The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana

Treatment Cost and Psychological Impact of Burkitt Lymphoma on Ghanaian Families and Caregivers

OBJECTIVE

Before June 2022, the treatment cost of Burkitt lymphoma (BL) in Ghana was mainly borne by the child's family or caregiver. We determined the treatment cost of BL in children and its psychological impact on parents and caregivers.

METHOD

This prospective observational study assessed the direct medical and nonmedical costs (US dollars [USD]) incurred during the treatment of a child with BL for 6 consecutive months using a cost diary. Productivity losses and the psychological impact on parents and caregivers were assessed using a self-administered questionnaire and the Caregiver Quality of Life Index-Cancer (CQOLC).

RESULTS

Of the 25 participants, 7 abandoned the treatment of their children, and 4 withdrew because the children passed away. The median (Q1, Q3) cost for treating BL per child for caregivers/parents (N = 12) was USD 947.42 (USD 763.03, USD 1953.05). Direct medical costs formed 71% (USD 11 458.97) of total treatment costs. Working hours of parents before the child's cancer diagnosis decreased from a median (Q1, Q3) of 44.00 (20.00, 66.00) hours to 1.50 (0, 20.00) hours after the diagnosis. The mean (SD) CQOLC score was 107.92 (15.89), with higher scores in men (111.00 [17.26]), married participants (111.26 [17.29]), Higher National Diploma certificate holders (113.00 [1.41]), and participants earning a monthly income more than USD 84.60.

CONCLUSION

Treatment costs reduced the overall household income of 5 families. Parents and caregivers experienced reduced work hours and loss of employment. CQOLC scores were higher in married participants, those with a higher educational background, and those with higher income.

Validation of the Amharic version of perceived access to healthcare services for patients with cervical cancer in Ethiopia: A second-order confirmatory factor analysis

BACKGROUND

Accessing healthcare services is a multifaceted phenomenon involving various elements, encompassing the demand, identification, reach, and utilization of healthcare needs. The literature offers methods for capturing patients' perceptions of healthcare access. However, to accurately measure patient perceptions, it is imperative to ensure the validity and reliability of such instruments by designing and implementing localized language versions.

AIM

The primary aim of this study was to validate the Amharic version of the perceived access to health-care services among patients diagnosed with cervical cancer in Ethiopia.

METHOD

A cross-sectional study was conducted among cervical cancer patients at oncology centers in Addis Ababa, Ethiopia. A consecutive sampling approach was used and data collection took place from January 1 to March 30, 2023. Following initial validation and pretesting, a KoboCollect mobile phone application was employed for data collection. Subsequently, the collected data underwent cleaning in Microsoft Excel and analysis through Amos software v.26 and R programming. Various validity and reliability tests, such as content validity, convergent validity, face validity, divergent validity, known-group validity, and reliability tests, were executed. A second-order confirmatory factor analysis was developed to calculate incremental model fit indices, including CFI and TLI, along with absolute measures, namely SRMR and RMSEA.

RESULTS

A total of 308 participants were involved in the study, with 202 (65.6%) being patients referred from outside Addis Ababa. The initial evaluation of content validity by expert panels indicated that all criteria were met, with a CVR range of 0.5 to 1, I-CVI values ranging from 0.75 to 1, an S-CVI value of 0.91, and face validity values ranging from 2.4 to 4.8. The internal consistency of items within the final constructs varied from 0.76 to 0.93. Convergent, known-group, and most divergent validity tests fell within acceptable fit ranges. Common incremental fit measures for CFI and TLI were achieved with corresponding values of 0.95 and 0.94, respectively. The absolute fit measures of SRMR and RMSEA were 0.04 and 0.07, indicating good and moderate fit, respectively.

CONCLUSION

The study indicated a high internal consistency and validity of items with good fit to the data, suggesting potential accuracy of the domains. A five-domain structure was developed which enables adequate assessment of perceived access to health-care services of patients with cervical cancer in Ethiopia. We suggest that the tool can be utilized in other patient populations with a consideration of additional constructs, such as geographic accessibility.

Economic inequalities in health insurance subscription renewal: Evidence from Ghana's National Health Insurance Scheme

Ghana's national health insurance scheme (NHIS) is considered a major step towards achieving Universal Health Coverage (UHC) in the country. However, over the years the scheme has faced challenges, including subscription non-renewal, that threaten its sustenance. In this study, we estimate and analyse the nature of economic inequalities in NHIS subscription renewal and determine factors that contribute to the observed inequality. Data from the seventh round of the Ghana Living Standard Survey (GLSS) was used for the study. A sample of 40,170 ever insured individuals was included in the analysis comprising 18,066 males and 22,104 females. We computed concentration indices (CIs) and used linear regression techniques to decompose the CIs. The results show that NHIS renewal is pro-rich [CI = 0.126; P < 0.01] and favored males [CI = 0.110; P < 0.01] and urban dwellers [CI = 0.066; p < 0.01]. Major contributors to the observed inequality in subscription renewal include premium and processing fees payment, access to information, and economic wellbeing. The observed rural-urban and male-female differences in subscription renewal were explained by differences in premium and processing fee payments, education outcomes, employment status and access to information. The findings suggest that interventions that reduce cost barriers to NHIS subscription for the poor, improve physical access to healthcare and improve sensitization efforts should be encouraged.

Expectations of clients, insurers, and providers: a qualitative responsiveness assessment among private health insurance sector in Kampala-Uganda

BACKGROUND

There is less attention to assessing how health services meet the expectations of private health insurance (PHI) actors, clients, insurers, and providers in developing countries. Interdependently, the expectations of each actor are stipulated during contract negotiations (duties, obligations, and privileges) in a PHI arrangement. Complementary service roles performed by each actor significantly contribute to achieving their expectations. This study assessed the role of PHI in meeting the expectations of clients, insurers, and providers in Kampala. Lessons from this study may inform possible reviews and improvements in Uganda's proposed National Health Insurance Scheme (NHIS) to ensure NHIS service responsiveness.

METHODS

This study employed a qualitative case-study design. Eight (8) focus group discussions (FGDs) with insured clients and nine (9) key informant interviews (KIIs) with insurer and provider liaison officers between October 2020 and February 2021 were conducted. Participants were purposively selected from eligible institutions. Thematic analysis was employed, and findings were presented using themes with corresponding anonymized narratives and quotes.

RESULTS

Client-Provider, Client-Insurer, and Provider-Insurer expectations were generally not met. Client-provider expectations: Although most facilities were clean with a conducive care environment, clients experienced low service care responsiveness characterized by long waiting times. Both clients and providers received inadequate feedback about services they received and delivered respectively, in addition to prompt care being received by a few clients. For client-insurer expectations, under unclear service packages, clients received low-quality medicines. Lastly, for provider-insurer expectations, delayed payments, selective periodic assessments, and inadequate orientation of clients on insurance plans were most reported. Weak coordination between the client-provider and insurer did not support delivery processes for responsive service.

CONCLUSION

Health care service responsiveness was generally low. There is a need to commit resources to support the setting up of clearer service package orientation programs, and efficient monitoring and feedback platforms. Uganda's proposed National Health Insurance Act may use these findings to: Inform its design initiatives focusing on operating under realistic expectations, investment in quality improvement systems and coordination, and efficient and accountable client care relationships.

Maternal health care policy intervention and its impact on perinatal mortality outcomes in Ghana: evidence from a quasi-experimental design

OBJECTIVE

This study aimed to evaluate the impact of Ghana's free maternal health care policy on stillbirth and perinatal death since its implementation a decade ago.

STUDY DESIGN

The study used the propensity score matching method, a quasi-experimental design technique and secondary data to construct two groups of mothers with a history of perinatal deaths who subscribed to the 'free' maternal health care policy versus mothers who did not.

METHOD

The study merged two rounds of repeated cross-sectional data sets obtained from the Ghana Demographic and Health Survey (GDHS), 2008 and 2014, and generated exposure variables; pregnant women policy holding status and outcome variables; stillbirth and perinatal death by constructing binary outcomes from the under-five mortality variables of the DHS data sets. Fetal and early neonatal deaths within the data set were categorized into two groups: those exposed to the free maternal health care policy and those who did not. The propensity scores of the two groups were then generated and analyzed after checking for bias and common support. The analysis applied sample weighting to account for clustering and stratification due to the complex design of the DHS. All analyses were done with STATA 15 and adjusted for confounding using independent covariates.

