Analysing the Influence of Health Insurance Status on Peoples' Health Seeking Behaviour in Rural Ghana

Does health insurance status influence healthcare-seeking behavior in rural communities? evidence from rural Ghana

Introduction

National health insurance programs are considered important mechanisms for ensuring equity in access to and utilization of healthcare services by removing financial barriers associated with seeking treatment in healthcare facilities. Although studies on health insurance schemes in many low-and-middle-income countries (LMICs) have demonstrated a significant relationship between health insurance status and healthcare-seeking behavior, data on the influence of this health financing policy on the decision to seek formal healthcare among rural inhabitants remains limited. Underpinned by the Andersen-Newman behavioral model of healthcare use, this study examined the influence of health insurance status on healthcare-seeking behavior among rural dwellers in Ghana.

Methods

A community-based cross-sectional study was conducted among 460 rural residents in Ghana from 8th September to 5th December 2022. Chi-square tests were used to study the significance level and association between healthcare-seeking behavior and selected independent variables. A multiple logistic regression model was fitted to test the association between health insurance status and healthcare-seeking behavior, introducing other selected explanatory variables as controls.

Results

The mean age of the respondents was 29.6 ± 6.8 years. A little above half (53.1 %) disclosed having insurance, whereas 46.1 % stated they were without coverage. Regarding healthcare-seeking behavior, the most commonly chosen treatment source was traditional healers (37.2 %), followed by the public healthcare system (28.3 %) and self-treatment (18.2 %). The private healthcare system was the least preferred, with only 16.3 % opting for it. While the bivariate analysis demonstrated a significant relationship between health insurance status and healthcare-seeking behavior (p-0.001), the logistic regression model results showed that health insurance status was not an independent predictor of healthcare-seeking behavior (p = 0.069).

Conclusion

It could, therefore, not be concluded that the respondents with health insurance coverage were more likely than the uninsured to use formal healthcare providers as their most frequent source of treatment during illness. This study provides vital information for policymakers aiming at increasing access to and utilization of facility-based formal care in rural and remote settings.

Place, displacement, and health-seeking behaviour among the Ugandan Batwa: A qualitative study

For many Indigenous Peoples, relationships to the land are inherent in identity and culture, and to all facets of health and wellbeing, physically, emotionally, psychologically, and spiritually. The Batwa are Indigenous Peoples of rural, southwest Uganda who have experienced tremendous social and economic upheaval, due to relatively recent forced displacement and land dispossession. This loss of physical connection to their ancestral lands has significantly impacted Batwa health, and also affected available healthcare options for Batwa. This exploratory study (1) identified and characterized factors that influence Batwa health-seeking behaviour, using acute gastrointestinal illness, a critical public health issue, as a focal point for analysis; and (2) explored possible intersections between the Batwa's connection to place-and displacement-and their health-seeking behaviour for acute gastrointestinal illness. Twenty focus group discussions, stratified by gender, were conducted in ten Batwa settlements in Kanungu District, Uganda and eleven semi-structured interviews were conducted with primary healthcare workers, community health coordinators, clinical officers, and development program coordinators. Qualitative data were thematically analyzed using a constant comparative method. Batwa identified several significant motivators to engage with Indigenous and/or biomedical forms of healthcare, including transition to life outside the forest and their reflections on health in the forest; 'intellectual access' to care and generational knowledge-sharing on the use of Indigenous medicines; and Batwa identity and way of life. These nuanced explanations for health-seeking behaviour underscore the significance of place-and displacement-to Batwa health and wellbeing, and its relationship to their health-seeking behaviour for acute gastrointestinal illness. As such, the results of this study can be used to inform healthcare practice and policy and support the development of a culturally- and contextually-appropriate healthcare system, as well as to reduce the burden of acute gastrointestinal illness among Batwa.

