Health insurance and maternal, newborn services utilisation and under-five mortality

Archives of Public Health, Volume 73, No. 1, Year 2015

Interprétation

Background: Ghana’s National Health Insurance Scheme (NHIS) was introduced in 2005 as a demand side intervention to remove financial barriers to accessing health services. After almost a decade of implementation, this study aims to investigate the association of NHIS membership with antenatal visits (ANC), postnatal visits (PNC) and under-five mortality, using data from the most recent Multiple Indicator Cluster Survey (MICS). Methods: The survey was nationally representative and used a two-stage sample design to produce separate estimates for key indicators for each of the ten regions in Ghana. A generalised linear model (GLM) with binomial-family logit-link was used to estimate the effect of NHIS membership on each of the MNCH service utilisation indicators, adjusting for relevant confounding factors. Using birth history data, the Cox proportional hazard regression model was used to estimate the effect of NHIS membership on the incidence of under-five deaths, adjusted for wealth quintiles and other potential confounders. Results: The results support the role of health insurance membership in improving access to maternal and child health services, including antenatal care (ANC4+ adjusted OR = 1.94; 95 % CI = [1.28, 2.95]; P < 0.01), and content of antenatal care (adjusted OR = 2.05; 95 % CI = (1.46, 2.90); P < 0.0001). However, the study failed to show evidence of association of NHIS membership and under-five mortality (adjusted hazard rate = 0.86; 95 % CI = [0.64, 1.14]; P = 0.30). Conclusions: National health insurance membership is associated with increased access to and utilisation of health care but not with under-five mortality. Ethical approval for the Multiple Indicator Cluster Survey (MICS) was obtained from the Ghana Health Service. The data available for this study cannot be linked to an individual who participated in the study. The MICS 2011 was used for this analysis [20]. The choice of using MICS 2011 data was made to allow for a sufficient time period after the introduction of NHIS, yielding a greater likelihood of observing its potential effects on maternal and child health service utilisation and outcomes. The survey is nationally representative and used a two-stage sample design to produce separate estimates for key indicators for each of the ten regions in Ghana. The first stage involved systematically selecting clusters (called enumeration areas or EAs) with probability proportional to size from an updated master sampling frame constructed from the Ghana Population and Housing Census (2010) [21]. The second stage of selection involved the systematic sampling of the households listed in each cluster. The MICS (2011) duly interviewed 11,925 households. In these households, 10,627 women aged 15–49 years were duly interviewed giving a response rate of 97 percent. Complete responses were obtained on 7550 children under age 5 from their mother/caregiver. The number of women age 15–49 who had a live birth in the two years preceding the survey was 2,528. Further details of the sample design and questionnaire are described elsewhere [20]. In this analysis, the main exposure of interest was NHIS membership defined as having a valid insurance card, which was seen and confirmed by the interviewer. To examine if the membership to the NHIS contributes to increasing access and utilization of health services, the following maternal, newborn and child health (MNCH) service access and utilisation measures were selected: 1) ANC 4+, defined as the percentage of at least four antenatal care visits during pregnancy among women who had a live birth during the two years preceding the survey; 2) Content of antenatal care, defined as the percentage of comprehensive ANC (i.e. blood pressure measured, urine sample taken, and blood sample taken as part of antenatal care) among women who had a live birth during the two years preceding the survey; and 3) Post-natal health checks for newborns within 2 days of delivery, defined as percentage of newborns born in the last two years who received health checks and post-natal care (PNC) visits from any health provider within 2 days of delivery. All women who gave birth in the two years preceding the survey were included in the analysis. Pearson design-based F test was used to explore the association of NHIS membership and background characteristics of women aged 15–49 years dully interviewed. A generalised linear model (GLM) with binomial-family logit-link was used to estimate the effect of NHIS membership on each of the service utilisation indicators, adjusting for relevant confounding factors. Socioeconomic status measured by household wealth quintiles, using an asset index, was considered a priori as potential confounder for the NHIS membership-service utilisation relationship and so was adjusted for in all the analyses. Other maternal and household characteristics such as mother’s level of education and area of residence were explored for potential confounding. An adjusted Wald test was used to calculate the P-value as a measure of random error in the adjusted regression model. To examine if NHIS membership can contribute to improved health outcome for children, the study also considered under-five mortality, defined as the probability of dying before the fifth birthday. Every child recorded in the complete birth history dataset who was born within five years preceding the survey was included. The death before the child’s fifth birthday or the woman’s date of interview was estimated using the Kaplan-Meier failure method. The hazard function was estimated for key maternal and household characteristics as well as wealth quintiles. The Cox proportional hazard regression model was used to estimate the effect of NHIS membership on the incidence of under-five deaths adjusted for wealth quintiles and other potential confounders. The birth history data is suitable because it records the three key variables of survival data, i.e. date of birth of child, date of death of child (or age at death), and event status - death or alive. All analyses were adjusted for survey design characteristics (i.e. sampling weight, cluster sampling, and stratification). The analyses were performed using Stata version 13 (StatCorp, College Station, Texas, USA).

