Abstract
BackgroundDespite the focus of the National Health Insurance Scheme (NHIS) to bridge healthcare utilisation gap among women in Ghana, recent evidence indicates that most maternal deaths still occur from rural Ghana. The objective of this study was to examine the rural-urban differences in the effects of NHIS enrolment on delivery care utilisation (place of delivery and assistance at delivery) and antenatal care services among Ghanaian women.MethodsA nationally representative sample of 4169 women from the 2014 Ghana Demographic and Health Survey was used. Out of this sample, 2880 women are enrolled in the NHIS with 1229 and 1651 being urban and rural dwellers, respectively. Multivariate logistic and negative binomial models were fitted as the main estimation techniques. In addition, the Propensity Score Matching technique was used to verify rural-urban differences.ResultsAt the national level, enrolment in NHIS was observed to increase delivery care utilisation and the number of ANC visits in Ghana. However, rural-urban differences in effects were pronounced: whereas rural women who are enrolled in the NHIS were more likely to utilise delivery care [delivery in a health facility (OR = 1.870; CI = 1.533–2.281) and assisted delivery by a medical professional (OR = 1.994; CI = 1.631–2.438)], and have a higher number of ANC visits (IRR = 1.158; CI = 1.110–1.208) than their counterparts who are not enrolled, urban women who are enrolled in the NHIS on the other hand, recorded statistically insignificant results compared to their counterparts not enrolled. The PSM results corroborated the rural-urban differences in effects.ConclusionThe rural-urban differences in delivery and antenatal care utilisation are in favour of rural women enrolled in the NHIS. Given that poverty is endemic in rural Ghana, this positions the NHIS as a potential social equaliser in maternal health care utilisation especially in the context of developing countries by increasing access to delivery care services and the number of ANC visits.
Highlights
Despite the focus of the National Health Insurance Scheme (NHIS) to bridge healthcare utilisation gap among women in Ghana, recent evidence indicates that most maternal deaths still occur from rural Ghana
In order to make attributions at the national level, three hypotheses were tested: (1) Pregnant women who are enrolled in the NHIS are more likely to deliver in a health facility compared to their counterparts who are not enrolled in the NHIS; (2) Pregnant women who are enrolled in the NHIS are more likely to be assisted by a medical professional during delivery in a health facility compared to their counterparts who are not enrolled in the NHIS; (3) The occurrence of regular antenatal care (ANC) visits are higher for pregnant women who are enrolled in the NHIS compared to their counterparts who are not enrolled on to the Scheme
The results indicate that, at the national level, women who are enrolled in the NHIS are 1.805 times more likely to deliver in a health facility compared to their counterparts who are not enrolled in the NHIS
Summary
Despite the focus of the National Health Insurance Scheme (NHIS) to bridge healthcare utilisation gap among women in Ghana, recent evidence indicates that most maternal deaths still occur from rural Ghana. The disparity in maternal healthcare access and utilisation within countries constitutes one of the cardinal areas where inequality manifests strongly, and as a result, the SDG three seeks to offset in-country maternal healthcare inequalities and guarantee equal access to achieve less than 70 maternal mortality by the year 2030 [1] These global efforts put Ghana at the forefront of maternal healthcare discourse. Almost every pregnant woman (98%) in Ghana accesses and utilises ANC services in the country Though these proportions are impressive, rural-urban differences call for concern as 90% urban women delivered and were assisted in a health facility compared to their rural counterparts of only 68% utilisation [3]. Rural women are at the disadvantaged end of inadequate access and utilisation [3,4,5] despite the introduction of the National Health Insurance Scheme (NHIS) in 2003 [6]
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