Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling, who is not and why?

The role of gender in health insurance enrollment among geriatric caregivers: results from the 2022 informal caregiving, health, and healthcare survey in Ghana

BACKGROUND

Female informal caregivers of older adults experience a higher burden of physical and mental health problems compared to their male counterparts due to the greater intensity of care they provide. This is likely to result in an imbalance in health needs, including health insurance enrollment, between male and female informal caregivers of older adults. However, to date, no study is available on the role of gender in health insurance enrollment among informal caregivers of older adults in Ghana. This study examines the association between gender and health insurance enrollment among informal caregivers of older adults in Ghana.

METHODS

Cross-sectional data from the Informal Caregiving, Health, and Healthcare Survey among caregivers of older adults aged 50 years or above (N = 1,853 and mean ages =   39.15 years and  75.08 years of informal caregivers and their care recipients, respectively) in Ghana were analyzed. A binary logit regression model was used to estimate the association between gender and health insurance enrollment. All statistical inferences were made at the 5% significance level.

RESULTS

The final Model (3) showed that female informal caregivers were 2.70 times significantly more likely to enrol in a health insurance scheme than their male counterparts (AOR: 2.70, 95% CI: 2.09-3.48, p-value = 0.001). Apart from gender, the results revealed that participants aged 55-64 years (AOR = 2.38, 95%CI: 1.29-4.41, p-value = 0.006), with tertiary education (AOR: 3.62, 95% CI: 2.32-5.66, p-value = 0.001) and living with the care recipients (AOR: 1.50, 95% CI: 1.14-1.98, p-value = 0.003) were significantly more likely to enrol in a health insurance scheme than their counterparts. The findings further showed that those who earned between GH¢1000 and 1999 (US$99.50-198.50) monthly (AOR: 0.70, 95% CI: 0.52-0.95, p-value = 0.022) and were affiliated with African traditional religion (AOR: 0.30, 95%CI: 0.09-0.99, p-value = 0.048) were significantly less likely to enrol in a health insurance scheme than their counterparts.

CONCLUSION

Gender was a significant predictor of health insurance enrollment among informal caregivers of older adults. This finding contributes to the empirical debates on the role of gender in health insurance enrollment among informal caregivers of older adults. Policymakers need to develop gender-specific measures to address gender gaps in health insurance enrollment among informal caregivers of older adults in Ghana. Such health policies and programs should consider other significant demographic and socioeconomic factors associated with health insurance enrolment among informal caregivers of older adults in Ghana.

Prevalence, perceptions and associated factors of health insurance enrollment among older persons in selected cash grant communities in Ghana: a cross-sectional mixed method

BACKGROUND

Universal Health Coverage has been openly recognized in the United Nations health-related Sustainable Development Goals by 2030, though missing under the Millennium Development Goals. Ghana implemented the National Health Insurance Scheme programme in 2004 to improve financial access to healthcare for its citizens. This programme targeting low-income individuals and households includes an Exempt policy for older persons and indigents. Despite population ageing, evidence of the participation and perceptions of older persons in the scheme in cash grant communities is unknown. Hence, this paper examined the prevalence, perceptions and factors associated with health insurance enrollment among older persons in cash grant communities in Ghana.

METHODS

Data were from a cross-sectional household survey of 400 older persons(60 + years) and eight FGDs between 2017 and 2018. For the survey, stratified and simple random sampling techniques were utilised in selecting participants. Purposive and stratified sampling techniques were employed in selecting the focus group discussion participants. Data analyses included descriptive, modified Poisson regression approach tested at a p-value of 0.05 and thematic analysis. Stata and Atlas-ti software were used in data management and analyses.

RESULTS

The mean age was 73.7 years. 59.3% were females, 56.5% resided in rural communities, while 34.5% had no formal education. Two-thirds were into agriculture. Three-fourth had non-communicable diseases. Health insurance coverage was 60%, and mainly achieved as Exempt by age. Being a female [Adjusted Prevalence Ratio (APR) 1.29, 95%CI:1.00-1.67], having self-rated health status as bad [APR = 1.34, 95%CI:1.09-1.64] and hospital healthcare utilisation [APR = 1.49, 95%CI:1.28-1.75] were positively significantly associated with health insurance enrollment respectively. Occupation in Agriculture reduced insurance enrollment by 20.0%. Cited reasons for poor perceptions of the scheme included technological challenges and unsatisfactory services.

CONCLUSION

Health insurance enrollment among older persons in cash grant communities is still not universal. Addressing identified challenges and integrating the views of older persons into the programme have positive implications for securing universal health coverage by 2030.

Spatial distribution and geographical heterogeneity factors associated with households' enrollment level in community-based health insurance

Background

Healthcare service utilization is unequal among different subpopulations in low-income countries. For healthcare access and utilization of healthcare services with partial or full support, households are recommended to be enrolled in a community-based health insurance system (CBHIS). However, many households in low-income countries incur catastrophic health expenditure. This study aimed to assess the spatial distribution and factors associated with households' enrollment level in CBHIS in Ethiopia.

Methods

A cross-sectional study design with two-stage sampling techniques was used. The 2019 Ethiopian Mini Demographic and Health Survey (EMDHS) data were used. STATA 15 software and Microsoft Office Excel were used for data management. ArcMap 10.7 and SaTScan 9.5 software were used for geographically weighted regression analysis and mapping the results. A multilevel fixed-effect regression was used to assess the association of variables. A variable with a p < 0.05 was considered significant with a 95% confidence interval.

Results

Nearly three out of 10 (28.6%) households were enrolled in a CBHIS. The spatial distribution of households' enrollment in the health insurance system was not random, and households in the Amhara and Tigray regions had good enrollment in community-based health insurance. A total of 126 significant clusters were detected, and households in the primary clusters were more likely to be enrolled in CBHIS. Primary education (AOR: 1.21, 95% CI: 1.05, 1.31), age of the head of the household >35 years (AOR: 2.47, 95% CI: 2.04, 3.02), poor wealth status (AOR: 0.31, 95% CI: 0.21, 1.31), media exposure (AOR: 1.35, 95% CI: 1.02, 2.27), and residing in Afar (AOR: 0.01, 95% CI: 0.003, 0.03), Gambela (AOR: 0.03, 95% CI: 0.01, 0.08), Harari (AOR: 0.06, 95% CI: 0.02, 0.18), and Dire Dawa (AOR: 0.02, 95% CI: 0.01, 0.06) regions were significant factors for households' enrollment in CBHIS. The secondary education status of household heads, poor wealth status, and media exposure had stationary significant positive and negative effects on the enrollment of households in CBHIS across the geographical areas of the country.

Conclusion

The majority of households did not enroll in the CBHIS. Effective CBHIS frameworks and packages are required to improve the households' enrollment level. Financial support and subsidizing the premiums are also critical to enhancing households' enrollment in CBHIS.

Effect of social capital on enrolment of informal sector occupational groups in the national health insurance scheme in Ghana: a cross-sectional survey

BACKGROUND

Enrolment of informal sector workers in Ghana's National Health Insurance Scheme (NHIS) is critical to achieving increased risk-pooling and attainment of Universal Health Coverage. However, the NHIS has struggled over the years to improve enrolment of this subpopulation. This study analysed effect of social capital on enrolment of informal sector workers in the NHIS.

METHODS

A cross-sectional survey was conducted among 528 members of hairdressers and beauticians, farmers, and commercial road transport drivers' groups. Descriptive statistics, principal component analysis, and multinomial logit regression model were used to analyse the data.

RESULTS

Social capital including membership in occupational group, trust, and collective action were significantly associated with enrolment in the NHIS, overall. Other factors such as household size, education, ethnicity, and usual source of health care were, however, correlated with both enrolment and dropout. Notwithstanding these factors, the chance of enrolling in the NHIS and staying active was 44.6% higher for the hairdressers and beauticians; the probability of dropping out of the scheme was 62.9% higher for the farmers; and the chance of never enrolling in the scheme was 22.3% higher for the commercial road transport drivers.

