Jenna Dixon

Ghana's National Health Insurance Scheme: Helping the Poor or Leaving Them Behind?

We present findings on the determinants of enrolment for Ghanas 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.

National health insurance scheme enrolment and antenatal care among women in Ghana: is there any relationship?

The objective of this study was to examine whether enrolment in the National Health Insurance Scheme (NHIS) affects the likelihood and timing of utilising antenatal care among women in Ghana.

Can she make it? Transportation barriers to accessing maternal and child health care services in rural Ghana

BackgroundThe Ghana Community based Health Planning and Services (CHPS) strategy targets to bring health services to the doorsteps of clients in a manner that improves maternal and child health outcomes. In this strategy, referral is an important component but it is threatened in a rural context where transportation service is a problem. Few studies have examined perceptions of rural dwellers on transportation challenges in accessing maternal health care services within CHPS.MethodsUsing the political ecology of health framework, this paper investigates transportation barriers in health access in a rural context based on perceived cause, coping mechanisms and strategies for a sustainable transportation system. Eight (8) focus group discussions involving males (n = 40) and females (n = 45) in rural communities in a CHPS zone in the Upper West Region of Ghana were conducted between September and December 2013.ResultsLack of vehicular transport is suppressing the potential positive impact of CHPS on maternal and child health. Consistent neglect of road infrastructural development and endemic poverty in the study area makes provision of alternative transport services for health care difficult. As a result, pregnant women use risky methods such as bicycle/tricycle/motorbikes to access obstetric health care services, and some turn to traditional medicines and traditional birth attendants for maternal health care services.ConclusionThese findings underscore the need for policy to address rural transport problems in order to improve maternal health. Community based transport strategy with CHPS is proposed to improve adherence to referral and access to emergency obstetric services.

Ghana's National Health Insurance Scheme: a national level investigation of members' perceptions of service provision.

BackgroundGhana’s National Health Insurance Scheme (NHIS), established into law in 2003 and implemented in 2005 as a ‘pro-poor’ method of health financing, has made great progress in enrolling members of the general population. While many studies have focused on predictors of enrolment this study offers a novel analysis of NHIS members’ perceptions of service provision at the national level.MethodsUsing data from the 2008 Ghana Demographic Health Survey we analyzed the perceptions of service provision as indicated by members enrolled in the NHIS at the time of the survey (n = 3468; m = 1422; f = 2046). Ordinal Logistic Regression was applied to examine the relationship between perceptions of service provision and theoretically relevant socioeconomic and demographic variables.ResultsResults demonstrate that wealth, gender and ethnicity all play a role in influencing members’ perceptions of NHIS service provision, distinctive from its influence on enrolment. Notably, although wealth predicted enrolment in other studies, our study found that compared to the poorest men and uneducated women, wealthy men and educated women were less likely to perceive their service provision as better/same (more likely to report it was worse). Wealth was not an important factor for women, suggesting that household gender dynamics supersede household wealth status in influencing perceptions. As well, when compared to Akan women, women from all other ethnic groups were about half as likely to perceive the service provision to be better/same.ConclusionsFindings of this study suggest there is an important difference between originally enrolling in the NHIS because one believes it is potentially beneficial, and using the NHIS and perceiving it to be of benefit. We conclude that understanding the nature of this relationship is essential for Ghana’s NHIS to ensure its longevity and meet its pro-poor mandate. As national health insurance systems are a relatively new phenomenon in sub-Saharan Africa little is known about their long term viability; understanding user perceptions of service provision is an important piece of that puzzle.

Is dengue a disease of poverty? A systematic review.

Abstract Policy prescriptions for combating dengue fever tend to focus on addressing environmental and social conditions of poverty. However, while poverty has long been considered a determinant of dengue, the research evidence for such a relationship is not well established. Results of a systematic review of the research literature designed to identify and assess the current state of the empirical evidence for the dengue–poverty link reveal a mixed story. Of 260 peer-reviewed articles referencing dengue–poverty relationships, only 12 English-language studies empirically assessed these relationships. Our analysis covering various social and economic conditions of poverty showed no clear associations with dengue rates. While nine of the 12 studies demonstrated some positive associations between measures of dengue and poverty (measured inconsistently through income, education, structural housing condition, overcrowding, and socioeconomic status), nine also presented null results and five with negative results. Of the five studies relating to access to water and sanitation, four reported null associations. Income and physical housing conditions were more consistently correlated with dengue outcomes than other poverty indicators. The small size of this sample, and the heterogeneity of measures and scales used to capture conditions of poverty, make it difficult to assess the strength and consistency of associations between various poverty indicators and dengue outcomes. At present, the global body of eligible English-language peer-reviewed literature investigating dengue–poverty relationships is too small to support a definitive relationship. We conclude that more research, particularly using standardized measures of both outcomes and indicators, is needed to support evidence-informed policies and approaches.

Hepatitis B in Ghana's upper west region: a hidden epidemic in need of national policy attention.

