Perceptions of healthcare quality in Ghana: Does health insurance status matter?

Patient satisfaction and associated factors among insured and uninsured patients in Deder General Hospital, eastern Ethiopia: a facility-based comparative cross-sectional study

Background

Patient satisfaction is a crucial measure of healthcare quality, as dissatisfied patients are more likely to miss appointments, disregard treatment plans, and leave hospitals, leading to poor treatment outcomes. Therefore, the study aimed to compare levels of satisfaction with health services and associated factors among insured and uninsured patients in Deder General Hospital, eastern Ethiopia.

Methods

A comparative cross-sectional study with 532 participants was conducted from December 1-30, 2021. Data was collected through a structured questionnaire, analyzed using SPSS, and predictors assessed using a multivariate logistic regression model. Statistical significance was set at p < 0.05.

Results

Overall, patient satisfaction with health services was 65.6% (95% CI: 61.5-69.5), and the level of patient satisfaction with health services among insured and noninsured patients was 68.8% (95% CI: 62.8-74.4) and 62.4% (95% CI: 56.8-68.0), respectively. In the final model of multivariable analysis, factors such as educational status of secondary school (AOR = 4.90; 95% CI: 2.05-11.76), and a higher level (AOR = 3.08; 95% CI: 1.05-9.03), getting the entire prescribed drugs (AOR = 3.49; 95% CI: 1.43-8.54), getting some of the ordered drugs (AOR = 3.34; 95% CI: 1.61-6.94), paying less than 100 Ethiopian birrs (AOR = 4.85; 1.35-17.40) were significantly associated with patient satisfaction among insured patients. Whereas getting the entire and some prescribed drugs were (AOR = 6.28; 95% CI: 3.26-12.05), and (AOR = 3.40; 95% CI: 1.70-6.78) times more likely to be satisfied with the service among noninsured patients as compared to their counterparts, respectively.

Conclusion

The study found that about six in 10 patients in the study area were satisfied with healthcare services, with insurance patients reporting higher satisfaction. Factors such as receiving prescribed drugs, paying less than 100 Ethiopian birr, having a secondary school education, and having a higher education were associated with satisfaction.

Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review

INTRODUCTION

Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs.

METHODS

We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed.

RESULTS

The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation.

CONCLUSIONS

We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.

Causes of dropout from health insurance program: An experience from Lumbini Province, Nepal

The Health Insurance Program (HIP) in Nepal is experiencing low enrolment and high dropout rates, but the causes of these issues have remained unknown. This study aimed to explore the causes of dropouts of the HIP implemented by the Health Insurance Board, Nepal. We employed an exploratory qualitative research design. We purposefully selected the informants for the data collection who had previously enrolled and currently not renewed their insurance scheme. We gathered qualitative information from 16 in-depth interviews, four key informant interviews, and four focus group discussion in Palpa and Bardia Districts of Lumbini Province, Nepal. The qualitative data were analyzed using thematic analysis. We identified two major themes and nine drop-out-related sub-themes. These were: unnecessary health insurance; negligence to renew; unable to pay the contribution amount; poor cooperation between institutions as well as insurees and insurers; limited coverage and ceiling amount; rigid processes to receive health services; health professionals' behaviors; poor quality healthcare services; inadequate information. Dropout-related factors were associated with personal or individual factors and institutional or policy-related (process-related) factors. The major causes/reasons for dropout include lengthy procedures, poor quality and unsatisfactory services, a lack of knowledge on health insurance norms and procedures, and health professionals' behavior towards insurees during treatment. Information, education, and communication programs related to health insurance are still necessary to make the insurees familiar with the insurance systems and its processes. These factors could be taken into account by policymakers while planning interventions to minimize the low enrollment and high dropout.

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.

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.

Differentials in the Prevalence of Acute Respiratory Infections Among Under-Five Children: An Analysis of 37 Sub-Saharan Countries

Objective

We investigated the prevalence and risk factors of ARI in children under 5 years old in 37 SSA countries.

Methods

Data from Demographic and Health Survey (DHS) of 37 African countries was examined in this analysis. Data from children under the age of 5 years old were examined. Forest plot was used to identify disparities in the occurrence of ARIs across SSA countries.