CONCLUSIONS

Social capital particularly collective action and predominantly female occupational groups are key determinants of informal sector workers' participation in the NHIS. Policy interventions to improve enrolment of this subpopulation should consider group enrolment, targeting female dominated informal sector occupational groups. Further studies should consider inclusion of mediating and moderating variables to provide a clearer picture of the relationship between occupational group social capital and enrolment in health insurance schemes.

Barriers and Motivations for Health Insurance Subscription Among Health-Care Users in Cameroon

INTRODUCTION

Surgical care is a significant component of the overall health expenditure in low- and middle-income countries. In Cameroon, out-of-pocket payments for surgical service are very high with many patients declining potentially curative surgical procedures. Less than 2% of the population is enrolled in a health insurance scheme leading to a propensity for catastrophic health expenses when accessing care. To assess the perceived barriers and motivations for health insurance subscription among health-care users in Cameroon.

METHODS

This was a cross-sectional community-based qualitative study conducted in the Center Region of Cameroon. A total of 37 health-care users (health insurance subscribers and nonsubscribers) were purposively identified. Four focused group discussions and thirteen in-depth interviews were conducted. All anonymized transcripts were analyzed using a thematic analysis approach.

RESULTS

The six major themes identified as barriers to health insurance subscription were lack of trust in the existing health insurance schemes, inadequate knowledge on how health insurance works, premiums believed to be too expensive, the complexity of the claims processing system, minimal usage of health-care services and practice of self-medication. Motivational factors included the knowledge of having access to quality health services even without money in the event of an unforeseen illness and having a large family/household size. The importance of mass sensitization on the benefits of health insurance was noted.

CONCLUSION

Health insurance is still very underutilized in Cameroon. This results in significant out-of-pocket payment for health services by Cameroonians with catastrophic consequences to households. With most Cameroonians in the informal sector and underemployed, it is imperative to put in place a national strategic plan to overcome existing barriers and increase health insurance coverage especially among the poor. This has the potential to significantly increase access to safe, quality, timely and affordable surgical care.

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.

Can a private sector engagement intervention that prioritizes pro-poor strategies improve healthcare access and quality? A randomized field experiment in Kenya

Private sector engagement in health reform has been suggested to help reduce healthcare inequities in sub-Saharan Africa, where populations with the most need seek the least care. We study the effects of African Health Markets for Equity (AHME), a cluster randomized controlled trial carried out in Kenya from 2012 to 2020 at 199 private health clinics. AHME included four clinic-level interventions: social health insurance, social franchising, SafeCare quality-of-care certification programme and business support. This paper evaluates whether AHME increased the capacity of private health clinics to serve poor clients while maintaining or enhancing the quality of care provided. At endline, clinics that received AHME were 14.5 percentage points (pp) more likely to be empanelled with the National Health Insurance Fund (NHIF), served 51% more NHIF clients and served more clients from the middle three quintiles of the wealth distribution compared to control clinics. Comparing individuals living in households near AHME treatment and control clinics (N = 8241), AHME led to a 6.7-pp increase in the probability of holding any health insurance on average. We did not find any additional effect of AHME on insurance holding among poor households. We measured quality of care using a standardized patient (SP) experiment (N = 596 SP-provider interactions) where recruited and trained SPs were randomized to present as either 'not poor', and able to afford all services provided, or 'poor' by telling the provider they could only afford ∼300 Kenyan Shillings (US$3) in fees. We found that poor SPs received lower levels of both correct and unnecessary services, and AHME did not affect this. More work must be done to ensure that clients of all wealth levels receive high-quality care.

Barriers to health care access and utilization among aged indigents under the Livelihood Empowerment Against Poverty Programme (LEAP): the perspective of users and service providers in north-western Ghana

AIM

This article draws on the poverty and access to health care framework to explore the barriers to access and utilization of primary health care among aged indigents under the Livelihood Empowerment Against Poverty Programme (LEAP) in Ghana.

BACKGROUND

Although many developing countries have made progress in extending primary health care to their populations following the Alma-Ata Declaration of 1978, the establishment of the Millennium Development Goals, and the Sustainable Development Goals (SDGs), barriers remain pervasive, particularly among vulnerable population groups. Previous studies have hardly paid in-depth attention to this important indicator for measuring progress toward achieving SDG 3.

METHODOLOGY

To this end, we conducted a case study of access to health care services and utilization among aged indigents enrolled on the LEAP programme in the Daffiama Bussie Issa District of the Upper West. We collected and analyzed qualitative data from indigents aged 65 years and above, health care providers, and staff of the LEAP and the National Health Insurance Scheme (NHIS).

FINDINGS

Our analysis found geographic inaccessibility of health care, high costs of drugs and related services, exclusion of essential services from NHIS benefits package, and irregular transfer of cash to negatively influence access and utilization of health care among aged LEAP beneficiaries in the district. In addition to the need to strengthen the economy, provide health infrastructure and human resources for health in rural areas, the government needs to review the beneficiaries' bimonthly stipends to reflect the daily minimum wage, eliminate the delay in payments, and review the benefits package of the NHIS to include essential services and medical devices commonly used by aged people. Yet implementing these recommendations has affordability implications that require innovation to mobilize additional resources and create the desired fiscal space and institutions that can sustainably implement universal coverage programmes such as the LEAP.

Factors influencing the free maternal health care policy under the national health insurance scheme's provision for skilled delivery services in Ghana: a narrative literature review

BACKGROUND

Skilled Birth Attendance (SBA) is important in achieving the Sustainable Development Goals (SDGs) targets 3.1, 3.2 and 3.3.1. Ghana has made steady progress in SBA, yet, unsupervised deliveries still occur. The introduction of the Free Maternal Health Care Policy under the National Health Insurance Scheme (FMHCP under the NHIS) has improved the uptake of SBA but with some implementation challenges. This narrative review sought to explore the factors influencing the FMHCP under the NHIS provision for skilled delivery services in Ghana.

METHODS

Electronic searches were conducted of databases including PubMed, Popline, Science direct, BioMed Central, Scopus and Google scholar for peer reviewed articles as well as grey articles from other relevant sources, published between 2003 and 2021 on factors influencing FMHCP/NHIS provision for skilled delivery services in Ghana. Keywords used in the literature search were in various combinations for the different databases. The articles were screened to determine the inclusion and exclusion criteria and quality was assessed using a published critical appraisal checklist. A total of 516 articles were retrieved for initial screening based on their titles, of which 61 of them, were further screened by reading their abstracts and full text. Of this number, 22 peer-reviewed and 4 grey articles were selected for the final review based on their relevance.

RESULTS

The study revealed that the FMHCP under the NHIS does not cover the full costs associated with skilled delivery and low socioeconomic status of households affects SBA. Also, funding and sustainability, hinders the quality-of-service delivery offered by the policy.

CONCLUSION

For Ghana to achieve the SDGs above and further improve SBA, the cost associated with skilled delivery should be fully covered by the NHIS. Also, the government and the key stakeholders involved in the policy implementation, must put in place measures that will enhance the operation and the financial sustainability of the policy.

Long-term care insurance purchase decisions of registered nurses: Deep learning versus logistic regression models

OBJECTIVE

The purpose of this study was to use a deep learning model and a traditional statistical regression model to predict the long-term care insurance decisions of registered nurses.

METHODS

We Prospectively surveyed 1,373 registered nurses with a minimum of 2 years of full-time working experience at a large medical center in Taiwan: 615 who already owned long-term care insurance (LTCI), 332 who had no intention to purchase LTCI (group 1), and 426 who intended to purchase LTCI (group 2).