RESULTS

Stillbirth (43.3%) and perinatal death (60.2%) were high in the intervention group compared to the comparison group, and the differences were statistically significant (stillbirth, 0.0156, and perinatal death, 0.0012). Stillbirth and perinatal deaths were 12 and 13 percentage points higher in the intervention group, and these were statistically significant: adj. coef. = 0.12; 95% CI: [0.03-0.19]; P = 0.005 and adj. coef. = 0.13; 95% CI: [0.03-0.22]; P = 0.005.

CONCLUSION

The results show that stillbirth and perinatal death were high in the maternal health care policy group, poorly reflecting as outcomes. However, the percentage point difference between stillbirth and perinatal death suggests a decline in early neonatal mortality and a positive impact of the 'free' maternal health care policy on perinatal death over stillbirth.

Effects of Health Insurance on Quality of Care in Low-Income Countries: A Systematic Review

Objectives: To evaluate the effectiveness of health insurance on quality of care in low-income countries (LICs). Methods: We conducted a systematic review following PRISMA guidelines. We searched seven databases for studies published between 2010 and August 2022. We included studies that evaluated the effects of health insurance on quality of care in LICs using randomized experiments or quasi-experimental study designs. Study outcomes were classified using the Donabedian framework. Results: We included 15 studies out of the 6,129 identified. Available evidence seems to suggest that health insurance has limited effects on structural quality, and its effects on the process of care remain mixed. At the population level, health insurance is linked to improved anthropometric measures for children and biomarkers such as blood pressure and hemoglobin levels. Conclusion: Based on the currently available evidence, it appears that health insurance in LICs has limited effects on the quality of care. Further studies are required to delve into the mechanisms that underlie the impact of health insurance on the quality of care and identify the most effective strategies to ensure quality within insurance programs. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=219984, identifier PROSPERO CRD42020219984.

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.

Assessing Client Satisfaction with Health Service Delivery under the National Health Insurance Scheme: The Case of Komfo Anokye Teaching Hospital

Background. Client satisfaction is the direct effect of service delivery and, in essence, the basis for quality improvement in any industry. In health financing, it is a significant determinant of clients’ enrolment in an insurance scheme. Objectives. This study sought to assess client satisfaction with healthcare delivery under the National Health Insurance Scheme (NHIS) at a tertiary facility in Ghana. Methods. A cross-sectional study was conducted among patients attending the outpatient department of the Komfo Anokye Teaching Hospital. Data were collected using structured questionnaires. Questionnaires were administered to 300 purposively selected patients, stratified based on their insurance status. Data obtained were then analysed using mean score ranking and an independent sample t-test. Results. The client satisfaction variable with a high level of satisfaction was observed for physical environment (πins = 3.80; πunins = 3.69). The least rated construct was responsiveness (πins = 2.59; πunins = 2.51). A statistically significant difference in the means between the insured and uninsured was observed for two of the five constructs, namely, communication (πdiff = 0.36; $p<0.05$ ) and service availability (πdiff = 0.33; $p<0.05$ ). Conclusions. This study advocates for prioritization of measures and policy initiatives aimed at improving responsiveness in healthcare delivery, as the least rated construct. It further draws health providers’ attention to modesty in communication regardless of socioeconomic or insurance status.

Effect of mobile phone-based health insurance contribution payment system on retention of coverage in the National Health Insurance Scheme in Ghana: an evaluation study

BACKGROUND

Ghana introduced a mobile phone-based contribution payment system in its national health insurance scheme (NHIS) in December 2018 to improve the process of enrolment. We evaluated the effect of this digital health intervention on retention of coverage in the Scheme, one year after its implementation.

METHODS

We used NHIS enrolment data for the period, 1 December 2018-31 December 2019. Descriptive statistics and propensity-score matching method were performed to examine a sample of 57,993 members' data.

RESULTS

Proportion of members who renewed their membership in the NHIS via the mobile phone-based contribution payment system increased from 0% to 8.5% whilst those who did so through the office-based system only grew from 4.7% to 6.4% over the study period. The chance of renewing membership was higher by 17.4 percentage points for users of the mobile phone-based contribution payment system, compared to those who used the office-based contribution payment system. The effect was greater for the informal sector workers, males and the unmarried.

CONCLUSIONS

The mobile phone-based health insurance renewal system is improving coverage in the NHIS particularly for members who hitherto were less likely to renew their membership. Policy makers need to devise an innovative way for new members and all member categories to enrol using this payment system to accelerate progress towards attainment of universal health coverage. Further study needs to be conducted using mixed-method design with inclusion of more variables.

Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania: an explorative qualitative study

BACKGROUND

Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania.

METHODS

An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data.

RESULTS

Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement.

CONCLUSION

While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions?

BACKGROUND

Despite political promise to reduce out-of-pocket (OOP) expenditure on healthcare through the National Health Insurance Program (NHIP) of Nepal, its implementation is challenging with low enrolment and high drop-out rates. Program performance can often be linked with political economy considerations and interests of stakeholders. This study aimed to develop an in-depth understanding of organizational and systemic challenges in implementing NHIP.

METHODS

We conducted a structured narrative review of available literature on the NHIP in Nepal. We analysed data using a political economy analysis for health financing reform framework. The findings were explained under six broad categories: interest groups, bureaucracy, budgets, leadership, beneficiary and external actors. In addition, we triangulated and further presented the literature review findings using expert opinions (views expressed in public forums).

RESULTS

Nepal has formulated acts, rules, regulations, and policies to implement NHIP. Under this program, the Health Insurance Board (HIB) is the purchaser of health services, and health facilities under the Ministry of Health and Population (MoHP) are the providers. The NHIP has been rolled out in all 77 districts. Several challenges have hindered the performance of NHIP at the policy and implementation levels. Challenges under interest groups included inadequate or delayed reimbursement and drop-out of hospitals in implementing the programme. Bureaucracy-related challenges were hegemony of provider over the purchaser, and inadequate staff (delay in the approval of organogram of HIB). There was inadequate monitoring of premium collection, and claim reimbursement was higher than collected premium. Challenges under leadership included high political commitments but weak translation into action, consideration of health insurance as poor return on investment, and intention of leaders to privatize the NHIP. Beneficiaries experienced compromised quality of care or lack of services when needed, high drop-out rates and low interest in renewal of premiums. External actors provided technical assistance in policy design but limited support in implementation.

CONCLUSIONS

Despite enabling a policy environment, the NHIP faced many challenges in implementation. There is an urgent need for institutional arrangements (e.g. digitalization of claims and reimbursement, endorsement of organogram of HIB and recruitment of staff), increased coverage of financial protection and service (increased benefit package and introduction of cost-sharing/co-payment model), legislative reforms (e.g. legal provision for cost-sharing mechanism, integration of fragmented schemes, tripartite agreement to reimburse claims and accreditation of health facilities to ensure quality healthcare), and leveraging technical support from the external actors. High levels of commitment and accountability among political leaders and bureaucrats are required to strengthen financial sustainability and implementation.

Adopting social health insurance in Nepal: A mixed study

Objective

The Social Health Insurance Program (SHIP) shares a major portion of social security, and is also key to Universal Health Coverage (UHC) and health equity. The Government of Nepal launched SHIP in the Fiscal Year 2015/16 for the first phase in three districts, on the principle of financial risk protection through prepayment and risk pooling in health care. Furthermore, the adoption of the program depends on the stakeholders' behaviors, mainly, the beneficiaries and the providers. Therefore, we aimed to explore and assess their perception and experiences regarding various factors acting on SHIP enrollment and adherence.

