dynamics in the rural setting.

Viability of diagnostic decision support for antenatal care in rural settings: findings from the Bliss4Midwives Intervention in Northern Ghana

Background

Antenatal screening is useful for early identification and management of high-risk pregnancies. In low-resource settings, provision of the full complement of tests is limited and diagnostic referrals incure additional costs for pregnant women. We assessed the viability of Bliss4Midwives (B4M) - a point-of-care diagnostic decision support device for decentralized screening of pre-eclampsia, gestational diabetes and anaemia during antenatal care (ANC).

Methods

The device was piloted in seven health facilities across two districts in Northern Ghana over a ten-month period. Health workers were expected to screen women at each ANC visit till delivery. All screening records from the device were automatically archived digitally and later downloaded. After removing duplicates or invalid entries, descriptive quantitative analysis was carried out with IBM SPSS Statistics (version 23). B4M usage behavior, diagnostic and referral outcome were analyzed.

Results

Health workers conducted 1323 partial or full antenatal screening on 940 women, resulting in decision support for 835 (88.8%) B4M beneficiaries. Diagnostic referral was eliminated for 708 (84.7%) beneficiaries, with 335 (40.1%) of these from facilities without on-site diagnostic alternatives. Of visits with complete data, 92/559 (16.4%) women were screened in their first trimester, 28/940 (2.9%) had 4+ B4M visits and 107/835 (12.8%) women were recommended for urgent referral to a higher-level facility on the first visit. Follow-up screenings flagged an additional 17 women for urgent referral with 10 cases of repeated alerts in five women. Wide variations between high (9 months use) and low adopting (1.5 months use) facilities were observed, with some similarities in usage trend.

Conclusions

B4M helped decentralize ANC screening and decrease unnecessary referrals. Project outcomes were influenced by implementation strategy, technical features and behavioural dispositions of users and beneficiaries.

Exposure to mass media family planning messages among post-delivery women in Nigeria: testing the structural influence model of health communication

OBJECTIVES

While media campaigns are documented to be useful for increasing the uptake of family planning, very little is known about the population prevalence and correlates of exposure to mass media family planning messages among post-delivery women in Nigeria. We aimed to address this void by exploring the underlying factors that explain disparities in exposure to mass media family planning messages among post-delivery women in Nigeria.

METHODS

Our study was a secondary analysis of the Nigeria Demographic and Health Survey, a nationally representative dataset of men and women. Using logistic regression techniques and drawing on the structural influence model of health communication, we explored post-delivery women's (N = 13,889) exposure to mass media family planning messages in Nigeria.

RESULTS

We found that 32% of post-delivery women were exposed to family planning messages on mass media in Nigeria. At the bivariate level, Muslim women were less likely to be exposed to mass media family planning messages compared with Christian women (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.36, 0.41); however, the OR became positive once we controlled for structural determinants such as household wealth and education (OR 1.22; 95% CI 1.07, 1.40). In the multivariate analysis, we found that traditionalist women (OR 0.29; 95% CI 0.14, 0.58) and women from rural areas (OR 0.69; 95% CI 0.62, 0.76) were less likely to be exposed to such messages. Moreover, richer, better educated, and employed women were more likely to be exposed to mass media family planning messages compared with their poorer, less educated and unemployed counterparts. Similarly, living in the South West region was positively associated with higher odds of being exposed to such messages.

CONCLUSION

Findings were largely consistent with the structural influence model of health communication, as highlighted by inequalities in exposure to mass media messages. Based on these findings, we provide several policy recommendations.

Health insurance and social capital in Ghana: a cluster randomised controlled trial

BACKGROUND

The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003, enrolment is still far from the desired target of universal coverage. Low community engagement in the design and management of the system was identified as one of the main barriers. The aim of the current study was to explore the role of social capital in NHIS enrolment in two regions of Ghana, Western and Greater Accra.

