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

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

The Effects of Ghana's Free Maternal and Healthcare Policy on Maternal and Infant Healthcare: A Scoping Review

Ghana was the first sub-Saharan country to implement a National Health Insurance Scheme (NHIS). In furtherance of the nation's Universal Health Coverage (UHC) goals, in 2008, Ghana actualized plans for a Free Maternal Healthcare Policy (FMHCP) under the NHIS. The FMHCP was aimed at removing financial barriers to accessing maternal and neonatal health services. This scoping review was conducted to map out the literature on the effects of the FMHCP under the NHIS on the utilization of maternal and infant health care in Ghana. Six databases including CINAHL, PubMed, Sage Journals, Academic Search Premier, Science Direct, and Medline were searched in conducting this review with key terms. A total of 175 studies were retrieved after the search and finally, 23 articles were included in the study after various stages of elimination. The review followed the reporting guidelines stated in the Preferred Reporting Items for Systematic and Meta-analyses Extensions for Scoping Reviews (PRISMA-ScR). The results showed an overall increase in the utilization of antenatal care, facility-based delivery, and postnatal care services. However, certain systemic issues persist regarding access to maternal and infant healthcare. Socio-demographic inequalities such as maternal level of education, place of residence, and economic status likewise barriers such as the existence of out-of-pocket payments, long distance to health facilities, and poor distribution of resources in rural areas hindered the utilization of maternal and infant healthcare. The country faces significant work to eliminate existing barriers and inequalities to ensure that it achieves its UHC goals.

Adolescent maternal health services utilization and associated barriers in Sub-Saharan Africa: A comprehensive systematic review and meta-analysis before and during the sustainable development goals

Introduction

Effective and adequate maternal health service utilization is critical for improving maternal and newborn health, reducing maternal and perinatal mortality, and important to achieve global sustainable development goals (SDGs). The purpose of this systematic review was to assess adolescent maternal health service utilization and its barriers before and during SDG era in Sub-Saharan Africa (SSA).

Methods

Systematic review of published articles, sourced from multiple electronic databases such as Medline, PubMed, Scopus, Embase, CINAHL, PsycINFO, Web of Science, African Journal Online (AJOL) and Google Scholar were conducted up to January 2024. Assessment of risk of bias in the individual studies were undertaken using the Johanna Briggs Institute (JBI) quality assessment tool. The maternal health service utilization of adolescent women was compared before and after adoption of SDGs. Barriers of maternal health service utilization was synthesized using Andersen's health-seeking model. Meta-analysis was carried out using the STATA version 17 software.

Results

Thirty-eight studies from 15 SSA countries were included in the review. Before adoption of SDGs, 38.2 % (95 % CI: 28.5 %, 47.9 %) adolescents utilized full antenatal care (ANC) and 44.9 % (95%CI: 26.2, 63.6 %) were attended by skilled birth attendants (SBA). During SDGs, 42.6 % (95 % CI: 32.4 %, 52.8 %) of adolescents utilized full ANC and 53.0 % (95 % CI: 40.6 %, 65.5 %) were attended by SBAs. Furthermore, this review found that adolescent women's utilization of maternal health services is influenced by various barriers, including predisposing, enabling, need, and contextual factors.

Conclusions

There was a modest rise in the utilization of ANC services and SBA from the pre-SDG era to the SDG era. However, the level of maternal health service utilization by adolescent women remains low, with significant disparities across SSA regions and multiple barriers to access services. These findings indicate the importance of developing context-specific interventions that target adolescent women to achieve SDG3 by the year 2030.

Determinants of early antenatal care visits among women of reproductive age in Ghana: evidence from the recent Maternal Health Survey

BACKGROUND

Antenatal care services play a crucial role in promoting positive pregnancy outcomes by facilitating the early identification of pregnancy risk factors and early diagnosis of pregnancy-related complications. This study aimed to assess the frequency and timing of ANC attendance of mothers in Ghana as well as determine the predictors of early ANC attendance.

METHODS

The data for this study was extracted from the 2017 Ghana Maternal Health Survey (GMHS). The study population was women aged 15-49 years with a live birth or stillbirth in the 5 years preceding the survey. Data was analysed using STATA/SE version 17, using descriptive statistics and multiple binary logistic regression analysis.