Methods

A cross-sectional, facility-based, concurrent mixed-methods study was carried out in seven health facilities in the Kailali, Baglung, and Ilam districts of Nepal. A total of 822 beneficiaries, sampled using probability proportional to size (PPS), attending health care institutions, were interviewed using a structured questionnaire for quantitative data. A total of seven focus group discussions (FGDs) and 12 in-depth interviews (IDIs), taken purposefully, were conducted with beneficiaries and service providers, using guidelines, respectively. Quantitative data were entered into Epi-data and analyzed with SPSS, MS-Excel, and Epitools, an online statistical calculator. Manual thematic analysis with predefined themes was carried out for qualitative data. Percentage, frequency, mean, and median were used to describe the variables, and the Chi-square test and binary logistic regression were used to infer the findings. We then combined the qualitative data from beneficiaries' and providers' perceptions, and experiences to explore different aspects of health insurance programs as well as to justify the quantitative findings.

Results and prospects

Of a total of 822 respondents (insured-404, uninsured-418), 370 (45%) were men. Families' median income was USD $65.96 (8.30-290.43). The perception of insurance premiums did not differ between the insured and uninsured groups (p = 0.53). Similarly, service utilization (OR = 220.4; 95% CI, 123.3-393.9) and accessibility (OR = 74.4; 95% CI, 42.5-130.6) were found to have high odds among the insured as compared to the uninsured respondents. Qualitative findings showed that the coverage and service quality were poor. Enrollment was gaining momentum despite nearly a one-tenth (9.1%) dropout rate. Moreover, different aspects, including provider-beneficiary communication, benefit packages, barriers, and ways to go, are discussed. Additionally, we also argue for some alternative health insurance schemes and strategies that may have possible implications in our contexts.

Conclusion

Although enrollment is encouraging, adherence is weak, with a considerable dropout rate and poor renewal. Patient management strategies and insurance education are recommended urgently. Furthermore, some alternate schemes and strategies may be considered.

The Health Experiences of Young Internal Migrants in Ghana-Identifying Priorities for Sustainable Health Promotion

The Sustainable Development Goals underscore the importance of migration to the achievement of health, and global migration presents both opportunities and challenges for the development of health promotion. Despite such recognition, very little work has focused on health promotion with young migrants, including how migration shapes opportunities for positive health. This paper reports findings from a qualitative study that sought to advance knowledge of the health experiences of young internal migrants in Ghana (n = 14) and considers ways to harness these perspectives in the development of sustainable health promotion solutions. Methods included community consultations, participatory workshops and interviews with young migrants aged 14-21 years. Findings highlighted how the social determinants of health affected young migrants' opportunities to support their health. Our analysis highlights how a lack of access to adequate food, shelter and health services often resulted in the adoption of alternative health practices, including the use of herbal remedies. Supporting positive livelihoods as part of tackling the social determinants of health is crucial to mitigate the impacts of poverty and inequalities on young migrants' health practices and outcomes. We conclude by considering how to advance relevant health promotion with young migrants living in contexts of vulnerability.

A mixed methods study of community-based health insurance enrollment trends and underlying challenges in two districts of northeast Ethiopia: A proxy for its sustainability

Background

The term "community-based health insurance" refers to a broad range of nonprofit, prepaid health financing models designed to meet the health financing needs of disadvantaged populations, particularly those in the rural and informal sectors. Due to their voluntary nature, such initiatives suffer from persistently low coverage in low- and middle-income countries. In Ethiopia, the schemes’ membership growth has not been well investigated so far. This study sought to examine the scheme’s enrollment trend over a five-year period, and to explore the various challenges that underpin membership growth from the perspectives of various key stakeholders.

Methods

The study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia: Tehulederie and Kallu. By reviewing the databases of health insurance schemes, quantitative data were collected retrospectively from 2017 to 2021 to examine enrollment trends. Trends for each performance indicator were analyzed descriptively for the period under study. Face-to-face interviews were conducted with nine community members and 19 key informants. Study participants were purposely selected using the maximum variation technique. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was employed with both deductive and inductive coding approaches.

Results

Over the course of the study period, enrollment in the scheme at both districts exhibited non-linear trends with both positive and negative growth rates being identified. Overall, the scheme in Tehulederie has a relatively higher population coverage and better membership retention, which could be due to the strong foundation laid by a rigorous public awareness campaign and technical support during the pilot phase. The challenges contributing to the observed level of performance have been summarized under four main themes that include quality of health care, claims reimbursement for insurance holders, governance practices, and community awareness and acceptability.

Conclusions

The scheme experienced negative growth ratios in both districts, indicating that it is not functionally viable. It will fail to meet its mission unless relevant stakeholders at all levels of government demonstrate political will and commitment to its implementation, as well as advocate for the community. Interventions should target on the highlighted challenges in order to boost membership growth and ensure the scheme’s viability.

Financial viability of a community-based health insurance scheme in two districts of northeast Ethiopia: a mixed methods study

BACKGROUND

Community-based health insurance initiatives in low- and middle-income countries encountered a number of sustainability challenges due to their voluntary nature, small risk pools, and low revenue. In Ethiopia, the schemes' financial viability has not been well investigated so far. This study examined the scheme's financial viability and explored underlying challenges from the perspectives of various key stakeholders.

METHODS

This study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia. By reviewing financial reports of health insurance schemes, quantitative data were collected over a seven years period from 2014 to 2020 to examine trends in financial status. Trends for each financial indicator were analyzed descriptively for the period under review. Interviews were conducted face-to-face with nine community members and 19 key informants. We used the maximum variation technique to select the study participants. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was applied with both inductive and deductive coding methods.

RESULTS

Both schemes experienced excess claims costs and negative net income in almost all the study period. Even after government subsidies, the scheme's net income remained negative for some reporting periods. The challenges contributing to the observed level of financial performance have been summarized under five main themes, which include adverse selection, moral hazard behaviors, stockout of medicines, delays in claims settlement for service providers, and low insurance premiums.

CONCLUSIONS

The health insurance scheme in both districts spent more than it received for claims settlement in almost all the period under the study, and experienced heavy losses in these periods, implying that it is not financially viable for the period in question. The scheme is also unable to fulfill its purpose of protecting members against out-of-pocket expenses at the point of health care. Interventions should target on the highlighted challenges to restore financial balance and enhance the scheme's viability.

Incidence of patients leaving against medical advice in government-subsidized hospitals: a descriptive retrospective study

Introduction

this study aimed to determine the prevalence of leaving against medical advice (LAMA) in the local context and the associated predictors to help develop effective strategies to reduce its likelihood.

Methods

this study employed a retrospective approach using medical records of the 16233 patients between 2016 and 2020 at various government-subsidized hospitals in the Hail region of Saudi Arabia.

Results

the prevalence of LAMA was the highest in 2019 (91.9%) and 2017 (21.45%) among insured and non-insured patients, respectively. Furthermore, it was the highest among patients aged 20-25 years and the lowest among patients aged 46 years and above. The incidence of LAMA was the highest (15.48% for males and 29.53% for females) in 2016. In 2016-2019, the most common reason for LAMA was "wanted medication only," while in 2020, the "fear of infection with COVID-19" was the main reason. High blood sugar was the most common diagnosis among the patients under consideration during the study period. Significant association was found between LAMA and patient's insurance status (t = 4.3123; p < 0.002); however, no association was found between LAMA and age (t = -0.8748; p > 0.658) and gender of patients (t = 1.9008; p > 0.302).

Conclusion

strategies such as developing a suitable environment for patients and taking due care of their needs, providing individual consulting services, enhancing staff relations, and providing support to patients in need are vital. The likelihood of LAMA can be minimized by informing hospitalized patients and their relatives about the adverse effects of LAMA.

The Shared Experience of Insured and Uninsured Patients: A Comparative Study

Background

Despite efforts to ensure equitable quality of care for all patients, a significant gap persists between the quality of care experienced by insured and uninsured patients in Saudi Arabia. This study aims to identify and compare the differences between insured and uninsured patients in terms of their experience of quality of care in a tertiary hospital.

Methods

A descriptive cross-sectional study was utilized. Insured and uninsured individuals who had undergone identical medical procedures in early 2021 were identified from a public 500-bed tertiary hospital. About 350 patients participated in this study by completing an online, self-administered questionnaire, adopted by Abuosi and others in 2016, assessing six dimensions of quality of care.

Results

Significant differences were reported between the quality of care experienced by insured and uninsured subjects (M = 3.37, SD = 0.525, and M = 3.06, SD = 0.452, respectively, p=0.001). While insured group reported high quality of care, followed by fairness of care (r = 0.744 and r = 0.675, p ≤ 0.001, n = 175), uninsured subjects experienced less fairness with low quality of care.