RESULTS

After inverse probability of treatment weighting (IPTW), no statistically significant differences were identified in the study characteristics of the two groups. All the performance indices for the deep neural network (DNN) model were significantly higher than those of the multiple logistic regression (MLR) model (P<0.001). The strongest predictor of an individual's long-term care insurance decision was their risk propensity score, followed by their caregiving responsibilities, whether they live with older adult relatives, their experiences of catastrophic illness, and their openness to experience.

CONCLUSIONS

The DNN model is useful for predicting long-term care insurance decisions. Its prediction accuracy can be increased through training with temporal data collected from registered nurses. Future research can explore designs for two-level or multilevel models that explain the contextual effects of the risk factors on long-term care insurance decisions.

Confidence in the health system and health insurance enrollment among the informal sector population in Lusaka, Zambia

BACKGROUND

To improve equitable access to quality essential services and reduce financial hardship, low-and-middle-income countries are increasingly relying on prepayment strategies such as health insurance schemes. Among the informal sector population, confidence in the health system to provide effective treatment and trust in institutions can play an important role in health insurance enrollment. The objective of this study was to examine the extent to which confidence and trust affect enrollment into the recently introduced Zambia National Health insurance.

METHODS

We conducted a regionally representative cross-sectional household survey in Lusaka, Zambia collecting information on demographics, health expenditure, ratings of last health facility visit, health insurance status and confidence in the health system. We used multivariable logistic regression to assess the association between enrollment and confidence in the private and public health sector as well as trust in the government in general.

RESULTS

Of the 620 respondents interviewed, 70% were enrolled or planning to enroll in the health insurance. Only about one-fifth of respondents were very confident that they would receive effective care in the public health sector 'if they became sick tomorrow' while 48% were very confident in the private health sector. While confidence in the public system was only weakly associated with enrollment, confidence in the private health sector was strongly associated with enrollment (Adjusted odds ratio (AOR) 3.40 95% CI 1.73 - 6.68). No association was found between enrollment and trust in government or perceived government performance.

CONCLUSIONS

Our results suggest that confidence in the health system, particularly in the private health sector, is strongly associated with health insurance enrollment. Focusing on achieving high quality of care across all levels of the health system may be an effective strategy to increase enrollment in health insurance.

Determinants of national health insurance enrolment among people at risk of statelessness in the Awutu Senya East Municipality and Gomoa East District of Ghana

BACKGROUND

This paper investigates the factors influencing the decision to enrol in Ghana's National Health Insurance Scheme (NHIS) among people at risk of statelessness, with emphasis on the individual's demographic and socioeconomic factors.  METHODS: The study used data from a cross-sectional household survey undertaken in the Awutu Senya East Municipality and Gomoa East District of Ghana's Central Region between March 9 and June 26, 2021, on healthcare utilization culture among people at risk of statelessness. Descriptive statistics and binary logistic regression were used in analysing data from a sample of 384 people at risk of statelessness.  RESULTS: The results reveal that about 51% of the at-risk population have ever enrolled while 48% of the respondents were enrolled on the NHIS at the time of the survey (active members). The majority of the enrolled members acquired their membership through self-payment of the enrolment fee. Additionally, respondents aged 26-35 had higher odds of enrolling, whiles those within 56-65 years had lower odds of enrolling in health insurance. Also, persons who are married and have a high school education or an equivalent qualification were more likely to enrol, while persons with no employment were less likely to enrol.

CONCLUSION

According to the paper, while the gap in coverage between rich and poor, married and single appears to have narrowed, these factors continue to determine NHIS coverage among people at risk of statelessness. The same is true for education. Efforts must be increased to ensure equal access to healthcare financing interventions for better access to health services.

Effect of Health Insurance Uptake on Hesitancy toward COVID-19 Vaccines in Nigeria: A Recursive Bivariate Probit and Decomposition Estimation

Moral hazard remains one of the major challenges of health insurance administration. This paper recursively analyzed the effect of health insurance on the willingness to take COVID-19 vaccines in Nigeria. The data comprised 1892 unvaccinated respondents in the 2021/2022 National Longitudinal Phone Survey (NLPS). The data were analyzed with Coban's recursive probit regression and decomposition approaches. The results revealed that 5.87% were health insured, and 7.93% were willing to take COVID-19 vaccines. Health insurance uptake significantly increased (p < 0.05) with an adult being the decision-maker on vaccination, requiring family planning, and urban residence, while it reduced with loss of jobs and residence in the southeast and southwest zones. In addition, health insurance significantly (p < 0.01) increased the willingness to take COVID-19 vaccines, along with each adult, all adults, and households' heads being the major vaccination decision-makers, loss of jobs, and support for making COVID-19 vaccines compulsory. The average treatment effects (ATEs) and average treatment effect on the treated (ATET) of health insurance were significant (p < 0.01), with positive impacts on willingness to be vaccinated. It was concluded that policy reforms to promote access to health insurance would enhance COVID-19 vaccination in Nigeria. In addition, hesitancy toward COVID-19 vaccines can be reduced by targeting adults and household heads with adequate information, while health insurance uptake should target southern states and rural areas.

Equity of national publicly funded health insurance schemes under the universal health coverage agenda: a systematic review of studies conducted in Africa

BACKGROUND

The implementation of publicly funded health insurance schemes (PFHIS) is the major strategy to drive progress and achievement of universal health coverage (UHC) by 2030. We appraised evidence on the equity of insurance schemes across Africa.

METHODS

We conducted a systematic review of published studies that assessed equity in health insurance schemes implemented under the UHC agenda in Africa. Seven databases, Web of Science, Medline, CINAHL, Scopus, Cochrane Library, EMBASE and World Bank eLibrary, were searched; we operationalized the PROGRESS-Plus (place of residence; race/ethnicity/culture/language; occupation; gender/sex religion; education; socioeconomic status; social capital) equity framework to assess equity areas.

RESULTS

Forty-five studies met the inclusion criteria and were included in the study, in which 90% assessed equity by socioeconomic status. Evidence showed that rural residents, those self-employed or working in the informal sector, men, those with lower educational attainment, and the poor were less likely to be covered by health insurance schemes. Broadly, the insurance schemes, especially, community-based health insurance (CBI) schemes improved utilization by disadvantaged groups, however, the same groups were less likely to benefit from health services.

CONCLUSIONS

Evidence on equity of PFHIS is mixed, however, CBI schemes seem to offer more equitable coverage and utilization of essential health services in Africa.

The effect of community engagement on healthcare utilization and health insurance enrollment in Ghana: Results from a randomized experiment

Health insurance enrollment in many Sub-Saharan African countries is low, even with highly subsidized premiums and exemptions for vulnerable populations. One possible explanation is low service quality, which results in a low valuation of health insurance. Using a randomized control trial in 64 primary health care facilities in Ghana, this study assesses the impact of a community engagement intervention designed to improve the quality of healthcare and health insurance services on households living nearby the facilities. Although the intervention improved the medical-technical quality of health services, our results show that households' subjective perceptions of the quality of healthcare and insurance services did not increase. Nevertheless, the likelihood of illness and concomitant healthcare utilization reduced, and especially households who were not insured at baseline were more likely to enroll in health insurance. The results show that solely increasing the technical quality of care is not sufficient to increase households' subjective assessments of healthcare quality. Still, improving technical quality can directly contribute to health outcomes and further increase health insurance coverage, especially among the previously uninsured.

Women empowerment and health insurance utilisation in Rwanda: a nationwide cross-sectional survey

Background

Health insurance coverage is one of the several measures being implemented to reduce the inequity in access to quality health services among vulnerable groups. Although women’s empowerment has been viewed as a cost-effective strategy for the reduction of maternal and child morbidity and mortality, as it enables women to tackle the barriers to accessing healthcare, its association with health insurance usage has been barely investigated. Our study aims at examining the prevalence of health insurance utilisation and its association with women empowerment as well as other socio-demographic factors among Rwandan women.