The role of community-based health insurance on healthcare seeking behavior of households in Addis Ababa, Ethiopia

Community-based health insurance is a new and promising concept for delivering easily accessible, affordable, and efficient healthcare services. More importantly, a significant risk pooling arrangement between the wealthy and poor. So far, little has been done regarding community-based health insurance and healthcare seeking behavior in developing countries. Therefore, the aim of this study was to assess healthcare seeking behavior of households due to the introduction of the scheme and associated factors in Addis Ababa. Community-based cross-sectional study was conducted among 270 male and 207 female respondents. The data was collected using standardized and pretested questionnaire and it was analyzed using SPSS software. A bivariate and multivariable logistic regression analysis was applied to determine the relationship between healthcare seeking behavior and determinant variables. Finally, statistical association was declared with a p-value of less than 0.05 in the multivariable logistic regression analysis. The proportion of people who had appropriate healthcare-seeking behavior was 47.31% (95 %CI: 43.27-51.39%). Furthermore, having more than four children [AOR: 0.171, 95%, CI:(0.403-0.99)], being Muslim [AOR: 1.712, 95 %CI: (1.117 2.625)], owning a government house [AOR: 4.472, 95%, CI: (2.037-9.819)], and having under-five children [AOR: 0.548, 95%, CI: (0.375-0.801)] were factors significantly associated with healthcare-seeking behavior. Even though this study was conducted in an urban area, it showed that the magnitude of appropriate healthcare-seeking behavior was low. Therefore, the government of Ethiopia should work to improve housing conditions and family planning provision for the residents to improve the healthcare seeking behavior of community-based health insurance users.

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.

Socioeconomic disparities in healthcare utilization under universal health coverage: evidence from Dubai household health survey

Background

In 2013, Dubai implemented the Insurance System of Advancing Health in Dubai (ISAHD) law which required mandatory health insurance for all residents of Dubai effective in 2016. This study compares the effect of the ISAHD on the utilization and out-of-pocket (OOP) expenditures for low and high socio-economic status sub-groups.

Methods

The study used the 2014 and 2018 Dubai Household Health Survey (DHHS) a representative survey of Dubai stratified as: 1) Nationals; 2) Non-nationals in households; 3) Non-nationals in collective housing; and 4) Non-nationals in labor camps. The probability that each household would have expenditures was calculated, then multiplied by a weighted estimate of the average total OOP expenditure.

Results

Overall Dubai’s health spending rose from 12.8 billion AED (3.4 billion US $) in 2014 to 16.8 billion AED (4.6 billion US $) in 2017. Concurrently, the OOP share in total health spending in Dubai fell from 25% in 2014 to 13% in 2017. From 2014 to 2018, there were increases in the utilization of inpatient, outpatient and discretionary services for all groups except non-nationals living in camps. In 2018, nationals spent a total of 1064.65 AED, non-nationals in households spent 675.01 AED, collective households spent 82.35 AED, and labor camps spent 100.32 AED out-of-pocket per capita for healthcare expenditures. During and after the implementation of ISAHD, there was a substantial growth in the OOP expenditure per capita for nationals and non-nationals in households due to increased utilization. OOP spending did not rise for the lower-income non-National households.

Conclusion

Dubai has been successful in reducing the household share of OOP expenditures by shifting the financial burden to government and employers. Emiratis and expatriate households increased their health service utilization after ISAHD but blue-collar workers did not. Remaining non-financial barriers to care for Dubai’s blue-collar workers must be identified and addressed.

Influence of sub-national social health insurance scheme on enrollees' health seeking behaviour in Anambra state, Nigeria: a pre and post study

Background

Appropriate health-seeking behaviour (HSB) is crucial for improving health outcomes and achieving universal health coverage (UHC). Accessing healthcare through the state social health insurance scheme (SSHIS) could lead to improved HSB. The study explores the influence of access to healthcare through health insurance on the HSB of the enrollees of the SSHIS in southeast, Nigeria.

Methods

A descriptive cross-sectional study undertaken in twelve health facilities in Anambra state using quantitative and qualitative research methods. Data were collected through a facility-based survey (n = 447) and sex-disaggregated focus group discussions (n = 12) of health insurance enrollees. Univariate and bivariate analyses were performed for quantitative data, while qualitative data were analyzed using a manual content approach.