Conclusions

The insured individuals were found to be more attentive to the quality of care offered by the hospital than their counterparts. Efforts to close the gap in quality of care should include monitoring healthcare outcomes, adopting transparency standards, and facilitating procedures to minimize barriers among patients.

Exploring for-profit healthcare providers' perceptions of inclusion in the Zambia National Health Insurance Scheme: A qualitative content analysis

BACKGROUND

In 2019, Zambia introduced the national health insurance (NHI) as a healthcare financing strategy to increase universal access to health care services. The private health sector can complement public sector providers as service providers under the NHI. As such, the NHI Management Authority seeks to accredit for-profit private healthcare facilities in the NHI. Ascertaining factors that influence private-for-profit health providers to participate in the NHI is essential, but the evidence is lacking. In this study, we aimed to explore and characterize perceptions and experiences of for-profit private hospitals, dental clinics, eye clinics, diagnostic centres, and pharmacies regarding their inclusion in the NHI.

METHODS

We conducted in-depth interviews with owners or management officers of purposively sampled private health care providers in Lusaka, Zambia (n = 22) between May and June 2020. Qualitative content analysis was used to analyse data.

RESULTS

The findings highlight low awareness of the NHI among providers and a need to understand the NHI. Providers revealed their positions and views on the accreditation process and payment arrangements and stated that their participation would complement the NHI. They also cited conditions to participate in the NHI, highlighted opportunities and challenges of engaging in the NHI, and expressed a need for sustainable ways of governing the scheme.

CONCLUSION

The assessment of health providers' inclusion in the NHI scheme is multifaceted. The results of this study surfaced factors such as raising awareness on the NHI among providers and how their concerns on aspects such as payments can be considered as inputs to enlighten consensual agreements between the NHI authority and health providers in leveraging the private health sector. Private providers' concerns must be further understood and considered as the NHI strives to include this group as health care providers in the scheme.

Equity in the Perceived Quality of Care Received by Malaria Patients Under National Health Insurance Scheme in Ghana

The Ghana National Health Insurance Scheme (NHIS) seeks to provide access to quality healthcare to its members regardless of the health facility in which they receive care. However, it is unclear if all members of the Scheme receive quality care. The objective of the study is to examine the equity of perceived healthcare quality received by NHIS members depending on the type of facility in which care was provided. The study purposively sampled 2000 NHIS members who sought malaria treatment in the study areas. Only patients who had visited the health facilities at least twice not more than 12 months, before the data collection, were sampled. The SERVQUAL model was used to examine perceived quality of healthcare services in 5 quality dimensions: Reliability, Assurance, Tangibility, Empathy, and Responsiveness. These quality dimensions were compared in health facilities according to ownership (public, private, and faith-based facilities), capacity (hospital vs health centers), and finally location (urban vs rural health facilities). Instrumental variable estimation method was used to analyze data to address health facility selection bias problem. The results showed that faith-based health facilities scored the highest in all 5 perceived quality dimensions followed by public and private. Hospitals had higher score in perceived quality than health centers just as urban facilities scored higher in quality than rural facilities. These results represent high inequality in the perceived quality of care received by NHIS members.

Improving hospital-based processes for effective implementation of Government funded health insurance schemes: evidence from early implementation of PM-JAY in India

Background

Government-sponsored health insurance schemes (GSHIS) aim to improve access to and utilization of healthcare services and offer financial protection to the population. India’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one such GSHIS. This paper aims to understand how the processes put in place to manage hospital-based transactions, from the time a beneficiary arrives at the hospital to discharge are being implemented in PM-JAY and how to improve them to strengthen the scheme’s operation.

Methods

Guidelines were reviewed for the processes associated with hospital-based transactions, namely, beneficiary authentication, treatment package selection, preauthorization, discharge, and claims payments. Across 14 hospitals in Gujarat and Madhya Pradesh states, the above-mentioned processes were observed, and using a semi-structured interview guide fifty-three respondents were interviewed. The study was carried out from March 2019 to August 2019.

Results

Average turn-around time for claim reimbursement is two to six times higher than that proposed in guidelines and tender. As opposed to the guidelines, beneficiaries are incurring out-of-pocket expenditure while availing healthcare services. The training provided to the front-line workers is software-centric. Hospital-based processes are relatively more efficient in hospitals where frontline workers have a medical/paramedical/managerial background.

Conclusions

There is a need to broaden capacity-building efforts from enabling frontline staff to operate the scheme’s IT platform to developing the technical, managerial, and leadership skills required for them. At the hospital level, an empowered frontline worker is the key to efficient hospital-based processes. There is a need to streamline back-end processes to eliminate the causes for delay in the processing of claim payment requests. For policymakers, the most important and urgent need is to reduce out-of-pocket expenses. To that end, there is a need to both revisit and streamline the existing guidelines and ensure adherence to the guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07448-3.

Patient satisfaction with the Nigerian National Health Insurance Scheme two decades since establishment: A systematic review and recommendations for improvement

Background

To improve healthcare access and mitigate healthcare costs for its population, Nigeria established a National Health Insurance Scheme (NHIS) in 1999. The NHIS remains Nigeria’s leading vehicle for achieving universal health coverage; nonetheless, questions remain regarding its quality and effectiveness. Studies on patient satisfaction have served as a useful strategy to further understand the patient experience and the efficacy of health systems.

Aim

To synthesise current knowledge on patient satisfaction with the NHIS.

Methods

The authors performed a systematic review of primary literature from 1999 to 2020 reporting on NHIS patient satisfaction in eight databases (including PubMed, Embase, and Africa-wide Information).

Results

This search returned 764 unique records of which 21 met criteria for full data extraction. The 21 qualifying studies representing 11 of the 36 Nigerian states, were published from 2011 to 2020, and found moderate overall satisfaction with the NHIS (64%). Further, when disaggregated into specific domains, NHIS enrolees were most satisfied with provider attitudes (77%) and healthcare environments (70%), but less satisfied with laboratories (62%), billings (62%), pharmaceutical services (56%), wait times (55%), and referrals (51%). Importantly, time trends indicate satisfaction with the NHIS is increasing – although to differing degrees depending on the domain.

Conclusion

The beneficiaries of the NHIS are moderately satisfied with the scheme. They consider it an improvement from being uninsured, but believe that the scheme can be considerably improved. The authors present two main recommendations: (1) shorter wait times may increase patient satisfaction and can be a central focus in improving the overall scheme, and (2) more research is needed across all 36 states to comprehensively understand patient satisfaction towards NHIS in anticipation of potential scheme expansion.

Client satisfaction on community based health insurance scheme and associated factors at Boru Meda Hospital, Northeast, Ethiopia: institutional based cross-sectional study

Background

Community-based health insurance systems are usually voluntary and characterized by community members pooling funds and protecting themselves against the high costs of seeking medical care and treatment for illness. Client satisfaction with health service provision during the implementation of health insurance schemes has often been neglected. This study aimed to determine client satisfaction with the community-based health insurance scheme and associated factors.

Methods

An institutional-based cross-sectional study design was applied from February 22–March 11 /2019. A total of 420 study participants were included in the study using a systematic random sampling technique. Data were collected using a pretested semi-structured interviewer-administered questionnaire with a patient exit interview. Bivariate and multivariate logistic regression analyses were used to identify factors associated with Community-based Health Insurance of client satisfaction. Statistical significance was decided at a p-value less than 0.05.

Result

A total of 420 community-based health insurance clients of health service users participated in the study with a 100% response rate. The overall client satisfaction was 80% at 95% Cl (76.1, 83.9), respondents who have perceived that partially or none availability of prescribing drugs were 0.09 times less likely satisfied as compared to full availability of prescribing drugs (AOR =0.09; 95% Cl: (0.04, 0.19)). Besides, study participants waiting time to consult service providers within 30 min were more satisfied than those who were delayed 60 min and above (AOR =3.16; 95% Cl: (1.19, 8.41)).