Results

We observed a higher prevalence of ARI among children under 5 in Uganda, Kenya, Sao Tome and Principe (9% each), Gabon, Chad, Eswatini (8% each), Burundi, Ethiopia, Congo Democratic Republic (7.0% each). The prevalence of ARI among under-five children who sought medical advice/treatment from health facility was higher in South Africa (88%), Sierra Leone (86%), Tanzanian (85%), Guinea (83%) and Uganda (80%). The prevalence rate of ARI among under-five children who received antibiotics was higher in Tanzania (61%), Sao Tome and Principe (60%), Rwanda and Congo (58% each), Angola (56.0%), Mozambique (54.0%), Kenya (53.0%), Namibia (52.0%) and Gabon (50.0%). This study found that the household wealth index, maternal education, and urban residence were significantly associated with ARI (p <0.001). A higher prevalence of ARI was observed among urban residents, low income families, and those with mothers with lower education.

Conclusion

ARI prevalence could be reduced by improving household socioeconomic status, child nutrition and community awareness of indoor and outdoor pollution. Interventions and programs focused on early diagnosis, treatment and prevention of ARIs are crucial in reducing ARIs particularly in developing countries.

Out-of-Pocket expenditure and patient experience of care under-Indonesia's national health insurance: A cross-sectional facility-based study in six provinces

BACKGROUND

Low- and middle-income countries worldwide are striving to achieve universal health coverage (UHC), frequently through expansion of statutory health insurance schemes. However, oftentimes evidence is lacking on progress towards quality patient-centred care and out-of-pocket expenditure (OOPE), particularly for poor population groups. We contribute patient-centred evidence examining patient experience and OOPE under JKN, the Indonesian social health insurance.

METHODS

Using data from 2526 patient exit interviews conducted among JKN beneficiaries in 2015, we computed a summative patient experience measure from 14 experience items. We used descriptive statistics to assess patient experience and the probability, amount and components of OOPE. We applied a two-part model to examine the relationships between socio-demographics, facility types, and OOPE and an OLS regression on patient experience determinants.

RESULTS

The mean patient experience measure was 11.7 out of 14 maximal points. Differences were observed between single items, with highest ratings on ease of understanding providers' language (97%) and lowest on waiting time (54%). OOPE were reported by 20% of patients with a mean equivalent to US$40, the most prevalent reason being medicines (61% of all OOPE). Considerable OOPE heterogeneity occurred by province and facility type. We found differentials in OOPE by gender (females paying more likely, but less) and subsidised JKN membership (same likelihood as non-subsidised, but paying less).

CONCLUSION

Our findings suggest that during its early implementation, patients under JKN reported mostly positive patient experience yet a fifth incurred OOPE, mostly on medicines. Further patient-centred research is needed to ensure JKN's progress towards UHC.

Does Health System Responsiveness Differ between Insured and Uninsured Outpatients in Primary Health Care Facilities in Asagirt District, Ethiopia? A Cross-Sectional Study

Background. An effective designation of health facilities improves the facility’s ability to respond to patients’ legitimate expectations. Limited evidence exists regarding the association between health system responsiveness and financial fairness in Sub-Saharan Africa, particularly in Ethiopia. The purpose of the study was, therefore to evaluate the health system responsiveness among insured and uninsured outpatients in primary healthcare facilities and determine the association between health insurance and health system responsiveness among outpatients. Methods. A facility-based cross-sectional study was conducted between March 30 and April 30,2021. The study sampled 423 participants using a systematic random sampling technique, and the data was collected with structured and pretested questionnaires administered by interviewers. Responsiveness was measured using the short version of the World Health Organization’s multicountry responsiveness survey, which has seven dimensions including autonomy, communication, confidentiality, attention, dignity, choice, and amenities. Using quantile regression, a specific association between health insurance and the health system responsiveness index was examined, adjusting for sociodemographic, quality, and satisfaction-related factors. Results. Of a total of 417 outpatients, 70.74% had health insurance. There was no statistical difference in health system responsiveness among insured and uninsured outpatients. Possession of health insurance was not associated with responsiveness (−0.67; 95%CI: −1.59, 0.25). There was a statistically significant negative relationship between age and responsiveness (−1.33; 95% CI: −2.47, −0.19) among 30–39 year olds and (−1.66; 95% CI: −3.02, −0.32) among 40–49 year olds. However, there was a positive statistical association between responsiveness with urban residence (+1.33; 95%CI: 0.37, 2.29), perceived quality of healthcare (+2.96; 95%CI: 1.95, 4.05), and patient satisfaction (3; 95%CI: 1.94, 4.07). Conclusions. There was no difference in the responsiveness of the health system between insured and uninsured outpatients. All domains need further improvement, particularly those more closely related to patients’ concerns, such as waiting time to get service and choices of healthcare providers. Furthermore, health facility administrators and the government should enhance responsive healthcare services in parallel with quality improvement and patient satisfaction, based on feedback from service users for better performance.