Methods

We used Rwanda Demographic and Health Survey (RDHS) 2020 data of 14,634 women aged 15–49 years, who were selected using multistage sampling. Health insurance utilisation, the outcome variable was a binary response (yes/no), while women empowerment was assessed by four composite indicators; exposure to mass media, decision making, economic and sexual empowerment. We conducted multivariable logistic regression to explore its association with socio-demographic factors, using SPSS (version 25).

Results

Out of the 14,634 women, 12,095 (82.6%) (95% CI 82.0–83.2) had health insurance, and the majority (77.2%) were covered by mutual/community organization insurance. Women empowerment indicators had a negative association with health insurance utilisation; low (AOR = 0.85, 95% CI 0.73–0.98) and high (AOR = 0.66, 95% CI 0.52–0.85) exposure to mass media, high decision making (AOR = 0.78, 95% CI 0.68–0.91) and high economic empowerment (AOR = 0.63, 95% CI 0.51–0.78). Other socio-demographic factors found significant include; educational level, wealth index, and household size which had a negative association, but residence and region with a positive association.

Conclusions

A high proportion of Rwandan women had health insurance, but it was negatively associated with women’s empowerment. Therefore, tailoring mass-media material considering the specific knowledge gaps to addressing misinformation, as well as addressing regional imbalance by improving women’s access to health facilities/services are key in increasing coverage of health insurance among women in Rwanda.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictors of Healthcare Utilization Among Older Adults with Moderate to Severe Cognitive Limitations in Ghana: A Cross-Sectional Analysis of the WHO Study on Global Ageing and Adult Health (SAGE) Wave 1

BACKGROUND

As the number of older adults in Ghana keeps increasing, so does the prevalence of aging-related diseases and conditions that tend to lead to cognitive decline. However, knowledge on the predicting factors of healthcare utilization among older adults with cognitive limitations is still scarce.

OBJECTIVE

This study examines the predictive factors of healthcare-seeking behavior among older adults with moderate-to-severe cognitive limitations in Ghana.

METHODS

Based on Andersen's behavioral model of health service utilization, the study analyzed data from 3106 older adults with moderate to severe cognitive limitations in Ghana aged 50+ using Bivariate Probit Regression and the Heckman Selection Model.

RESULTS

Results showed that individuals who were aged 75+, living in urban settlements, educated, higher income levels and parents who had some level of education, pension benefits, and both mandatory and voluntary health insurance were more likely to seek inpatient care. Enabling resources such as the national health insurance scheme and other types of medical insurance, household income, pension benefits, and predisposition factors like education influenced outpatient and inpatient healthcare consumption for older adults with moderate to severe cognitive limitations but had little influence on the choice of healthcare facility except for health insurance.

CONCLUSION

Since the healthcare-seeking behavior of older adults with moderate-to-severe cognitive limitations is driven by an amalgamation of several internal and external factors, there is a need for policy change to understand and cautiously incorporate these factors into the decision to improve equitable access to healthcare services for these individuals, as not all sizes fit all in providing quality care for them.

Estimating willingness to pay for public health insurance while accounting for protest responses: A further step towards universal health coverage in Tunisia?

Introduction

Developing countries face major challenges in implementing universal health coverage (UHC): a widespread informal sector, general discontent with rising economic insecurity and inequality and the rollback of state and public welfare. Under such conditions, estimating the demand for a health insurance scheme (HIS) on voluntary basis can be of interest to accelerate the progress of UHC‐oriented reforms. However, a major challenge that needs to be addressed in such context is related to protest attitudes that may reflect, inter alia, a null valuation of the expected utility or unexpressed demand.

Methods

We propose to tackle this by applying a contingent valuation survey to a non‐healthcare‐covered Tunisian sample vis‐à‐vis joining and paying for a formal HIS. Our design pays particular attention to identifying the nature of the willingness‐to‐pay (WTP) values obtained, distinguishing genuine null values from protest values. To correct for potential selection issues arising from protest answers, we estimate an ordered‐Probit‐selection model and compare it with the standard Tobit and Heckman sample selection models.

Results

Our results support the presence of self‐selection and, by predicting protesters' WTP, allow the “true” sample mean WTP to be computed. This appears to be about 14% higher than the elicited mean WTP.

Conclusion

The WTP of the poorest non‐covered respondents represents about one and a half times the current contributions of the poorest formal sector enrolees, suggesting that voluntary participation in the formal HIS is feasible.

We study how protest positions may impact affiliation to formal health insurance

We apply a contingent valuation survey to a non‐healthcare‐covered population

We account and correct for selection issues with appropriate econometric models

Accounting for protest positions is found to impact the implementation of UHC

Strategic Health Purchasing Progress Mapping: A Spotlight on Ghana's National Health Insurance Scheme

Ghana is a lower-middle-income economy that has made significant efforts to improve its health system, in order to achieve universal health coverage. Ghana has adopted strategic health purchasing as an important tool for efficient utilization of resources. This paper focuses on Ghana's National Health Insurance Scheme (NHIS) analyzing its governance arrangements and purchasing functions; and providing recommendations for improvement. The study applied the Strategic Health Purchasing Progress Tracking Framework co-created by the Strategic Purchasing Africa Resource Center (SPARC) and its partners to collect data from secondary and primary sources between September 2019 and June 2020. A descriptive and narrative approach was used to synthesize information on the NHIS governance arrangements and purchasing functions based on the framework. Benchmarks were used to describe the NHIS on the continuum from passive to strategic purchasing and to identify steps to make purchasing more strategic. Strengths and weaknesses were found in governance and purchasing functions. Progress was seen in how the NHIS selects the services in the benefit package, regularly reviewing the package to respond to the health needs of the population, and in how it selectively contracts with providers, particularly private providers, to ensure that standards for quality of care are met. However, challenges remain in performance monitoring, due to claims being mostly processed manually, and provider payment, due to frequent unbundling and upcoding of services Ghana has made significant strides toward the achievement of universal health coverage, but there is room for improvement in provider payment and performance monitoring.

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

Background

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

Methods

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

Results

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

Conclusion

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

Registration

Not available

Supplementary Information

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

Barriers to providing healthcare to children living with cerebral palsy in Ghana: A qualitative study of healthcare provider perspectives

Children with neurodevelopmental disabilities in low- and middle-income countries (LMICs) experience profound health and social inequities. While challenges faced by children living with disabilities and their caregivers have been widely documented, little is known about barriers faced by healthcare providers (HCPs) who serve these children. This study seeks to understand the barriers to testing, diagnosing, referral, and treatment of children living with cerebral palsy (CLWCP) from the perspectives of HCPs in Ghana. This qualitative study was conducted in the Greater Accra region of Ghana. A snowball sampling strategy was used to recruit HCPs from major hospitals, education centers, and health facilities. Data were collected through 11 semi-structured in-depth interviews (IDIs) with HCPs. Using an adapted version of the Sweat & Denison socio-ecological framework (SDSF), barriers to providing healthcare to CLWCPs were organized into superstructural, structural, environmental, relational, individual, and technological levels. We found that barriers to providing healthcare to CLWCPs exist at all levels of the adapted framework. The most salient barriers were identified at the superstructural, structural, and environmental levels. All HCPs expressed frustration with Ghana's health insurance policies and inadequacies of the health systems infrastructures, such as patient assessment rooms, health information systems, and pharmaceutical products for CP care. HCPs also reported that disability-related stigma often discourages providers in training from specializing in the area of developmental disabilities. HCPs emphasized critical challenges related to local perceptions of disability, gender norms and ideologies, and health system policies and infrastructure. Findings highlight the importance of identifying multi-level factors that can influence testing, diagnosing, referral, treatment, and provision of care for CLWCPs in Ghana. Addressing identified challenges from each level of influence may improve CLWCP's experiences throughout the care continuum.