Conclusion

Community-based health insurance client satisfaction provided in the present study was 80% indicating low proportion. Full availability of prescribing drugs, clients renewed their community-based health insurance membership, and preference of clients to use the hospital for future health care need were positively associated with client satisfaction while the perception of waiting time before physician consultation negatively affected client’s satisfaction. Therefore, the hospital management members and service providers need to give attention to reduce waiting time preceding consultation, improve drug availability, and sustain the hospital preference by the client.

Mandatory employer-sponsored health financing scheme for semiformal workers in Bangladesh: An experimental assessment

In this study, we present findings from an experimental evaluation of a mandatory employer-sponsored health insurance scheme in Bangladesh. We randomly introduced the scheme to female artisans to understand the impacts on healthcare utilisation, expenditure and subjective well-being using both survey and administrative data. Our findings suggest that the scheme broke even; however, it covered only six percent of the overall health expenditure and 16 percent of the hospitalisation costs. We find higher inpatient care utilisation, particularly among women, and in favour of empanelled hospitals causally associated with the intervention, consistent with the design of the scheme. We do not find significant healthcare savings or improvement in subjective well-being, consistent with low coverage. The findings suggest the scheme to be financially sustainable and it changes the healthcare seeking behaviours as the scheme incentivises. However, meaningful savings and protection against catastrophic health expenditures will require a higher level of coverage.

Health financing reforms for Universal Health Coverage in five emerging economies

BACKGROUND

Many countries have committed to achieving Universal Health Coverage. This paper summarizes selected health financing themes from five middle-income country case studies with incomplete progress towards UHC.

METHODS

The paper focuses on key flagship UHC programs in these countries, which exist along other publicly financed health delivery systems, reviewed through the lens of key health financing functions such as revenue raising, pooling and purchasing as well as governance and institutional arrangements.

RESULTS

There is variable progress across countries. Indonesia's Jaminan Kesehatan Nasional (JKN) reforms have made substantial progress in health services coverage and health financing indicators though challenges remain in its implementation. In contrast, Ghana has seen reduced funding levels for health and achieved less than 50% in the UHC service coverage index. In India, despite Ayushman Bharat (PM-JAY) reforms having provided important innovations in purchasing and public-private mix, out of pocket spending remains high and the public health financing level low. Kenya still has a challenge to use public financing to enhance coverage for the informal sector, while South Africa has made little progress in strategic purchasing.

CONCLUSIONS

Despite variations across countries, therefore, important challenges include inadequate financing, sub-optimal pooling, and unmet expectations in strategic purchasing. While complex federal systems may complicate the path forward for most of these countries, evidence of strong political commitment in some of these countries bodes well for further progress.

What alternative and innovative domestic methods of healthcare financing can be explored to fix the current claims reimbursement challenges by the National Health Insurance Scheme of Ghana? Perspectives of health managers

BACKGROUND

Low-and-middle -income countries (LMICs), to achieve sustainable universal health coverage (UHC) governments are implementing local and sustainable methods of healthcare financing. However, in Ghana, there is limited evidence on these local methods for healthcare financing to inform policy. This study aimed at exploring health managers views on alternative domestic and sustainable methods of healthcare financing for UHC under the National Health Insurance Scheme (NHIS).

METHODS

A qualitative study using in-depth interviews with 16 health facility managers were held. The health facilities and participants were selected using convenience and purposive sampling methods. A written consent was obtained from participants prior to participation in the interview. Data was transcribed verbatim and analyzed using thematic framework approach.

RESULTS

Health managers across all the health facilities mentioned delayed and erratic claims reimbursement to health facilities as the main challenge. Participants attributed the main reason to lack of funds by the National Health Insurance Authority (NHIA). They said the delayed and irregular payments has been a challenge to efficient delivery of quality healthcare to clients. That in some instances they have been compelled to demand cash or out-of-pocket payment from insured clients or insurance card bearers to be able to render needed healthcare services to them. Participants think that to ensure regular reimbursement of claims to the health facilities by the NHIA, the managers think alternative local sources of funding need to be explored to fill the funding gap. To put in place this, they suggested the need to start levying special taxes on natural resources such as crude oil and gas, gold, bauxite, cocoa, mobile money transfers, airtime and increasing the proportion of levies on the existing Value Added Tax (VAT).

CONCLUSION

The study provides important insights into potential innovative alternative domestic sources for raising additional funds to finance healthcare services in Ghana. Despite the potential of these sources, it is important for governments and health policy makers in Ghana and other LMICs who are working towards implementing innovative local methods using special levies on mobile communication services and natural resources to finance their UHC, to implement those that best suit their economies to ensure equity for better health.

Access Differentials in Primary Healthcare among Vulnerable Populations in a Health Insurance Setting in Kumasi Metropolis, Ghana: A Cross-Sectional Study

Background. Access to healthcare remains a challenge towards the achievement of the Sustainable Development Goals in Ghana. There still remain inequalities in the distribution of health services especially among vulnerable groups despite sustained efforts to strengthen the health system. This study was conducted to analyze access differentials among different vulnerable groups in the context of primary healthcare under a National Health Insurance Scheme (NHIS) in Ghana. Methods. This study was a descriptive cross-sectional study conducted among multilevel participants of vulnerable groups in Kumasi Metropolis: 710 vulnerable people constituting elderly/aged (n = 359), pregnant women (n = 117), head poters (teenage girls who migrated from the northern Ghana mainly to the capital cities of the Ashanti and Greater Accra region to help in carrying of goods for their livelihood) (n = 86), sex workers (n = 75), and other vulnerable groups (people with disabilities and street participants) (n = 73). Data were collected using a semistructured questionnaire. Poisson regression with robust variance was used to access the association between vulnerability and access to healthcare. Results. Close to a fifth, 18.5% of the study respondents were unable to access care at any point in time during the last 12 months. Reasons for the inability to access healthcare included limited funding (69.7%), poor attitude of service providers (7.6%), distance to health centers (8.3%), and religious reasons (6.2%). More than 95% of respondents were insured under the NHIS, but acceptability of service provision under the NHIS was low among the vulnerable groups. In the crude models, pregnant women had lower prevalence of access to medications as compared to the elderly (prevalence ratio (PR): 0.88; 95% CI: 0.80–0.98). Head poters and other vulnerable groups were also less likely to view healthcare as affordable as compared to the elderly. The differences in healthcare access observed were attenuated after adjustment for sociodemographic characteristics and healthcare-related factors. Conclusions. Despite the introduction of a NHIS in Ghana, this study highlights challenges in healthcare access among vulnerable populations independent of the type of vulnerability. This suggests the need for stakeholders to work to address access differentials in the NHIS and adopt other innovative care strategies that may have broader applicability for all populations.

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.

Positioning the National Health Insurance for financial sustainability and Universal Health Coverage in Ghana: A qualitative study among key stakeholders

INTRODUCTION

The National Health Insurance Scheme (NHIS) was introduced in 2003 to reduce "out-of-pocket" payments for health care in Ghana. Over a decade of its implementation, issues about the financial sustainability of this pro-poor policy remains a crippling fact despite its critical role to go towards Universal Health Coverage. We therefore conducted this study to elicit stakeholders' views on ways to improve the financial sustainability of the operations of NHIS.

METHODS

Twenty (20) stakeholders were identified from Ministry of Health, Ghana Health Services, health workers groups, private medical practitioners, civil society organizations and developmental partners. They were interviewed using an interview guide developed from a NHIS policy review and analysis. All interviews were recorded and transcribed verbatim. The data were analysed thematically with the aid of NVivo 12 software.

RESULTS

Stakeholders admitted that the NHIS is currently unable to meet its financial obligations. The stakeholders suggested first the adoption of capitation as a provider payment mechanism to minimize the risk of providers' fraud and protection from political interference. Secondly, they indicated that rapid releases of specific statutory deductions and taxes for NHIS providers could reduce delays in claims' reimbursement which is one of the main challenges faced by healthcare providers. Aligning the NHIS with the Community-based Health Planning and Services and including preventive and promotive health is necessary to position the Scheme for Universal Health Coverage.

CONCLUSION

The Scheme will potentially achieve UHC if protected from political interference to improve the governance and transparency that affects the finances of the scheme and the expansion of services to include preventive and promotive services and cancers.

