| Introduction:The Millennium Development Goal(MDG)has came into limelight since 2000.Under this goal,United Nations member states pledged to work to less the 1990 maternal mortality ratio by three-quarters by 2015.Several countries in the sub-Saharan African as a result started rolling out policies in their quest to make deliveries and healthcare for mothers and children free or nearly free to meet the Millennium Development Goal number 5.In its quest to cut maternal mortality to attain the MDG5,government of Ghana in 2003 introduced a policy exempting pregnant women from all forms of payment for maternal health services.The exemption policy covered services such as normal deliveries,assisted deliveries including caesarean section and management of medical and surgical complications coming out of deliveries,including the repair of vesico-vaginal and recto-vaginal fistulae.The policy covered delivery services not only in public health facilities but private and faith-based health facilities as well.The first phase of the policy started in four out of the ten regions;Central,Northern,Upper West and Upper East with funding from the Highly Indebted Poor Countries fund.The remaining six regions were later covered by the policy in April 2005.There were problems associated with implementation of the policy with regard to its fiscal sustainability which was like problem that earlier health sector user fee exemptions schemes confronted with in Ghana.Reimbursements for exemptions granted by providers were somewhat erratic and run out over time.As in previous exemption schemes met with the user fee system in Ghana,providers reacted to the delayed and partial reimbursements granting lesser exemptions.The Ministry of Finance budgets for paying health service providers under the various exemptions program associated with the preceding user fee systems dwindled still further until,by 2007,almost all these programs died a natural death.Preliminary data of the Ghana Maternal Health Survey which became available at the start of 2008 show that the country was off-track to meeting the maternal health targets of MDGs.In his speech on April 23,2008 during the Annual Health Summit,the Minister of Health emphasized on the low coverage of skilled deliveries with its associated high institutional maternal mortality rate.It was then declared a national emergency that called for action.A task team was set up to look at possibility of subsidizing enrolment of pregnant women on the National Health Insurance Scheme.The ministry of health on June 1,2008 issued implementation guidelines for the financing of free delivery through the insurance scheme.On July 1,2008,implementation of the free maternal health care initiative started nationwide including Kintampo North Municipality and Kintampo South Districts in the Brong Ahafo Region of Ghana.A national consultation on reduction of maternal mortality in Ghana organized on July 8,2008.The program exempted women from paying for their maternal healthcare out-of-pocket after they get pregnancy confirmation from health facility and following their enrollment into the national health insurance scheme.Services covered under the policy are six antenatal care visits,delivery care,two postnatal care visits in one and a half months after childbirth and care of infants up to three months of age.After three months a child qualifies for an exemption as a person who is less than 18 years of age;however it would be the duty of the parents to make sure the child is enrolled on the insurance.The National Health Insurance Scheme was set up by an act of parliament,Act 650 in 2003.This Act was replaced by Act 852 in 2012 to establish National Health Insurance Authority to,among other things,manage the National Health Insurance Fund,and undertake programs that further sustainability of the scheme.Currently,275 District Mutual Health Insurance Schemes,including Kintampo North Municipal and Kintampo South Districts,are operational nationwide.The National Health Insurance Scheme is funded from four main sources.The first is the 2.5%Value Added Tax on selected goods and services,called the National Health Insurance Levy.This is the largest source which constitutes 70%of the total revenues for the national health insurance.The second is a tax imposed on the social security contribution made by formal sector salary earners known as Social Security Tax which accounts for 23%of the total revenue to the scheme.The third source of revenue is the premiums paid by non-formal sector workers when they register to enroll to the health insurance scheme which gives 5%.The forth source of revenue is the donations,and other funds which covers the remaining 2%.ObjectivesThe objectives of this study is to understand the cost and the current situation in implementing Ghana national health insurance program through policy analysis,to assess the effectiveness,sustainability and the impact of the national free maternal health program on maternal health services utilization and maternal health outcomes,and to find the main challenges during policy implementation,to put forward feasible interventions to improve Ghana national free maternal health programs.Methods:Between May and July 2015,a cross-sectional qualitative and quantitative study was conducted in the Kintampo North Municipality and Kintampo South District of Brong Ahafo Region.The study was carried out among all women of reproductive age group 15-49 years who have children aged three to twelve months.Women who were aged 15-49 years but were not having children or having children but less than three months or older than 12 months,were excluded from the study.Also women who were less than 15 years or older than 49 years but were having children either within the age of 3-12 months or above were also excluded from the study.Three main kinds of interviews;household,focus group discussions,and key informant were conducted to gather data from both primary and secondary