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Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana's National Health Insurance Scheme.

ABSTRACT: OBJECTIVES:The study aimed to understand the impact of integrating a fee waiver for the National Health Insurance Scheme (NHIS) with Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer programme on health insurance enrolment. SETTING:The study was conducted in five districts implementing Ghana's LEAP 1000 programme in Northern and Upper East Regions. PARTICIPANTS:Women, from LEAP households, who were pregnant or had a child under 1 year and who participated in baseline and 24-month surveys (2497) participated in the study. INTERVENTION:LEAP provides bimonthly cash payments combined with a premium waiver for enrolment in NHIS to extremely poor households with orphans and vulnerable children, elderly with no productive capacity and persons with severe disability. LEAP 1000, the focus of the current evaluation, expanded eligibility in 2015 to those households with a pregnant woman or child under the age of 12 months. Over the course of the study, households received 13 payments. PRIMARY AND SECONDARY OUTCOME MEASURES:Primary outcomes included current and ever enrolment in NHIS. Secondary outcomes include reasons for not enrolling in NHIS. We conducted a mixed-methods impact evaluation using a quasi-experimental design and estimated intent-to-treat impacts on health insurance enrolment among children and adults. Longitudinal qualitative interviews were conducted with an embedded cohort of 20 women and analysed using systematic thematic coding. RESULTS:Current enrolment increased among the treatment group from 37.4% to 46.6% (n=5523) and decreased among the comparison group from 37.3% to 33.3% (n=4804), resulting in programme impacts of 14 (95% CI 7.8 to 20.5) to 15 (95% CI 10.6 to 18.5) percentage points for current NHIS enrolment. Common reasons for not enrolling were fees and travel. CONCLUSION:While impacts on NHIS enrolment were significant, gaps remain to maximise the potential of integrated programming. NHIS and LEAP could be better streamlined to ensure poor households fully benefit from both services, in a further step towards integrated social protection. TRIAL REGISTRATION NUMBER:RIDIE-STUDY-ID-55942496d53af.

SUBMITTER: Palermo TM

PROVIDER: S-EPMC6858157 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana's National Health Insurance Scheme.

Palermo Tia M TM Valli Elsa E Ángeles-Tagliaferro Gustavo G de Milliano Marlous M Adamba Clement C Spadafora Tayllor Renee TR Barrington Clare C

BMJ open 20191104 11

<h4>Objectives</h4>The study aimed to understand the impact of integrating a fee waiver for the National Health Insurance Scheme (NHIS) with Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer programme on health insurance enrolment.<h4>Setting</h4>The study was conducted in five districts implementing Ghana's LEAP 1000 programme in Northern and Upper East Regions.<h4>Participants</h4>Women, from LEAP households, who were pregnant or had a child under 1 year and who particip ...[more]

PMID: 31690603

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Project description:Ghana's National Health Insurance Scheme (NHIS), established by an Act of Parliament (Act 650), in 2003 and since replaced by Act 852 of 2012 remains, in African terms, unprecedented in terms of growth and coverage. As a result, the scheme has received praise for its associated legal reforms, clinical audit mechanisms and for serving as a hub for knowledge sharing and learning within the context of South-South cooperation. The scheme continues to shape national health insurance thinking in Africa. While the success, especially in coverage and financial access has been highlighted by many authors, insufficient attention has been paid to critical and context-specific factors. This paper seeks to fill that gap.Based on an empirical qualitative case study of stakeholders' views on challenges and success factors in four mutual schemes (district offices) located in two regions of Ghana, the study uses the concept of policy translation to assess whether the Ghana scheme could provide useful lessons to other African and developing countries in their quest to implement social/NHISs.In the study, interviewees referred to both 'hard and soft' elements as driving the "success" of the Ghana scheme. The main 'hard elements' include bureaucratic and legal enforcement capacities; IT; financing; governance, administration and management; regulating membership of the scheme; and service provision and coverage capabilities. The 'soft' elements identified relate to: the background/context of the health insurance scheme; innovative ways of funding the NHIS, the hybrid nature of the Ghana scheme; political will, commitment by government, stakeholders and public cooperation; social structure of Ghana (solidarity); and ownership and participation.Other developing countries can expect to translate rather than re-assemble a national health insurance programme in an incomplete and highly modified form over a period of years, amounting to a process best conceived as germination as opposed to emulation. The Ghana experience illustrates that in adopting health financing systems that function well, countries need to customise systems (policy customisation) to suit their socio-economic, political and administrative settings. Home-grown health financing systems that resonate with social values will also need to be found in the process of translation.

Project description:BACKGROUND:According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe. METHODS:We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017 - October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual's income. RESULTS:Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58-87% of insured patients would face financial catastrophe, versus 83-98% of uninsured patients (all comparisons by definition were significant, p < .05). CONCLUSION:This study-the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana-found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana's national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care. TRIAL REGISTRATION:Registered at www.clinical trials.gov identifier NCT03604458.