Does health insurance contribute to improved utilization of health care services for the elderly in rural Tanzania? A cross-sectional study

Background: Health care systems in developing countries such as Tanzania depend heavily on out-of-pocket payments. This mechanism contributes to inefficiency, inequity and cost, and is a barrier to patients seeking access to care. There are efforts to expand health insurance coverage to vulnerable groups, including older adults, in Sub-Saharan African countries. Objective: To analyse the association between health insurance and health service use in rural residents aged 60 and above in Tanzania. Methods: Data were obtained from a household survey conducted in the Nzega and Igunga districts. A standardised survey instrument from the World Health Organization Study on global AGEing and adult health was used. This comprised of questions regarding demographic and socio-economic characteristics, health and insurance status, health seeking behaviours, sickness history (three months and one year prior to the survey), and the receipt of health care. A multistage sampling method was used to select wards, villages and respondents in each district. Local ward and hamlet officers guided the researchers in identifying households with older people. Crude and adjusted logistic regression methods were used to explore associations between health insurance and outpatient and inpatient health care use. Results: The study sample comprised 1,899 people aged 60 and above of whom 44% reported having health insurance. A positive statistically significant association between health insurance and the utilisation of outpatient and inpatient care was observed in all models. The odds of using outpatient (adjusted OR = 2.20; 95% CI: 1.54, 3.14) and inpatient services (adjusted OR = 3.20; 95% CI: 2.46, 4.15) were higher among the insured. Conclusion: Health insurance is a predictor of outpatient and inpatient health services in people aged 60 and above in rural Tanzania. Further research is needed to understand the perceptions of both the insured and uninsured regarding the quality of care received.

Insured clients out-of-pocket payments for health care under the national health insurance scheme in Ghana

BACKGROUND

In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) designed to promote universal health coverage and equitable access to health care. The scheme has largely been successful, yet it is confronted with many challenges threatening its sustainability. Out-of-pocket payments (OOP) by insured clients is one of such challenges of the scheme. This study sought to examine the types of services OOP charges are made for by insured clients and how much insured clients pay out-of-pocket.

METHODS

This was a descriptive cross-sectional health facility survey. A total of 2066 respondents were interviewed using structured questionnaires at the point of health care exit in the Ashanti, Northern and Central regions of Ghana. Health facilities of different levels were selected from 3 districts in each of the three regions. Data were collected between April and June 2018. Using Epidata and STATA Version 13.1 data analyses were done using multiple logistic regression and simple descriptive statistics and the results presented as proportions and means.

RESULTS

Of all the survey respondents 49.7% reported paying out-of-pocket for out-patient care while 46.9% of the insured clients paid out-of-pocket. Forty-two percent of the insured poorest quintile also paid out-of-pocket. Insured clients paid for consultation (75%) and drugs (63.2%) while 34.9% purchased drugs outside the health facility they visited. The unavailability of drugs (67.9%) and drugs not covered by the NHIS (20.8%) at the health facility led to out-of-pocket payments. On average, patients paid GHS33.00 (USD6.6) out-of-pocket. Compared to the Ashanti region, patients living in the Northern region were 74% less at odds to pay out-of-pocket for health care.

CONCLUSION AND RECOMMENDATION

Insured clients of Ghana's NHIS seeking health care in accredited health facilities make out-of-pocket payments for consultation and drugs that are covered by the scheme. The out-of-pocket payments are largely attributed to unavailability of drugs at the facilities while the consultation fees are charged to meet the administrative costs of services. These charges occur in disadvantaged regions and in all health facilities. The high reliance on out-of-pocket payments can impede Ghana's progress towards achieving Universal Health Coverage and the Sustainable Development Goal 3, seeking to end poverty and reduce inequalities. In order to build trust and confidence in the NHIS there is the need to eliminate out-of-pocket payments for consultation and medicines by insured clients.

An ultrasound observation study on the levator hiatus with or without diastasis recti abdominis in postpartum women

INTRODUCTION AND HYPOTHESIS

We hypothesized that differences in post-partum levator hiatus (LH) measurements, as well as the area of urethra and bladder (AUB), viewed under ultrasound, correlate with diastasis rectus abdominis (DRA) occurrence. The primary objective of this study is to determine ultrasound parameters available for diagnosing DRA in post-partum women. We compared LH and AUB measurements under ultrasound in primiparous women, with and without DRA, at 24-26 weeks postpartum.

METHODS

One hundred ninety-four women underwent routine examination, including a self-made clinical symptoms questionnaire, DRA evaluation, and LH and AUB measurements. Independent samples t- and chi-squared tests were used to compare the differences between women with and without DRA.

RESULTS

DRA incidence was significantly higher among those who underwent cesarean section (CS) than for vaginal delivery (VD) (P = 0.038). DRA patients could potentially have urinary urgency, frequency, pain, dysuria, and perineal tears. Additionally, statistically significant differences were found between VD patients, with or without DRA, in the resting LH transverse diameter (TrD) (P = 0.032) and the area of the levator hiatus (ALH) (P = 0.048) as well as AUB at Valsalva (P = 0.049). No differences, however, were found between the DRA and no DRA groups for all those measurements among women who had cesarean deliveries.

CONCLUSIONS

DRA was more likely in post-CS women. Furthermore, the results showed a plausible association between DRA occurrence and LH expansion, especially in women with VD under rest and Valsalva. This could be useful for developing therapeutic plans based on these parameters for post-partum rehabilitation of women with DRA to avoid long-term complications.

Quality of care in the free maternal healthcare era in sub-Saharan Africa: a scoping review of providers' and managers' perceptions

BACKGROUND

Free maternal healthcare financing schemes play an essential role in the quality of services rendered to clients during antenatal care in sub-Saharan Africa (SSA). However, healthcare managers' and providers' perceptions of the healthcare financing scheme may influence the quality of care. This scoping review mapped evidence on managers' and providers' perspectives of free maternal healthcare and the quality of care in SSA.

METHODS

We used Askey and O'Malley's framework as a guide to conduct this review. To address the research question, we searched PubMed, CINAHL through EBSCOhost, ScienceDirect, Web of Science, and Google Scholar with no date limitation to May 2019 using keywords, Boolean terms, and Medical Subject Heading terms to retrieve relevant articles. Both abstract and full articles screening were conducted independently by two reviewers using the inclusion and exclusion criteria as a guide. All significant data were extracted, organized into themes, and a summary of the findings reported narratively.

RESULTS

In all, 15 out of 390 articles met the inclusion criteria. These 15 studies were conducted in nine countries. That is, Ghana (4), Kenya (3), and Nigeria (2), Burkina Faso (1), Burundi (1), Niger (1), Sierra Leone (1), Tanzania (1), and Uganda (1). Of the 15 included studies, 14 reported poor quality of maternal healthcare from managers' and providers' perspectives. Factors contributing to the perception of poor maternal healthcare included: late reimbursement of funds, heavy workload of providers, lack of essential drugs and stock-out of medical supplies, lack of policy definition, out-of-pocket payment, and inequitable distribution of staff.

CONCLUSION

This study established evidence of existing literature on the quality of care based on healthcare providers' and managers' perspectives though very limited. This study indicates healthcare providers and managers perceive the quality of maternal healthcare under the free financing policy as poor. Nonetheless, the free maternal care policy is very much needed towards achieving universal health, and all efforts to sustain and improve the quality of care under it must be encouraged. Therefore, more research is needed to better understand the impact of their perceived poor quality of care on maternal health outcomes.

Evaluating health service coverage in Ghana's Volta Region using a modified Tanahashi model

Background: The United Nations 2030 Sustainable Development Goals have reaffirmed the international community’s commitment to maternal, newborn, and child health, with further investments in achieving quality essential service coverage and financial protection for all.

Objective: Using a modified version of the 1978 Tanahashi model as an analytical framework for measuring and assessing health service coverage, this paper aims to examine the system of care at the community level in Ghana’s Volta Region to highlight the continued reforms needed to achieve Universal Health Coverage.

Methods: The Tanahashi model evaluates health system coverage through five key measures that reflect different stages along the service provision continuum: availability of services; accessibility; initial contact with the health system; continued utilization; and quality coverage. Data from cross-sectional household and health facility surveys were used in this study. Immunization and antenatal care services were selected as tracer interventions to serve as proxies to assess systems bottlenecks.