Résumé de l’IA

Study Justification:

This study aims to investigate the association between Ghana’s National Health Insurance Scheme (NHIS) membership and the utilization of maternal and child health services, as well as under-five mortality. The NHIS was introduced in 2005 to remove financial barriers to accessing health services. After almost a decade of implementation, it is important to assess the impact of NHIS membership on healthcare utilization and health outcomes.

Highlights:

– The study found that NHIS membership is associated with increased access to and utilization of maternal and child health services, including antenatal care and the content of antenatal care.
– However, there was no evidence of an association between NHIS membership and under-five mortality.
– These findings suggest that while NHIS membership improves access to healthcare, it may not directly impact child survival.

Recommendations:

– The study recommends continued support and promotion of NHIS membership to improve access to maternal and child health services.
– Further research is needed to explore other factors that may contribute to under-five mortality and develop interventions to address them.

Key Role Players:

– Ghana Health Service: Responsible for overseeing the implementation and management of the NHIS.
– Ministry of Health: Provides policy direction and guidance for the healthcare system in Ghana.
– Health Insurance Authority: Responsible for regulating and monitoring the NHIS.
– Health facilities and healthcare providers: Play a crucial role in delivering maternal and child health services.

Cost Items for Planning Recommendations:

– Public awareness campaigns: Budget for promoting NHIS membership and its benefits to the public.
– Training and capacity building: Allocate funds for training healthcare providers to deliver quality maternal and child health services.
– Infrastructure and equipment: Budget for improving healthcare facilities and providing necessary equipment for maternal and child health services.
– Monitoring and evaluation: Allocate resources for monitoring the impact of NHIS membership on healthcare utilization and health outcomes.
Please note that the cost items provided are general categories and not actual cost estimates.

Force de la preuve

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is robust, using a nationally representative survey with a two-stage sample design. The statistical analysis methods used are appropriate for the research questions. However, the evidence could be strengthened by providing more information on the sample size and the specific confounding factors adjusted for in the analysis. Additionally, it would be helpful to include information on the potential limitations of the study, such as any biases or limitations in the data collection process. To improve the evidence, the authors could consider conducting a larger sample size study to increase the statistical power and provide more precise estimates. They could also consider conducting a longitudinal study to examine the long-term effects of NHIS membership on under-five mortality. Finally, it would be beneficial to include a discussion of the policy implications of the findings and any recommendations for future research.

