An exploratory study of the policy process and early implementation of the free NHIS coverage for pregnant women in Ghana

International Journal for Equity in Health

Valéry Ridde³  Bertha Garshong¹  Sophie Witter² 

[1] Research and Development Division, Ghana Health Services, Accra, Ghana;FEMHealth project, Immpact, Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK;Centre de recherche du Centre hospitalier de l’Université de Montréal, Montréal (CRCHUM), Montréal, Canada

关键词: Implementation;    Policy process;    Health insurance;    Ghana;    Exemptions;    Maternal health;   

Others  :  825096
DOI  :  10.1186/1475-9276-12-16

 received in 2012-09-05, accepted in 2013-02-17,  发布年份 2013

【 摘 要 】

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.

【 授权许可】

   
2013 Witter et al; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Witter S, Adjei S, Armar-Klemesu M, Graham W: Providing free maternal health care: ten lessons from an evaluation of the national delivery exemption policy in Ghana. Global Health Action 2009. 2.
• [2]Ghana Statistical Service, Ghana Health Service, ICF Macro: Ghana Demographic and Health Survey 2008: Key Findings. Calverton, Maryland, USA: GSS, GHS, and ICF Macro; 2009.
• [3]GHS: Ghana Health Service Annual Report 2009. Accra: Ghana Health Service; 2010.
• [4]Countdown to 2015. Building a future for women and children: the 2012 report. Geneva: WHO and UNICEF; 2012.
• [5]Ghana Ministry of Health: Implementation guidelines for financing free delivery through NHIS. Accra: MoH; 2008.
• [6]NHIS: National Health Insurance Scheme website. Accra: NHIS; 2012.
• [7]Dzakpasu S, Soremekun S, Manu A, Ten Asbroek G, Tawiah C: Impact of Free Delivery Care on Health Facility Delivery and Insurance Coverage in Ghana’s Brong Ahafo Region. PLoS One 2012, 7(11):e49430.
• [8]Witter S, Arhinful D, Kusi A, Zakariah-Akoto S: The experience of Ghana in implementing a user fee exemption policy to provide free delivery care. Reprod Health Matters 2007, 15(30):1-11.
• [9]Witter S, Dieng T, Mbengue D, Moreira I, De Brouwere V: The free delivery and caesarean policy in Senegal – how effective and cost-effective has it been? Health Policy Plan 2010, 25(5):384-392.
• [10]Meessen B, Hercot D, Noirhomme M, Ridde V, Tibouti A, Tashobya C: Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries. Health Policy Plan 2011, 2(26):ii16-ii29.
• [11]Ridde V, Robert E, Meessen B: A literature review of the disruptive effects of user fee exemption policies on health systems. BMC Publ Health 2012., 12(289).
• [12]Community of Practice Financial Access to Health Services: Maternal health exemptions: policy brief. Bamako: CoP FAHS; 2012.
• [13]Witter S, Richard F, De Brouwere V: Learning lessons and moving forward: how to reduce financial barriers to obstetric care in low-income contexts. Studies in Health Services Organisation and Policy 2008, 24:277-304.
• [14]Witter S, Adjei S: Start-stop funding, its causes and consequences: a case study of the delivery exemptions policy in Ghana. Int J Health Plann Manage 2007, 22(2):133-143.
• [15]Ghana Ministry of Health: National consultative meeting on the reduction of maternal mortality in Ghana: partnership for action - a synthesis report. Accra: MoH; 2008.
• [16]Witter S, Garshong B: Something old or something new? Social health insurance in Ghana. BMC International Health and Human Rights 2009., 9(20).
• [17]Asenso-Boadi F: Free maternal health care programme and its cost implications. 2009. Ref Type: Slide
• [18]Ridde V, Diarra A, Moha M: User fees abolition policy in Niger: comparing the under five years exemption implementation in two districts. Health Policy 2011, 99:219-225.
• [19]Schieber G, Cashin C, Saleh K, Lavado R: Health financing in Ghana at a crossroad. Washington, D.C: World Bank; 2012. Report 67325
• [20]De Sardan O, Ridde V: Une comparaison provisoire des politiques d’exemption de paiement dans trois pays sahéliens (Burkina Faso, Mali, Niger). Niamey: LASDEL/CRCHUM; 2011. Report No.: Etudes et travaux numéro 89
• [21]Atinga R, Mensah S, Asenso-Boadi F, Adjei F: Migrating from user fees to social health insurance: exploring the prospects and challenges for hospital management. BMC Health Serv Res 2012., 12(174).
• [22]Ridde V, Queuille L, Kafando Y: Capitalisations de politiques publiques d’exemption du paiement des soins en Afrique de l’Ouest. Ouagadougou: CRCHUM/HELP/ECHO; 2012.
• [23]Ridde V, Richard F, Bicaba A, Queuille L, Conombo G: The national subsidy for deliveries and emergency obstetric care in Burkina Faso. Health Policy Plan 2011, Supplement 2(26):ii30-ii40.
• [24]Ridde V, Diarra A: A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa). BMC Health Serv Res 2009. 89.
• [25]Agyepong I, Ngai R: “We charge them; otherwise we cannot run the hospital”: front line workers, clients and health financing policy implementation gaps in Ghana. Health Policy 2011, 99:226-233.
• [26]Dalinjong P, Laar A: The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana. Heal Econ Rev 2012., 2(13).
• [27]Nyonator F, Diamenu S, Ameedo E, Eleezer J: Caring for the health of the poor: policy versus implementation. A baseline evaluation of exemption practices in health facilities in the Volta Region of Ghana. Ho, Ghana: Regional Health Administration; 1997.
• [28]Ridde V, Molestin F: A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan 2011, 26(1):1-11.
• [29]Aboagye P: Key messages from the EmONC needs assessment. Accra: Presentation to Health Partners meeting - MDG Acceleration Framework; 2012.