Competition and quality of care under regulated fees: evidence from Ghana

BACKGROUND

How competition affects the quality of care is still not well understood empirically because of limited and mixed results. This study examined whether competition leads to higher or lower quality health outcomes in Ghana.

METHODS

We used administrative claims data of hypertension patients for 2017 - 2019 (36 months), and an instrumental variable method to examine the effect of competition, measured as an increase in district doctor-to-population ratio on hospital-level ambulatory care sensitive condition hospitalization and in-hospital death rates.

RESULTS

Overall, we found that an increase in doctor density improves the quality of care for hypertension patients in Ghana. That is, when there are more doctors, fewer patients are hospitalized, and the risk of in-hospital deaths decreases. This result is robust to analyses at the individual and district population levels for ambulatory care sensitive hospitalizations rate.

CONCLUSIONS

Our findings suggest that in the presence of physician-induced demand, competition can lead to improvement in the quality of care, possibly through improved access to healthcare and increased physician time and contact per patient. Future health policies need to consider possible welfare benefits of induced medical services and training more doctors.

Perceived quality of care among households ever enrolled in a community-based health insurance scheme in two districts of northeast Ethiopia: a community-based, cross-sectional study

OBJECTIVES

To examine how clients perceived the quality of healthcare they received and identify associated factors both at the individual and facility levels.

DESIGN

A community-based, cross-sectional study.

SETTING

Two rural districts of northeast Ethiopia, Tehulederie and Kallu.

PARTICIPANTS

1081 rural households who had ever been enrolled in community-based health insurance and visited a health centre at least once in the previous 12 months. Furthermore, 194 healthcare providers participated in the study to provide cluster-level data.

OUTCOME MEASURES

The outcome variable of interest was the perceived quality of care, which was measured using a 17-item scale. Respondents were asked to rate the degree to which they agreed on 5-point response items relating to their experiences with healthcare in the outpatient departments of nearby health centres. A multilevel linear regression analysis was used to identify predictors of perceived quality of care.

RESULTS

The mean perceived quality of care was 70.28 (SD=8.39). Five dimensions of perceived quality of care were extracted from the factor analysis, with the patient-provider communication dimension having the highest mean score (M=77.84, SD=10.12), and information provision having the lowest (M=64.67, SD=13.87). Wealth status, current insurance status, perceived health status, presence of chronic illness and time to a recent health centre visit were individual-level variables that showed a significant association with the outcome variable. At the cluster level, the work experience of healthcare providers, patient volume and an interaction term between patient volume and staff job satisfaction also showed a significant association.

CONCLUSIONS

Much work remains to improve the quality of care, especially on information provision and access to care quality dimensions. A range of individual-level and cluster-level characteristics influence the perceived quality of care. For a better quality of care, it is vital to optimise the patient-provider ratio and enhance staff job satisfaction.

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

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

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.

The Impact of Healthcare 4.0 on the Healthcare Service Quality: A Systematic Literature Review

Healthcare 4.0 is inspired by Industry 4.0 and its application has resulted in a paradigmatic shift in the field of healthcare. However, the impact of this digital revolution in the healthcare system on healthcare service quality is not known. The purpose of this study is to examine the impact of healthcare 4.0 on healthcare service quality. This study used the systematic literature review methodology suggested by Transfield et al. to critically examine 67 articles. The impact of healthcare 4.0 is analyzed in-depth in terms of the interpersonal, technical, environmental, and administrative aspect of healthcare service quality. This study will be useful to hospitals and other stakeholders to understand the impact of healthcare 4.0 on the service quality of health systems. Besides, this study critically analyses the existing literature and identifies research areas in this field and hence will be beneficial to researchers. Though there are few literature reviews in healthcare 4.0, this is the first study to examine the impact of Healthcare 4.0 on healthcare service quality.

Health system responsiveness and associated factors among outpatients in primary health care facilities in Ethiopia

Background

Health system responsiveness is defined as the outcome of designing health facility relationships so that they are familiar and responsive to patients’ universally legitimate expectations. Even though different strategies have been implemented to measure responsiveness, only limited evidence exists in Sub-Saharan Africa. In Ethiopia, information about health system responsiveness among outpatients is limited. Assessing responsiveness could help facilities in improving service delivery based on patient expectations.

