Ghana National Research Articles

Political economy and the pursuit of universal health coverage in Ghana: a case study of the National Health Insurance Scheme.

The road to universal health coverage depends on resources committed to the health sector. In many cases, the political structure and strength of advocacy play an important role in setting budgets for health. However, this has, until recently, not been of interest to health system researchers and policymakers. In this study, we document the political path to the establishment of the Ghana National Health Insurance Scheme (NHIS) as well as continuous political interest in the scheme. To achieve our objectives, we used qualitative data from interviews with key stakeholders. These include stakeholders instrumental in the design and establishment of the NHIS. We also reviewed party manifestoes from the two main political parties in the country. Promises relating to the NHIS were extracted from the various manifestos and analysed. Other documents that account for the design and implementation of the scheme were reviewed. We found that the establishment of the NHIS was down to political commitment and effective engagement with relevant stakeholders. It was considered a solution to the political promise to remove user fees and make healthcare accessible to all. A review of the manifestos shows that in almost every election year after the NHIS was established, there has been some promise related to improving the scheme. There were several policy propositions repeated in different election years. The findings imply that advocacy to get health financing on the political agenda is crucial. This should start from the development of party manifestos. It is important to also ensure that proposed party policies are consistent with national priorities in the medium to long term.

Ownership and use of insecticide-treated nets under Ghana's National Malaria Control Program: What are the correlates?

Ghana's National Malaria Control Program distributes free insecticide-treated nets (ITNs) as a malaria control measure. Some households with the ITN do not use it, however. This paper explores the socioeconomic and demographic determinants of ITN ownership and use among Ghanaian families. Data on 5741households were obtained from the 2019 Ghana Malaria Indicator Survey. The survey is a nationally representative survey that obtains data on malaria-related issues. Negative binomial and Tobit regressions were applied to achieve the study's objectives. Residence (rural-urban), wealth, and administrative region emerged as the most important predictors of ITN ownership and usage in Ghana. The results favoured rural and non-Greater Accra residents. However, wealth had a contrasting association with ITN ownership and use. Whereas affluent households owned more ITNs than the extremely poor, the latter used them more. Also, age and household size were significant for ITN ownership. Both variables had a nonlinear (inverted U-shaped) relationship with ITN ownership. In contrast, the proportion of household members under 5 and the bed net-to-household size ratio were positive and statistically significant determinants of ITN use. The study highlights the need to effectively target the poor, especially in rural areas, for ITNs under the NMCP instead of universal distribution.

Effect of the Ghana National Health Insurance Scheme on exit time from catastrophic healthcare expenditure

AbstractCatastrophic healthcare expenditure (CHE) can plunge households into poverty. Faced with CHE, the question that becomes relevant is how long it will take the household to exit CHE. This paper examines the effect of the Ghana National Health Insurance Scheme (NHIS) on exit time from CHE. The paper uses the Cox proportional hazard model for the analysis, with data sourced from round six of the Ghana Living Standard Survey and World Development Indicators. The results show that households that spend 40% (20%) of their non‐food incomes on healthcare, on average, exit CHE after 10 months and 4 days (13 months and 24 days) being in CHE and those with NHIS coverage exit CHE 19 days (30 days) earlier than those without NHIS coverage. Policy implications arising from this paper include the need to expand NHIS enrolment to mitigate impoverishment due to out‐of‐pocket healthcare payments. Households with higher risks of severe CHE and longer exit time from CHE should be identified and provided with comprehensive NHIS coverage than those with lower risks.

A review of the design and implementation of Ghana's National Water Policy (2007)

AbstractAccess to water is a matter of daily survival for people around the world. Water is crucial for human survival and also central to the development of every nation. The recent literature on world water suggests that the water crisis being experienced is related to governance and not a real crisis of scarcity and stress. This paper aims at identifying water governance practices and the challenges associated with water governance in Ghana. The paper reviews the literature on the implementation of policy directives and actions with specific focus on water resources governance aspects of Integrated Water Resources Management (IWRM) in Ghana. Ghana's National Water Policy is expected to turn the fortunes of the country around in terms of water resources management. Concerning water resources management, the policy advocates for an IWRM approach. Since its implementation, certain setbacks have been challenging the effectiveness of the policy, such as inadequate institutional capacity, inadequate funding, ineffective enforcement of existing regulations, inadequate legal framework, and lack of adequate data. The paper suggests, among other things, the building of both human and institutional capacity, and making the environment a government priority, as ways to contribute to the effective implementation of the National Water Policy.