METHODS

The study involved a cluster-randomised controlled trial of 3246 clients of 64 healthcare facilities who completed both a baseline and a follow-up survey. Thirty-two facilities were randomly selected to receive two types of intervention. The remaining facilities served as control. The interventions were co-designed with stakeholders. Baseline and follow up surveys included measures of different types of social capital, as well as enrolment in the health insurance scheme.

RESULTS

The study found that the interventions encouraged NHIS enrolment (from 40.29 to 49.39% (intervention group) versus 36.49 to 36.75% (control group)). Secondly, certain types of social capital are associated with increased enrolment (log-odds ratios (p-values) of three types of vertical social capital are 0.127 (< 0.01), 0.0952 (< 0.1) and 0.15 (< 0.01)). Effectiveness of the interventions was found dependent on initial levels of social capital: respondents with lowest measured level of interpersonal trust in the intervention group were about 25% more likely to be insured than similar respondents in the control group. Among highly trusting respondents this difference was insignificant. There was however no evidence that the interventions effect social capital. Limitations of the study are discussed.

CONCLUSION

We showed that the interventions helped to increase enrolment but that the positive effect was not realized by changes in social capital that we hypothesised based on result of the first phase of our study. Future research should aim to identify other community factors that are part of the enrolment process, whether other interventions to improve the quality of services could help to increase enrolment and, as a result, could provide community benefits in terms of social capital.Our findings can guide the NHIS in Ghana and other health organizations to enhance enrolment.

TRIAL REGISTRATION

Ethical Clearance by Ghana Health Service Ethical Committee No. GHS-ERC 08.5.11.

Perceived satisfaction with health services under National Health Insurance Scheme: Clients' perspectives

The study aims to explore the perceived satisfaction of insured clients in financing health services through National Health Insurance in Ghana. A quantitative method was used to recruit 380 respondents, selected by multistage cluster sampling. Data were collected through the administration of questionnaires. More than half, 57.9%, of respondents were males, and the average age was 34 years. Most respondents, 74.3%, were insured. Overall, 53.12% of insured clients were dissatisfied with the services of providers. Factors, such as benefit package of insurance, willingness to pay higher premium, and perceived discrimination were significantly associated with poor satisfaction with health services. The current advocacy for and awareness about the use of health insurance as a prepayment plan should be prioritised in policy initiatives. The benefit package for the insurance should be increased in order to cover all disease conditions that afflict the Ghanaian population.

Predictors of Health Care Service Quality among Women Insured Under Ghana's National Health Insurance Scheme

Background:

Insured women in Ghana are more likely to use maternity care services than their uninsured counterparts. To improve service quality among insured women in Ghana, better understanding of the factors that predict quality standards of primary health care services is essential.

Objective:

To examine predictors of health care service quality among insured women under the National Health Insurance Scheme (NHIS) in Ghana.

Methods:

Data from the 2014 Ghana Demographic Health Survey was analysed. Cluster analysis was applied to construct a dependent variable; service care quality. Socio-demographic/background characteristics were used as independent variables. Descriptive and inferential analyses were performed followed by multiple regression to predict service quality among the insured population of women aged 15–49 years. SPSS version 21 was used during the clustering while STATA version 14 was used to perform the inferential and regression analyses.

Findings:

A total of 5,457 women with valid health insurance were included in the analysis. Overall, geographical region of respondents was significant to expressions of insured service quality (χ² = 495.4, p ≤ 0.001). Literacy levels were significant at χ² = 69.232 and p < 0.001 for service quality. On place of residence, the estimation showed urban residency to be more positively correlated with indicating quality ratings of health services compared to rural residency (χ² = 70.29, p < 0.001). Highest educational level had the highest predictive influence (coefficient = 0.15) on women’s views about the quality of health care services.

Conclusions:

A health insurance system that shifts towards introducing valued-based care models for patients, insurers, and health care providers could be supportive in improving the quality of healthcare delivered to Ghanaians.

Predictors of Health Care Service Quality among Women Insured Under Ghana's National Health Insurance Scheme

BACKGROUND

Insured women in Ghana are more likely to use maternity care services than their uninsured counterparts. To improve service quality among insured women in Ghana, better understanding of the factors that predict quality standards of primary health care services is essential.

