Has the free maternal health policy eliminated out of pocket payments for maternal health services? Views of women, health providers and insurance managers in Northern Ghana

Abstract

IntroductionThe free maternal health policy was implemented in Ghana in 2008 under the National Health Insurance Scheme (NHIS). The policy sought to eliminate out of pocket (OOP) payments and enhance the utilisation of maternal health services. It is unclear whether the policy had altered OOP payments for services. The study explored views on costs and actual OOP payments during pregnancy. The source of funding for payments was also explored.MethodsA convergent parallel mixed methods design, involving quantitative and qualitative data collection approaches. The study was set in the Kassena-Nankana municipality, a rural area in Ghana. Women (n = 406) who utilised services during pregnancy were surveyed. Also, 10 focus groups discussions (FGDs) were held with women who used services during pregnancy as well as 28 in-depth interviews (IDIs) with midwives/nurses (n = 25) and insurance managers/directors (n = 3). The survey was analysed using descriptive statistics, focussing on costs from the women’s perspective. Qualitative data were audio recorded, transcribed and translated verbatim into English where necessary. The transcripts were read and coded into themes and sub-themes.ResultsThe NHIS did not cover all expenses in relation to maternal health services. The overall mean for OOP cost during pregnancy was GH¢17.50 (US$8.60). Both FGDs and IDIs showed that women especially paid for drugs and ultrasound scan services. Sixty-five percent of the women used savings, whilst twenty-two percent sold assets to meet the OOP cost. Some women were unable to afford payments due to poverty and had to forgo treatment. Participants called for payments to be eliminated and for the NHIS to absorb the cost of emergency referrals. All participants admitted the benefits of the policy.ConclusionWomen needed to make payments despite the policy. Measures should be put in place to eliminate payments to enable all women to receive services and promote universal health coverage.

Determinants of individual healthcare expenditure: A cross‐sectional analysis in rural Burkina Faso

“…Such an egalitarian finding inevitably leads to equity considerations. Although our study falls short of exploring how regressive OOPEs in Burkina Faso are, it stands to reinforce the overwhelming existing evidence pointing at how exemption policies targeting the ultra‐poor are not implemented as they should be in Burkina Faso as elsewhere in SSA …”

“…In line with the Millennium Development Goals 4 and 5, most policies targeted women and children by making services for maternal and/or child care less expensive or fully free of charge . Examples come from Ghana, where women were first offered coverage for maternal healthcare services as early as 2003; Senegal, which removed user fees for delivery care at the national level in 2006; Mali, which removed fees for C‐sections in 2005; and Sierra Leone, which removed all fees for pregnant women and children in 2010…”

“…Those OOPEs stand in direct relation to healthcare access and hence represent an important barrier to healthcare use . Evidence indicates that even in case of partial user fee removal, the very poor and ill often cannot afford to pay for their treatment due to uncovered costs or have to sell assets in order to be able to do so . High rates of OOPE have been shown to perpetuate and/or generate impoverishment across sub‐Saharan African (SSA) countries .…”

Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review

“…Although free/subsidised maternal health services are offered in some African countries, women still pay out of pocket for some direct medical costs such as laboratory investigation and non-medical costs for transport. These costs pose financial barriers to using ANC services by pregnant women 116 117. Further reflecting the role of the woman’s ability to fund ANC on utilisation, early initiation and attending ANC for at least four times were reduced in women who did not have health insurance.…”

The implementation of the free maternal health policy in rural Northern Ghana: synthesised results and lessons learnt

“…Therefore, we undertook a study to explore the affordability, availability, acceptability and quality of services under the free maternal health policy. Some of the results have been published in [ 7 , 8 ], specifically those relating to affordability. In this manuscript, we present the overall synthesised results in the form of facilitators and barriers to access to services under the free maternal health policy.…”