Objective

The study aimed to assess health system responsiveness and associated factors among outpatients in primary health care facilities, Asagirt District, Ethiopia, 2021.

Methods

Facility-based cross-sectional quantitative study was implemented between March 30 and April 30/2021. A systematic random sampling technique was employed to select 423 participants, and interviewer-administered data were collected using structured and pretested questionnaires. Both bivariable and multivariable logistic regressions were employed to identify factors associated with health system responsiveness. Adjusted Odds Ratio with their corresponding 95% CI was used to declare factors associated with health system responsiveness. A p-value less than 0.05 was used to declare significant statistical variables.

Results

The overall health system responsiveness performance was 66.2% (95% CI: 61.4—70.7). Confidentiality and dignity were the highest responsive domains. Health system responsiveness was higher among satisfied patients (AOR: 9.9, 95% CI: 5.11–19.46), utilized private clinics (AOR: 8.8, 95% CI: 4.32–18.25), and no transport payment (AOR: 1.7, 95% CI: 1.03–2.92) in the study setting.

Conclusion

Overall, health system responsiveness performance was higher than a case-specific study in Ethiopia. To improve the health systems responsiveness and potentially fulfil patients’ legitimate expectations, we need to facilitate informed treatment choice, provide reasonable care within a reasonable time frame, and give patients the option of consulting a specialist. Aside from that, enhancing patient satisfaction, using input from service users, Collaboration, and exchanging experiences between public and private facilities will be important interventions to improve HSR performance.

Health insurance and health system (un) responsiveness: a qualitative study with elderly in rural Tanzania

Background

Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania.

Method

An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems’ responsiveness. Qualitative content analysis was used to analyse the data.

Results

Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare.

Conclusions

The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients´ communication skills and care rights is highly recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07144-2.

Dropping out of voluntary community-based health insurance in rural Uganda: Evidence from a cross-sectional study in rural south-western Uganda

AIM

Community Based Health Insurance (CBHI) schemes have become central to health systems financing as avenues of achieving universal health coverage in developing countries. Yet, while emphasis in research and policy has mainly concentrated on enrolment, very little has been apportioned to high rates of dropping out after initial enrolment. The main aim of this study is to understand the factors behind CBHI dropping out through a cross-sectional quantitative research design to gain insights into curtailing the drop out of CBHI in Uganda.

METHODS

The survey for the quantitative research component took place between August 2015 and March 2016 covering 464 households with under-5 children in south-western Uganda. To understand the factors associated with dropping out of CBHI, we employ a multivariate logistic regression on a subsample of 251 households who were either currently enrolled or had enrolled at one time and later dropped out.

RESULTS

Overall, we find that 25.1 percent of the households that had ever enrolled in insurance reported dropping out. Household socioeconomic status (wealth) was one of the key factors that associated with dropping out. Larger household sizes and distance from the hospital were significantly associated with dropping out. More socially connected households were less likely to drop out revealing the influence of community social capital in keeping households insured.

CONCLUSION

The findings have implications for addressing equity and inclusion concerns in community-based health insurance programmes such as one in south-western Uganda. Even when community based informal system aim for inclusion of the poorest, they are not enough and often the poorest of the poor slip into the cracks and remain uninsured or drop out. Moreover, policy interventions toward curtailing high dropout rates should be considered to ensure financial sustainability of CBHI schemes.

ADAPTED SERVQUAL: A Health Service Quality Scale Incorporating Indicators of Sanitation and Hygiene

BACKGROUND AND OBJECTIVES

Many scales have been developed to measure health care quality over the years, but no scale available today incorporates all important indicators of sanitation and hygiene in health care. This study therefore assessed the psychometric properties of an adapted scale, hereby called ADAPTED SERVQUAL, in an attempt to provide a scale that includes relevant indicators of hospital hygiene and sanitation.

METHODS

The setting of the study was low- and medium-capacity hospitals in the Greater Accra Region of Ghana. Patients in wards and outpatient departments in the hospitals participated in the study. We used relevant statistical tools to estimate the psychometric properties of ADAPTED SERVQUAL. To understand the relative importance of the new scale, we compared and related it to a recent scale, HEALTHQUAL.