OBJECTIVE

To examine predictors of health care service quality among insured women under the National Health Insurance Scheme (NHIS) in Ghana.

METHODS

Data from the 2014 Ghana Demographic Health Survey was analysed. Cluster analysis was applied to construct a dependent variable; service care quality. Socio-demographic/background characteristics were used as independent variables. Descriptive and inferential analyses were performed followed by multiple regression to predict service quality among the insured population of women aged 15-49 years. SPSS version 21 was used during the clustering while STATA version 14 was used to perform the inferential and regression analyses.

FINDINGS

Overall, geographical region of respondents was significant to expressions of insured service quality (χ2=495.4, p ≤ 0.001). Literacy levels were significant at χ2=69.232 and p ≤ 0.001 for service quality. On place of residence, the estimation show urban residency was more positively correlated with indicating quality ratings of health services compared to rural residency (χ2=70.29, p ≤ 0.001). Highest educational level had the highest predictive influence with a coefficient of 0.15.

CONCLUSIONS

A more supportive health insurance system approach that shifts towards introducing valued-based care models for patients, insurers and health care providers could be supportive in improving quality standards among insured population groups in Ghana.

Identifying strengths and weaknesses of the integration of biomedical and herbal medicine units in Ghana using the WHO Health Systems Framework: a qualitative study

Background

The use of herbal medicines in developing countries has been increasing over the years. In Ghana, since 2011, the government has been piloting the integration of herbal medicine in 17 public hospitals. However, the strengths and the weaknesses of the integration have not been fully explored. The current study sought to examine the strengths and weaknesses of the integration using the WHO health systems framework.

Methods

This study used qualitative, exploratory study design involving interviews of 25 key informants. The respondents had experience in conducting herbal medicine research. Two key informants were medical herbalists practising in hospitals piloting the integration in Ghana. We used Framework analysis to identify the perspectives of key informants in regards to the integration. 

Results

Key informants mostly support the integration although some noted that the government needs to support scale-up in other public hospitals. Among the strengths cited were the employment of medical herbalists, utilization of traditional knowledge, research opportunities, and efficient service delivery by restricting the prescription and use of fake herbal medicine. The weaknesses were the lack of government policies on implementing the integration, financial challenges because the National Health Insurance Scheme does not cover herbal medicine, poor advocacy and research opportunities, and lack of training of conventional health practitioners in herbal medicine.

Conclusions

Researchers view the integration of the two healthcare systems–biomedicine, and herbal medicine– positively but it has challenges that need to be addressed. The integration could offer more opportunities for researching into herbal medicine. More training for conventional health professionals in herbal medicine could increase the chances of better coordination between the two units. Additionally, strong advocacy and publicity is needed to educate more people on the integration and the utilization of the services.

Electronic supplementary material

The online version of this article (10.1186/s12906-018-2334-2) contains supplementary material, which is available to authorized users.

Factors for healthcare utilization and effect of mutual health insurance on healthcare utilization in rural communities of South Achefer Woreda, North West, Ethiopia

OBJECTIVE

To identify factors for healthcare utilization and to describe effect of Mutual Health Insurance on health service utilization in rural community in South Achefer, North West Ethiopia.

METHODS

Across-sectional study was conducted. A total of 652 households consented to participate in the study (326 insured and 326 uninsured households). Propensity score matching was used to explain possible differences in the baseline variables between enrolled and un-enrolled households. Logistic regression analysis was used to identify factors for healthcare utilization.

