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Background: The introduction of the national health insurance scheme (NHIS) in Ghana in 2003 significantly contributed to improved health services utilization and health outcomes. However, stagnating active membership, reports of poor quality health care rendered to NHIS-insured clients and cost escalations have raised concerns on the operational and financial sustainability of the scheme. This paper reviewed peer reviewed articles and grey literature on the sustainability challenges and prospects of the NHIS in Ghana. Methods: Electronic search was done for literature published between 2003–2016 on the NHIS and its sustainability in Ghana. A total of 66 publications relevant to health insurance in Ghana and other developing countries were retrieved from Cochrane, PubMed, ScienceDirect and Googlescholar for initial screening. Out of this number, 31 eligible peer reviewed articles were selected for final review based on specific relevance to the Ghanaian context. Results: Ability of the NHIS to continue its operations in Ghana is threatened financially and operationally by factors such as: cost escalation, possible political interference, inadequate technical capacity, spatial distribution of health facilities and health workers, inadequate monitoring mechanisms, broad benefits package, large exemption groups, inadequate client education, and limited community engagement. Moreover, poor quality care in NHIS-accredited health facilities potentially reduces clients’ trust in the scheme and consequently decreases (re)enrolment rates. These sustainability challenges were reviewed and discussed in this paper. Conclusions: The NHIS continues to play a critical role towards attaining universal health coverage in Ghana albeit confronted by challenges that could potentially collapse the scheme. Averting this possible predicament will largely depend on concerted efforts of key stakeholders such as health insurance managers, service providers, insurance subscribers, policy makers and political actors. [ABSTRACT FROM AUTHOR]

Ghana has made significant stride towards universal health coverage (UHC) by implementing the National Health Insurance Scheme (NHIS) in 2003. This paper investigates the progress of UHC indicators in Ghana from 1995 to 2015 and makes future predictions up to 2030 to assess the probability of achieving UHC targets. National representative surveys of Ghana were used to assess health service coverage and financial risk protection. The analyses estimated the coverage of 13 prevention and four treatment service indicators at the national level and across wealth quintiles. In addition, we calculated catastrophic health payments and impoverishment to assess financial hardship and used a Bayesian regression model to estimate trends and future projections as well as the probabilities of achieving UHC targets by 2030. Wealth-based inequalities and regional disparities were also assessed. At the national level, 14 out of the 17 health service indicators are projected to reach the target of 80% coverage by 2030. Across wealth quintiles, inequalities were observed amongst most indicators with richer groups obtaining more coverage than their poorer counterparts. Subnational analysis revealed while all regions will achieve the 80% coverage target with high probabilities for the prevention services, the same cannot be applied to the treatment services. In 2015, the proportion of households that suffered catastrophic health payments and impoverishment at a threshold of 25% non-food expenditure were 1.9% (95%CrI: 0.9–3.5) and 0.4% (95%CrI: 0.2–0.8), respectively. These are projected to reduce to 0.4% (95% CrI: 0.1–1.3) and 0.2% (0.0–0.5) respectively by 2030. Inequality measures and subnational assessment revealed that catastrophic expenditure experienced by wealth quintiles and regions are not equal. Significant improvements were seen in both health service coverage and financial risk protection over the years. However, inequalities across wealth quintiles and regions continue to be cause of concerns. Further efforts are needed to narrow these gaps. [ABSTRACT FROM AUTHOR]

In the past four decades, there has been an increase in the occurrence of zoonotic diseases. Some outbreaks have been devastating because of the inability of individuals and health workers to identify the diseases early. Generally, most zoonotic diseases are heralded by a fever. While fevers are common, they are often the symptoms of different diseases. This paper explores how a population at potential risk of zoonotic diseases identify fevers, and what treatments they seek when they develop fevers. The data are from focus group discussions and a survey of three communities in the Brong Ahafo, Volta and Greater Accra regions in Ghana. The quantitative data were analysed using descriptive statistics while the qualitative data were analysed using thematic analysis. The findings indicate that the perceived causes of fever differ from the traditional biomedical view. While orthodox treatment was the preferred choice for most participants, rural dwellers utilised traditional medicine more than their urban counterparts. Though there is no record of bat-borne zoonotic disease in Ghana, our findings could be used as a proxy to indicate how populations at risk of exposure might respond in the event of a spillover event from a zoonosis. We recommend that educational campaigns on zoonotic diseases should target rural dwellers, especially farmers, who may be most at risk of zoonoses. [ABSTRACT FROM AUTHOR]