An Analysis of Catastrophic Out-of-Pocket Health Expenditures in Ghana

Introduction

Ghana implemented a universal health coverage scheme aimed at attaining financial risk protection against catastrophic out-of-pocket health expenditures. The effort has yielded mixed benefits for the different socio-economic profiles of the population. The present study estimates the incidence of catastrophic payments among Ghanaian households.

Methods

The study analyzed the round seven dataset of the Ghana Living Standards Survey collected between 2016 and 2017. We estimated the incidence and intensity of catastrophic payments for total household consumption and non-food consumption for a range of thresholds. The analysis further weighted the measures of catastrophic payments to determine the distribution sensitivity.

Results

As the threshold increased from 10 to 25% of total household consumption, the incidence of catastrophic payments dropped from 1.0 to 0.1%. At the 40% threshold of non-food consumption, the estimated incidence was 0.2%. For both total household consumption and non-food consumption, the concentration indices were negative at all the thresholds. The results were indicative of a higher concentration of financial catastrophe among the poorest households and significant inequalities in the incidence between the poorest and richest households.

Conclusion

The study confirmed the declining trend in the general incidence of catastrophic health expenditures in Ghana. However, the incidence and risk of financial catastrophe remained disproportionately higher among the poorest households, which is instructive of gaps in financial risk protection coverage. The Ghana National Health Insurance Scheme must therefore strengthen its targeting and enrolment of this sub-population group to reduce their vulnerability to catastrophic payments.

A multidimensional study of public satisfaction with the healthcare system: a mixed-method inquiry in Ghana

BACKGROUND

Many governments in sub-Saharan Africa have recently sought to improve their health systems by increasing investment in healthcare facilities and introducing social insurance programmes. However, little is known about the impact of these intended improvements on public perceptions about the healthcare systems. This article examines whether and why people of different socioeconomic and ideological backgrounds are satisfied (or not) with the current healthcare system in Ghana from a social ecological perspective.

METHOD

Data were elicited from a cross-sectional mixed-method study conducted in four regions in Ghana in 2018. We used ordinal logistic regression and thematic analysis techniques to analyse the data.

RESULTS

Satisfaction with the healthcare system was generally low. From our quantitative study, intrapersonal factors (e.g., being older and having good health and well-being status); interpersonal factors (e.g., linking social capital); community factors (e.g., living in rural areas); and organisational and public policy factors (e.g., trust in the health system, favouring welfare policies, and being interested in politics) were positively associated with satisfaction with the healthcare system. These were corroborated by the qualitative study, which showed that poor attitudes of health personnel, financial constraints, perceived poor health facilities, and perceived inefficacy of services contribute to dissatisfaction with the healthcare system.

CONCLUSION

Strategies to improve satisfaction with the healthcare system in Ghana should incorporate ecological perspectives by considering factors such as demographic profile, health needs, political orientation, issues of trust in the healthcare system, and the dynamics and impact of social relationships of populations concerned.

Predictors of health insurance enrolment and wealth-related inequality in Nepal: evidence from Multiple Indicator Cluster Survey (MICS) 2019

OBJECTIVES

We analysed predictors of health insurance enrolment in Nepal, measured wealth-related inequality and decomposed inequality into its contributing factors.

DESIGN

Cross-sectional study.

SETTING

We used nationally representative data based on Nepal Multiple Indicator Cluster Survey 2019. Out of 10 958 households included in this study, 6.95% households were enroled in at least one health insurance scheme.

PRIMARY OUTCOME

measures health insurance (of any type) enrolment.

RESULTS

Households were more likely to have health insurance membership when household head have higher secondary education or above compared with households without formal education (adjusted OR 1.87; 95% CI: 1.32 to 2.64)). Households with mass media exposure were nearly three times more likely to get enroled into the schemes compared with their counterparts (adjusted OR 2.96; 95% CI 2.03 to 4.31). Hindus had greater odds of being enroled (adjusted OR 1.82; 95% CI 1.20 to 2.77) compared with non-Hindus. Dalits were less likely to get enroled compared with Brahmin, Chhetri and Madhesi (adjusted OR 0.66; 95% CI 0.47 to 0.94). Households from province 2, Bagmati and Sudurpaschim were less likely to have membership compared with households from province 1. Households from Richer and Richest wealth quintiles were more than two times more likely to have health insurance membership compared with households from the poorest wealth quintile. A positive concentration index 0.25 (95% CI 0.21 to 0.30; p<0.001) indicated disproportionately higher health insurance enrolment among wealthy households.

CONCLUSIONS

Education of household head, exposure to mass media, religious and ethnic background, geographical location (province) and wealth status were key predictors of health insurance enrolment in Nepal. There was a significant wealth-related inequality in health insurance affiliation. The study recommends regular monitoring of inequality in health insurance enrolment across demographic and socioeconomic groups to ensure progress towards Universal Health Coverage.

Political economy and the pursuit of universal health coverage in Ghana: a case study of the National Health Insurance Scheme

The road to universal health coverage depends on resources committed to the health sector. In many cases, the political structure and strength of advocacy play an important role in setting budgets for health. However, this has, until recently, not been of interest to health system researchers and policymakers. In this study, we document the political path to the establishment of the Ghana National Health Insurance Scheme (NHIS) as well as continuous political interest in the scheme. To achieve our objectives, we used qualitative data from interviews with key stakeholders. These include stakeholders instrumental in the design and establishment of the NHIS. We also reviewed party manifestoes from the two main political parties in the country. Promises relating to the NHIS were extracted from the various manifestos and analysed. Other documents that account for the design and implementation of the scheme were reviewed. We found that the establishment of the NHIS was down to political commitment and effective engagement with relevant stakeholders. It was considered a solution to the political promise to remove user fees and make healthcare accessible to all. A review of the manifestos shows that in almost every election year after the NHIS was established, there has been some promise related to improving the scheme. There were several policy propositions repeated in different election years. The findings imply that advocacy to get health financing on the political agenda is crucial. This should start from the development of party manifestos. It is important to also ensure that proposed party policies are consistent with national priorities in the medium to long term.

Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders' perspectives

The development of effective and inclusive health financing reforms is crucial for the progressive realisation of universal health coverage in low-income and middle-income countries. Tanzania has been reforming health financing policies to expand health insurance coverage and achieve better access to quality healthcare for all. Recent reforms have included improved community health funds (iCHFs), and others are underway to implement a mandatory national health insurance scheme in order to expand access to services and improve financial risk protection. Governance is a crucial structural determinant for the successful implementation of health financing reforms, however there is little understanding of the governance elements that hinder the implementation of health financing reforms such as the iCHF in Tanzania. Therefore, this study used the perspectives of health sector stakeholders to explore governance factors that influence the implementation of health financing reforms in Tanzania. We interviewed 36 stakeholders including implementers of health financing reforms, policymakers and health insurance beneficiaries in the regions of Dodoma, Dar es Salaam and Kilimanjaro. Normalisation process theory and governance elements guided the structure of the in-depth interviews and analysis. Governance factors that emerged from participants as facilitators included a shared strategic vision for a single mandatory health insurance, community engagement and collaboration with diverse stakeholders in the implementation of health financing policies and enhanced monitoring of iCHF enrolment due to digitisation of registration process. Governance factors that emerged as barriers to the implementation were a lack of transparency, limited involvement of the private sector in service delivery, weak accountability for revenues generated from community level and limited resources due to iCHF design. If stakeholders do not address the governance factors that hinder the implementation of health financing reforms, then current efforts to expand health insurance coverage are unlikely to succeed on their own.