RESULTS

Healthcare utilization among insured households was 50.5% (95% CI: 44.8%, 56.2%). Whilst among uninsured households, healthcare utilization was 29.3% (95% CI: 24.11, 34.47). In general, the overall healthcare utilization was 39.89% (95% CI: 35.7, 43.8). The overall increase in patient-attendance given illness among insured households was 25.2% higher compared with uninsured (t = 4.94, 95% CI: 0.145, 0.359). Educated (primary and above) (AOR = 1.84; 95% CI: 1.14, 2.98), chronic patient (AOR = 1.86; 95% CI: 1.13, 3.06), first choice was health facilities at the point of illness (AOR = 6.33; 95% CI: 2.97-13.51), rich (AOR = 2.1; 95%CI: 1.29, 3.43), and insured (AOR = 2.16; 95% CI: 1.45, 3.23) were independently associated with increased healthcare utilization.

CONCLUSION

Enrolment to mutual health insurance increases healthcare utilization. Presence of illness in the households, household earnings, educational status, first choice of treatment at point of illness, and membership to Mutual Health Insurance scheme should be targeted during escalating of healthcare utilization.

Determinants of choice of skilled antenatal care service providers in Ghana: analysis of demographic and health survey

BACKGROUND

The International Safe Motherhood initiative provides a focus for programmes and research to improve maternal health in low - income countries. Antenatal care is one of the key pillars of the initiative. This study sought to examine the association between background characteristics and choice of skilled providers of antenatal care services in Ghana.

METHODS

The study used data from the six rounds of the Ghana Demographic and Health Survey (GDHS). Binary logistic regression models were applied to analyse the data.

RESULTS

Results show that the proportion of women who received antenatal care (ANC) services from skilled providers improved over the period. Also, women with secondary education (OR = 1.42, CI = 1.07-1.88), richest wealth status (OR = 5.10, CI = 2.28-11.85) were more likely to utilise antenatal care services from skilled providers. Whereas women from rural areas (OR = 0.55, CI = 0.41-0.74), with four births or more (OR = 0.55, CI = 0.36-0.85) and from the northern ethnic group were less likely to utilise antenatal care services from skilled providers.

CONCLUSION

Choice of skilled providers of antenatal care services were predicted by some predisposing factors including education, ethnicity, and ecological zone. Also enabling factors such as wealth status, residence and the need for care factor, parity predicted choice of skilled providers of antenatal care services. Women with secondary or higher education, those within richer and richest wealth status, those from forest zone are more likely to utilise the services of skilled providers during their antenatal care visits. Whereas women from rural areas, those with four births or more and those with the northern ethnic group were more likely to utilise ANC service from unskilled providers. The Ghana Health Service and Ministry of Health should encourage women in rural areas to utilise antenatal care services from skilled providers through social and behaviour change communication campaigns.

Has the free maternal health policy eliminated out of pocket payments for maternal health services? Views of women, health providers and insurance managers in Northern Ghana

INTRODUCTION

The free maternal health policy was implemented in Ghana in 2008 under the National Health Insurance Scheme (NHIS). The policy sought to eliminate out of pocket (OOP) payments and enhance the utilisation of maternal health services. It is unclear whether the policy had altered OOP payments for services. The study explored views on costs and actual OOP payments during pregnancy. The source of funding for payments was also explored.

METHODS

A convergent parallel mixed methods design, involving quantitative and qualitative data collection approaches. The study was set in the Kassena-Nankana municipality, a rural area in Ghana. Women (n = 406) who utilised services during pregnancy were surveyed. Also, 10 focus groups discussions (FGDs) were held with women who used services during pregnancy as well as 28 in-depth interviews (IDIs) with midwives/nurses (n = 25) and insurance managers/directors (n = 3). The survey was analysed using descriptive statistics, focussing on costs from the women's perspective. Qualitative data were audio recorded, transcribed and translated verbatim into English where necessary. The transcripts were read and coded into themes and sub-themes.

RESULTS

The NHIS did not cover all expenses in relation to maternal health services. The overall mean for OOP cost during pregnancy was GH¢17.50 (US$8.60). Both FGDs and IDIs showed that women especially paid for drugs and ultrasound scan services. Sixty-five percent of the women used savings, whilst twenty-two percent sold assets to meet the OOP cost. Some women were unable to afford payments due to poverty and had to forgo treatment. Participants called for payments to be eliminated and for the NHIS to absorb the cost of emergency referrals. All participants admitted the benefits of the policy.