Background: Health worker density per 1000 population in Ghana is one of the lowest in the world estimated to be 2.3, below the global average of 9.3. Low health worker motivation induced by poor working conditions partly explain this challenge. Albeit the wage bill for public sector health workers is about 90% of domestic government expenditure on health in countries such as Ghana, staff motivation and performance output remain a challenge, suggesting the need to complement financial incentives with non-financial incentives through a community-based approach. In this study, a systematic community engagement (SCE) intervention was implemented to engage community groups in healthcare quality assessment to promote mutual collaboration between clients and healthcare providers, and enhance health worker motivation levels. SCE involves structured use of existing community groups and associations to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements made and rewards given to best performing facilities for closing quality care gaps. Purpose: To evaluate the effect of SCE interventions on health worker motivation and experiences with clients. Methods: The study is a cluster randomized trial involving health workers in private (n = 38) and public (n = 26) primary healthcare facilities in two administrative regions in Ghana. Out of 324 clinical and non-clinical staff randomly interviewed at baseline, 234 (72%) were successfully followed at end-line and interviewed on workplace motivation factors and personal experiences with clients. Propensity score matching and difference-in-difference estimations were used to estimate treatment effect of the interventions on staff motivation. Results: Intrinsic (non-financial) work incentives including cordiality with clients and perceived career prospects appeared to be prime sources of motivation for health staff interviewed in intervention health facilities while financial incentives were ranked lowest. Intervention health facilities that were assessed by female community groups (Coef. = 0.2720, p = 0.0118) and informal groups with organized leadership structures like Artisans (Coef. = 0.2268, p = 0.0368) associated positively with higher intrinsic motivation levels of staff. Conclusion: Community-based approach to health worker motivation is a potential complementary strategy that needs policy deliberation to explore its prospects. Albeit financial incentives remain critical sources of staff motivation, innovative non-financial approaches like SCE should complement the latter. [ABSTRACT FROM AUTHOR]

The practice of early marriage, although acknowledged as a human rights violation, continues to occur in many countries. Different studies have identified the associated factors in many developing countries. However, these factors often assume no geographical variation in these factors within countries. Again, cultural practices and beliefs which strongly influence the acceptance and practices of early marriage vary geographically. In addition, geographic clusters of high rates of early marriage and union formation are also unknown. Thus, area specific correlates of early child marriage are required for the development of location specific policies to aid the eradication of early child marriage. Using data from the 2010 Ghana Population and Housing Census, this study examines the extent of geospatial clustering in early marriage amongst girls and their spatially-varying associated factors at the district level. The findings reveal strong clustering of high early marriage amongst districts in the Upper West, Northern and Volta regions. Nationally, 6.96% (CI = 6.83, 7.08) of girls are married or in union before their 18th birthday. The estimates range from 2.7% in the Jaman North district in Brong Ahafo region to 19.0% in the Gushiegu district in Northern region. Economic factors were observed as important spatially-varying associated factors. The findings suggest that targeted interventions are required in the effort to eradicate the practice in Ghana. [ABSTRACT FROM AUTHOR]

Background: Ghana introduced capitation payment method in 2012 but was faced with resistance from provider groups and civil society organizations for its perceived negative effects on quality care delivery. This study seeks to explore the views of providers to understand their preferred payment method for the various types of services they provide in order to inform the discussion and negotiations during this period of reform. Findings will not only aid the National Health Insurance Authority (NHIA) to improve the implementation arrangements but also provide useful inputs for other low and middle-income countries (LMICs) in their quest to reform their provider payment systems. Materials and methods: We conducted a cross-sectional survey of 200 credentialed health care providers’ in the three regions of Ghana on providers’ preference for payment method. We administered closed-ended questionnaires employing 5-point Likert scales for measurement of payment method preference. Descriptive and regression analysis were performed to examine healthcare providers’ background characteristics and their association with preferred payment method for primary care. Results: In general, health care providers prefer the Ghana-Diagnosis-Related Grouping (G-DRG) payment method to fee-for-service and capitation payment methods. Result of bivariate analyses showed that healthcare providers’ preference for payment method for primary outpatient services differed significantly by their region of residence (p<0.001). The multinomial logic model showed that being a female (p = 0.013) or healthcare provider in the Volta region (p = 0.008) was significantly associated with health provider preference for G-DRG payment method relative to fee-for-service. Similarly, being a healthcare provider in the Volta region (p = 0.026) or Medical Assistant (p = 0.032) was significantly associated with capitation relative to fee-for-service payment method. Conclusion: We conclude that the most preferred payment method across all regions is the G-DRG. However, whereas providers in the Volta region are not willing to accept capitation as payment method, this was not the case in Ashanti and Central regions. Capitation payment method as an option for primary care services in Ghana should, therefore, not be ruled out of the discussion. [ABSTRACT FROM AUTHOR]

