Evaluation of m-Health Interventions

Background: The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2004 with the goal of achieving universal coverage within 5 years. Evidence, however, shows that expanding NHIS coverage and especially retaining members have remained a challenge. A multilevel perspective was employed as a conceptual framework and methodological tool to examine why enrolment and retention in the NHIS remains low. Methods: A household survey was conducted after 20 months educational and promotional activities aimed at improving enrolment and retention rates in 15 communities in the Central and Eastern Regions (ERs) of Ghana. Observation, indepth interviews and informal conversations were used to collect qualitative data. Forty key informants (community members, health providers and district health insurance schemes’ [DHISs] staff) purposely selected from two casestudy communities in the Central Region (CR) were interviewed. Several community members, health providers and DHISs’ staff were also engaged in informal conversations in the other five communities in the region. Also, four staff of the Ministry of Health (MoH), Ghana Health Service (GHS) and National Health Insurance Authority (NHIA) were engaged in in-depth interviews. Descriptive statistics was used to analyse quantitative data. Qualitative data was analysed using thematic content analysis. Results: The results show that factors that influence enrolment and retention in the NHIS are multi-dimensional and cut across all stakeholders. People enrolled and renewed their membership because of NHIS’ benefits and health providers’ positive behaviour. Barriers to enrolment and retention included: poverty, traditional risk-sharing arrangements influence people to enrol or renew their membership only when they need healthcare, dissatisfaction about health providers’ behaviour and service delivery challenges. Conclusion: Given the multi-dimensional nature of barriers to enrolment and retention, we suggest that the NHIA should engage DHISs, health providers and other stakeholders to develop and implement intervention activities to eliminate corruption, shortage of drugs in health facilities and enforce the compulsory enrolment stated in the NHIS policy to move the scheme towards universal coverage.

ABSTRACTNational health insurance is a health financing strategy that facilitates risk‐sharing across populations and aims to achieve universal financial protection for healthcare. This article examines the effect of Ghana's National Health Insurance Scheme (NHIS) on out‐of‐pocket (OOP) healthcare expenditures. The study uses nationally representative data from the Ghana Socioeconomic Panel Survey (GSPS). Three waves were utilized in the analyses. The study addresses the issue of endogeneity related to health insurance status by employing a fixed‐effects two‐stage least squares (2SLS) approach with instrumental variables, using employment in the formal sector as the instrumental variable. The findings indicate that enrollment in Ghana's NHIS significantly reduces OOP healthcare costs, thereby offering financial protection to its members. Additionally, the results identify education, self‐assessed health, physical inactivity, and hospitalization as other key predictors of out‐of‐pocket health expenditures. The study recommends the implementation of income‐based subsidies to alleviate the financial burden on economically disadvantaged individuals and strengthening the Free Maternal Health Care Policy to address gender disparities in healthcare expenses, thereby enhancing financial protection and ensuring equitable access to healthcare. Furthermore, the National Health Insurance Authority should enforce regulations that prohibit excessive charges and ensure strict compliance with established pricing guidelines by healthcare providers.

Ghana's National Health Insurance Authority and Provision of Quality Healthcare Services

While access to and uptake of modern family planning (FP) in Ghana has steadily risen over the last decade, the modern Contraceptive Prevalence Rate (mCPR) among all women reached only 22% in 2019 with 30% of women still reporting unmet need. To increase FP uptake via mitigation of cost barriers among women with unmet need, the Government of Ghana is seeking to integrate claims-based FP services into the National Health Insurance Scheme benefits package. The impact of these activities has the potential to be significant with the proportion of women accessing modern FP shifting dramatically to public facilities over the past decade. The Ghana Ministry of Health, the National Health Insurance Authority, Marie Stopes International Ghana, and the Population Council launched a pilot in nine districts from 2018–20. This report uses data from pilot activity to model four scenarios involving implementation of cost removal, demand generation, and long-acting reversible contraceptives training to estimate impact on mCPR. These are input into the Health Policy Project’s ImpactNow tool to obtain estimates of health and economic benefits, intended to inform decisions regarding scale-up of these activities across the country.