Prevalence and quality of antihypertensive therapy among hypertension patients enrolled in the Ghana National Health Insurance Scheme

Hypertension is a leading cause of morbidity in Ghana. However, there is insufficient data on the prevalence and quality of antihypertensive therapy. To describe the prevalence of use and quality of antihypertensive therapy. A cross-sectional study design was used to analyze the 2015 Ghana National Health Insurance Scheme (NHIS) electronic claims data. Hypertension diagnosis was defined using ICD-10 codes. The primary outcomes assessed were the prevalence of use and quality of antihypertensive therapy. Quality of antihypertensive therapy was defined as the use of antihypertensive agents recommended for treating hypertension patients with comorbid heart failure, myocardial Infarction/Coronary Artery Disease, diabetes, chronic kidney disease or stroke. We used multivariable logistic regression models to identify predictors of antihypertensive use and quality of therapy. Antihypertensive medication use was very high (86%) among the 161 873 hypertension patients covered under the Ghana NHIS. Only a third (32%) of hypertension patients received guideline-concordant therapy. Angiotensin receptor blockers were consumed at the highest dosages of 120 (Interquartile Range [IQR]: 60, 180) daily defined doses over a year. Males (odds ratio [OR]=0.60; 95% Confidence Interval [CI]:0.58, 0.61) and those with comorbid stroke (OR=0.91, 95% CI:0.84, 0.99), diabetes (OR=0.72; 95% CI:0.69, 0.74) and stroke (OR=0.74, 95%CI:0.68, 0.80) were less likely to use antihypertensives, all other predictors were associated with higher use. Antihypertensive medication use was very high among hypertension patients covered under the Ghana NHIS. However, there was indication of suboptimal quality of the antihypertensive therapy provided.

Review: Architecture in Global Socialism: Eastern Europe, West Africa, and the Middle East in the Cold War

Review: <i>Architecture in Global Socialism: Eastern Europe, West Africa, and the Middle East in the Cold War</i>

Domestic End-users’ Participation in Managing Urban Water Supply in Emerging Cities: Evidence from Wa, Ghana

Domestic end-users’ participation in urban water management is essential to achieving improved water delivery system that meet the needs of all urban dwellers in Ghana. This paper examined how domestic end-users can effectively participate in managing urban water in Wa. The study used semi-structured questionnaires and key informant interviews with a sample of 379 households and two staff from Ghana Water Company Limited (GWCL) and Public Utilities Regulatory Commission (PURC). Kendall’s coefficient of concordance analysis and content analysis were the analytical techniques employed. It found that households’ level of participationin urban water management was 14%. Results of the Kendall’s analysis showed a coefficient of 0.59, which indicates that there is a high agreement level among households that the low level of participation is attributed to GWCL’s lack of trust in end-users’ capacity to make meaningful inputs. It identifies formation of urban zonal water management committees, communication and information sharing, operational transparency and assigning specific roles to end-users as some of the strategies for improving participation in urban water management. These findings have implications for the realisation of the Ghana National Water Policy objective of participatory decision-making in urban water management. It is important that GWCL streamlines its operations and sensitise end-users on its operations&#x0D; Keywords: End-users, Participation, Urban Water, Management, Challenges

Ghana National Community Health Planning and Services (CHPS) policy; gaps between policy and implementation, the need for policy review to address specific gaps

The study examines gaps in primary health policy designed to enable Ghana to achieve universal access to health. The policy has existed for over 15 years with remarkable achievements, but data shows gaps between the procedure and what is going on. The researchers use a qualitative technique to explore the gap by focusing on persons directly involved in policy implementation as participants. Three main japs were identified, insufficient collaboration between community health officers and community leaders, favoritism in promoting CHOs, and inadequate provision of medical consumables and tools to CHPS-compounds as stated by the policy. The study concluded with the call for a review of the procedures and examining of the outlined gaps

Vertical equity in access to health insurance services: An exploration of perceptions and enrolment in the Jirapa Municipality, north-western Ghana

