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Background: Pregnant women were offered free access to health care through National Health Insurance (NHIS) membership in Ghana in 2008, in the latest phase of policy reforms to ensure universal access to maternal health care. During the same year, free membership was made available to all children (under-18). This article presents an exploratory qualitative analysis of how the policy of free maternal membership was developed and how it is being implemented. Methods. The study was based on a review of existing literature – grey and published – and on a key informant interviews (n = 13) carried out in March-June 2012. The key informants included representatives of the key stakeholders in the health system and public administration, largely at national level but also including two districts. Results: The introduction of the new policy for pregnant women was seen as primarily a political initiative, with limited stakeholder consultation. No costing was done prior to introduction, and no additional funds provided to the NHIS to support the policy after the first year. Guidelines had been issued but beyond collecting numbers of women registered, no additional monitoring and evaluation have yet been put in place to monitor its implementation. Awareness of the under-18 s policy amongst informants was so low that this component had to be removed from the final study. Initial barriers to access, such as pregnancy tests, were cited, but many appear to have been resolved now. Providers are concerned about the workload related to services and claims management but have benefited from increased financial resources. Users still face informal charges, and are reported to have responded differentially, with rises in antenatal care and in urban areas highlighted. Policy sustainability is linked to the survival of the NHIS as a whole. Conclusions: Ghana has to be congratulated for its persistence in trying to address financial barriers. However, many themes from previous evaluations of exemptions policies in Ghana have recurred in this study – particularly, the difficulties of getting timely reimbursement to facilities, of controlling charging of patients, and of reaching the poorest. This suggests that providing free care through a national health insurance system has not solved systemic weaknesses. The wider concerns about raising the quality of care, and ensuring that all supply-side and demand-side elements are in place to make the policy effective will also take a longer term and bigger commitment. © 2013 Witter et al; licensee BioMed Central Ltd.
The exploratory study was based on six main research questions, which were adapted from a checklist [13]. This checklist distilled good practices for implementation of exemptions policies, based on previous evaluations. The good practices centred on the six areas of policy design; the policy development process; dissemination of policy; resource allocation; payment systems; and management, monitoring and evaluation. The six questions aimed: 1. To understand the policy development process of the introduction of the national free maternal health policy and exemptions for children under 18 years. 2. To find out if the exemptions policy was costed and the process of resource allocation to implement it. 3. To find out how funds for the implementation of the policy arrived at the implementation level. 4. To find out if guidelines were put in place for the dissemination, implementation, monitoring and evaluation of the policy and how these were implemented. 5. To find out the perception of key stakeholders about the policy and its implementation. 6. To make recommendations to policy makers and managers for the effective implementation of the policy. The study was conducted between March and June 2012, using two research methods – a literature review and key informant interviews. A document review was conducted of relevant MoH and Ghana Health Service (GHS) policy documents on maternal exemptions policies in Ghana. These were gained through requests to the key informants and from the archives of the researchers. A search was also done through Google Scholar for published articles on maternal exemptions in Ghana. Search terms included Ghana and national health insurance or NHIS and pregnant women or children and free care or exemption. The few articles and documents of relevance were analysed thematically, using the six main research questions. Thirteen key informant semi-structured interviews were conducted with a purposively selected sample comprising most of the main stakeholder groups, including parliamentarians [1], donors [1], staff from various concerned ministries (Health, Finance and Economic Development, and Women and Children) [5], health insurance representatives [1], and implementers within the GHS, at national [3] and district [2] levels. Participants were identified based on the posts they held, which included some responsibility for or involvement in the policy’s development and implementation. The two districts were selected pragmatically as being close to Accra – one urban and one rural. The interviews were tape recorded and transcribed. They were analysed thematically. The results are presented below following the framework presented in Figure 1, which adopts the logical sequence of policy development, implementation and effects. Thematic framework for results from exploratory interviews. Ethical clearance of the study protocol was given by the Ghana Health Service Ethical Review Committee in March 2012 (GHS-ERC: 18/01/12). Consent of all interviewees was sought. They were informed about the study and the purpose of the study, and that their participation was entirely voluntary. Confidentiality of all respondents was ensured. Given that the stakeholder group was limited, no identifiers are given for the citations below, to respect the anonymity of informants. Although the scope of the original study covered both maternal and under-18 exemptions, the awareness of respondents of the details and operation of the policy for under-18 s were so limited that this component had to be removed in the analysis.
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