Abstrait

Ethical approval for the Multiple Indicator Cluster Survey (MICS) was obtained from the Ghana Health Service. The data available for this study cannot be linked to an individual who participated in the study. The MICS 2011 was used for this analysis [20]. The choice of using MICS 2011 data was made to allow for a sufficient time period after the introduction of NHIS, yielding a greater likelihood of observing its potential effects on maternal and child health service utilisation and outcomes. The survey is nationally representative and used a two-stage sample design to produce separate estimates for key indicators for each of the ten regions in Ghana. The first stage involved systematically selecting clusters (called enumeration areas or EAs) with probability proportional to size from an updated master sampling frame constructed from the Ghana Population and Housing Census (2010) [21]. The second stage of selection involved the systematic sampling of the households listed in each cluster. The MICS (2011) duly interviewed 11,925 households. In these households, 10,627 women aged 15–49 years were duly interviewed giving a response rate of 97 percent. Complete responses were obtained on 7550 children under age 5 from their mother/caregiver. The number of women age 15–49 who had a live birth in the two years preceding the survey was 2,528. Further details of the sample design and questionnaire are described elsewhere [20]. In this analysis, the main exposure of interest was NHIS membership defined as having a valid insurance card, which was seen and confirmed by the interviewer. To examine if the membership to the NHIS contributes to increasing access and utilization of health services, the following maternal, newborn and child health (MNCH) service access and utilisation measures were selected: 1) ANC 4+, defined as the percentage of at least four antenatal care visits during pregnancy among women who had a live birth during the two years preceding the survey; 2) Content of antenatal care, defined as the percentage of comprehensive ANC (i.e. blood pressure measured, urine sample taken, and blood sample taken as part of antenatal care) among women who had a live birth during the two years preceding the survey; and 3) Post-natal health checks for newborns within 2 days of delivery, defined as percentage of newborns born in the last two years who received health checks and post-natal care (PNC) visits from any health provider within 2 days of delivery. All women who gave birth in the two years preceding the survey were included in the analysis. Pearson design-based F test was used to explore the association of NHIS membership and background characteristics of women aged 15–49 years dully interviewed. A generalised linear model (GLM) with binomial-family logit-link was used to estimate the effect of NHIS membership on each of the service utilisation indicators, adjusting for relevant confounding factors. Socioeconomic status measured by household wealth quintiles, using an asset index, was considered a priori as potential confounder for the NHIS membership-service utilisation relationship and so was adjusted for in all the analyses. Other maternal and household characteristics such as mother’s level of education and area of residence were explored for potential confounding. An adjusted Wald test was used to calculate the P-value as a measure of random error in the adjusted regression model. To examine if NHIS membership can contribute to improved health outcome for children, the study also considered under-five mortality, defined as the probability of dying before the fifth birthday. Every child recorded in the complete birth history dataset who was born within five years preceding the survey was included. The death before the child’s fifth birthday or the woman’s date of interview was estimated using the Kaplan-Meier failure method. The hazard function was estimated for key maternal and household characteristics as well as wealth quintiles. The Cox proportional hazard regression model was used to estimate the effect of NHIS membership on the incidence of under-five deaths adjusted for wealth quintiles and other potential confounders. The birth history data is suitable because it records the three key variables of survival data, i.e. date of birth of child, date of death of child (or age at death), and event status – death or alive. All analyses were adjusted for survey design characteristics (i.e. sampling weight, cluster sampling, and stratification). The analyses were performed using Stata version 13 (StatCorp, College Station, Texas, USA).

Matériaux

N/A

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide information and reminders about antenatal and postnatal care, as well as access to telemedicine consultations with healthcare providers.

2. Community Health Workers: Train and deploy community health workers to provide education, support, and basic healthcare services to pregnant women and new mothers in remote or underserved areas.

3. Telemedicine: Establish telemedicine networks to connect pregnant women and healthcare providers in remote areas, allowing for virtual consultations and remote monitoring of maternal health.

4. Maternal Health Vouchers: Implement voucher programs that provide financial assistance to pregnant women, enabling them to access essential maternal health services, including antenatal care and postnatal care.

5. Transportation Support: Develop transportation initiatives to address the challenge of accessing healthcare facilities, particularly in rural areas. This could include providing transportation vouchers or arranging community transportation services for pregnant women.

6. Maternal Health Insurance Subsidies: Explore options for subsidizing maternal health insurance premiums or providing free insurance coverage for pregnant women, ensuring that financial barriers do not prevent access to essential maternal health services.

7. Maternal Health Education Campaigns: Launch targeted education campaigns to raise awareness about the importance of antenatal and postnatal care, as well as the benefits of health insurance coverage for maternal health.

8. Integration of Maternal Health Services: Promote the integration of maternal health services with other healthcare services, such as family planning and child immunization, to improve overall access and continuity of care.