RESULTS

Principal component analysis yielded 6 factors: "tangibles," "reliability," "responsiveness," "assurance," "empathy," and "sanitation and hygiene," which explained 84% of the total variance. ADAPTED SERVQUAL has a good internal consistency (Cronbach α = 0.96). Confirmatory factor analysis confirmed the 6-factor solution and produced satisfactory discriminant validity and convergent validity indicators. The adapted scale was highly correlated with all dimensions of HEALTHQUAL, including continuous quality improvement (r ≥0.75, P < .001). In multiple linear regression, the 5 domains of HEALTHQUAL explained 59% of the variance in ADAPTED SERVQUAL (P < .001).

CONCLUSIONS

The study concluded that 8 items that make up a single factor (ie, sanitation and hygiene) and contribute most of the total variance satisfactorily fit into the SERVQUAL scale as additional indicators of health care quality.

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.

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.

Responsiveness of health care services towards the elderly in Tanzania: does health insurance make a difference? A cross-sectional study

BACKGROUND

Responsiveness has become an important health system performance indicator in evaluating the ability of health care systems to meet patients' expectations. However, its measurement in sub-Saharan Africa remains scarce. This study aimed to assess the responsiveness of the health care services among the insured and non-insured elderly in Tanzania and to explore the association of health insurance (HI) with responsiveness in this population.

METHODS

A community-based cross-sectional study was conducted in 2017 where a pre-tested household survey, administered to the elderly (60 + years) living in Igunga and Nzega districts, was applied. Participants with and without health insurance who attended outpatient and inpatient health care services in the past three and 12 months were selected. Responsiveness was measured based on the short version of the World Health Organization (WHO) multi-country responsiveness survey study, which included the dimensions of quality of basic amenities, choice, confidentiality, autonomy, communication and prompt attention. Quantile regression was used to assess the specific association of the responsiveness index with health insurance adjusted for sociodemographic factors.

RESULTS

A total of 1453 and 744 elderly, of whom 50.1 and 63% had health insurance, used outpatient and inpatient health services, respectively. All domains were rated relatively highly but the uninsured elderly reported better responsiveness in all domains of outpatient and inpatient care. Waiting time was the dimension that performed worst. Possession of health insurance was negatively associated with responsiveness in outpatient (- 1; 95% CI: - 1.45, - 0.45) and inpatient (- 2; 95% CI: - 2.69, - 1.30) care.

CONCLUSION

The uninsured elderly reported better responsiveness than the insured elderly in both outpatient and inpatient care. Special attention should be paid to those dimensions, like waiting time, which ranked poorly. Further research is necessary to reveal the reasons for the lower responsiveness noted among insured elderly. A continuous monitoring of health care system responsiveness is recommended.

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.

Supplier relationship management and organizational performance of hospitals in an emerging economy context

Purpose

Integrating the social exchange and resource dependency theories, the study aims to comparatively examine the supplier relationship management (SRM) dimensions and organizational performance links of private and public hospitals in Ghana.

Design/methodology/approach

Comparative in nature; employing a quantitative approach; and using simple random and convenience sampling techniques, the study tested the proposed hypotheses using structural equation model-partial least square based on 205 usable questionnaires. Partial least square-multigroup analysis (PLS-MGA) was performed to test the significance of the difference in the parameters between the two samples: private and public hospitals in Ghana.

Findings

The dimensions of SRM (communication, cooperation, trust, atmosphere and adaptation) have a significant, positive impact on private hospitals’ performance in Ghana. Similarly, communication and trust were found to be positively and significantly correlated to public hospitals’ performance. In contrast, cooperation, atmosphere and adaptation dimensions showed no significant, positive effect on public hospitals’ performance. PLS-MGA disclosed that these observed differences in the findings between the private and public hospitals in Ghana are statistically significant.

Research limitations/implications

The findings of the study, while limited to hospitals in Ghana, are likely to be relevant in other emerging economies for effective and enhanced supply chain relationship management.

Practical implications

The findings provide pragmatic insights for marketing practitioners and organizational leaders of hospitals about the significance of SRM dimensions in today’s globalized marketplace, and how to nurture them to enhance organizational performance.

Originality/value

The value of the study lies in the examination of the relationship between SRM and organizational performance in the health sector by comparing private and public hospitals in an emerging economy context.