Given concerns about the spiralling cost of health services in low and middle-income countries (LMICs), this study draws on a framework for assessing poverty and access to health services to ascertain progress towards achieving vertical equity in the National Health Insurance Scheme (NHIS) in a rural setting in northern Ghana. Rural-urban disparities in financial access to NHIS services are seldom explored in equity-related studies although there is a knowledge gap of progress and challenges of implementing the scheme’s vertical equity objectives to inform social health protection planning and implementation. A qualitative approach was used to collect and analyse the data. Specifically, in-depth interviews and observation were deployed to explore participants’ lived experiences, the relationship between location, livelihoods and ability to pay for health insurance services. The article found that flat rate contributions for populations in the informal sector of the economy and lack of flexibility and adaptability of timing premium collections to the needs of rural residents make the cost of membership disproportionately higher for them, and this situation contradicts the vertical equity objectives of the NHIS. The study concludes that the current payment regimes serve as important deterrence to poor rural residents enrolling in the scheme. Based on this, we advocate strict adherence and implementation of the scheme’s vertical equity measures through the adoption of the Ghana National Household Register (GNHR) as a tool for ensuring that contributions are based on income, and collection is well-timed

Alternative medicine devices and the making of scientific herbal medicine in Ghana

ABSTRACT Many herbal medicine clinics in the West African nation of Ghana employ alternative medicine diagnostic equipment to help them stand out within a competitive popular medical sector. These devices are a prominent feature of clinics that identify as practising scientific herbal medicine, and they promise scientifically advanced methods of diagnosis and treatment that stand outside mainstream biomedicine. Based on ethnographic research at two such clinics, I argue that frustrations with the functionality of these devices reveal the ongoing legacies of colonialism and its aftermath in Ghanaian cultures of expertise. Alternative medicine devices were sometimes represented as objects of spectacle. However, their failure to operate as advertised engendered debates about Ghana’s place in transnational technoscientific networks. Finally, access to alternative medicine devices was structured through morally ambiguous financial transactions. In these ways, the construction of scientific herbal medicine is patterned by cultural meanings of science and technology produced through legacies of Ghana’s twentieth-century history.

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

Financial barriers are a key limitation to accessing health services, such as tuberculosis (TB) care in resource-poor settings. In Ghana, the National Health Insurance Scheme (NHIS), established in 2003, officially offers free TB care to those enrolled. Using data from the first Ghana's national TB patient cost survey, we address two key questions 1) what are the key determinants of costs and affordability for TB-affected households, and 2) what would be the impact on costs for TB-affected households of expanding NHIS to all TB patients?We reported the level of direct and indirect costs, the proportion of TB-affected households experiencing catastrophic costs (defined as total TB-related costs, i.e., direct and indirect, exceeding 20% of their estimated pre-diagnosis annual household income), and potential determinants of costs, stratified by insurance status. Regression models were used to determine drivers of costs and affordability. The effect of enrolment into NHIS on costs was investigated through Inverse Probability of Treatment Weighting Analysis.Higher levels of education and income, a bigger household size and an multi-drug resistant TB diagnosis were associated with higher direct costs. Being in a low wealth quintile, living in an urban setting, losing one's job and having MDR-TB increased the odds of experiencing catastrophic costs. There was no evidence to suggest that enrolment in NHIS defrayed medical, non-medical, or total costs, nor mitigated income loss. Even if we expanded NHIS to all TB patients, the analyses suggest no evidence for any impact of insurance on medical cost, income loss, or total cost.An expansion of the NHIS programme will not relieve the financial burden for TB-affected households. Social protection schemes require enhancement if they are to protect TB patients from financial catastrophe.

Democracy in postcolonial Ghana: tropes, state power and the defence committees

This article examines how the Jerry Rawlings military government, the Provisional National Defence Council (PNDC) in Ghana, framed its political agenda using liberal tropes about participatory democracy as a strategy to manufacture legitimacy and mediate political-economic crisis. The People’s Defence Committees (PDCs) and Workers’ Defence Committees (WDCs), created in 1981 and dissolved in 1984, were presented by the PNDC as innovative programmes aimed at nurturing citizen participation representative of the highest form of democracy. However, the introduction of these reforms came at a time when the ruling PNDC faced critical problems of legitimacy, administrative incapability and popular opposition to austerity measures associated with structural adjustment programs (SAPs). We utilise primary source material from the University of Ghana National Reconciliation Commission collection to argue that the discourses and practice of the PDCs/WDCs functioned simultaneously to violently consolidate state power, depoliticise alternatives, and manufacture legitimacy to mediate political-economic crisis while simultaneously being a vehicle for illegitimacy by providing constrained opportunities for individual nepotism, grassroots empowerment and claim-making against the state.