CONCLUSION

Women needed to make payments despite the policy. Measures should be put in place to eliminate payments to enable all women to receive services and promote universal health coverage.

Households Sociodemographic Profile as Predictors of Health Insurance Uptake and Service Utilization: A Cross-Sectional Study in a Municipality of Ghana

Introduction. Attempts to use health insurance in Low and Middle Income Countries (LMICs) are recognized as a powerful tool in achieving Universal Health Coverage (UHC). However, continuous enrolment onto health insurance schemes and utilization of healthcare in these countries remain problematic due to varying factors. Empirical evidence on the influence of household sociodemographic factors on enrolment and subsequent utilization of healthcare is rare. This paper sought to examine how household profile influences the National Health Insurance Scheme (NHIS) status and use of healthcare in a municipality of Ghana. Methods. A cross-sectional design with quantitative methods was conducted among a total of 380 respondents, selected through a multistage cluster sampling. Data were collected using a semistructured questionnaire. Data were analysed using descriptive and multiple logistics regression at 95% CI using STATA 14. Results. Overall, 57.9% of respondents were males, and average age was 34 years. Households’ profiles such as age, gender, education, marital status, ethnicity, and religion were key predictors of NHIS active membership. Compared with other age groups, 38–47 years (AOR 0.06) and 58 years and above (AOR = 0.01), widow, divorced families, Muslims, and minority ethnic groups were less likely to have NHIS active membership. However, females (AOR = 3.92), married couples (AOR = 48.9), and people educated at tertiary level consistently had their NHIS active. Proximate factors such as education, marital status, place of residence, and NHIS status were predictors of healthcare utilization. Conclusion. The study concludes that households’ proximate factors influence the uptake of NHIS policy and subsequent utilization of healthcare. Vulnerable population such as elderly, minority ethnic, and religious groups were less likely to renew their NHIS policy. The NHIS policy should revise the exemption bracket to wholly cover vulnerable groups such as minority ethnic and religious groups and elderly people at retiring age of 60 years.

National health insurance subscription and maternal healthcare utilisation across mothers' wealth status in Ghana

INTRODUCTION

This study is against the backdrop that despite the forty-nine percent decline in Maternal Mortality Rate in Ghana, the situation still remains high averaging 319 per 100,000 live births between 2011 and 2015.

OBJECTIVE

To examine the relationship between National Health Insurance and maternal healthcare utilisation across three main wealth quintiles (Poor, Middle and Rich).

METHODS

The study employed data from the 2014 Ghana Demographic and Health Survey. Both descriptive analysis and binary logistic regression were conducted.

RESULTS

Descriptively, rich women had high antenatal attendance and health facility deliveries represented by 96.5% and 95.6% respectively. However, the binary logistic regression results revealed that poor women owning NHIS are 7% (CI = 1.76-2.87) more likely to make at least four antenatal care visits compared to women in the middle wealth quintile (5%, CI = 2.12-4.76) and rich women (2%, CI = 1.14-4.14). Similarly, poor women who owned the NHIS are 14% (CI = 1.42-2.13) likely to deliver in health facility than women in the middle and rich wealth quintile.

CONCLUSION

The study has vindicated the claim that NHIS Scheme is pro-poor in Ghana. The Ministry of Health should target women in the rural area to be enrolled on the NHIS to improve maternal healthcare utilisation since poverty is principally a rural phenomenon in Ghana.