Results: Financial access and quality coverage were identified as the biggest bottlenecks for both tracer indicators. Financial accessibility, measured by enrollment in Ghana’s National Health Insurance Scheme was poor with 16.94% presenting valid membership cards. Childhood immunization was high but dropped modestly from 93.8% at initial contact to 76.7% quality coverage. For antenatal care, estimates ranged from 65.9% at initial visit to 25.1% quality coverage.

Conclusion: Results highlight the difficulty in achieving high levels of quality service coverage and the large variations that exist within services provided at the primary care level. While vertical investments have been prioritized to benefit specific health services, a comprehensive systems approach to primary health care needs to be further strengthened to reach Ghana’s Universal Health Coverage objectives.

Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children

Introduction

Ghana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana.

Methods

We performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE.

Results

Of the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08–0.55).

Conclusions

NHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children.

•

Despite strides toward universal health coverage with the National Health Insurance Scheme (NHIS) in Ghana, one third of injured children did not have insurance.

•

Families on uninsured injured children pay markedly more out-of-pocket costs than families of insured children.

•

Although families of uninsured children were more likely to experience catastrophic health expenditure (CHE), CHE was commonly experienced regardless of insurance.

•

These findings have useful implications for NHIS, agencies working toward universal health coverage, and trauma systems generally.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Access to care for childhood cancers in India: perspectives of health care providers and the implications for universal health coverage

BACKGROUND

There are multiple barriers impeding access to childhood cancer care in the Indian health system. Understanding what the barriers are, how various stakeholders perceive these barriers and what influences their perceptions are essential in improving access to care, thereby contributing towards achieving Universal Health Coverage (UHC). This study aims to explore the challenges for accessing childhood cancer care through health care provider perspectives in India.

METHODS

This study was conducted in 7 tertiary cancer hospitals (3 public, 3 private and 1 charitable trust hospital) across Delhi and Hyderabad. We recruited 27 healthcare providers involved in childhood cancer care. Semi-structured interviews were audio recorded after obtaining informed consent. A thematic and inductive approach to content analysis was conducted and organised using NVivo 11 software.

RESULTS

Participants described a constellation of interconnected barriers to accessing care such as insufficient infrastructure and supportive care, patient knowledge and awareness, sociocultural beliefs, and weak referral pathways. However, these barriers were reflected upon differently based on participant perception through three key influences: 1) the type of hospital setting: public hospitals constituted more barriers such as patient navigation issues and inadequate health workforce, whereas charitable trust and private hospitals were better equipped to provide services. 2) the participant's cadre: the nature of the participant's role meant a different degree of exposure to the challenges families faced, where for example, social workers provided more in-depth accounts of barriers from their day-to-day interactions with families, compared to oncologists. 3) individual perceptions within cadres: regardless of the hospital setting or cadre, participants expressed individual varied opinions of barriers such as acceptance of delay and recognition of stakeholder accountabilities, where governance was a major issue. These influences alluded to not only tangible and structural barriers but also intangible barriers which are part of service provision and stakeholder relationships.

CONCLUSION

Although participants acknowledged that accessing childhood cancer care in India is limited by several barriers, perceptions of these barriers varied. Our findings illustrate that health care provider perceptions are shaped by their experiences, interests and standpoints, which are useful towards informing policy for childhood cancers within UHC.

Contracting of private medical practitioners in a National Health Insurance pilot district: What has been the effect on primary healthcare utilisation indicators?

BACKGROUND

In 2012, the National Department of Health in South Africa started contracting of private medical practitioners (MPs) as part of the first phase of National Health Insurance (NHI) in 11 pilot districts to improve access to healthcare.

AIM

The aim of this study was to describe the effect of contracting private MPs on the utilisation of primary healthcare (PHC) services in public healthcare facilities.

SETTING

A National Health Insurance pilot district compared to a non-pilot district.

METHODS

A quasi-experimental ecological study design was used to compare selected PHC utilisation indicators in the District Health Management Information System from June 2010 to May 2014 between a pilot and a non-pilot district. Both single and controlled interrupted time series analyses were used for comparing before and after implementation of the intervention.

FINDINGS

Single interrupted time series analysis showed an increase in adults remaining on anti-retroviral therapy, clients seen by a nurse practitioner and clients 5 years of age and older in both districts. However, controlled interrupted time series analysis found no difference in all parametres. Despite a decrease in total headcounts in both districts using single interrupted time series analysis, controlled interrupted time series analysis found no differences in all parameters before and after the intervention.

CONCLUSIONS

The increase in utilisation of PHC services in the pilot district may not be attributable to the implementation of contracting private MPs, but likely the result of other healthcare reforms and transitions taking place in both districts around the same time.

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.

Maternal perceptions of the quality of Care in the Free Maternal Care Policy in sub-Sahara Africa: a systematic scoping review

BACKGROUND

The world aims to achieve universal health coverage by removing all forms of financial barriers to improve access to healthcare as well as reduce maternal and child deaths by 2030. Although free maternal healthcare has been embraced as a major intervention towards this course in some countries in sub-Saharan Africa (SSA), the perception of the quality of healthcare may influence utilization and maternal health outcomes. We systematically mapped literature and described the evidence on maternal perceptions of the quality of care under the free care financing policies in SSA.

METHODS

We employed the Arskey and O'Malley's framework to guide this scoping review. We searched without date limitations to 19th May 2019 for relevant published articles in PubMed, Google Scholar, Web of Science, Science Direct, and CINAHL using a combination of keywords, Boolean terms, and medical subject headings. We included primary studies that involved pregnant/post-natal mothers, free maternal care policy, quality of care, and was conduct in an SSA country. Two reviewers independently screened the articles at the abstract and full-text screening guided by inclusion and exclusion criteria. All relevant data were extracted and organized into themes and a summary of the results reported narratively. The recent version of the mixed methods appraisal tool was used to assess the methodological quality of the included studies.

RESULTS

Out of 390 studies, 13 were identified to have evidence of free maternal healthcare and client perceived quality of care. All the 13 studies were conducted in 7 different countries. We found three studies each from Ghana and Kenya, two each in Burkina Faso and Nigeria, and a study each from Niger, Sierra Leone, and Tanzania. Of the 13 included studies, eight reported that pregnant women perceived the quality of care under the free maternal healthcare policy to be poor. The following reasons accounted for the poor perception of service quality: long waiting time, ill-attitudes of providers, inadequate supply of essential drugs and lack of potable water, unequal distribution of skilled birth attendants, out-of-pocket payment and weak patient complaint system.

CONCLUSION

This study suggests few papers exist that looked at maternal perceptions of the quality of care in the free care policy in SSA. Considering the influence mothers perceptions of the quality of care can have on future health service utilisation, further studies at the household, community, and health facility levels are needed to help unearth and address all hidden quality of care challenges and improve maternal health services towards attaining the sustainable development goals on maternal and child health.

Preferences of healthcare providers for capitation payment in Kenya: a discrete choice experiment

Provider payment mechanisms (PPMs) are important to the universal health coverage (UHC) agenda as they can influence healthcare provider behaviour and create incentives for health service delivery, quality and efficiency. Therefore, when designing PPMs, it is important to consider providers' preferences for PPM characteristics. We set out to uncover senior health facility managers' preferences for the attributes of a capitation payment mechanism in Kenya. We use a discrete choice experiment and focus on four capitation attributes, namely, payment schedule, timeliness of payments, capitation rate per individual per year and services to be paid by the capitation rate. Using a Bayesian efficient experimental design, choice data were collected from 233 senior health facility managers across 98 health facilities in seven Kenyan counties. Panel mixed multinomial logit and latent class models were used in the analysis. We found that capitation arrangements with frequent payment schedules, timelier disbursements, higher payment rates per individual per year and those that paid for a limited set of health services were preferred. The capitation rate per individual per year was the most important attribute. Respondents were willing to accept an increase in the capitation rate to compensate for bundling a broader set of health services under the capitation payment. In addition, we found preference heterogeneity across respondents and latent classes. In conclusion, these attributes can be used as potential targets for interventions aimed at configuring capitation to achieve UHC.