Background: Strong primary health care (PHC) is essential for achieving universal health coverage, but in many low- and middle-income countries (LMICs) PHC services are of poor quality. Facility management is hypothesized to be critical for improving PHC performance, but evidence about management performance and its associations with PHC in LMICs remains limited. Methods: We quantified management performance of PHC facilities in Ghana and assessed the experiences of women who sought care at sampled facilities. Using multi-level models, we examined associations of facility management with five process outcomes and eight experiential outcomes. Findings: On a scale of 0 to 1, the average overall management score in Ghana was 0·76 (IQR = 0·68–0·85). Facility management was significantly associated with one process outcome and three experiential outcomes. Controlling for facility characteristics, facilities with management scores at the 90th percentile (management score = 0·90) had 22% more essential drugs compared to facilities with management scores at the 10th percentile (0·60) (p = 0·002). Positive statistically non-significant associations were also seen with three additional process outcomes—integration of family planning services (p = 0·054), family planning types provided (p = 0·067), and essential equipment availability (p = 0·104). Compared to women who sought care at facilities with management scores at the 10th percentile, women who sought care at facilities at the 90th percentile reported 8% higher ratings of trust in providers (p = 0·028), 15% higher ratings of ease of following provider’s advice (p = 0·030), and 16% higher quality rating (p = 0·020). However, women who sought care in the 90th percentile facilities rated their waiting times as worse (22% lower, p = 0·039). Interpretation: Higher management scores were associated with higher scores for some process and experiential outcomes. Large variations in management performance indicate the need to strengthen management practices to help realize the full potential of PHC in improving health outcomes. [ABSTRACT FROM AUTHOR]

Health disparities research in low- and middle-income countries (LMICs) is hampered by the difficulty of measuring economic status in low-resource settings. We previously developed the EconomicClusters k-medoids clustering-based algorithm for defining population-specific economic models based on few Demographic and Health Surveys (DHS) assets. The algorithm previously defined a twenty-group economic model for Cameroon. The aims of this study are to optimize the functionality of our EconomicClusters algorithm and app based on collaborator feedback from early use of this twenty-group economic model, to test the validity of the model as a metric of economic status, and to assess the utility of the model in another LMIC context. We condense the twenty Cameroonian economic groups into fewer, ordinally-ranked, groups using agglomerative hierarchical clustering based on mean cluster child height-for-age Z-score (HAZ), women’s literacy score, and proportion of children who are deceased. We develop an EconomicClusters model for Ghana consisting of five economic groups and rank these groups based on the same three variables. The proportion of variance in women’s literacy score accounted for by the EconomicClusters model was 5–12% less than the proportion of variance accounted for by the DHS Wealth Index model. The proportion of the variance in child HAZ and proportion of children who are deceased accounted for by the EconomicClusters model was similar to (0.4–2.5% less than) the proportion of variance accounted for by the DHS Wealth Index model. The EconomicClusters model requires asking only five questions, as opposed to greater than twenty Wealth Index questions. The EconomicClusters algorithm and app could facilitate health disparities research in any country with DHS data by generating ordinally-ranked, population-specific economic models that perform nearly as well as the Wealth Index in evaluating variability in health and social outcomes based on wealth status but that are more feasible to assess in time-constrained settings. [ABSTRACT FROM AUTHOR]