Clients insured by Ghana's National Health Insurance Scheme (NHIS) who seek healthcare at credentialed facilities incur substantial out-of-pocket (OOP) payments for services covered by the scheme. While co-payments are part of OOP payments, the extent of these co-payments has received limited empirical attention. This study sought to determine co-payment levels and identify the social and demographic factors associated with co-payment for outpatient services, inpatient care, and drugs among insured clients of the scheme. We used the 2022 Ghana Demographic and Health Survey data. This was a cross-sectional design, which employed a stratified two-stage random sampling technique. We analysed data involving 8,467 respondents with information on utilisation and payment for health services. Data were analysed using Stata version 16. Descriptive and inferential statistics were performed with statistical significance at p < 0.05. Among insured clients who made any out-of-pocket payment, 58.4% reported it as a co-payment for drugs, 52.5% for inpatient care, and 48.4% for outpatient consultation. Respondents aged 25-34 years (AOR: 0.43; CI: 0.18-0.99; p < 0.05) had significantly reduced odds of co-payment for inpatient care, while urban residents had increased odds of co-payment for drugs (AOR: 1.42; CI: 1.03-1.95; p < 0.05) compared to their rural counterparts. Furthermore, being from the Eastern (p < 0.05), Upper West (p < 0.05) and Northern (p < 0.05) regions was associated with reduced odds of co-payment for outpatient consultation and drugs. However, compared to no formal education, having primary education statistically significantly increases the odds of co-payment for outpatient consultation (AOR: 2.66; CI: 1.13-6.27; p < 0.05) and drugs (AOR: 1.82; CI: 1.11-2.99; p < 0.05) while being rich significantly reduces the odds of co-payment for outpatient consultation (AOR: 0.40; CI: 0.19-0.84; p < 0.05). Insured clients presenting at credentialed health facilities make co-payments for outpatient services, inpatient care, and drugs covered by the scheme. The study highlights the multifaceted determinants of co-payments. The extent of co-payments may impede Ghana's progress toward achieving Universal Health Coverage (UHC). There is a need to eliminate co-payments for outpatient services, inpatient care, and drugs for insured clients to realize the UHC goal.

We present findings on the determinants of enrolment for Ghana's National Health Insurance Scheme (NHIS). With this study we contribute to the literature by providing one of the few quantitative analyses on a nationwide survey. Using data from the 2008 Ghana Demographic and Health Survey, we find that those from the poorest households remain significantly less likely to enrol in the NHIS compared with respondents from wealthy households, even after controlling for theoretically relevant variables. However, our analysis also shows that respondents in Northern Ghana, considered the poorest part of the country, are more likely to be enroled than those in Southern Ghana. The findings present a clear challenge to the original mandate of the NHIS as a propoor policy and suggest that health policy makers should consider expanding and clarifying the criteria for declaring a person as indigent and that the scheme be further evaluated for obstacles that may be hindering enrolment.

PurposeHospital and health system managers are facing several problems following the introduction of Ghana's national health insurance policy. This study aims to investigate the opinions of health managers about the problems emanating from the national health insurance policy for hospital managers in regard to reimbursement, claims management, service delivery and waiting time.Design/methodology/approachThe study involved key informants from 12 National Health Insurance Scheme (NHIS) accredited district hospitals, which were purposively selected from five regions in Ghana. Data were collected using in‐depth personal interviews with managers of pharmacy, supply/procurement, accounts and insurance scheme units of the hospitals. Data analysis was guided by the major themes that emerged during the interviews. A framework approach to analysis was used, grouping and incorporating themes and sub‐themes that emerged from the interview data.FindingsThe major findings identified by interviewees with regards to problems confronting hospital management were: cash flow delays from the health insurance authority; lack of capacity to procure essential drug and non‐drug consumables; and the inability to take initiatives and carry on effective administrative work. Other problems identified by the interviewee included inadequate logistics and human resources, limited space within the hospitals to cope with the increasing number of service users and “moral hazard” on the part of policy holders.Originality/valueThe NHIS has brought many organizational and service management challenges to hospitals. To overcome these challenges, services under the health insurance authority need to be streamlined to remove cash flow bottlenecks. Also, accredited hospitals need to adopt and use new technology, especially computerization and automation of the health insurance service delivery system. This would enable the authority to cope with the huge management problems confronting hospitals and the national insurance scheme. Above all, appropriate fund management systems would have to be established in the hospitals to reduce moral hazards.