Blood Pressure Control, Accessibility, and Adherence to Antihypertensive Medications: Patients Seeking Care in Two Hospitals in the Ashanti Region of Ghana

Hypertension is the second leading cause of death in Ghana, partly accounting for two-thirds of all medical admissions and more than 50% of deaths. This study aimed to comparatively evaluate adherence and accessibility to antihypertensive medications at two different levels of healthcare facilities in Kumasi, Ghana, and determine factors associated with medicine accessibility and adherence. A cross-sectional study involving outpatient department (OPD) hypertensive patients, 143 at KNUST Hospital (UHS) and 342 at Komfo Anokye Teaching Hospital (KATH), was conducted using a semistructured questionnaire. Correlations were drawn to evaluate the effect of accessibility and adherence on blood pressure control. A face-to-face interview was also conducted with relevant stakeholders involved in procurement of medicines. Blood pressure was uncontrolled in 50.4% (n = 72) of participants at UHS and 52.9% (n = 181) at KATH. With respect to medicine accessibility, 98.8% (n = 338) and 42.9% (n = 61) received at least one medication from the hospital pharmacy of KATH and UHS, respectively. Using MARS-10, 49.2% (n = 70) and 52.9% (n = 181) were nonadherent in UHS and KATH, respectively. There was a significant association between adherence and BP control at both UHS (p=0.038) and KATH (p=0.043). At UHS, there was a significant association between accessibility to medicines at the hospital and BP control (p=0.031), whilst at KATH, no significant association was observed (p=0.198). Supply chain practices and delays in payment by the NHIA affected accessibility to antihypertensive medications. Blood pressure control was inadequate among participants in both facilities. Accessibility to medicines was better at the tertiary facility compared to the secondary facility. Increased accessibility and adherence to antihypertensives were related to blood pressure control in both facilities. Good supply chain practices and prompt payment by the National Health Insurance Authority would enhance accessibility to antihypertensive medications.

Factors Influencing Nonrenewal of Health Insurance Membership in Ejisu-Juaben Municipality of Ashanti Region, Ghana

Background. In the quest to prevent households from making catastrophic expenditures at the point of seeking healthcare, the government of Ghana introduced the National Health Insurance in 2003. However, people are reluctant to renew their membership. This study was, therefore, conducted to identify factors influencing the nonrenewal of National Health Insurance membership in the Ejisu-Juaben Municipality. Methods. A cross-sectional study was conducted among 427 respondents in the Ejisu-Juaben Municipality to ascertain factors influencing the nonrenewal of health insurance membership status. Data were entered and analyzed using Stata version 14. Univariate and multivariate analyses were performed to determine sociodemographic factors, household factors, and systemic factors influencing the nonrenewal of health insurance status. Statistical significance for all testing was set as $p\le 0.05$ . Results. Sociodemographic factors such as gender (AOR = 0.531; CI = 0.287–0.985) and educational level (AOR = 5.268; CI = 1.130–24.551)) were associated with the nonrenewal of health insurance membership. Income levels in Ghana Cedis were 500–1000 (AOR = 0.216; CI = 0.075–0.617) and 1001–2000 (AOR = 0.085; CI = 0.019–0.383). Systemic decision on factors such as clients’ satisfaction (AOR = 0.149; CI = 0.035–0.640), making copayment (AOR = 0.152; CI = 0,068–0.344), acquiring all prescribed drugs (AOR = 4.191; CI = 2.027–8.668), and awareness of mobile renewal (AOR = 3.139; CI = 1.462–6.739) was associated with nonrenewal of membership. Conclusions. The nonrenewal of health insurance membership was influenced by sociodemographic, household, and systemic factors. Therefore, the Municipal Health Directorate and the National Health Insurance Authority have to work on these factors to reach the target of 100% active coverage in the municipality.

Aiming for Universal Health Coverage through insurance in Ethiopia: State infrastructural power and the challenge of enrolment

Many developing countries are considering insurance as a means of pursuing Universal Health Coverage. A key challenge to confront is how to achieve high levels of health insurance enrolment. For voluntary schemes this entails mass awareness raising and promotional activity, though as schemes move to compulsory enrolment, monitoring and enforcement are required. This paper focuses on Ethiopia, which has made state health insurance for the informal sector a central pillar of its Universal Health Coverage strategy. The paper shows that high enrolment requires particular forms of state capacity, captured by Michael Mann's concept of state 'infrastructural power'. The paper draws on detailed case studies of insurance implementation in the Tigray and Oromiya regions of Ethiopia to illustrate variation in state infrastructural power and the implications for health insurance. Findings suggest that the potential of state health insurance as a means of promoting health access for a broad section of the population may be limited to the minority of countries or regions within countries exhibiting high levels of infrastructural power.

Analysis of independent National Health Insurance ownership of informal workers: Study of market traders in Gowa District, Indonesia

OBJECTIVE

This study aimed to determine the factors associated with ownership of independent National Health Insurance (NHI) in market traders, Gowa District, Indonesia.

METHOD

This type of research was quantitative with a cross-sectional design. The population was 567 traders. Samples were 85 respondents: data collection using questionnaires, and data processing with Chi-square test analysis.

RESULT

The results indicated that 43 (50.6%) respondents had NHI, and 42 (49.45%) respondents did not. Based on the results obtained bivariate analysis knowledge (p=0.003), income (p=0.039), attitude (p=0.000), social support (p=0.000), age (p=1.000), education (p=0.311), perception (p=0.234) and access to care (p=0.336).

CONCLUSION

Factors related to the ownership of independent NHI traders in the Central Public Market Gowa were knowledge, income, attitude, and social support. It is recommended that market managers include traders in health insurance and the government improve the quality of the NHI program and increase socialization to informal sector traders.

Education and Experience as Determinants of Micro Health Insurance Enrolment

BACKGROUND

India faces a formidable challenge of providing universal health coverage to its uninsured population in the informal sector of the economy. Numerous micro health insurance (MHI) schemes have emerged as health financing mechanisms to reduce medical-illness-induced poverty. Existing research shows that the purchase of health insurance is most likely to be determined by health status, expected healthcare expenditure, and past health experiences in addition to socio-economic variables. We add to the understanding of various factors influencing enrolment in MHI from an Indian perspective.

METHODS

A survey was carried out to collect quantitative data in three districts in the state of Karnataka, India.

RESULTS

We show that education does not matter as significantly as experience does, in the determination of new insurance purchases. In other words, the importance of new insurance is not understood by those who are merely educated, but by those who have either fallen ill, or have previously seen the hazards of usurious borrowing.

CONCLUSION

Our study provides deeper insights into the role of usurious borrowing and past illness in determining insurance purchases and highlights the formidable challenge of financial sustainability in the MHI market of India.

Strategies for financing social health insurance schemes for providing universal health care: a comparative analysis of five countries

Background: Universal Health Coverage has become a political priority for many African countries yet there are clear challenges in achieving this goal. Though social health insurance is considered a mechanism for providing financial protection, less well documented in the literature is evidence from countries in Africa who are at various stages of adopting this financing strategy as a way to improve health insurance coverage for their populations. Objectives: The study investigates whether social health insurance schemes are effectively and efficiently covering all groups. The objective is to provide evidence of how these schemes have been implemented and whether the fundamental goals are met. The selected countries are Ghana, Rwanda, Tanzania, Kenya and Ethiopia. The study draws lessons from the literature about how policy tools can be used to reduce financial barriers whilst ensuring a broad geographic coverage in Africa. Methods: The study relies primarily on a review of literature, both documented and grey matter, which include key documents such as government health policy documents, strategic plans, health financing policy documents, Universal Health Coverage policy documents, published literature, unpublished documents, media reports and National Health Accounts reports. Results: The results show that each of the selected countries relies on a plurality of health insurance schemes with each targeting different groups. Additionally, many of the Social Health Insurance programs start by covering the formal sector first, with the hope of covering other groups in the informal sector at a later stage. Health insurance coverage for poor groups is very low, with targeting mechanisms to cover the poor in the form of exemptions and waivers achieving no desirable results. Conclusions: The ability for Social Health Insurance programs to cover all groups has been limited in the selected countries. Hence, relying solely on social health insurance schemes to achieve Universal Health Coverage may not be plausible in Africa. Also, highly fragmented risk pools impede efforts to widen the insurance pools and promote cross-subsidies.

