Ghana’s National Health insurance scheme and maternal and child health: a mixed methods study

Abstract

BackgroundGhana is attracting global attention for efforts to provide health insurance to all citizens through the National Health Insurance Scheme (NHIS). With the program’s strong emphasis on maternal and child health, an expectation of the program is that members will have increased use of relevant services.MethodsThis paper uses qualitative and quantitative data from a baseline assessment for the Maternal and Newborn errals Evaluation from the Northern and Central Regions to describe women’s experiences with the NHIS and to study associations between insurance and skilled facility delivery, antenatal care and early care-seeking for sick children. The assessment included a quantitative household survey (n = 1267 women), a quantitative community leader survey (n = 62), qualitative birth narratives with mothers (n = 20) and fathers (n = 18), key informant interviews with health care workers (n = 5) and focus groups (n = 3) with community leaders and stakeholders. The key independent variables for the quantitative analyses were health insurance coverage during the past three years (categorized as all three years, 1–2 years or no coverage) and health insurance during the exact time of pregnancy.ResultsQuantitative findings indicate that insurance coverage during the past three years and insurance during pregnancy were associated with greater use of facility delivery but not ANC. Respondents with insurance were also significantly more likely to indicate that an illness need not be severe for them to take a sick child for care. The NHIS does appear to enable pregnant women to access services and allow caregivers to seek care early for sick children, but both the quantitative and qualitative assessments also indicated that the poor and least educated were less likely to have insurance than their wealthier and more educated counterparts. Findings from the qualitative interviews uncovered specific challenges women faced regarding registration for the NHIS and other barriers such lack of understanding of who and what services were covered for free.ConclusionEfforts should be undertaken so all individuals understand the NHIS policy including who is eligible for free services and what services are covered. Increasing access to health insurance will enable Ghana to further improve maternal and child health outcomes.

The Association Between Health Insurance Coverage and Skilled Birth Attendance in Ghana: A National Study

“…While our current analysis cannot address the reasons for non-enrollment, other analysis shows that convenience and perceived benefits of health insurance can sway women to enroll in the NHIS within certain regions of Ghana [33]. Other qualitative data point out that poverty and “uncertainties” around being referred to facilities (transport, costs, dealing with a new facility) as barriers to facility care [29]. Further work to understand the non-enrollment of women in the NHIS can be undertaken to broader the evidence base on this area.…”

“…We also note that nearly all women have been to ANC at least once [30] and close to 9 out of 10 have had at least four ANC visits though SBA use is much lower suggesting that the barriers to SBA are different to those of ANC. A sub-national study in Ghana points out that ANC visits incur less indirect costs as women can usually walk to ANC visits though this is not possible immediately before birth [29], while other studies in Nepal and rural Kenya show that distance and accessibility to a facility for maternity care are key barriers to SBA use [39–40]. The disparity between ANC use and SBA use also may indicate the need to implement or strengthen counseling on birth preparedness plans for pregnant women which addresses the “three delays” for maternal care.…”

“…Household members with NHIS are also less likely to sleep under self-treated mosquito nets [28]. Finally, a study in the North and Central regions of Ghana shows that insurance coverage during pregnancy is associated with increased facility delivery but not antenatal care [29]. …”

Mobilising faith-based and lay leaders to address antenatal care outcomes in northern Ghana

“…Ghana instituted its National Health Insurance Scheme (NHIS) in 2003 -with a primary objective to limit cost as a barrier to accessing MNCH services. A recent study in northern Ghana illustrated that enrolment in the NHIS had a positive association with uptake of institutional delivery; however, there was no effect on women's attendance of four or more ANC visits (Singh et al 2015).…”

“…Ghana instituted its National Health Insurance Scheme (NHIS) in 2003 -with a primary objective to limit cost as a barrier to accessing MNCH services. A recent study in northern Ghana illustrated that enrolment in the NHIS had a positive association with uptake of institutional delivery; however, there was no effect on women's attendance of four or more ANC visits (Singh et al 2015).Socio-cultural factors have also been shown to be important determinants of MNCH behaviours in SSA, including ANC attendance (Ahmed et al 2010;Hiarlaithe et al 2014;Pell et al 2013;Simkhada et al 2008;Underwood et al 2014). A study on facility delivery in northern Ghana, for example, found that traditional power hierarchies in the household and communities influenced the uptake of key health-seeking behaviours, and that often "someone must give the order", potentially hindering uptake of essential MNCH behaviours (Moyer et al 2014).…”