The “universal” in UHC and Ghana’s National Health Insurance Scheme: Policy and implementation challenges and dilemmas of a lower middle income country

listen audio

Study Justification:
– The study aims to explore the challenges and dilemmas faced by Ghana in achieving universal health coverage (UHC) through its National Health Insurance Scheme (NHIS).
– The study provides insights and lessons for Ghana and other low and middle income countries (LMIC) on how to attain the goal of universality in UHC.
– The study examines the factors that facilitate or hinder enrollment in the NHIS, which is crucial for achieving population coverage and equity.
Study Highlights:
– The study found that population coverage in the NHIS was not growing towards near universality due to the failure of many enrollees to regularly renew their enrollment.
– Factors facilitating and enabling enrollment were influenced by the design details of the scheme, implementation arrangements, and contextual factors.
– The study highlights the importance of making enrollment effectively compulsory in practice and addressing stakeholder incentives and behavior at implementation levels.
Study Recommendations:
– UHC policy and program design should ensure that enrollment is effectively compulsory in practice.
– Attention should be given to subscriber, purchaser, and provider incentives and behavior at implementation levels.
– The NHIS should improve its renewal process to encourage regular enrollment.
Key Role Players:
– National Health Insurance Authority (NHIA)
– District insurance scheme staff
– Local government (district assembly)
– Health service providers
– Community members
Cost Items for Planning Recommendations:
– Staff training and capacity building
– Information and communication technology infrastructure
– Outreach and awareness campaigns
– Administrative and operational costs
– Monitoring and evaluation systems

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional mixed methods study conducted in an urban and rural district in Southern Ghana. The study utilized document review, routine data analysis, key informant interviews, and focus group discussions to explore enablers and barriers to enrollment in the National Health Insurance Scheme (NHIS). The study provides insights into the factors affecting population coverage in the NHIS and highlights the need for effective compulsory enrollment and attention to stakeholder incentives and behavior. However, the abstract does not provide specific details about the sample size, representativeness, or statistical analysis methods used in the study. To improve the strength of the evidence, future research could consider increasing the sample size, ensuring random selection of participants, and conducting statistical analysis to support the findings.

Background: Despite universal population coverage and equity being a stated policy goal of its NHIS, over a decade since passage of the first law in 2003, Ghana continues to struggle with how to attain it. The predominantly (about 70 %) tax funded NHIS currently has active enrolment hovering around 40 % of the population. This study explored in-depth enablers and barriers to enrolment in the NHIS to provide lessons and insights for Ghana and other low and middle income countries (LMIC) into attaining the goal of universality in Universal Health Coverage (UHC). Methods: We conducted a cross sectional mixed methods study of an urban and a rural district in one region of Southern Ghana. Data came from document review, analysis of routine data on enrolment, key informant in-depth interviews with local government, regional and district insurance scheme and provider staff and community member in-depth interviews and focus group discussions. Results: Population coverage in the NHIS in the study districts was not growing towards near universal because of failure of many of those who had ever enrolled to regularly renew annually as required by the NHIS policy. Factors facilitating and enabling enrolment were driven by the design details of the scheme that emanate from national level policy and program formulation, frontline purchaser and provider staff implementation arrangements and contextual factors. The factors inter-related and worked together to affect client experience of the scheme, which were not always the same as the declared policy intent. This then also affected the decision to enrol and stay enrolled. Conclusions: UHC policy and program design needs to be such that enrolment is effectively compulsory in practice. It also requires careful attention and responsiveness to actual and potential subscriber, purchaser and provider (stakeholder) incentives and related behaviour generated at implementation levels.