Hypertension is a major cause of cardiovascular disease morbidity and mortality in Ghana. This study examines the prevalence, awareness, treatment and control of hypertension among Ghanaian aged 15–49 years. This cross-sectional study retrieved data from the 2014 Ghana Demographic and Health Survey (GDHS). The sample, comprising of 13,247 respondents aged 15–49 years, was analysed using descriptive statistics, Chi-Square tests, independent sample t-tests and binary logistic regressions. The overall prevalence of hypertension was 13.0% (12.1% for males and 13.4% for females). Among respondents who had hypertension, 45.6% were aware of their hypertension status; 40.5% were treating the condition while 23.8% had their blood pressure controlled (BP <140/90 mmHg). Socio-economic and demographic factors, health insurance coverage and recent visit to health facilities played significant roles in hypertension prevalence and awareness. While region of residence and health facility visits were predictors of hypertension treatment, age and region of residence predicted hypertension control in this population. This study suggests that in order to address the increasing burden of hypertension in Ghana, there should be an expansion of the National Health Insurance Scheme and development of measures to reduce health inequities. Also, some of the determining factors such as age, gender, marital status are similar to other cultures; therefore, existing interventions from those cultures could be adapted in addressing hypertension prevalence, awareness, treatment and control in Ghana. [ABSTRACT FROM AUTHOR]

This study’s objective is to provide an alternative explanation for the low enrolment in health insurance in Ghana by analysing differences in perceptions between the insured and uninsured of the non-technical quality of healthcare. It further explores the association between insurance status and perception of healthcare quality to ascertain whether insurance status matters in the perception of healthcare quality. Data from a survey of 1,903 households living in the catchment area of 64 health centres were used for the analysis. Two sample independent t-tests were employed to compare the average perceptions of the insured and uninsured on seven indicators of non-technical quality of healthcare. A generalised ordered logit regression, controlling for socio-economic characteristics and clustering at the health facility level, tested the association between insurance status and perceived quality of healthcare. The perceptions of the insured were found to be significantly more negative than the uninsured and those of the previously insured were significantly more negative than the never insured. Being insured was associated with a significantly lower perception of healthcare quality. Thus, once people are insured, they tend to perceive the quality of healthcare they receive as poor compared to those without insurance. This study demonstrated that health insurance status matters in the perceptions of healthcare quality. The findings also imply that perceptions of healthcare quality may be shaped by individual experiences at the health facilities, where the insured and uninsured may be treated differently. Health insurance then becomes less attractive due to the poor perception of the healthcare quality provided to individuals with insurance, resulting in low demand for health insurance in Ghana. Policy makers in Ghana should consider redesigning, reorganizing, and reengineering the National Healthcare Insurance Scheme to ensure the provision of better quality healthcare for both the insured and uninsured. [ABSTRACT FROM AUTHOR]

The author discusses the implementation of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) by the World Health Organization (WHO) that aim to eradicate the lymphatic filariasis (LF) in Ghana. Topics discussed include the effect of mass drug administration (MDA) in the immunoparasitological indicators, the use of albendazole (ALB) and ivermectin (IVM) as a treatment for lymphatic filariasis, and the challenges encountered while implementing the national program.

Background: Maternal and neonatal mortality indicators remain high in Ghana and other sub-Saharan African countries. Both maternal and neonatal health outcomes improve when skilled personnel provide delivery services within health facilities. Determinants of delivery location are crucial to promoting health facility deliveries, but little research has been done on this issue in Ghana. This study explored factors influencing delivery location in predominantly rural communities in Ghana. Methods: Data were collected from 1,500 women aged 15–49 years with live or stillbirths that occurred between January 2011 and April 2013. This was done within the three sites operating Health and Demographic Surveillance Systems, i.e., the Dodowa (Greater Accra Region), Kintampo (Brong Ahafo Region), and Navrongo (Upper-East Region) Health Research Centers in Ghana. Multivariable logistic regression was used to identify the determinants of delivery location, controlling for covariates that were statistically significant in univariable regression models. Results: Of 1,497 women included in the analysis, 75.6% of them selected health facilities as their delivery location. After adjusting for confounders, the following factors were associated with health facility delivery across all three sites: healthcare provider’s influence on deciding health facility delivery, (AOR = 13.47; 95% CI 5.96–30.48), place of residence (AOR = 4.49; 95% CI 1.14–17.68), possession of a valid health insurance card (AOR = 1.90; 95% CI 1.29–2.81), and socio-economic status measured by wealth quintiles (AOR = 2.83; 95% CI 1.43–5.60). Conclusion: In addition to known factors such as place of residence, socio-economic status, and possession of valid health insurance, this study identified one more factor associated with health facility delivery: healthcare provider’s influence. Ensuring care provider’s counseling of clients could improve the uptake of health facility delivery in rural communities in Ghana. [ABSTRACT FROM AUTHOR]