Making Cities Resilient in Ghana: The Realities of Slum Dwellers That Confront the Accra Metropolitan Assembly

Over the past three decades, various countries and stakeholders have aimed at having cities&amp;nbsp;that can better handle natural and human-made disasters, protect human life, absorb the impact of economic, environmental and social hazards and promote well-being, inclusive and sustainable growth. This paper investigates how informal ties result in in-filling and the creation of slums in the context of efforts to make cities resilient in Ghana using the Accra Metropolis as case study. The United Nations Habitat classification of slums was used to purposively select two slum settlements in Accra for the study. The study used mixed methods of quantitative and qualitative approaches to collect data from April 2018 to August 2018. Quantitative data was collected from 400 slum dwellers while qualitative data was collected from eight focus group discussion sessions and in-depth interviews with at least one senior official from related institutions such as Accra Metropolitan Assembly (AMA), Ministry of Local Government and Rural Development (MLGRD), Ministry of Water Resources (MWR), Ministry of Works and Housing (MWH), Ministry of Inner City and Zongo Development (MICZD), Environmental Protection Agency (EPA), Ghana Police Service, and Ghana National Fire Service. Descriptive techniques were used for the analysis. The findings are that informal ties contribute to in-filling in slums. Slum dwellers do not plan to return home, they are not involved in land use decision making and the slums have opportunities and challenges to the slum dwellers and AMA. The AMA should avoid forced eviction of slums and rather enforce development control bye-laws, implement slum upgrading programs, and involve slum dwellers in upgrading programs. Slum dwellers must cooperate with AMA to make Accra resilient. The mainstreaming of the issue of slums in all urban development agendas needs to be given the needed political and policy attention by central government and all stakeholders.

Agents of urban (in)security: contextualising the banning of political vigilantism in Ghana

In 2019, a new law banning vigilantism was adopted in the West African nation of Ghana. The law followed years of debate and violent incidents related to the presence of informally mobilised so-called �political vigilantes�, charged with providing security during political events. At first glance, the ridding of such state-competing elements through legal measures appears unproblematic and in line with democratic values. However, as this article argues, by drawing on the case study of Ghana and the pre-2020 election phase, such legal actions against non-state actors can be problematic and, in the worst case, constitute a threat to security and stability if public trust in authorities and formal state security providers is not sufficiently solid. Grounded in a broader discussion on security in fragile contexts and urban centres on the African continent, this article analyses the consequences of banning vigilantism where formal security provision is weak or not fully trusted.

Knowledge on malaria among caregivers with children aged under 5 years at Kenyasi Health Center

Background: Malaria remains one of the leading causes of morbidity and mortality among children under 5 years old in many low- and middle-income countries. According to the Ghana National Malaria Control Program, malaria kills at least three children every day and also tops the outpatient department cases in Ghana.Objective: The present study sought to determine the knowledge of malaria among caregivers of children under 5 years at Kenyasi Health Center, Ghana.Materials and Methods: The study was a descriptive, cross-sectional study. One hundred and three caregivers with children under 5 years old were recruited using the systematic random sampling technique, and data were collected using a structured questionnaire.Results: The findings revealed that majority (98%) of the respondents knew at least one cause of malaria. Furthermore, all respondents knew at least one complication of malaria and majority (97%) knew at least one preventive measure of malaria.Conclusion: Caregivers of children have adequate knowledge about malaria and its mode of transmission. Further education on the implementation of the preventive methods is still needed to help reduce the incidence of malaria among children.

All the Nation’s a Stage: The Ghana National Theatre as Sankofa Praxis

This essay theorizes the architectural history of Ghana’s National Theatre Movement as the material instantiation of national culture. By attending to the architectural trajectory of the national theatre, it explores how the burgeoning state used the edifice to construct a national identity both rooted in a cultural past and representative of their aspirations for a national future by mobilizing the Indigenous concept of Sankofa. The essay focuses on the evolution of the theatre building during three separate periods in Ghana’s history: the pre-independence era, under Kwame Nkrumah’s leadership, and the Jerry John Rawlings presidential era. A close consideration of questions like who led the architectural conversation and who designed, constructed, and funded the theatre building during each respective time period offers a case study of the process by which (post)colonial ideology gets spatially inscribed onto the national terrain. As Sankofa transforms from an abstract cultural symbol to an actualized and grounded national site, its manifestation in the material environment is shaped, challenged, done, and undone by the nation’s fluctuating relationship to the larger global community.