Result

The findings revealed a positive change in enrollee’s HSB post-health insurance enrollment. Majority (83%) of the respondents reported that they immediately take action when ill post-health insurance enrollment as against 34% (pre-health insurance) resulting in a 49% increase, with a statistically significant difference (p < 0.02). There was a statistically significant association between positive HSB and marital status (p < 0.04); educational level (p < 0.00); occupation (p < 0.03) and ownership of health facility (p < 0.00). There was an increase in the percentage of enrollees who use the hospital as their first choice of provider during an illness episode post-health insurance enrollment. This increased from 37.4% to 90.2% (post-health insurance enrollment), representing a 52.8% increase, which is statistically significant (p < 0.03), in seeking care in hospitals. Similarly, the percentage (46%) of enrollees using patent medicine vendors (PMVs) as their first choice of provider when ill prior to enrollment in health insurance decreased to 8.1% post-health insurance enrollment, representing a 38% decline with a statistically significant (p < 0.00) drop in PMV patronage. Reasons for positive HSB include low cost of services and availability of quality care such as quality drugs, presence of doctors, and other skilled health workers by the health insurance facilities.

Conclusion

Health insurance has been established as an effective strategy for improving appropriate HSB. Hence, increasing coverage of health insurance among the uninsured is crucial in improving access to quality and affordable health care towards achieving UHC, particularly in developing countries.

Determinants of life satisfaction among Ghanaians aged 15 to 49 years: A further analysis of the 2017/2018 Multiple Cluster Indicator Survey

The inclusion of life satisfaction in government policies as a tracker of the social and economic progress of citizens has been recommended. This has encouraged the scientific investigation of life satisfaction levels of people in tandem with factors responsible for these levels. Only a few studies have attempted to do this in Ghana with mixed findings. This study, therefore, extends previous literature by examining the determinants of life satisfaction among Ghanaians in two ways: a full sample and a gender-stratified sample. We analysed cross-sectional data from the 2017/2018 Ghana Multiple Indicator Cluster Survey Six (MICS 6). A sample of 20,059 women and men of ages ranging from 15 to 49 years participated in this study. The Cantril's Self-Anchoring Ladder Life Satisfaction scale was used to capture the life satisfaction of participants alongside relevant sociodemographic questions. About 35% of participants reported they were satisfied in life with males reporting more suffering levels [39.59%; 95% CI:36.38, 42.88] and females more thriving levels [36.41%; 95% CI:35.01, 37.84]. In the full sample multivariable model, gender, age, parity, education, marital status, wealth index, and region of residence were significantly associated with life satisfaction. Gender variations were also found across these associations. These findings collectively provide useful information for policymakers and practitioners to optimize interventions for the Ghanaian population aimed at improving life satisfaction. Evidence from this study also calls on the government of Ghana to begin tracking the life satisfaction of her citizens.

Examining gender differentials and determinants of private health insurance coverage in Zambia

BACKGROUND

Health insurance is an essential aspect of healthcare. This is because it enables the insured to acquire timely and essential healthcare services, besides offering financial protection from catastrophic treatment costs. This paper seeks to establish gender differentials and determinants of health insurance coverage in Zambia.

METHODS

The data used in this study was obtained from the 2018 Zambia Demographic and Health Survey. Data were analyzed using STATA 13.0 software and focused on descriptive and Probit regression analyses.

RESULTS

The study reveals that for women and men, age, wealth category, education, and professional occupation are positively associated with health insurance while being self-employed in the agricultural sector negatively influences health insurance coverage for both sexes. Other variables have gender-specific effects. For instance, being in marital union and having a clerical occupation increases the probability of having health insurance for women while being in the services, skilled, and unskilled manual occupations increases the probability of having health insurance for men. Further, residing in rural areas reduces the probability of having health insurance for men.

CONCLUSION

The study concludes that there are differences in factors that influence health insurance between women and men. Hence, this study highlights the need to enhance health insurance coverage by addressing the different factors that influence health insurance coverage among men and women. These factors include enhancing education, job creation, diversifying insurance schemes, and gender consideration in the design of National Health Insurance Scheme.