9. Quality Improvement Initiatives: Implement quality improvement programs in healthcare facilities to ensure that maternal health services are delivered in a timely, respectful, and effective manner, thereby increasing trust and utilization.

10. Public-Private Partnerships: Foster collaborations between the government, private sector, and non-profit organizations to leverage resources and expertise in improving access to maternal health services, including health insurance coverage.

AI Innovations Description

Based on the provided description, the recommendation to improve access to maternal health is to expand and strengthen the National Health Insurance Scheme (NHIS) in Ghana. The study mentioned in the description found that NHIS membership was associated with increased access to and utilization of maternal and child health services, including antenatal care. Therefore, expanding the NHIS would help remove financial barriers and ensure that more women have access to essential maternal health services.

To implement this recommendation, the following steps can be taken:

1. Increase awareness: Conduct public awareness campaigns to educate the population about the benefits of NHIS membership and the importance of maternal health services.

2. Improve coverage: Expand the NHIS coverage to reach more individuals, especially those in rural and underserved areas. This can be done by increasing the number of NHIS accredited health facilities and providers.

3. Enhance quality of care: Work towards improving the quality of maternal health services provided under the NHIS. This can include training healthcare providers, ensuring the availability of necessary equipment and supplies, and monitoring the quality of care.

4. Address barriers: Identify and address any remaining barriers to accessing maternal health services, such as transportation challenges or cultural beliefs. This may involve implementing targeted interventions, such as providing transportation vouchers or engaging community leaders to promote the importance of maternal health.

5. Monitor and evaluate: Continuously monitor the impact of the expanded NHIS on maternal health outcomes, including antenatal care utilization and maternal mortality rates. This will help identify any gaps or areas for improvement and guide future interventions.

By implementing these recommendations, Ghana can improve access to maternal health services and ultimately reduce maternal and child mortality rates.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening the National Health Insurance Scheme (NHIS): The study mentioned that NHIS membership is associated with increased access to maternal and child health services. Therefore, one recommendation could be to further strengthen and expand the NHIS to ensure more women have access to affordable maternal health services.

2. Increasing awareness and education: Another recommendation could be to implement awareness campaigns and educational programs to inform women about the importance of maternal health services and the benefits of NHIS membership. This could help increase demand and utilization of these services.

3. Improving healthcare infrastructure: Investing in improving healthcare infrastructure, particularly in rural areas, can help ensure that maternal health services are easily accessible to all women. This could include building more health facilities, equipping them with necessary resources, and ensuring a sufficient number of skilled healthcare providers.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be as follows:

1. Define the target population: Identify the specific population group that the recommendations aim to benefit, such as pregnant women or women of reproductive age.

2. Collect baseline data: Gather data on the current access to maternal health services, including the percentage of women receiving antenatal care, postnatal care, and the under-five mortality rate. This data can be obtained from surveys, health records, or other relevant sources.

3. Define indicators: Determine the key indicators that will be used to measure the impact of the recommendations. For example, the percentage increase in antenatal care utilization or the reduction in under-five mortality rate.

4. Develop a simulation model: Use statistical software, such as Stata, to develop a simulation model that incorporates the baseline data and the potential impact of the recommendations. This model should consider factors such as population size, NHIS coverage, healthcare infrastructure, and other relevant variables.

5. Run simulations: Run the simulation model multiple times, adjusting the parameters based on the potential impact of the recommendations. This will allow for the estimation of the expected changes in access to maternal health services and under-five mortality rates.

6. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. This can be done by comparing the simulated indicators with the baseline data.

7. Validate the results: Validate the simulation results by comparing them with real-world data, if available. This will help assess the accuracy and reliability of the simulation model.

8. Refine and iterate: Based on the simulation results and validation, refine the recommendations and simulation model if necessary. Iterate the process to further optimize the impact of the recommendations on improving access to maternal health.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and available data.

Auteurs et co-auteurs

Statistics:

Citations: 24

Authors: 4

Identifiers:

DOI: 10.1186/s13690-015-0101-0

ISSN: 07787367

Research Areas:

Community Interventions, Environmental, Health System and Policy, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ghana

Study Design:

Cohort Study, Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female

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