Project description:BackgroundThe National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003 to remove financial barriers and to promote equitable access to health care services. Post implementation has been characterized by increases in access and utilization of services among the insured. The uninsured have been less likely to utilize services due to unaffordability of health care costs. In this study, we explored the experiences of the insured members of the NHIS, the uninsured and health professionals in accessing and utilizing health care services under the NHIS in the Hohoe Municipality of Ghana.MethodsQualitative in-depth interviews were held with twenty-five NHIS insured, twenty-five uninsured, and five health care professionals, who were randomly sampled from the Hohoe Municipality to collect data for this study. Data was analyzed using thematic analysis.ResultsParticipants identified both enablers or motivating factors and barriers to health care services of the insured and uninsured. The major factors motivating members to access and use health care services were illness severity and symptom persistence. On the other hand, barriers identified included perceived poor service quality and lack of health insurance among the insured and uninsured respectively. Other barriers participants identified included financial constraints, poor attitudes of service providers, and prolonged waiting time. However, the level of care received were reportedly about the same among the insured and uninsured with access to quality health care much dependent on ability to pay, which favors the rich and thereby creating inequity in accessing the needed quality care services.ConclusionThe implication of the financial barriers to health care access identified is that the poor and uninsured still suffer from health care access challenges, which questions the efficiency and core goal of the NHIS in removing financial barrier to health care access. This has the potential of undermining Ghana's ability to meet the Sustainable Development Goal 3.8 of universal health coverage by the year 2030.

Project description:BackgroundCommunity Based Health Insurance (CBHI) is a type of health insurance program that provides financial protection against the cost of illness and improving access to health care services for communities engaged in the informal sector. In Ethiopia, the coverage of CBHI enrolment varies across regions and decision of household enrolment is affected by different factors. There are pocket studies on CBHI scheme with different coverage in Ethiopia and there is no pooled study on CBHI enrolment coverage in Ethiopia for better understanding the scheme and decision making. The aim of this systematic review and meta-analysis was to identify the pooled coverage of CBHI enrolment in Ethiopia to understand its policy implications.MethodsThe systematic review and meta-analysis was done by adhering the PRISMA guideline with exhaustive search in PubMed/Medline, HINARI, SCOPUS and Google scholar complemented by manual search. Two authors independently selected studies, extracted data, and assessed quality of studies. The I2 test statistic was used to test heterogeneity among studies. The overall coverage of CBHI scheme was estimated by using random-effects model.ResultAmong 269 identified, 17 studies were included in this meta-analysis and the overall coverage of CBHI scheme was 45% (95% CI 35%, 55%) in Ethiopia. The sub-group analysis shows higher enrolment rate 55.97 (95%CI: 41.68, 69.77) in earlier (2016-2017) studies than recent 37.33 (95%CI: 24.82, 50.77) studies (2018-2020).ConclusionThe pooled coverage of CBHI enrolment is low in Ethiopia compared the national target of 80% set for 2020. It is also concentrated in only major regions of the country. The finding of the study helps national decision making for CBHI scheme service improvement. Due attention to be given to improving geographic expansion of CBHI and to the declining coverages with in the CBHI implementing regions by addressing the main bottlenecks restraining coverages.Trial registrationThe protocol of this systematic review and meta-analysis was published in PROSPERO with registration number: CRD42021252762 .

Project description:Provider payment reforms, such as capitation, are very contentious. Such reforms can drop off the policy agenda due to political and contextual resistance. Using the Shiffman and Smith (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 2007; 370 1370-9) framework, this study explains why Ghana's National Health Insurance capitation payment policy that rose onto the policy agenda in 2012, dropped off the agenda in 2017 during its pilot implementation in the Ashanti region. We conducted a retrospective qualitative policy analysis by collecting field data in December 2019 in the Ashanti region through 18 interviews with regional and district level policy actors and four focus group discussions with community-level policy beneficiaries. The thematically analysed field data were triangulated with media reports on the policy. We discovered that technically framing capitation as a cost-containment strategy with less attention on portraying its health benefits resulted in a politically negative reframing of the policy as a strategy to punish fraudulent providers and opposition party electorates. At the level of policy actors, pilot implementation was constrained by a regional level anti-policy community, weak civil society mobilization and low trust in the then political leadership. Anti-policy campaigners drew on highly contentious and poorly implemented characteristics of the policy to demand cancellation of the policy. A change in government in 2017 created the needed political window for the suspension of the policy. While it was technically justified to pilot the policy in the stronghold of the main opposition party, this decision carried political risks. Other low- and middle-income countries considering capitation reforms should note that piloting potentially controversial policies such as capitation within a politically sensitive location can attract unanticipated partisan political interest in the policy. Such partisan interest can potentially lead to a decline in political attention for the policy in the event of a change in government.

Dataset Information

Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana's National Health Insurance Scheme.

Publications

Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana's National Health Insurance Scheme.

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