sources to answer the study objectives.The study adopted multi-stage sampling method.The two capital towns,kintampo and Jema were purposefully selected.A stratified sampling method was employed to select the sub-districts study samples according to their categorizations.The names of communities in each sub-district were compiled and Simple Random Sampling(lottery)was used to select one community from each of them.A systematic sampling was used to select houses.Every third house was selected and women,who fell within the target group,were identified and interviewed.Where there was more than one eligible respondent in a house only one of them was randomly selected,through balloting,to participate in the study.Where there was no eligible respondent,interviewers moved to the next house.The eligible respondents in each community were interviewed to give a total of 343 participants.The two managers of both kintampo north and south health insurance schemes were purposefully selected and interviewed.Both the household interviews and focus group discussions were conducted in the local language(Twi)while the key informant's interviews were conducted in the official language(English).A focus group discussion guide was used for the focus group discussion.Among the topics considered for discussion during discussion session were,the number of women who have heard of the free maternal health policy,what it is about as well as services provided under the policy,how many of the women have registered and benefited from the policy.Also at what stage of pregnancy do women start antenatal care visit,how many times do they have to attend before delivery,are they informed about signs of pregnancy complications,what do they do when seen these signs.What informs the women choice of place of delivery and the women assessment of altitude of nurses were discussed.This allowed the women to freely but critically express their views about the subject matter of the study such as their understanding of social and cultural issues,like norms and expectations and construction of their local definitions of concepts of interest,such as pregnancy and delivery.It also afforded the researcher the opportunity to probe further on the understanding of the women on the socio-cultural as well as financial components of the policy.Again it encouraged the researcher to work and engage with study participants rather than simply observing them.It further allowed for full and uncompromising recognition of how the study participants'experiences create meaning for them and influences their maternal health seeking behavior and life choices.Qualitative data emerged from Key Informant Interviews were transcribed verbatim and checked for completeness and accuracy.Also Focus Group Discussions were audio recorded,transcribed verbatim and checked for completeness and accuracy.Familiarization of the data was done by listening to the tape recordings repeatedly to ensure that the correct transcription and coding have been done.This was followed by preliminary coding of data by identifying how the respondents conceptualized certain key phrases and words.The document was analyzed by using content analysis through identification of general themes that emerged taken into consideration,the objectives of the study.From the various themes and categories that emerged,the data was analyzed thoroughly.Relevant quotes that best described the various themes were included as support to the quantitative findings.The results were presented in tables and figures.Ghana Cedi was converted into United States Dollars based on December 31st 2014 exchange rate for the understanding of international readers.All quantitative data collected were entered into Microsoft excel(2007)with restrictions for entry and exported to Statistical Package for Social Sciences(SPSS)version 23 and subsequently cleaned and analyzed.A logistic regression model was used to predict the likelihood of enrolling in NHIS.The model was built from the background characteristics of respondents(place of residence,marital status,age,employment,level of education and religion)to predict chance of registering for NHIS or not.A one-way multivariate analysis of variance(MANOVA)was conducted specifically;descriptive analysis,univariate and multivariate analysis of NHIS status and healthcare services provided to pregnant women were considered.The p-value for the analysis was pegged at 5%significant level(P<.05).Main Results:The model coefficient(i.e.likelihood ratio of chi-square)(X2)of 76.57 with a p-value of.000 at 6 degree of freedom was recorded.This indicates the outcome of the overall model fits significantly to predict likelihood of occurrence of NHIS status in relation to respondents' background(X2 = 76.57,df=6,p<0.001).Nagelkerke pseudo R2 value of 0.27(Nagelkerke pseudo R2 =0.27)suggested that"respondents' background in total,explains relatively a little over a quarter(27%)of the variance in NHIS enrolment.This implies that the model performance is good for prediction.Chi-square test of statistics using SPSS software evaluated at 5%probability level(p= 0.05)was used to ascertain effects of NHIS enrolment on skilled delivery both at antenatal care,labor and delivery,and postpartum care to respondents.Majority of the respondents(69.6%)who had more than four ANC visits during their previous pregnancy had enrolled on the health insurance program compared to those not registered.This indicates some element of association between health insurance enrolment and Antenatal care visits.The Chi-square statistic indicates evidence of significant effect of health insurance enrolment on antenatal care visit(X2= 121.871,DF=1,p=0.0001).In terms of strength of the relationship,Crammers'V test conducted produced a coefficient of.60,indicating a strong relationship between health insurance enrolment and antenatal care services.Sustainability was measured based on the trend of the income of the two districts mutual health