Institutional Effects on National Health Insurance Digital Platform Development and Use: The Case of Ghana

The purpose of this study is to understand institutional effects on digital platform development and use for national health insurance in a developing country. Information systems research on digital platforms for the health sector has focused more on healthcare. Less research exists on health insurance. This study, therefore, addresses the research gap by focusing on digital platform for national health insurance service in a developing country. The study employs qualitative, interpretive case study as methodology and institutional theory as analytical lens to investigate regulative, normative, and cultural-cognitive institutional effects on digital platform development and use for national health insurance in Ghana. The findings show the institutional enablers as: (1) health-seeking culture; (2) mobile network penetration and use; and (3) appropriate laws and regulations. Conversely, the constraints are (1) Unstructured supplementary service data (USSD) functionality; and (2) extended family system.

Jakartans' Perceptions of Health Care Services

Health Care Services (HCSs) should implement ongoing innovation and continuously improve their quality. However, in evaluating the quality of HCSs, too little attention has been given to the experience of the users concerning the acquired services. This study focused on how the community values the current services in order to improve HCSs in Indonesia, especially in Jakarta. Four focus group discussions were conducted among 45 community members in the Grogol Petamburan sub-district, in Jakarta. Participants were recruited using a convenience sampling and the data were analyzed using a combination of human coding and NVivo-12. Overall, we found that participants had a negative view of the government-mandated Community Health Centers (CHCs) and they preferred to visit private clinics and hospitals over the CHCs. Participants associated CHCs with unfriendly staffs, longer waiting times, shorter opening hours, and crowded visitors. At the same time, participants had a positive view on the affordability of the CHCs. Additionally, we found the reasoning of Jakartans' (i.e., the citizens of Jakarta city) on using self- and traditional treatments before visiting HCSs and they also expressed the need for psychological services at CHCs. The discussion focuses on the results as feedback on how the government and health care providers may facilitate the community's needs in providing HCSs in Indonesia, especially Jakarta. In brief, we recommend the policy-makers to improve the hospitality of the staff members and the quality of the medical equipment; also, to provide psychological services at CHCs. These efforts need to be done while paying more attention to the cultural aspects of medicinal uses.

Women's overall satisfaction with health facility delivery services in Ghana: a mixed-methods study

Background

Skilled birth delivery has increased up to nearly 74% in Ghana, but its quality has been questioned over the years. As understanding women's satisfaction could be important to improving service quality, this study aimed to determine what factors were associated with women's overall satisfaction with delivery services quantitatively and qualitatively in rural Ghanaian health facilities.

Results

This cross-sectional, mixed methods study used an explanatory sequential design across three Ghana Health Service research areas in 2013. Participants were women who had delivered in the preceding 2 years. Two-stage random sampling was used to recruit women for the quantitative survey. Relationships between women's socio-demographic characteristics and their overall satisfaction with health facility delivery services were examined using univariate and multiple logistic regression analyses. For qualitative analyses, women who completed the quantitative survey were purposively selected to participate in focus group discussions. Data from the focus group discussions were analyzed based on predefined and emerging themes. Overall, 1130 women were included in the quantitative analyses and 136 women participated in 15 focus group discussions. Women's mean age was 29 years. Nearly all women (94%) were satisfied with the overall services received during delivery. Women with middle level/junior high school education [adjusted odds ratio (AOR) = 0.50, 95% confidence interval (CI) = (0.26-0.98)] were less likely to be satisfied with overall delivery services compared to women with no education. Qualitatively, women were not satisfied with the unconventional demands, negative attitude, and unavailability of healthcare workers, as well as the long wait time.

Conclusions

Although most women were satisfied with the overall service they received during delivery, they were not satisfied with specific aspects of the health services; therefore, higher quality service delivery is necessary to improve women's satisfaction. Additional sensitivity training and a reduction in work hours may also improve the experience of clients.

