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

Abstract

Skilled birth attendance (SBA) is a key health intervention used by roughly two-thirds of women in Ghana. The National Health Insurance Scheme (NHIS) provided by the Government of Ghana is widely expected to improve maternal health outcomes by removing financial barriers to health services. Using data from the 2011 national Ghana Multiple Indicator Cluster Survey implemented by the Ghana Statistical Services and UNICEF, we examine the effect of insurance on SBA using a multivariate logistic model, controlling for a number of enabling and predisposing factors and past experience with the health system. Our sample is 2 528 women who had a birth in the two years before the survey. Our results show that women with health insurance are 74% more likely to use SBA than women without health insurance. Results also underscore that health insurance, while it eliminates a monetary barrier, does not solve health services availability problems and widespread geographic disparities in coverage of SBA persist. Additionally, we find that higher parity women and poor women are much less likely to use SBA and should be the focus of health interventions in order to fulfil development goals. Health insurance may indeed be a useful mechanism to improve coverage of SBA though further work to understand the effect of health insurance on other maternal outcomes is warranted.

Health insurance coverage and access to skilled birth attendance in Togo

“…This finding is consistent with observations made in Ghana, a neighboring West African country that is undergoing similar transformative changes to expand health insurance coverage for its population. Using a nationally representative sample, Khan and Singh found that insurance coverage in Ghana increased the odds of SBA use by 47%. Several other studies conducted in Sub‐Saharan Africa have also found a positive relationship between insurance and access to maternal health services including SBA.…”

“…The dominant paradigm that prevails today in Sub-Saharan Africa in terms of accessing healthcare services is the user fee system (out-ofpocket payment), which is also one of the most widely used strategies to finance health delivery systems. [1][2][3] This approach has an enormous negative impact both financially and in terms of access to quality health care, 3 including maternal health services such as prenatal care, skilled birth attendance (SBA), and postnatal care. 4 The more a country relies on this kind of strategy, the more its citizens face scarcity 5 and financial hardship.…”

Prevalence of Plasmodium falciparum and non-P. falciparum infections in a highland district in Ghana, and the influence of HIV and sickle cell disease

“…More than half of the pregnant women with malaria (14/21) had not taken any anti-malarials in the last 6 months. This could be due to low or late attendance of antenatal clinics in rural areas [ 41 , 42 ], regardless of provision of free medical care for pregnant women under the National Health Insurance Scheme [ 41 ]. Another possible reason is the availability of poor quality sulfadoxine–pyrimethamine; some SP drugs on the Ghanaian market have been found to be of low quality.…”

Health Insurance in Sub-Saharan Africa: A Scoping Review of the Methods Used to Evaluate its Impact

“…Another major limitation frequently discussed by authors (n = 13 studies) concerned recall bias [13,21,25,26,30,31,33,35,38,39,48,73,76], as information on insurance membership (exposure) and health status and/or health-service use (outcomes of interest) was often collected at different time points, not always allowing a perfect match between the two. Authors of studies relying on secondary data often discussed limitations due to the nature of the secondary data [15,19,21,27,32,33,36,37,39,49,55,56,58,64,67,77], including lack of information on specific covariates to refine model estimation; impossibility of checking the quality and/or accuracy of the data; and for one study relying on medical charts, with large amounts of missing data [65]. Finally, only eight authors (four from quasi-experimental studies [22,61,62,73] and four from observational studies [37,38,59,76]), acknowledged the impossibility of establishing a causal link between insurance and outcomes of interest due to the crosssectional nature of the data being used.…”