RESULTS

It was found that 44.4% of the women obtained eight (8) + ANC visits. A majority of the women (66%) initiated ANC visits in the first trimester of pregnancy. Early ANC visit was significantly associated with age of the respondent, education, wealth index, religion, region and reason for first ANC visit. For instance, women between the ages of 25-29 years (aOR = 1.75, 95% CI: 1.31-2.33) had increased odds of early ANC visit compared to those aged 15-19 years. Women with higher education (aOR = 1.83, 95% CI: 1.27-2.64) were about twice as likely to initiate early ANC visits compared to those with no education. Also, women in the highest wealth index (aOR = 2.43, 95% CI: 1.83-3.23) were two times more likely to initiate early ANC visits compared to those in the lowest wealth index.

CONCLUSION

This study has shown that a majority of women in Ghana start their first ANC visit during the first trimester of pregnancy. A considerable proportion of the women failed to meet the WHO's recommendation of having a minimum of eight ANC visits throughout pregnancy. Early ANC visit was determined by socio-demographic factors. Going forward, it should be a priority for stakeholders to ensure that ANC services are accessible to all mothers in a timely manner.

Intimate partner violence and antenatal care utilization predictors in Uganda: an analysis applying Andersen's behavioral model of healthcare utilization

BACKGROUND

Optimal utilization of antenatal care (ANC) services improves positive pregnancy experiences and birth outcomes. However, paucity of evidence exists on which factors should be targeted to increase ANC utilization among women experiencing intimate partner violence (IPV) in Uganda.

OBJECTIVE

To determine the independent association between IPV exposure and ANC utilization as well as the predictors of ANC utilization informed by Andersen's Behavioral Model of Healthcare Utilization.

METHODS

We analyzed 2016 Uganda Demographic and Health Survey data that included a sample of 1,768 women with children aged 12 to 18 months and responded to both ANC utilization and IPV items. Our outcome was ANC utilization, a count variable assessed as the number of ANC visits in the last 12 months preceding the survey. The key independent variable was exposure to any IPV form defined as self-report of having experienced physical, sexual and/or emotional IPV. Covariates were grouped into predisposing (age, formal education, religion, problem paying treatment costs), enabling (women's autonomy, mass media exposure), need (unintended pregnancy, parity, history of pregnancy termination), and healthcare system/environmental factors (rural/urban residence, spatial accessibility to health facility). Poisson regression models tested the independent association between IPV and ANC utilization, and the predictors of ANC utilization after controlling for potential confounders.

RESULTS

Mean number of ANC visits (ANC utilization) was 3.71 visits with standard deviation (SD) of ± 1.5 respectively. Overall, 60.8% of our sample reported experiencing any form of IPV. Any IPV exposure was associated with lower number of ANC visits (3.64, SD ± 1.41) when compared to women without IPV exposure (3.82, SD ± 1.64) at p = 0.013. In the adjusted models, any IPV exposure was negatively associated with ANC utilization when compared to women with no IPV exposure after controlling for enabling factors (Coef. -0.03; 95%CI -0.06,-0.01), and healthcare system/environmental factors (Coef. -0.06; 95%CI -0.11,-0.04). Predictors of ANC utilization were higher education (Coef. 0.27; 95%CI 0.15,0.39) compared with no education, high autonomy (Coef. 0.12; 95%CI 0.02,0.23) compared to low autonomy, and partial media exposure (Coef. 0.06; 95%CI 0.01,0.12) compared to low media exposure.

CONCLUSION

Addressing enabling and healthcare system/environmental factors may increase ANC utilization among Ugandan women experiencing IPV. Prevention and response interventions for IPV should include strategies to increase girls' higher education completion rates, improve women's financial autonomy, and mass media exposure to improve ANC utilization in similar populations in Uganda.

Contribution of the Ghana National Health Insurance Scheme to Inequality in Healthcare Utilisation

Inequality in healthcare utilisation contributes to socio-economic disparities in health outcomes. The government of Ghana rolled out the Ghana National Health Insurance Scheme (NHIS) as a pro-poor health policy to reduce the financial barrier to accessing healthcare to increase healthcare utilisation, especially among the poor. Evidence showed a pro-rich utilisation inequality in Ghana prior to the nationwide start of the NHIS in 2005. This article applied the concentration index and decomposition methods to the round six of the Ghana Living Standard Survey data to investigate the contribution of the NHIS to utilisation inequality. The results showed the rich to benefit more than the poor from the NHIS and the NHIS contributed to about half of the pro-rich utilisation inequality. The NHIS increased utilisation but more so for the rich than the poor. A policy implication of the article is that pro-poorness of the NHIS might require separate NHIS schemes for the poor and non-poor to enable different policies implemented in the schemes to increase the distributional disparity of health subsidies in favour of the poor.