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

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

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.

ART use and associated factors among HIV positive caregivers of orphans and vulnerable children in Tanzania

Background

Utilization of antiretroviral therapy (ART) is crucial for better health outcomes among people living with the human immunodeficiency virus (PLHIV). Nearly 30% of the 1.6 million PLHIV in Tanzania are not on treatment. Since HIV positive status is the only eligibility criterion for ART use, it is critical to understand the obstacles to ART access and uptake to reach universal coverage of ART among PLHIV. For the caregivers of orphans and vulnerable children (OVC) LHIV and not on ART, attempts to identify them and ensure that they initiate and continue using ART is critical for their wellbeing and their ability to care for their children.

Methods

Data are from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya project that aims at scaling up the uptake of HIV/AIDS and other health and social services by orphans and vulnerable children (OVC) and their caregivers. HIV positive caregivers of OVC who were enrolled in the USAID Kizazi Kipya project between January 2017 and June 2018 were included in this cross-sectional study. The caregivers were drawn from 11 regions: Arusha, Iringa, Katavi, Kigoma, Mara, Mbeya, Morogoro, Ruvuma, Simiyu, Singida, and Tanga. The outcome variable was ART status (either using or not), which was enquired of each OVC caregiver LHIV at enrollment. Data analysis involved multivariable analysis using random-effects logistic regression to identify correlates of ART use.

Results

In total, 74,999 caregivers living with HIV with mean age of 44.4 years were analyzed. Of these, 96.4% were currently on ART at enrollment. In the multivariable analysis, ART use was 30% lower in urban than in rural areas (adjusted odds ratio (OR) = 0.70, 95% confidence interval (CI) 0.61–0.81). Food security improved the odds of being on ART (OR = 1.29, 95% CI 1.15–1.45). Disabled caregivers were 42% less likely than non-disabled ones to be on ART (OR = 0.58, 95% CI 0.45–0.76). Male caregivers with health insurance were 43% more likely than uninsured male caregivers to be on ART (OR = 1.43, 95% CI 1.11–1.83). Caregivers aged 40–49 years had 18% higher likelihood of being on ART than the youngest ones. Primary education level was associated with 26% increased odds of being on ART than no education (OR = 1.26, 95% CI 1.13–1.41).

Conclusions

Although nearly all the caregivers LHIV in the current study were on ART (96.4%), more efforts are needed to achieve universal coverage. The unreached segments of the population LHIV, even if small, may lead to worse health outcomes, and also spur further spread of the HIV epidemic due to unachieved viral suppression. Targeting caregivers in urban areas, food insecure households, who are uninsured, and those with mental or physical disability can improve ART coverage among caregivers LHIV.

A Qualitative Study on the Pathways to Evidence-Based Antenatal Care in Periurban Ghana

Maternal health care has become a major concern on international fora in the 21st century. Even though major interventions have been taken to scale up maternal health care locally, nationally, and globally, adequate utilisation has not been achieved due to system-induced setbacks, especially in sub-Saharan Africa. The study explored the facilitators and barriers to antenatal care use in periurban Ghana. Seventeen (17) respondents consisting of four mothers receiving ANC services, four mothers receiving postnatal care with their ANC experience, four midwives, and four nurses with the District Public Health Nurse were involved in the study. The exploratory case study design was used with respondents comprising two focus groups and interview participants. Using thematic analysis, the results revealed that restrictive factors like travel time, long waiting time, transport cost, service cost, quality of service, and attitude of hospital staff still act as constraining factors even after the introduction of free maternal health care. The study concludes that practices like focused ANC and routine monitoring to facilities among others have increased utilisation. The study therefore recommends that to ensure adequate utilisation, the government and other stakeholders should offer support to the less-privileged mothers. Again, services should be easily available at facilities to pregnant women even if they are to be bought. It is further recommended that antenatal care services should be reoriented and clinical psychologists should be placed at all health centres to empower health staff on the best attitude towards clients. Interventions if mainstreamed into the national maternal health policy could be useful.