insurance Schemes,the number of women registered and their ability to pay for expenditure on the free maternal healthcare policy within the period under study.The policy was found to be sustainable as the two districts had persistent and continuous revenue and were able to pay for the cost of implementing the policy within the period under study.Expenditure per head in Kintampo North Municipality ranged from USD$24.66 in 2009 to USD$58.93 in 2014 while it ranged from USD$26.22 in 2009 and USD$69.53 in 2014 in Kintampo South District.Although the amount spent on each woman increased a little over two times from 2009 to 2014,Kintampo South District spent much more than Kintampo North Municipal with the exception of the year 2009.In both districts,the per head expenditure was lower than the national health per head expenditure of USD$ 100 in 2013 and the Chatham House recommendation of USD$86.Generally,the lost revenue for Insurance Schemes and the forgone income,for the two districts was very low and did not pose any financial burden on the scheme.Educational level and occupation of respondents had significant association with maternal health insurance status as these recorded exponentiation coefficients(Exp(B))of = 3.238,p= 0.001 and 1.692,p=005 respectively.This suggests that the chance of likely increase NHIS enrolment would be predicted by an increase in these parameters holding all other predictors constant.However,the educational level of respondents was over 3 times more likely than occupation to indicate likelihood of being enrolled on insurance scheme(both p<0.05).Contrary,the estimate of the remaining variables such as location,marital status,age and religion of respondents did not show significant association with the probability of being registered with National Health Insurance Scheme.Information on effect of National Health Insurance Scheme enrolment on Antenatal Care attendance of respondents show that out of a total of 342 respondents,184(53%)visited Antenatal Care less than four times during their last pregnancy whilst 46.2%had this more than four times.It also shows that majority of the respondents(69.6%)who had more than four Antenatal Care visits during their last pregnancy had enrolled on the National Health Insurance Scheme program compared to those not registered.This indicates some element of association between National Health Insurance Scheme status and Antenatal Care attendance.The Chi-square statistic indicates evidence of significant effect of National Health Insurance Scheme enrolment onAntenatal Care visit(x2= 121.871,df=1,P=0.0001).In terms of strength of the relationship,Crammers' V test conducted produced a coefficient of 0.60,indicating a strong relationship between National Health Insurance Scheme enrolment and Antenatal Care visits.Majority,170(49%)out of total of 342 respondents gave birth at home.Out of this number 147(86.5%)do not have insurance.On the other hand,most 98(70.5%)of those who delivered at the district hospitals had health insurance compared to just 41(29.5)without insurance.This means that there exist a strong association(x2 ?121.871,df=1,P=0001)between registering with the insurance and given birth at the hospital.In terms of strength of the relationship,Crammers' V test conducted produced a coefficient of 58,indicating a strong relationship between National Health Insurance Scheme enrolment and skilled delivery.The results shows that 201(58.8%)out of 342 women,did not go for PNC after delivery whereas 141(41.2%)did.Only 54(38.3%)of those who went for Postnatal Care had insurance.There is no significant association(x2=16.01,P=0.999)between National Health Insurance Scheme status and Postnatal Care visits.Multivariate and univariate indicated significant effects of the relationship between health insurance enrolment on antenatal care,Wilks' ?=50,F(6,335)= 55.79,P<0.001,F(1)= 188.236,P =0.001 as well as place of delivery,Wilks' ? =0.73,F(2,336)?61.87,P<0.001.F(1)=123.68,P= 0.001.However there was no significant effect on postnatal care P= 0.79.Conclusions:The policy was found to be sustainable as the two districts had persistent and continuous revenue and were able to pay for the cost of implementing the policy within the period under study.In both districts expenditure per head was lower than the national health per head expenditure of USD$100 in 2013 and the Chatham House recommendation of USD$86.Generally,the lost revenue to National Health Insurance Scheme and the forgone income,for the two districts was very low and did not pose any financial burden on the scheme.Most of the women who were on the national health insurance have over four(4)antenatal care visits.Majority of the women who delivered at the hospital again were those on the national health insurance scheme which implies therefore that the free maternal healthcare program have impacted positively on skilled delivery which is generally known to reduce maternal mortality ratio.On the other hands most of the women who delivered at hospital did not go back for postnatal care check up.Those who went for postnatal check up were predominantly women who were not on the insurance scheme and delivered at home either by self,relative or traditional birth attendant.Their postnatal care seeking behavior was triggered by the various degrees of complications they had as a result of delivering at home.There is the need to intensify public education about the free maternal healthcare policy to encourage all pregnant women to enroll on it.Also women who delivered at the hospital must be encouraged to go back for postnatal checkup even if they did not experience any complications during delivery.This could be enhanced through intensification of community visit by community health nurses to visit and check on the health of these mothers and their babies.Further studies on how to capture the transport cost of women in labor is recommended. |
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