Like many countries in Sub-Saharan Africa, Hepatitis B virus (HBV) is highly prevalent in Ghana. Using qualitative methods, this paper draws from the political ecology of health theoretical framework to examine perceptions and understandings of HBV in the Upper West Region of Ghana. The findings reveal that extremely low levels of knowledge and pervasive lay misconceptions about the disease within this geographic context are shaped by large scale structural influences. Furthermore, in this context there is essentially no access to HBV immunizations, testing or treatment services which reinforces potential routes for the spread of HBV. An explosive spread of HBV is brewing with the potential to diffuse across space and time while, within the institutional contexts, it is the HIV epidemic that is largely consuming both policy attention and intervention.

The National Health Insurance Scheme in Ghana's Upper West Region: a gendered perspective of insurance acquisition in a resource-poor setting.

Ghanas National Health Insurance Scheme (NHIS) was designed as a pro-poor strategy to create wider access to health care. While recent studies have shown that wealth is an important factor in enrolment in the scheme, there is little understanding of its interlinkages with the geographical divisions and deep-seated deprivation in the northern region. In response to the nexus of poverty, gender and access to health care, this research took place in Ghanas Upper West Region (UWR), one of the poorest regions and yet paradoxically touting the highest enrolment rates. Using data from a population survey (n = 2119) collected between May to December 2011, we used multinomial regression to examine factors that influence enrolment, controlling for theoretically relevant covariates. Findings reveal that although wealth and desire for health insurance are contributing factors, education was the primary determinant in both never enrolling and in dropping out, and that these factors impact men and women differently. The study also shows that Muslims were less likely to enrol and also women living in non-nuclear households were far more likely to dropout. Our results demonstrate clear gendered divisions in accessing the NHIS, and raised serious equity concerns in the UWR. By focussing on the context of the UWR, we show the importance of understanding intra-household bargaining and resource allocation via the gender dynamics related to health insurance procurement and maintenance, and discuss associated policy implications.

“I was on the way to the hospital but delivered in the bush”: Maternal health in Ghana's Upper West Region in the context of a traditional birth attendants' ban

This study examines perceptions and experiences of mothers, traditional birth attendants (TBA), and skilled birth attendants (SBA) regarding Ghanas recent policy that forbids TBAs from undertaking deliveries and restricts their role to referrals. In the larger context of Ghanas highly underdeveloped and geographically uneven health care system, this study draws on the political ecology of health framework to explore the ways global safe motherhood policy discourses intersect with local socio-cultural and political environments of Ghanas Upper West Region (UWR). This study reveals that futile improvements in maternal health and the continued reliance on TBAs illustrate the governments inability to understand local realities marked by poor access to SBAs or modern health care services. Using focus group discussions (FGDs) (n = 10) and in-depth interviews (IDIs) (n = 48) conducted in Ghanas UWR, the findings suggest that mothers generally perceive TBAs as better placed to conduct deliveries in rural isolated communities, where in most cases no SBAs are present or easily accessible. The results indicate that by adhering to the World Health Organizations guidelines, the local government may be imposing detrimental, unintended consequences on maternal and child health in remote rural locations. In addition, the findings suggest that the new policy has resulted in considerable confusion among TBAs, many of whom remain oblivious or have not been officially notified about the new policy. Furthermore, participant accounts suggest that the new policy is seen as contributing to worsening relations and tensions between TBAs and SBAs, a situation that undermines the delivery of maternal health services in the region. The study concludes by suggesting relevant policy recommendations.

Management challenges of urban biosolids: narratives around facility siting in rural Ontario

The emerging challenge of managing increasing volumes of urban sewage has resulted in municipalities pursuing sustainable ways to manage urban biosolids and their by-products. Using content analysis of public debates, and situating the debate within science, policy and facility siting literature, this study examines claims and counterclaims relating to the siting of a biosolid processing facility in rural Ontario. The equivocal evidence on the health and environmental effects of biosolids resulted in a heated “expert versus lay” debate. The study critically evaluates the importance of trust and the shifting role of scientific evidence in politicised settings, while making relevant policy recommendations.

Gendered Inequalities within Ghana's National Health Insurance Scheme: Are Poor Women Being Penalized with a Late Renewal Policy?

This article addresses the implications of the mandatory delay in coverage for individuals residing in the Upper West Region (UWR) of Ghana who have dropped out of the National Health Insurance Scheme (NHIS) but later attempt to reenroll. Using data collected in 2011 in Ghana’s UWR, we use a negative log-log model (n=1,584) to compare those who remain enrolled in the scheme with those who have dropped out. Women with unreliable incomes, who reported being food-insecure and those living with young children were more likely to drop out (OR range: 1.22–1.79, p<.05). Men, in contrast, were 50% more likely to drop out of the NHIS for being unsatisfied with services provided (OR range: 1.25–1.62, p<.01). Contrary to the original mandate of the NHIS, our study reveals clear gender differences in the factors contributing to dropouts, pointing to a bias in the impact of the block-out policy that is penalizing women for being poor.