Minding the gaps: health financing, universal health coverage and gender

In a webinar in 2015 on health financing and gender, the question was raised why we need to focus on gender, given that a well-functioning system moving towards Universal Health Coverage (UHC) will automatically be equitable and gender balanced. This article provides a reflection on this question from a panel of health financing and gender experts.We trace the evidence of how health-financing reforms have impacted gender and health access through a general literature review and a more detailed case-study of India. We find that unless explicit attention is paid to gender and its intersectionality with other social stratifications, through explicit protection and careful linking of benefits to needs of target populations (e.g. poor women, unemployed men, female-headed households), movement towards UHC can fail to achieve gender balance or improve equity, and may even exacerbate gender inequity. Political trade-offs are made on the road to UHC and the needs of less powerful groups, which can include women and children, are not necessarily given priority.We identify the need for closer collaboration between health economists and gender experts, and highlight a number of research gaps in this field which should be addressed. While some aspects of cost sharing and some analysis of expenditure on maternal and child health have been analysed from a gender perspective, there is a much richer set of research questions to be explored to guide policy making. Given the political nature of UHC decisions, political economy as well as technical research should be prioritized.We conclude that countries should adopt an equitable approach towards achieving UHC and, therefore, prioritize high-need groups and those requiring additional financial protection, in particular women and children. This constitutes the 'progressive universalism' advocated for by the 2013 Lancet Commission on Investing in Health.

The impact of health insurance on maternal health care utilization: evidence from Ghana, Indonesia and Rwanda

While research has assessed the impact of health insurance on health care utilization, few studies have focused on the effects of health insurance on use of maternal health care. Analyzing nationally representative data from the Demographic and Health Surveys (DHS), this study estimates the impact of health insurance status on the use of maternal health services in three countries with relatively high levels of health insurance coverage-Ghana, Indonesia and Rwanda. The analysis uses propensity score matching to adjust for selection bias in health insurance uptake and to assess the effect of health insurance on four measurements of maternal health care utilization: making at least one antenatal care visit; making four or more antenatal care visits; initiating antenatal care within the first trimester and giving birth in a health facility. Although health insurance schemes in these three countries are mostly designed to focus on the poor, coverage has been highly skewed toward the rich, especially in Ghana and Rwanda. Indonesia shows less variation in coverage by wealth status. The analysis found significant positive effects of health insurance coverage on at least two of the four measures of maternal health care utilization in each of the three countries. Indonesia stands out for the most systematic effect of health insurance across all four measures. The positive impact of health insurance appears more consistent on use of facility-based delivery than use of antenatal care. The analysis suggests that broadening health insurance to include income-sensitive premiums or exemptions for the poor and low or no copayments can increase use of maternal health care.

Determinants and the impact of the National Health Insurance on neonatal mortality in Ghana

The national health insurance was established to increase access to health care services and the maternal component was later introduced to improve the health outcomes of both mother and child. The main objectives of this study are to investigate the factors that affect neonatal deaths as well as examine the effect of the Ghana Health Insurance on neonatal deaths in Ghana. Using the most recent round of the Ghana Demographic and Health Survey, the study estimates the probit model with interaction effects to account for the heterogeneity in outcomes. Additionally, the study employs the propensity score matching approach to account for the possible endogeneity in the insurance enrolment decision. Results from the estimations, after controlling for relevant individual and household characteristics suggest that the national health insurance significantly reduces the likelihood of neonatal deaths. Estimates remain consistent even after more robust estimators are employed. Estimates from the interaction between place of residence and health insurance indicate that health insurance beneficiaries who reside in urban areas are at a higher risk of neonatal deaths compared to other women. Access to medical facilities proxied by distance to the nearest health post emerged as an important predictor of neonatal death. The study also suggests significant regional differences in neonatal deaths. We, therefore, conclude that the national health insurance may have the potential to substantially improve the health outcomes of neonates and have policy implications for increasing coverage to more mothers and their neonates, as well as coverage in critical neonatal services and drugs.

Stakeholders Perspectives on the Success Drivers in Ghana's National Health Insurance Scheme - Identifying Policy Translation Issues

Background: Ghana’s National Health Insurance Scheme (NHIS), established by an Act of Parliament (Act 650), in 2003 and since replaced by Act 852 of 2012 remains, in African terms, unprecedented in terms of growth and coverage. As a result, the scheme has received praise for its associated legal reforms, clinical audit mechanisms and for serving as a hub for knowledge sharing and learning within the context of South-South cooperation. The scheme continues to shape national health insurance thinking in Africa. While the success, especially in coverage and financial access has been highlighted by many authors, insufficient attention has been paid to critical and context-specific factors. This paper seeks to fill that gap.