The Volta region, one of the ten regions of Ghana, was purposively selected for the study because the co-sponsor for the study, the Korea Foundation for International Healthcare (KOFIH) was involved in supporting Maternal and Child Health programs in that region. Additionally, it was one of three regions where phase two of the scale up of the NHIS per capita provider payment system for primary care was planned, and findings from the study were considered of relevance to the scale up. In the 2010 national population census the Volta region had a population of a little over two million, about 8.6 % of Ghana’s population [18]. Its inter censal growth rate of 2.5 % was the same as the national average. Ghana has a relatively young population with 43 % of the population aged less than 18 years and the Volta region is no different. A municipality and a rural district adjoining each other, were purposively selected to study contrasting contexts of an urbanized district with relatively good health service access and a rural district with poor health service access. For reasons of research ethics and confidentiality, we do not use the names of the districts or the communities in which the study was conducted in this publication. The Municipality had a population of almost three hundred thousand in the 2010 population and housing census. It had relatively good social, economic and healthcare infrastructure, water and sanitary conditions, and fairly high literacy rates compared to the rest of the region. It had 45 health facilities including a regional and municipal hospital, with 43 run by the Ghana Health Service, one mission and one privately owned. Formal sector economic activity comprised mainly of employment in the public service, private services sector and private construction companies. Non formal sector economic activities were petty trading, subsistence farming, animal rearing, artisans and vocations such as hairdressing and dressmaking. It had an NHIS district scheme office. The population of the rural district was about 64,404 in the 2010 population and housing census. The district lacked basic social and economic infrastructure such as road networks, telecommunication, industry, banking etc. and had serious problems with access to healthcare, water and sanitation facilities. The main occupations were farming, Kente weaving and petty trading [19]. The Administrative Capital had one health centre with a trained midwife, nurses, dispenser and other supporting staffs. There was no hospital. Other sources of modern biomedical health care in the district were two health centres and several small clinics and Community Health Planning and Services compounds. We employed an exploratory, mixed methods cross sectional case study design. Data collection involved extraction of routine management information system data from the district insurance scheme records, community focus group discussions (FGD) and key informant (KI) interviews. We also reviewed NHIS policy and program document such as acts of parliament, legislative instruments and annual reports. Within each district, two communities each were selected for the community member FGD and key informant interviews. Criteria for selection were that in each district, one community should be within half an hour’s walking distance and the other an hour or more’s walking distance of the hospital (municipality) or health centre (rural district). Within each of the study districts, a mix of purposive and snowball sampling was used to select respondents for key informant interviews to get the views of key stakeholders namely purchaser (NHIA district scheme staff), providers, district assembly (local government) and clients. NHIA district scheme staff interviewed, were the district scheme manager (head of the team), Public Relations Officer, Management Information Systems officer. Within each district assembly (local government), those interviewed were the district Chief Executive, Finance Officer, Coordinating Directors, Assembly men (elected community representatives of the district assembly), heads of unit and area committees and opinion leaders. Providers interviewed were the district director of health services, and health insurance claims officers at the health facilities. NHIA regional management staff were also interviewed. In total 35 in-depth interviews were held. Interviews lasted between 30–70 min and were held in the offices and communities of the respondents. There were some rare situations where interviews were arranged and held at the homes of respondents for their convenience. Community focus group discussions were held with adult groups of currently enrolled, previously enrolled but currently uninsured because of failure to renew, and never insured in each of the four communities. Participants were purposively selected to ensure a mix of male and female and range of ages between 18 and 82. Community FGD were also held with insured pregnant women. They were recruited from pregnant women attending antenatal clinics and from the study communities. Pregnant women who participated in the FGD were between the ages 17–45. All focus group discussions were held in the community in the dominant local language, Ewe, and lasted between 30 – 60 min. In all 12 focus group discussions of between 8 – 11 persons per group were held. All Interviews were moderated by members of the research team assisted by research assistants who were recruited and trained for the purpose. Interviews were tape recorded in addition to the interviewers notes and transcribed verbatim into English so all team members could read the notes. All interviews and recordings were done with informed consent (Additional file 1). Qualitative data was analysed manually using thematic content analysis of the text around the study questions guided by the analytical framework for the study. Routine management information systems data on enrolment was analysed in Excel for percentages, patterns and trends.

Based on the provided information, it is not clear what specific innovations or recommendations are being sought to improve access to maternal health. The information provided describes a study conducted in Ghana to explore enablers and barriers to enrollment in the National Health Insurance Scheme (NHIS) and the factors affecting client experience of the scheme.

To improve access to maternal health, some potential innovations or recommendations could include:

1. Mobile health (mHealth) solutions: Implementing mobile health technologies, such as SMS reminders for prenatal care appointments and health education messages, can help improve access to maternal health services, especially in rural areas with limited healthcare infrastructure.

2. Community-based healthcare delivery: Establishing community-based healthcare centers or mobile clinics that provide maternal health services closer to where women live can improve access, particularly in remote or underserved areas.

3. Telemedicine: Using telemedicine technologies, such as video consultations, can enable pregnant women to access specialized maternal health care services without the need for long-distance travel.

4. Maternal health vouchers: Introducing maternal health vouchers that cover the cost of essential maternal health services can help reduce financial barriers and improve access for women who may otherwise be unable to afford these services.