Can National Health Insurance Pave the Way to Universal Health Coverage in Sub-Saharan Africa?

Countries of sub-Saharan Africa are increasingly turning to public contributory health insurance as a mechanism to advance UHC goals. Eight countries in sub-Saharan Africa have introduced national health insurance (NHI) systems, and at least seven more have plans or have passed legislation to establish NHI. Examining the experience of countries that have taken this path, some lessons emerge about whether and how contributory national health insurance may or may not be a viable path toward UHC in sub-Saharan Africa. Only Gabon, Ghana and Rwanda have been able to extend NHI coverage to a significant share of the population. None of the countries with NHI have peformed better on other UHC indicators-resource mobilization, service coverage and financial protection-than higher performing countries of Africa that did not introduce NHI. The experience of Gabon, Ghana and Rwanda provide lessons for what may be required to make NHI a viable path to UHC-there need to be explicit objectives and an understanding of why NHI can meet those objectives in the country's particular context; it must include key pro-equity design elements; and NHI needs to be supported by widespread political commitment and ongoing learning and adaptation. For many governments, achieving this kind of enabling environment for NHI may be particularly challenging for various political, economic, or social reasons. In these contexts, health sector leaders may consider looking inward to their existing health financing systems for ways to improve and be more effective.

Comprehensive eye care - Issues, challenges, and way forward

As we move from a disease-specific care model toward comprehensive eye care (CEC), there is a need for a more holistic and integrated approach involving the health system. It should encompass not only treatment, but also prevention, promotion, and rehabilitation of incurable blindness. Although a few models already exist, the majority of health systems still face the challenges in the implementation of CEC, mainly due to political, economic, and logistic barriers. Shortage of eye care human resources, lack of educational skills, paucity of funds, limited access to instrumentation and treatment modalities, poor outreach, lack of transportation, and fear of surgery represent the major barriers to its large-scale diffusion. In most low- and middle-income countries, primary eye care services are defective and are inadequately integrated into primary health care and national health systems. Social, economic, and demographic factors such as age, gender, place of residence, personal incomes, ethnicity, political status, and health status also reduce the potential of success of any intervention. This article highlights these issues and demonstrates the way forward to address them by strengthening the health system as well as leveraging technological innovations to facilitate further care.

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.

Adapting a skills-based stroke prevention intervention for communities in Ghana: a qualitative study

BACKGROUND

Stroke is a major cause of death in Ghana. Evidence-based interventions for stroke prevention have been successful in the US; however, in low- and middle-income countries (LMICs), such interventions are scarce. The "Discharge Education Strategies for Reduction of Vascular Events" (DESERVE) intervention led to a 10-mmHg reduction in systolic blood pressure (SBP) among Hispanic survivors of mild/moderate stroke and transient ischemic attack (TIA) at 1-year follow-up. Our objectives were to capture the perceptions of a diverse set of stakeholders in an urban community in Ghana regarding (1) challenges to optimal hypertension management and (2) facilitators and barriers to implementation of an evidence-based, skills-based educational tool for hypertension management in this context.

METHODS

This exploratory study used purposive sampling to enroll diverse stakeholders in Accra (N = 38). To identify facilitators and barriers, we conducted three focus group discussions: one each with clinical nurses (n = 5), community health nurses (n = 20), and hypertensive adults (n = 10). To further examine structural barriers, we conducted three key informant interviews with medical leadership. All interviews were audio recorded and transcribed. Thematic analysis was carried out via deductive coding based on Proctor's implementation outcomes taxonomy, which conceptualizes constructs that shape implementation, such as acceptability, adoption, appropriateness, cost, and feasibility.

RESULTS

Findings highlight facilitators, such as a perceived fit (appropriateness) of the core intervention components across stakeholders. The transferable components of DESERVE include: (1) a focus on risk knowledge, medication adherence, and patient-physician communication, (2) facilitation by lay workers, (3) use of patient testimonials, (4) use of a spirituality framework, and (5) application of a community-based approach. We report potential barriers that suggest adaptations to increase appropriateness and feasibility. These include addressing spiritual etiology of disease, allaying mistrust of biomedical intervention, and tailoring for gender norms. Acceptability may be a challenge among individuals with hypertension, who perceive relative advantage of alternative therapies like herbalism. Key informant interviews highlight structural barriers (high opportunity costs) among physicians, who perceive they have neither time nor capacity to educate patients.

CONCLUSIONS

Findings further support the need for theory-driven, evidence-based interventions among hypertensive adults in urban, multiethnic Ghana. Findings will inform implementation strategies and future research.

Implementation of the National Health Insurance Scheme (NHIS) in Ghana: Lessons for South Africa and Low- and Middle-Income Countries

BACKGROUND

South Africa is having difficulties in rolling out the National Health Insurance(NHI) policy. There are ongoing arguments on whether the NHI will provide access to quality and equitable healthcare it is intended to and whether South Africa is ready to implement the policy. Many stakeholders believe the country needs more preparation if the policy will be successful. Ghana, on the other hand, has successfully implemented the National Health Insurance Scheme(NHIS) for over 15 years.

OBJECTIVE

This paper sought to explore the implementation of the NHIS in Ghana and the lessons South Africa and other low- and middle-income countries can learn from such a process.

METHODS

A scoping review was conducted using the Joanna Brigs Institute's System for the Unified Management, Assessment and Review of Information (SUMARI) and Mendeley reference manager to manage the review process. Journal articles published on the NHIS in Ghana from January 2003 to December 2018 were searched from Science Direct, PubMed, Scopus, CINAHL, and Medline using the keywords: Ghana, Health, and Insurance.

RESULTS

The implementation of the NHIS has provided access to healthcare for the Ghanaian population, especially to poor and vulnerable . Despite the successful implementation of the NHIS in Ghana, the scheme is challenged with poor coverage; poor quality of care; corruption and ineffective governance; poor stakeholder participation; lack of clarity on concepts in the policy; intense political influence; and poor financing.

CONCLUSION

The marked inequity in the South African health system makes the implementation of the NHI inevitable. The challenges experienced in the implementation of the NHIS in Ghana are not new to the South African healthcare system. South Africa must learn from the experiences of Ghana,a context that shares common socio-cultural and economic factors and disease burden,in order to successfully implement the NHI.

Community utilisation and satisfaction with the community-based health planning and services initiative in Ghana: a comparative study in two system learning districts of the CHPS+ project

BACKGROUND

To strengthen the implementation of the Community-based Health Planning and Services (CHPS) programme which is Ghana's key primary health care delivery strategy, the CHPS+ Project was initiated in 2017. We examined community utilisation and satisfaction with CHPS services in two System Learning Districts (SLDs) of the project.

METHODS

This community-based descriptive study was conducted in the Nkwanta South Municipality and Central Tongu District of Ghana. Data were collected from 1008 adults and analysed using frequency, percentage, chi-square, and logistic regression models.

RESULTS

While the level of utilisation of CHPS services was 65.2%, satisfaction was 46.1%. Utilisation was 76.7% in Nkwanta South and 53.8% in Central Tongu. Satisfaction was also 55.2% in Nkwanta South and 37.1% in Central Tongu. Community members in Nkwanta South were more likely to utilise (AOR = 3.17, 95%CI = 3.98-9.76) and be satisfied (AOR = 2.77, 95%CI = 1.56-4.90) with CHPS services than those in Central Tongu. Females were more likely to utilise (AOR = 1.75, 95%CI = 1.27-2.39) but less likely to be satisfied [AOR = 0.47, 95%CI = 0.25-0.90] with CHPS services than males. Even though subscription to the National Health Insurance Scheme (NHIS) was just 46.3%, NHIS subscribers were more likely to utilise (AOR = 1.51, 95%CI = 1.22-2.03) and be satisfied (AOR = 1.45, 95%CI = 0.53-1.68) with CHPS services than non-subscribers.