Methods: Based on an empirical qualitative case study of stakeholders’ views on challenges and success factors in four mutual schemes (district offices) located in two regions of Ghana, the study uses the concept of policy translation to assess whether the Ghana scheme could provide useful lessons to other African and developing countries in their quest to implement social/NHISs.

Results: In the study, interviewees referred to both ‘hard and soft’ elements as driving the "success" of the Ghana scheme. The main ‘hard elements’ include bureaucratic and legal enforcement capacities; IT; financing; governance, administration and management; regulating membership of the scheme; and service provision and coverage capabilities. The ‘soft’ elements identified relate to: the background/context of the health insurance scheme; innovative ways of funding the NHIS, the hybrid nature of the Ghana scheme; political will, commitment by government, stakeholders and public cooperation; social structure of Ghana (solidarity); and ownership and participation.

Conclusion: Other developing countries can expect to translate rather than re-assemble a national health insurance programme in an incomplete and highly modified form over a period of years, amounting to a process best conceived as germination as opposed to emulation. The Ghana experience illustrates that in adopting health financing systems that function well, countries need to customise systems (policy customisation) to suit their socio-economic, political and administrative settings. Home-grown health financing systems that resonate with social values will also need to be found in the process of translation

Effectiveness of advertising availability of prenatal ultrasound on uptake of antenatal care in rural Uganda: A cluster randomized trial

In rural Uganda pregnant women often lack access to health services, do not attend antenatal care, and tend to utilize traditional healers/birth attendants. We hypothesized that receiving a message advertising that "you will be able to see your baby by ultrasound" would motivate rural Ugandan women who otherwise might use a traditional birth attendant to attend antenatal care, and that those women would subsequently be more satisfied with care. A cluster randomized trial was conducted across eight rural sub-counties in southwestern Uganda. Sub-counties were randomized to a control arm, with advertisement of antenatal care with no mention of portable obstetric ultrasound (four communities, n = 59), or an intervention arm, with advertisement of portable obstetric ultrasound. Advertisement of portable obstetric ultrasound was further divided into intervention A) word of mouth advertisement of portable obstetric ultrasound and antenatal care (one communitity, n = 16), B) radio advertisement of only antenatal care and word of mouth advertisement of antenatal care and portable obstetric ultrasound (one community, n = 7), or C) word of mouth + radio advertisement of both antenatal care and portable obstetric ultrasound (two communities, n = 75). The primary outcome was attendance to antenatal care. 159 women presented to antenatal care across eight sub-counties. The rate of attendance was 65.1 (per 1000 pregnant women, 95% CI 38.3-110.4) where portable obstetric ultrasound was advertised by radio and word of mouth, as compared to a rate of 11.1 (95% CI 6.1-20.1) in control communities (rate ratio 5.9, 95% CI 2.6-13.0, p<0.0001). Attendance was also improved in women who had previously seen a traditional healer (13.0, 95% CI 5.4-31.2) compared to control (1.5, 95% CI 0.5-5.0, rate ratio 8.7, 95% CI 2.0-38.1, p = 0.004). By advertising antenatal care and portable obstetric ultrasound by radio attendance was significantly improved. This study suggests that women can be motivated to attend antenatal care when offered the concrete incentive of seeing their baby.