5. Training and capacity building: Investing in training and capacity building for healthcare providers, particularly in rural areas, can help improve the quality of maternal health services and ensure that healthcare providers have the necessary skills and knowledge to provide comprehensive care.

6. Public-private partnerships: Collaborating with private healthcare providers to expand access to maternal health services can help alleviate the burden on public healthcare facilities and increase the availability of services in underserved areas.

7. Health education and awareness campaigns: Conducting targeted health education and awareness campaigns to promote the importance of maternal health care and address cultural or social barriers can help increase demand for services and improve access.

It is important to note that the specific context and needs of the population should be considered when implementing these innovations or recommendations.
AI Innovations Description
Based on the provided description, the recommendation to improve access to maternal health in Ghana is to ensure that the Universal Health Coverage (UHC) policy and program design effectively make enrollment in the National Health Insurance Scheme (NHIS) compulsory in practice. This would require careful attention and responsiveness to the incentives and behavior of subscribers, purchasers, and providers at the implementation level.

The study found that population coverage in the NHIS was not growing towards near universality because many of those who had enrolled did not regularly renew their enrollment annually as required by the NHIS policy. To address this issue, the UHC policy and program design should include measures to ensure regular renewal of enrollment, such as reminders and incentives for timely renewal.

Additionally, the study highlighted the importance of design details of the NHIS scheme, implementation arrangements by frontline staff, and contextual factors in facilitating and enabling enrollment. These factors should be taken into consideration when developing and implementing policies and programs to improve access to maternal health.

Overall, the recommendation is to develop and implement innovative strategies within the UHC framework to make enrollment in the NHIS effectively compulsory in practice, while also addressing the factors that affect client experience and decision to enroll and stay enrolled.
AI Innovations Methodology
Based on the provided description, it seems that the study is focused on understanding the barriers and enablers to enrollment in Ghana’s National Health Insurance Scheme (NHIS) and how to achieve universal coverage. The study utilized a mixed methods approach, including document review, analysis of routine data on enrollment, key informant interviews, and focus group discussions.

To improve access to maternal health within the context of the NHIS, here are some potential recommendations:

1. Strengthen awareness and education: Develop targeted campaigns to raise awareness about the importance of maternal health and the benefits of enrolling in the NHIS. This can include community outreach programs, informational materials, and partnerships with local organizations.

2. Improve enrollment processes: Simplify and streamline the enrollment process to make it more accessible and user-friendly. This can involve reducing paperwork, providing clear instructions, and offering assistance to those who may face challenges in completing the enrollment process.

3. Enhance provider network: Expand the network of healthcare providers, particularly in rural areas, to ensure that pregnant women have access to quality maternal health services. This can involve incentivizing providers to participate in the NHIS and improving infrastructure in underserved areas.

4. Address financial barriers: Explore options to reduce out-of-pocket expenses for maternal health services, such as waiving or reducing co-payments for pregnant women. This can help alleviate financial burdens and encourage more women to seek necessary care.

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

1. Define indicators: Identify key indicators that reflect access to maternal health, such as the number of pregnant women enrolled in the NHIS, the number of prenatal visits, and the percentage of births attended by skilled health personnel.

2. Collect baseline data: Gather data on the selected indicators before implementing the recommendations. This can involve reviewing existing data sources, conducting surveys, and analyzing relevant statistics.

3. Implement recommendations: Roll out the recommended interventions, such as awareness campaigns, enrollment process improvements, and provider network expansion. Monitor the implementation process to ensure that the interventions are being carried out effectively.

4. Collect post-intervention data: After a sufficient period of time, collect data on the selected indicators again to assess the impact of the recommendations. This can involve conducting follow-up surveys, analyzing updated statistics, and comparing the post-intervention data with the baseline data.

5. Analyze and evaluate: Analyze the collected data to determine the extent to which the recommendations have improved access to maternal health. Evaluate the impact of each recommendation individually and as a whole. This can involve statistical analysis, qualitative assessments, and comparison with established benchmarks or targets.

6. Adjust and refine: Based on the findings from the evaluation, make any necessary adjustments or refinements to the recommendations. This can involve scaling up successful interventions, addressing any unforeseen challenges, and continuously monitoring and evaluating the impact of the interventions over time.

By following this methodology, it would be possible to simulate the impact of the recommendations on improving access to maternal health within the context of the NHIS.

Yabelana ngalokhu:
Facebook
Twitter
LinkedIn
WhatsApp
Email