Prevalence and determinants of Acute Lower Respiratory Infections among children under-five years in sub-Saharan Africa: Evidence from demographic and health surveys

Acute Lower Respiratory Infections (ALRIs) account for 5.8 million deaths globally and 50% of these deaths occur in sub-Saharan Africa. In this paper, we examined the prevalence and determinants of ALRIs among children under-five years in 28 sub–Saharan African countries. We used data from the most recent (2011–2016) Demographic and Health Surveys of the 28 countries. Women aged 15–49 (N = 13,495) with children under-five years participated in the study. Data were extracted and analysed using STATA version 14.2. Bivariate and multivariate analyses were done to establish associations between the outcome and explanatory variables. The prevalence of ALRI for all the countries was 25.3%. Congo (39.8%), Gabon (38.1%), Lesotho (35.2%), and Tanzania (35.2%) were the countries with the highest prevalence of ALRIs. The results from the multivariate analyses showed that children aged 24–59 months (AOR = 1.15; 95% CI = 1.04–1.28), and children who received intestinal parasite in the 6 months preceding the survey (AOR = 1.11; 95% CI = 1.02–1.22) had higher odds of developing ALRIs. However, children whose mothers were employed (AOR = 0.77; 95% CI = 0.64–0.94) and those whose households used improved toilet facilities (AOR = 0.72; 95% CI = 0.64–0.97) had lower odds of contracting ALRIs. Our findings underscore the need for stakeholders in health in the various sub-Saharan African countries, especially those worst affected by ALRIs to implement programmes and develop policies at different levels aimed at reducing infections among children under-five years. Such strategies should specifically focus on improving the administration of medications for intestinal worms, health education to mothers with children under five on ALRIs and improving the sanitation situations of households through the provision of improved toilet facilities.

•

We examined the prevalence and determinants of Acute Lower Respiratory Infections (ALRIs) among children under-five years in sub–Sahara Africa.

•

ALRIs account for 5.8 million deaths globally.

•

The prevalence of ALRI is 25.3% in sub-Sahara Africa.

•

Children aged 24–59 months had higher odds of developing ALRIs.

•

Employed mothers and improved toilet facility are protective factors against ALRIs.

Is enrolment in the national health insurance scheme in Ghana pro-poor? Evidence from the Ghana Living Standards Survey

OBJECTIVES

This article examines equity in enrolment in the Ghana National Health Insurance Scheme (NHIS) to inform policy decisions on progress towards realisation of universal health coverage (UHC).

DESIGN

Secondary analysis of data from the sixth round of the Ghana Living Standards Survey (GLSS 6).

SETTING

Household based.

PARTICIPANTS

A total of 16 774 household heads participated in the GLSS 6 which was conducted between 18 October 2012 and 17 October 2013.

ANALYSIS

Equity in enrolment was assessed using concentration curves and bivariate and multivariate analyses to determine associated factors.

MAIN OUTCOME MEASURE

Equity in NHIS enrolment.

RESULTS

Survey participants had a mean age of 46 years and mean household size of four persons. About 71% of households interviewed had at least one person enrolled in the NHIS. Households in the poorest wealth quintile (73%) had enrolled significantly (p<0.001) more than those in the richest quintile (67%). The concentration curves further showed that enrolment was slightly disproportionally concentrated among poor households, particularly those headed by males. However, multivariate logistic analyses showed that the likelihood of NHIS enrolment increased from poorer to richest quintile, low to high level of education and young adults to older adults. Other factors including sex, household size, household setting and geographic region were significantly associated with enrolment.

CONCLUSIONS

From 2012 to 2013, enrolment in the NHIS was higher among poor households, particularly male-headed households, although multivariate analyses demonstrated that the likelihood of NHIS enrolment increased from poorer to richest quintile and from low to high level of education. Policy-makers need to ensure equity within and across gender as they strive to achieve UHC.

Utilization of the Ghana National Health Insurance Scheme and its association with patient perceptions on healthcare quality

OBJECTIVE

To determine the association between the utilization of the Ghana National Health Insurance Scheme (NHIS) and patient perceptions of quality of care.

METHODS

Ghana Demographic and Health Survey (GDHS) 2014 had 19 questions on perceptions of quality of care received during the last reported health visit (n = 4332). These questions were summarized into an overall 100-point perception score using item response theory (IRT). Patients were divided into three utilization categories: those paying with their NHIS card fully, those paying with their card and out-of-pocket (OOP), and those paying fully OOP. A multiple linear regression model was used to measure the association between NHIS utilization and overall perception.

RESULTS

In general, NHIS utilization was negatively associated with overall perception, and the difference across utilization categories was higher among private facility users than public facility users. Among private facilities, those who paid fully with NHIS reported five points lower than those who paid fully OOP (P = 0.005). Among public facilities, the difference is only 1.7 (P = 0.4342).

CONCLUSION

NHIS utilization was a negative predictor for patient perceptions, but the differences are more nuanced according to type of facility. Future GDHS rounds should continue measuring perceptions in aid of policy to improve service delivery under the NHIS.