'What a dog will see and kill, a cat will see and ignore it': An exploration of health-related help-seeking among older Ghanaian men residing in Ghana and the United Kingdom

BACKGROUND

Health care utilization rates are lower among men; however, little is known about how men's health care utilization is affected by migration. The aim of this study was to explore health-related help-seeking decisions among older Ghanaian men residing in the United Kingdom and in Ghana.

METHODS

Twenty-six men aged 50 years or over were recruited from community locations within two large cities in the UK and Ghana. Face-to-face semi-structured interviews were undertaken to explore the illness and help-seeking experiences of older men.

RESULTS

Help-seeking experiences differed among the Ghanaian men living in the UK and in Ghana. Three themes were identified that impacted on help-seeking decisions: (1) pluralistic approaches to managing health and illness and (2) perceptions of formal health services in Ghana and UK and (3) financial constraints and masculinity norms as barriers to help-seeking.

CONCLUSION

This is the first study to look at help-seeking decisions among older men residing in the UK and Ghana. Findings highlight how older migrant men's explanatory models of their health encompass enduring faith-based beliefs around causation of illness and approaches to management, as well as the use of pluralistic approaches to managing health. This study supports the call for culturally sensitive community-based interventions to increase engagement and facilitate improved health outcomes for migrant populations, particularly older men.

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.

The practise of paediatric optometry in a low-resource environment

BACKGROUND

The role of optometrists in paediatric visual assessment must compliment the role of other eye-care practitioners at all levels of care. This study was undertaken to determine if optometrists in Ghana screen, diagnose and manage paediatric ocular conditions (for example, strabismus, amblyopia), and further assessed if optometrists in Ghana have the requisite paediatric instrumentation in their practices.

METHODS

This was a cross-sectional descriptive survey involving optometrists in both public and private eye-care sectors in Ghana. A paediatric visual assessment questionnaire was sent to all registered optometrists in Ghana. The contents of the questionnaire evaluated areas of vision assessment, refraction, and previous diagnosis and management, which were matched with practice characteristics such as location, type of practice and type of employment. Chi-squared statistic was used to test associations between variables.

RESULTS

Responses were obtained from 140 optometrists out of the 326 registered optometrists, representing a response rate of 46 per cent. Overall, less than half of respondents (64 which represents 46 per cent) assessed themselves as practising full-scope paediatric eye care. These self-assessment views were more common among optometrists at the regional level (111: 79.3 per cent), followed by the district (20: 14.3 per cent) and sub-district levels (nine: 6.4 per cent) (χ² = 4.774, p < 0.05), but was not influenced by type of employment, type of practice and level of training (p > 0.05). In addition, the study revealed that many respondents were more likely to assess pre-schoolers' visual acuity (VA) (121: 96.0 per cent), do refraction (109: 88.6 per cent) and perform binocular vision (BV) assessment (93: 76.9 per cent) compared to the toddlers' VA (72: 55.4 per cent), refraction (57: 46 per cent) and BV assessment (68: 56.2 per cent).

CONCLUSION

Full-scope paediatric eye care services among optometrists in Ghana is limited.

Unawareness of health insurance expiration status among women of reproductive age in Northern Ghana: implications for achieving universal health coverage

BACKGROUND

Ghana implemented a national health insurance scheme in 2005 to promote the provision of accessible, affordable, and equitable healthcare by eliminating service user fees. Termed the National Health Insurance Scheme (NHIS), its active enrollment has remained low despite a decade of program implementation. This study assesses factors explaining this problem by examining the correlates of insurance status unawareness among women of reproductive age.

METHODS

In 2015, a random probability cross-sectional survey of 5914 reproductive-aged women was compiled in the Upper East Region, an impoverished and remote region in Northern Ghana. During the survey, two questions related to the NHIS were asked: "Have you ever registered with the NHIS?" and "Do you currently have a valid NHIS card?" If the answer to the second question was yes, the respondents were requested to show their insurance card, thereby enabling interviewers to determine if the NHIS requirement of annual renewal had been met. Results are based on the tabulation of the prevalence of unawareness status, tests of bivariate associations, and multivariate estimation of regression adjusted effects.

RESULTS

Of the 5914 respondents, 3614 (61.1%) who reported that they were actively enrolled in the NHIS could produce their insurance cards upon request. Of these respondents, 1243 (34.4%) had expired cards. Factors that significantly predicted unawareness of card expiration were occupation, district of residence, and socio-economic status. Relative to other occupational categories, farmers were the most likely to be unaware of their card invalidity. Respondents residing in three of the study districts were less aware of their insurance card validity than the other four study districts. Unawareness was observed to increase monotonically with relative poverty.

CONCLUSION

Unawareness of insurance care validity status contributes to low active enrollment in Ghana's NHIS. Educational messages aimed at improving health insurance coverage should include the promotion of annual renewal and also should focus on the information needs of farmers and low socio-economic groups.

Determinants of Enrolment and Renewing of Community-Based Health Insurance in Households With Under-5 Children in Rural South-Western Uganda

BACKGROUND

The desire for universal health coverage in developing countries has brought attention to communitybased health insurance (CBHI) schemes in developing countries. The government of Uganda is currently debating policy for the national health insurance programme, targeting the integration of existing CBHI schemes into a larger national risk pool. However, while enrolment has been largely studied in other countries, it remains a generally under-covered issue from a Ugandan perspective. Using a large CBHI scheme, this study, therefore, aims at shedding more light on the determinants of households' decisions to enrol and renew membership in these schemes.

METHODS

We collected household data from 464 households in 14 villages served by a large CBHI scheme in southwestern Uganda. We then estimated logistic and zero-inflated negative binomial (ZINB) regressions to understand the determinants of enrolment and renewing membership in CBHI, respectively.

RESULTS

Results revealed that household's socioeconomic status, husband's employment in rural casual work (odds ratio [OR]: 2.581, CI: 1.104-6.032) and knowledge of health insurance premiums (OR: 17.072, CI: 7.027-41.477) were significant predictors of enrolment. Social capital and connectivity, assessed by the number of voluntary groups a household belonged to, was also positively associated with CBHI participation (OR: 5.664, CI: 2.927-10.963). More positive perceptions on insurance (OR: 2.991, CI: 1.273-7.029), access to information were also associated with enrolment and renewing among others. Burial group size and number of burial groups in a village, were all significantly associated with increased the likelihood of renewing CBHI.

CONCLUSION

While socioeconomic factors remain important predictors of participation in insurance, mechanisms to promote inclusion should be devised. Improving the participation of communities can enhance trust in insurance and eventual coverage. Moreover, for households already insured, access to correct information and strengthening their social network information pathways enhances their chances of renewing.

Out-of-pocket payment for primary healthcare in the era of national health insurance: Evidence from northern Ghana

BACKGROUND

Ghana introduced a national health insurance program in 2005 with the goal of removing user fees, popularly called "cash and carry", along with their associated catastrophic and impoverishment effects on the population and ensuring access to equitable health care. However, after a decade of implementation, the impact of this program on user fees and out-of-pocket payment (OOP) is not properly documented. This paper contributes to understanding the impact of Ghana's health insurance program on out-of-pocket healthcare payments and the factors associated with the level of out-of-pocket payments for primary healthcare in a predominantly rural region of Ghana.

METHODS

Using a five-year panel data of revenues accruing to public primary health facilities in seven districts, We employed mean comparison tests (t-test) to examine the trend in revenues accruing from out-of-pocket payments vis-à-vis health insurance claims for health services, medication, and obstetric care. Furthermore, generalized estimation equation regression models were used to assess the relationship between explanatory variables and the level of out-of-pocket payments and health insurance claims.

RESULTS

Out-of-pocket payment for health services and medications declined by 63% and 62% respectively between 2010 and 2014. Insurance claims however increased by 16% within the same period. There was statistically a significant mean reduction in out-of-pocket payment over the period. Factors significantly associated with out-of-pocket payments in a given district are the number of community health facilities, availability of a district hospital and the year of observation.

CONCLUSION

The study provides evidence that Ghana's national health insurance program is significantly contributing to a reduction in out-of-pocket payment for primary healthcare in public health facilities. Efforts should therefore be put in place to ensure the sustainability of this policy as a major pathway for achieving universal health coverage in Ghana.