Stakeholders' views on maternity care shortcomings in rural Ghana: An ethnographic study among women, providers, public, and quasiprivate policy sector actors

Access to skilled provider and emergency obstetric care is not universal across all districts in Ghana. The lived experiences of 3 stakeholder groups on maternity care shortcomings in 3 rural Ghanaian districts are examined in this study. We applied an ethnographic study approach where field data were collected between March to May 2015 in 3 rural districts of northern Ghana. Data were collected among women with recent births experiences (n = 90), health care providers (n = 16), and policy actors (n = 6). Transcripts were read through to identify similar and divergent stakeholders' views. Significant expressions and experiences of stakeholders on maternity care shortcomings were extracted and evaluated to define key themes. Four themes emerged: social/community factors, payments for health care, facility level factors, and policy level factors. The results show that traditional women's roles divest time for maternity care. Poor transport arrangements, insufficient health workforce, health funding gaps, insurance reimbursements delays, and catastrophic health expenditures on travel and drugs are attested as major barriers across all stakeholder groups in all districts studied. The discussion of the study findings suggests it is important to ascertain the scale of informal payments and their impacts on health access. Investments in health workforce and reliable ambulatory service systems could help address poor referral difficulties in rural areas of the country. Social support for community initiatives that pool funds could provide extra resources and relieve cost access-related challenges for using maternity care in rural settings in Ghana.

Providers of antenatal care services in Ghana: evidence from Ghana demographic and health surveys 1988-2014

Background

Antenatal care is one of the three most essential care - antenatal, delivery and post-natal, given to women during pregnancy and has the potential to contribute towards the achievement of the Sustainable Development Goal (SDG) target 3.1- reducing the global maternal mortality ratio to less than 70 per 100,000 and target 3.8 – achieve universal health coverage. The main objective is to examine the contribution of the various providers of antenatal care services in Ghana from 1988 to 2014.

Methods

The study uses data from all the six rounds of the Ghana Demographic and Health Survey (GDHS). Binary logistic regression models were applied to examine the association between background characteristics of respondents and providers of antenatal care services.

Results

The results show that majority of antenatal care services were provided by nurses over the period under review. The proportion of women who received antenatal care services from nurses improved over the period from 55% in 1988 to 89.5% in 2014. Moreover, there was a decline in antenatal care services provided by traditional birth attendants and women who did not receive antenatal care services from any service provider over the years under review. It was observed that women from rural areas were more likely to utilise antenatal care services provided by traditional birth attendants, whilst those from urban areas were more likely to utilise antenatal care from doctors and nurses.

Conclusion

To further improve access to and utilisation of antenatal care services provided by nurses and doctors it is recommended that the Ghana Health Service and the Ministry of Health should put in place systems aimed at improving on the quality of care given such as regular training workshops for health personnel and assessment of patient’s satisfaction with services provided. Also, they should encourage women in rural areas especially those from the savannah zone to utilise antenatal care services from skilled providers through social and behaviour change communication campaigns.

Inequality trends in maternal health services for young Ghanaian women with childbirth history between 2003 and 2014

OBJECTIVE

To achieve universal coverage of reproductive healthcare and drastic reduction in maternal mortality, adequate attention and resources should be given to young women. This study therefore aimed to examine the inequality trends in the use of antenatal care (ANC) services and skilled birth attendance (SBA) within a subgroup of Ghanaian women aged 15-24 years between 2003 and 2014.

DESIGN

This is a cross-sectional study that used data from the Ghana Demographic and Health Surveys (DHS) 2003, 2008 and 2014. We applied regression-based total attributable fraction (TAF) as an index for measuring multiple dimensions of inequality in the use of ANC and SBA.

SETTING

Ghana.

PARTICIPANTS

Young women aged 15-24 years with at least one previous birth experience in the past 5 years prior to the surveys.

MAIN OUTCOME MEASURES

ANC visits and skilled attendance at birth.

RESULTS

Urbanicity-related, education-related and wealth-related inequality in non-use of SBA declined between 2003 and 2008, but increased between 2008 and 2014. A consistent decline was observed in urbanicity-related inequality in non-use of four or more ANC visits from 2003 through 2008 to 2014. A similar reduction was observed for education-related inequality in relation to the same outcome. In contrast, wealth-related inequality in ANC usage increased over time.

CONCLUSIONS

The rise in urbanicity-related, education-related and wealth-related inequality in the usage of SBA between 2008 and 2014 threatens the sustainability of the general progress made in the usage of maternal health services in Ghana within the same period.