Potential gains in reproductive-aged life expectancy if maternal mortality were eradicated from the Kintampo districts of Central Ghana

Is value-based payment for healthcare feasible under Ghana's National Health Insurance Scheme?

BACKGROUND

Effective payment mechanisms for healthcare are critical to the quality of care and the efficiency and responsiveness of health systems to meet specific population health needs. Since its inception, Ghana's National Health Insurance Scheme (NHIS) has adopted fee-for-service, diagnostic-related groups and capitation methods, which have contributed to provider reimbursement delays, rising costs and poor quality of care rendered to the scheme's clients. The aim of this study was to explore stakeholder perceptions of the feasibility of value-based payment (VBP) for healthcare in Ghana. Value-based payment refers to a system whereby healthcare providers are paid for the value of services rendered to patients instead of the volume of services.

METHODS

This study employed a cross-sectional qualitative design. National-level stakeholders were purposively selected for in-depth interviews. The participants included policy-makers (n = 4), implementers (n = 5), public health insurers (n = 3), public and private healthcare providers (n = 7) and civil society organization officers (n = 1). Interviews were audio-recorded and transcribed. Data analysis was performed using both deductive and inductive thematic analysis. The data were analysed using QSR NVivo 12 software.

RESULTS

Generally, participants perceived VBP to be feasible if certain supporting systems were in place and potential implementation constraints were addressed. Although the concept of VBP was widely accepted, study participants reported that efficient resource management, provider motivation incentives and community empowerment were required to align VBP to the Ghanaian context. Weak electronic information systems and underdeveloped healthcare infrastructure were seen as challenges to the integration of VBP into the Ghanaian health system. Therefore, improvement of existing systems beyond healthcare, including public education, politics, data, finance, regulation, planning, infrastructure and stakeholder attitudes towards VBP, will affect the overall feasibility of VBP in Ghana.

CONCLUSION

Value-based payment could be a feasible policy option for the NHIS in Ghana if potential implementation challenges such as limited financial and human resources and underdeveloped health system infrastructure are addressed. Governmental support and provider capacity-building are therefore essential for VBP implementation in Ghana. Future feasibility and acceptability studies will need to consider community and patient perspectives.

A Competing Risk Analysis of Women Dying of Maternal, Infectious, or Non-Communicable Causes in the Kintampo Area of Ghana

Background: Maternal, infectious, and non-communicable causes of death combinedly are a major health problem for women of reproductive age (WRA) in sub-Saharan Africa (SSA). Little is known about the relative risks of each of these causes of death in their combined form and their demographic impacts. The focus of studies on WRA has been on maternal health. The evolving demographic and health transitions in low- and middle-income countries (LMICs) suggest a need for a comprehensive approach to resolve health challenges of women beyond maternal causes. Methods: Deaths and person-years of exposure (PYE) were calculated by age for WRA within 15-49 years of age in the Kintampo Health and Demographic Surveillance System (KHDSS) area from January 2005 to December 2014. Causes of death were diagnosed using a standard verbal autopsy questionnaire and the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Identified causes of death were categorized into three broad areas, namely, maternal, infectious, and non-communicable diseases. Multiple decrements and associated single decrement life table methods were used. Results: Averting any of the causes of death was seen to lead to improved life expectancy, but eliminating infectious causes of death leads to the highest number of years gained. Infectious causes of death affected all ages and the gains in life expectancy, assuming that these causes were eliminated, diminished with increasing age. The oldest age group, 45-49, had the greatest gain in reproductive-aged life expectancy (RALE) if maternal mortality was eliminated. Discussion: This study demonstrated the existence of a triple burden. Infectious causes of death are persistently high while deaths from non-communicable causes are rising and the level of maternal mortality is still unacceptably high. It recommends that attention should be given to all the causes of death among WRA.

Impact of National Health Mission on infant mortality in India: An interrupted time series analysis

Government of India introduced National Rural Health Mission in 2005-now transformed into National Health Mission (NHM), to bring about architectural reforms in health sector. In this study, we evaluate the overall impact of NHM on infant mortality at national and state level. Annual data on infant mortality rate (IMR) from 1990 to 2016 were obtained from Sample Registration System bulletins. With reporting year 2009 considered as cut-off point, a two-step segmented time series regression analysis was conducted. Estimates of pre-slope, post-slope and change at the point of intervention were computed by applying auto-regressive integrated moving average (1, 0, 0) while adjusting for trend and auto correlation. We found that while IMR reduced from around 80 to 34 per 1000 live births at the national level from 1990 to 2016, the annual rate of reduction increased from 1.6 per 1000 live births before NHM to 2.2 per 1000 live births after NHM. This is estimated to have averted 248,212 infant deaths in India, between 2005 and 2017. The rate of decline in IMR accelerated in 13 out of 17 larger states, most significantly in Andhra Pradesh, Gujarat, Assam, Haryana, Punjab and Uttar Pradesh. NHM has thus been successful in accelerating the overall rate of reduction in IMR in India. There is still a need to identify the determinants of variations at state level. We recommend strengthening of NHM in terms of funding and implementation.