Economic inequalities in health insurance subscription renewal: Evidence from Ghana's National Health Insurance Scheme

BackgroundBarely a decade after introduction of Ghana’s National Health Insurance Scheme (NHIS), significant successes have been recorded in universal access to basic healthcare services. However, sustainability of the scheme is increasingly threatened by concerns on quality of health service delivery in NHIS-accredited health facilities coupled with stakeholders’ discontentment with the operational and administrative challenges confronting the NHIS. The study sought to ascertain whether or not Systematic Community Engagement (SCE) interventions have a significant effect on frontline health workers’ perspectives on the NHIS and its impact on quality health service delivery.MethodsThe study is a randomized cluster trial involving clinical and non-clinical frontline health workers (n = 234) interviewed at baseline and follow-up in the Greater Accra and Western regions of Ghana. Individual respondents were chosen from within each intervention and control groupings. Difference-in-difference estimations and propensity score matching were performed to determine impact of SCE on staff perceptions of the NHIS. The main outcome measure of interest was staff perception of the NHIS based on eight (8) factor-analyzed quality service parameters.ResultsStaff interviewed in intervention facilities appeared to perceive the NHIS more positively in terms of its impact on “availability and quality of drugs (p < 0.05)” and “workload on health staff/infrastructure” than those interviewed in control facilities (p < 0.1). Delayed reimbursement of service providers remained a key concern to over 70 % of respondents in control and intervention health facilities.ConclusionCommunity engagement in quality service assessment is a potential useful strategy towards empowering communities while promoting frontline health workers’ interest, goodwill and active participation in Ghana’s NHIS.

We examine the effect of Ghana's National Health Insurance Scheme's (NHIS) contraceptive coverage policy on modern contraceptive use among women in the country. We analyzed three rounds of Ghana Demographic and Health Survey data (2008-2022), using 2008-2014 as the pre-intervention period and 2022 as the post-intervention period. A propensity score matching was applied to the pre-intervention data to enhance comparability between intervention (NHIS) and control (non-NHIS) groups, before applying the difference-in-differences estimator. Multivariable linear probability models were used to estimate the effects. We also performed a placebo and sensitivity analysis to assess the validity and robustness of findings. Among the 26,713 weighted sample, 71.6 percent were in the intervention group and 28.4 percent in the control group. The NHIS contraceptive coverage policy significantly increased modern and long-term contraceptive use by 2.9 and 2.3 percentage points, respectively. We observed heterogeneous effects, with significantly higher increases in long-term method use among women in urban areas and smaller, nonsignificant increases among those in rural areas. Our findings underscore the potential for health insurance in enhancing access to and utilization of modern contraceptive methods. Sustained financing, timely provider reimbursement, and continuous monitoring are necessary to ensure reliable service availability and long-term policy sustainability.