CONCLUSION

Ghana may not be able to achieve the goal of universal health coverage (UHC) by the year 2030 if current levels of utilisation and satisfaction with CHPS services persist. To accelerate progress towards the achievement of UHC with CHPS as the vehicle through which primary health care is delivered, there should be increased public education by the Ghana Health Service (GHS) on the CHPS concept to increase utilisation. Service quality should also be improved by the GHS and other stakeholders in Ghana's health industry to increase satisfaction with CHPS services. The GHS and the National Health Insurance Authority (NHIA) should also institute innovative strategies to increase subscription to the NHIS since it has implications for CHPS service utilisation and satisfaction.

Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India

BACKGROUND

Universal health coverage (UHC) has provided the impetus for the introduction of publicly funded health insurance (PFHI) schemes in the mixed health systems of India and many other low- and middle-income countries. There is a need for a holistic understanding of the pathways of impact of PFHI schemes, including their role in promoting equity of access.

METHODS

This paper applies an equity-oriented evaluation framework to assess the impacts of PFHI schemes in Chhattisgarh State by synthesising literature from various sources and highlighting knowledge gaps. Data were collected from an extensive review of publications on PFHI schemes in Chhattisgarh since 2009, including empirical studies from the first author's PhD and grey literature such as programme evaluation reports, media articles and civil society campaign documents. The framework was constructed using concepts and frameworks from the health policy and systems research literature on UHC, access and health system building blocks, and is underpinned by the values of equity, human rights and the right to health.

RESULTS

The analysis finds that evidence of equitable enrolment in Chhattisgarh's PFHI scheme may mask many other inequities. Firstly, equitable enrolment does not automatically lead to the acceptability of the scheme for the poor or to equity in utilisation. Utilisation, especially in the private sector, is skewed towards the areas that have the least health and social need. Secondly, related to this, resource allocation patterns under PFHI deepen the 'infrastructure inequality trap', with resources being effectively transferred from tribal and vulnerable to 'better-off' areas and from the public to the private sector. Thirdly, PFHI fails in its fundamental objective of effective financial protection. Technological innovations, such as the biometric smart card and billing systems, have not provided the necessary safeguards nor led to greater accountability.

CONCLUSION

The study shows that development of PFHI schemes, within the context of wider neoliberal policies promoting private sector provisioning, has negative consequences for health equity and access. More research is needed on key knowledge gaps related to the impact of PFHI schemes on health systems. An over-reliance on and rapid expansion of PFHI schemes in India is unlikely to achieve UHC.

Are People Enrolled in NCMS and CURBMI Susceptible in Catastrophic Health Expenditure? Evidence From China

This study investigated associations between different types of medical insurance and the incidence of catastrophic health expenditure among middle-aged and the aged in China. The data came from the China Health and Retirement Longitudinal Survey implemented in 2013, with 9782 individuals analyzed. Probit regression models and multiple linear regressions were employed to explore the relationship mentioned above and potential mechanisms behind it. It was found that compared with participants in Urban Resident Basic Medical Insurance, individuals participating in New Cooperative Medical Scheme and Coordinating Urban and Rural Basic Medical Insurance was less likely to undergo catastrophic health expenditure (P < .001, P = .008), especially for low-income and middle-income group. Participants in New Cooperative Medical Scheme and Coordinating Urban and Rural Basic Medical Insurance were more likely to utilize inpatient medical service (P < .001, P = .020) and choose low-level medical institutions for treatment (P = .003, P = .006). And individuals participating in New Cooperative Medical Scheme had lower out-of-pocket expenditure (P = .034). The study showed the significant difference in the incidence of catastrophic health expenditure among participants in different medical insurances. Efforts should be made to improve the service quality of grassroots medical institutions except for the increase of reimbursement ratio, so that rural residents can enjoy high-quality medical services.

Seeking care in the context of social health insurance in Kenya and Ghana

BACKGROUND

Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa.

METHODS

This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018.

RESULTS

Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately.

CONCLUSIONS

Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Epidemiology and Perioperative Mortality of Exploratory Laparotomy in Rural Ghana

Background:

Perioperative mortality rate (POMR) has been identified as an important measure of access to safe surgical and anesthesia care in global surgery. There has been limited study on this measure in rural Ghana. In order to identify areas for future quality improvement efforts, we aimed to assess the epidemiology of exploratory laparotomy and to investigate POMR as a benchmark quality measure.

Methods:

Surgical records were reviewed at a regional referral hospital in Eastern Region, Ghana to identify cases of exploratory laparotomy from July 2017 through June 2018. Patient demographics, health information, and outcomes data were collected. Logistic regression was used to identify predictors of perioperative mortality.

Findings:

The study included operations for 286 adult and 60 pediatric patients. Only 60% of patients were covered by National Health Insurance (NHI). The overall POMR was 11.5% (12.6% adults; 6.7% pediatric). Sixty percent of mortalities were referrals from outside hospitals and the mortality rate for referrals was 13.5%. Odds of mortality was 13 times greater with perforated peptic ulcer disease (OR = 13.1, p = 0.025) and 12 times greater with trauma (OR = 11.7, p = 0.042) when compared to the most common operation. Female sex (OR = 0.3, p = 0.016) and NHI (OR = 0.4, p = 0.031) were protective variables. Individuals 60 years and older (OR = 3.3, p = 0.016) had higher mortality.

Conclusion:

POMR can be an important outcome and quality indicator for rural populations. Interventions aimed at decreasing emergent hernia repair, preventing perforation of peptic ulcer disease, improving rural infrastructure for response to major trauma, and increasing NHI coverage may improve POMR in rural Ghana.

Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya

BACKGROUND

Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality.

METHODS

We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach.

RESULTS

The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery.

CONCLUSION

While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.

Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya

BACKGROUND

Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality.

METHODS

We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach.

RESULTS

The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery.

CONCLUSION

While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.

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.

Community-Based Health Planning and Services Plus programme in Ghana: A qualitative study with stakeholders in two Systems Learning Districts on improving the implementation of primary health care

BACKGROUND

In 1999, Ghana introduced the Community-Based Health Planning and Services (CHPS) as the key primary health care strategy. In this study, we explored the challenges, capacity development priorities, and stakeholder perspectives on improving the CHPS concept as it has been fraught with a myriad of challenges since its inception. Our study is the outcome of the national programme for strengthening the implementation of CHPS Initiative in Ghana (CHPS+) introduced in 2017.

METHODS

This exploratory research was a qualitative study conducted in two Systems Learning Districts (SLDs) of CHPS+ in the Volta Region of Ghana from March to May, 2018. Four focus group discussions and two general discussions were conducted among 60 CHPS+ stakeholders made up of health workers and community members. Data analyses were conducted using conceptual content analysis. Statements of the participants were presented as quotes to substantiate the views expressed.

RESULTS

Negative attitude, high attrition, inadequacy and unavailability of health professionals at post when needed were challenges associated with the health professionals. Late referrals, lack of proper community entry and engagement, non-availability of essential logistics, distance of CHPS compounds from communities, and inadequate funding were challenges associated with the health system. Lack of community ownership of the CHPS programme, lack of security at CHPS compounds, and late reporting of cases by the community members were also realised as challenges emanating from the community members. Priority areas for capacity development of health workers identified included logistics management, community entry and engagement, emergency delivery, managing referrals at the CHPS level, and resuscitation of newborns.

CONCLUSION

Health-worker, community, and health systems-based challenges inhibit the implementation of CHPS in Ghana. Capacity development of health professionals and continuous community engagement are avenues that can improve implementation of the programme.