Subscribers' perception of quality of services provided by Ghana's National Health Insurance Scheme - what are the correlates?

Background

Ghana’s National Health Insurance Scheme (NHIS) has witnessed an upsurge in enrollment since its inception in 2003, with over 40% of the Ghanaian population actively enrolled in the scheme. While the scheme strives to achieve universal health coverage, this quest is derailed by negative perceptions of the quality of services rendered to NHIS subscribers. This paper presents an analysis on perceptions of service quality provided to subscribers of Ghana’s NHIS with emphasis on rural and urban scheme policy holders, using a nationally representative data.

Methods

The study used data from the 2014 Ghana Demographic and Health Survey. Ordered logistic regressions were estimated to identify the correlates of perceived quality of care of services rendered by the NHIS. Also, chi-square statistics were performed to test for significant differences in the proportions of subscribers in the two subsamples (rural and urban).

Results

Rural subscribers of the NHIS were found to identify more with better perception of quality of services provided by the NHIS than urban subscribers. Results from the chi-square statistics further indicated that rural subscribers are significantly different from urban subscribers in terms of the selected socioeconomic and demographic characteristics. In the full sample; age, out-of-pocket payment for healthcare and region of residence proved significant in explaining perceived quality of services rendered by the NHIS. Age, out-of-pocket payment for healthcare, region of residence, wealth status, and access to media were found to be significant predictors of perceived quality of services provided to both rural and urban subscribers of the NHIS. The significance of these variables varied among men and women in rural and urban areas.

Conclusion

Different factors affect the perception of quality of services provided to rural and urban subscribers of Ghana’s NHIS. Health financing policies geared toward improving the NHIS-related services in rural and urban areas should be varied.

"Let's talk about money": how do poor older people finance their healthcare in rural Ghana? A qualitative study

BACKGROUND

Older people utilise more healthcare services and are likely to incur higher healthcare expenditure, however, data on their healthcare financing mechanisms are scarce in low-and middle- income countries including Ghana. In this study, we aimed at exploring how poor older people finance their healthcare in rural Ghana.

METHODS

We conducted in-depth interviews and focus group discussions with 60 study participants comprising 30 poor older people, 15 healthcare providers and 15 caregivers in Atwima Nwabiagya District of Ghana. Data were analysed using thematic analytical framework and presented based on an a posteriori inductive reduction approach.

RESULTS

The study revealed that poor older people finance their healthcare through personal income, family support, Livelihood Empowerment Against Poverty grants and National Health Insurance Scheme subscription. It was also found that poor older people spent between GH¢ 20 and 250 on drugs, laboratory test and hospitalisation anytime they access a healthcare facility.

CONCLUSION

The findings contribute to our understanding of how poor older people finance their healthcare in rural Ghana. We argue that health stakeholders should strengthen healthcare financing mechanisms for poor older people for optimal healthcare use.

Trends and characteristics of enrolment in the National Health Insurance Scheme in Ghana: a quantitative analysis of longitudinal data

Background

In 2004, Ghana started experimenting a National Health Insurance Scheme (NHIS) to reduce  out-of-pocket payment for healthcare. Like many other social health insurance schemes in Africa, the NHIS is striving for universal health coverage (UHC). This paper examines trends and characteristics of enrolment in the scheme to inform policy decisions on attainment of UHC.

Methods

We conducted trend analysis of longitudinal enrolment data of the NHIS for the period, 2010-2017. Descriptive statistics were used to examine trends and characteristics of enrolment by geographical region and member groups.

Results

Over the 8-year period, the population enrolled in the scheme increased from 33% (8.2 million) to 41% (11.3 million) between 2010 and 2015 and dropped to 35% (10.3 million) in 2017. Members who renewed their membership increased from 44% to 75.4% between 2010 and 2013 and then dropped to 73% in 2017. On average, the urban regions had significantly higher number of new enrolments than the rural ones. Similarly, the urban and peri-urban regions recorded significantly higher number of renewals than the other regions. In addition, persons below the age of 18 years and the informal sector workers had significantly higher number of enrolment than any other member group.

Conclusions

Enrolment in the NHIS is declining and there are significant differences among geographical regions and member groups. Managers of the NHIS need to enforce the mandatory enrolment provision in the Act governing the scheme, employ innovative strategies such as mobile phone application for registration and renewals and address delays in healthcare provider claims to improve enrolment.