Objective: Examine Ghana’s National Health Insurance Act (Act 650) to identify coverage gaps limiting artificial intelligence (AI) therapy access and address medical negligence liability issues surrounding automated healthcare systems. Methods: Legal and regulatory analysis of Act 650 were conducted, review of academic literature on global uptake of AI interventions and medical negligence principles were elucidated, examination of case studies implementing pilot AI therapy programs under insurance schemes were considered. Results &amp; Conclusions: Act 650 lacks clear provisions for funding innovative AI treatments with proven efficacy and undefined negligence determination guidelines involving AI systems, contributing to accessibility and accountability issues. Proposed amendments to reimburse certain AI therapies through the National Health Insurance Scheme, expand certified provider eligibility, and institute transparent negligence compensation formulas. Recommendations: Reform Act 650 to support increased appropriate use of AI healthcare services, protect patients undergoing automated diagnosis/treatment, and clarify liability rules for medical negligence incidents relating to AI. Novelty &amp; Significance: First extensive analysis focused on opportunities for Ghana’s health insurance framework to catalyze equitable diffusion of advanced AI therapeutics and address emerging legal challenges and safety risks as automated medicine advances.

In 2018, Ghana's National Health Insurance Scheme (NHIS) introduced a mobile money payment system for membership renewal and premium payments to enhance enrolment and retention rates. However, the adoption of such innovations depends on various factors, including personal traits and public perceptions. This study aims to explore the determinants of NHIS membership renewal and premium payment via the mobile renewal system. Conducted at Kwame Nkrumah University of Science and Technology (KNUST) in Kumasi, Ghana, the study used a survey design to gather data from 951 KNUST students. Employing logistic regression analysis, the study identified key factors influencing the use of the NHIS mobile renewal service. The findings revealed that individuals aged 19-21, 25-27 or above 27, without mobile money accounts, and those with no history of online purchases were less likely to adopt the mobile renewal system (P < .05). Conversely, those perceiving the system as useful and easy to use were more likely to utilise it for NHIS membership renewal (P < .05). In conclusion, policymakers should prioritise system quality, accessibility, perceived ease of use, and usefulness to facilitate the adoption and usage of the NHIS mobile payment system. These findings contribute valuable insights for enhancing the effectiveness of health insurance innovations.

Ghana implemented the National Health Insurance Scheme (NHIS) in 2005 and introduced free maternal healthcare (FMH) into the scheme in 2008. These reforms aimed at improving the utilization of healthcare, especially for expectant mothers. Using data from the 2008 and 2014 Ghana Demographic and Health Surveys (GDHS) with a sample of 8,081, this study employed multivariate probit and conditional mixed process (CMP) estimators to analyze the NHIS enrolment and the use of facility‐based delivery services among expectant mothers within the context of Sustainable Development Goal 3 in Ghana. The influence of birth order on these policies has also been explored. Before and after analysis was used for the effect of the FMH on NHIS enrolment and the use of delivery services while CMP was used for the effect of NHIS on delivery services. It is concluded that higher birth order reduces the likelihood of NHIS enrolment and health facility delivery. Moreover, the FMH policy has improved both NHIS enrolment and facility‐based delivery. Finally, the NHIS policy proves to be a reliable factor to induce utilization of facility‐based delivery services. It is recommended that maternal health education at antenatal care visits should be enriched with potential consequences and complications associated with multiple births. The National Health Insurance Authority (NHIA) should provide registration desks for expectant mothers at health facilities.

Toward achieving universal health coverage, Ghana's national health insurance has been acclaimed as a pro-poor scheme, yet been criticized for leaving the poor behind. Arising from this is how poverty has been operationalized and how poor people are targeted for enrolment into the scheme. We examine the role of food insecurity (not currently considered) as a multidimensional vulnerability concept on enrolment into Ghana's health insurance using binary logistics regression on cross-sectional survey of household heads (n = 1438) in the Upper West Region of Ghana. Our analyses show that heads of severely food-insecure households were significantly less likely to enroll in national health insurance scheme (NHIS) relative to households who reported being food-secure (OR = 0.36, P < .05). We also found education, occupation, and religion as significant predictors of health insurance enrolment. Based on our findings, it is crucial to incorporate food security status in the identification of vulnerable people for free enrolment in Ghana's health insurance.

Does Ghana's National Health Insurance Scheme provide financial protection to tuberculosis patients and their households?