The ‘new’ institutional politics of Ghana’s hydrocarbon governance

Ghana’s discovery of oil in 2007 saw a rush to production in just three years. However, regulations lagged behind and it was not until 2011 that new legislation was enacted in key areas of oil and gas governance. Central to the legislative framework was the creation of the Petroleum Commission as the new regulator of upstream activity, while the national oil company – Ghana National Petroleum Corporation (GNPC) – was formally shorn of its regulatory role so that it could focus on commercial activities. This paper examines the performance of these separated institutions. Performance is always conditioned by deeper political dynamics and so we have moved beyond evaluating performance only from the perspective of the formal institutional remits. Using a political settlements lens, we argue that this separation of roles has been partially successful but that GNPC remains heavily involved in some aspects of regulation, due to its embedded power and the technical expertise it holds. The company has also become a vehicle for electoral politics in Ghana’s highly charged democratic system. At the same time, the Petroleum Commission has begun to find its feet after a few years of weak capacity but it remains heavily influenced by party political appointees and has only really been successful in putting in place critical subsidiary legislation and monitoring local content requirements. These dynamics around oil sector governance are in keeping with Ghana’s political settlement dynamics, which are competitive and clientelistic, so that key institutions become embroiled in partisan competition, producing mixed policy results.

What Factors Are Associated With Recent Changes in Men's Attitudes Towards Intimate Partner Violence Across Regional, Rural, and Urban Spaces of Ghana? Findings From Three Waves of Ghana National Surveys From 2003 to 2014.

Numerous studies have shown that men's attitudes towards intimate partner violence (IPV) remain a strong predictor of its actual perpetration. Very few trend studies available have also reported that IPV-acceptance is gradually declining globally. However, almost none of these trend studies have included men in their samples, nor have investigated factors associated with changes in men's attitudes towards IPV. To supplement this sparse knowledge, the current study employed three waves of the Ghana Demographic and Health Survey (GDHS): 2003 (n=4,901), 2008 (n = 4,481), and 2014 (n = 4,333) data, and reports trends and patterns in men's attitudes towards wife-beating at national, regional, and rural-urban residences of Ghana. Multivariable logistic regression models were fitted to further examine the key socioeconomic and cultural factors significantly associated with men's acceptance of IPV at 95% confidence interval. The results show that men's acceptance of wife-beating declined largely at the national level by 60.8% between 2003 and 2014: from 31.7% in 2003 to 12.4% in 2014. However, when disaggregated by region, data revealed a slight increase in men's IPV-acceptance in two regions between 2008 and 2014-the Western and Upper East regions, by 2.1% and 3.8%, respectively. Having less than secondary education, being in a polygynous union, and residence in certain regions, was significantly associated with justification of wife-beating. Whereas having access to media was not consistently significant in influencing men's attitudes against wife-beating, especially in the rural areas. The decreasing significance of education, household wealth, and religion in the 2014 wave (especially in urban areas) seem to suggest that recent decline in men's acceptance of wife-beating may not have been driven by a single isolated factor, but by complex interactions of several exogenous factors including those not captured in the current data. Study implications and need for further studies are discussed.

Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children.

IntroductionGhana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana.MethodsWe performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE.ResultsOf the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08–0.55).ConclusionsNHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children.

Colorectal Cancer Screening in Ghana: Physicians' Practices and Perceived Barriers.

IntroductionGhana has seen a rise in the incidence of colorectal cancer (CRC) over the past decade. In 2011, the Ghana National Cancer Steering Committee created a guideline recommending fecal occult blood testing (FOBT) for CRC screening in individuals over the age of 50. There is limited data available on current Ghanaian CRC screening trends and adherence to the established guidelines.MethodsWe conducted a survey of 39 physicians working at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. The survey evaluates physician knowledge, practice patterns, and perceived personal-, patient- and system-level barriers pertaining to CRC screening.ResultsAlmost 10% of physicians would not recommend colorectal cancer screening for asymptomatic, average risk patients who met the age inclusion criteria set forth in the national guidelines. Only 1 physician would recommend FOBT as an initial screening test for CRC. The top reasons for not recommending CRC screening with FOBT were the lack of equipment/facilities for the test (28.1%) and lack of training (18.8%). The two most commonly identified barriers to screening identified by >85% of physicians, were lack of awareness of screening/not perceiving colorectal cancer as a serious health threat (patient-level) and high screening costs/lack of insurance coverage (system-level).ConclusionDespite creation of national guidelines for CRC screening, there has been low uptake and implementation. This is due to several barriers at the physician-, patient- and system-levels including lack of resources and physician training to follow-up on positive screening results, limited monetary support and substantial gaps in knowledge at the patient level.