Towards achievement of Sustainable Development Goal 3: multilevel analyses of demographic and health survey data on health insurance coverage and maternal healthcare utilisation in sub-Saharan Africa.

BACKGROUND: Improving maternal health and achieving universal health coverage (UHC) are important expectations in the global Sustainable Development Goals (SDGs) agenda. While health insurance has been shown as effective in the utilisation of maternal healthcare, there is a paucity of literature on this relationship in sub-Saharan Africa (SSA). We examined the relationship between health insurance coverage and maternal healthcare utilisation using demographic and health survey data. METHODS: This was a cross-sectional study of 195 651 women aged 15-49 y from 28 countries in SSA. We adopted bivariable and multivariable analyses comprising χ2 test and multilevel binary logistic regression in analysing the data. RESULTS: The prevalence of maternal healthcare utilisation was 58, 70.6 and 40.7% for antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC), respectively. The prevalence of health insurance coverage was 6.4%. Women covered by health insurance were more likely to utilise ANC (adjusted OR [aOR]=1.48, 95% CI 1.41 to 1.54), SBA (aOR=1.37, 95% CI 1.30 to 1.45) and PNC (aOR=1.42, 95% CI 1.37 to 1.48). CONCLUSION: Health insurance coverage was an important predictor of maternal healthcare utilisation in our study. To accelerate progress towards the achievement of SDG 3 targets related to the reduction of maternal mortality and achievement of UHC, countries should adopt interventions to increase maternal insurance coverage, which may lead to higher maternal healthcare access and utilisation during pregnancy.

COVID-19 and Health Systems Functioning in Sub-Saharan Africa Using the "WHO Building Blocks": The Challenges and Responses.

Sub-Saharan Africa (SSA) has made major progress in improving access to health care over the past three decades. Despite efforts made toward achieving universal health coverage, the health systems of countries in the sub-region are inundated by a myriad of challenges that have become more virulent amid the COVID-19 pandemic. This paper discusses the health systems challenges and responses in SSA amidst the COVID-19 using the World Health Organization's (WHO) building blocks of health systems functioning. Long-lasting abysmal health system financing and insufficient government investment in SSA pose major challenges to the effective health systems functioning amid the COVID-19 pandemic. This situation also makes it difficult for the health system to meet the demands of the COVID-19 pandemic and at the same time, cater for other essential health services. Countries in SSA must prioritize the reformation of their health systems through effective health system policy development and implementation, human resources development, training, service delivery, governance and regulation, and sustainable health financing.

Prevalence and factors associated with health insurance coverage in urban sub-Saharan Africa: Multilevel analyses of demographic and health survey data.

INTRODUCTION: With the vision of achieving Universal Health Coverage (UHC) by the year 2030, many sub-Saharan African (SSA) countries have implemented health insurance schemes that seek to improve access to healthcare for their populace. In this study, we examined the prevalence and factors associated with health insurance coverage in urban sub-Saharan Africa (SSA). MATERIALS AND METHODS: We used the most recent Demographic and Health Survey (DHS) data from 23 countries in SSA. We included 120,037 women and 54,254 men residing in urban centres in our analyses which were carried out using both bivariable and multivariable analyses. RESULTS: We found that the overall prevalence of health insurance coverage was 10.6% among females and 14% among males. The probability of being covered by health insurance increased by level of education. Men and women with higher education, for instance, had 7.61 times (95%CI = 6.50-8.90) and 7.44 times (95%CI = 6.77-8.17) higher odds of being covered by health insurance than those with no formal education. Males and females who read newspaper or magazine (Males: AOR = 1.47, 95%CI = 1.37-1.57; Females: AOR = 2.19, 95%CI = 1.31-3.66) listened to radio (Males: AOR = 1.29, 95%CI = 1.18-1.41; Females: AOR = 1.42, 95%CI = 1.35-1.51), and who watched television (Males: AOR = 1.80, 95%CI = 1.64-1.97; Females: AOR = 1.86, 95%CI = 1.75-1.99) at least once a week had higher odds of being covered by health insurance. CONCLUSION: The coverage of health insurance in SSA is generally low among urban dwellers. This has negative implications for the achievement of universal health coverage by the year 2030. We recommend increased public education on the benefits of being covered by health insurance using the mass media which we found to be an important factor associated with health insurance coverage. The focus of such mass media education could target the less educated urban dwellers, males in the lowest wealth quintile, and young adults (15-29 years).

Health insurance coverage and timely antenatal care attendance in sub-Saharan Africa.

INTRODUCTION: Out-of-pocket payments for healthcare remain a significant health financing challenge in sub-Saharan Africa (SSA), preventing women from using maternal health services. There is a paucity of empirical literature on the influence of health insurance coverage on the timeliness of antenatal care (ANC) attendance in low- and middle-income countries. In this study, we examined the association between health insurance coverage and timely ANC attendance among pregnant women in SSA. METHODS: Secondary data from Demographic and Health Surveys conducted between 2015 and 2020 in sixteen (16) sub-Saharan African countries with 113,918 women aged 15-49 years were included in the analysis. The outcome variable was the timing of antenatal care (ANC). A multilevel binary logistic regression analysis was carried out to determine the association between health insurance coverage and timely ANC. RESULTS: The overall coverage of health insurance and timely antenatal attendance among pregnant women in SSA were 4.4% and 39.0% respectively. At the country level, the highest coverage of health insurance was found in Burundi (24.3%) and the lowest was in Benin (0.9%). For timely ANC attendance, the highest prevalence was in Liberia (72.4%) and the lowest was in Nigeria (24.2%). The results in the model showed that women who were covered by health insurance were more likely to have timely ANC attendance compared to those who were not covered by health insurance (aOR = 1.21, 95% CI = 1.11-1.31). CONCLUSION: Our findings show that that being covered under health insurance is associated with higher likelihood of seeking timely ANC attendance. To accelerate progress towards achievement of the Sustainable Development Goal targets by the year 2030, we recommend that governments and health insurance authorities across the sub-Saharan African countries actively implement health insurance policies as well as roll out health educational programmes that facilitate and ensure increased coverage of health insurance.

Fostering research integrity in sub-Saharan Africa: challenges, opportunities, and recommendations.

Integrity and adherence to appropriate ethical standards are important elements of research. These standards are key to protecting research participants´ rights as well as ensuring the reliability and quality of research outputs. Although empirical evidence is scanty, several authors have alluded to the fact that violation of research integrity standards could be common in low- and middle-income countries including sub-Saharan Africa (SSA). Understanding the issues, challenges, and opportunities of research integrity and ethics in SSA is key to promoting the responsible conduct of research and the protection of research participants. This paper presents the authors´ critical views and recommendations on the current state of research integrity in SSA. We argue that understanding the current research integrity architecture in SSA has the potential to identify opportunities to promote responsible conduct of research in SSA. Such opportunities include, but are not limited to transparency, accountability, and reproducibility of research, which collectively lead to enhanced public trust in the research enterprise. We highlight the need to embrace equity, fairness, diversity, and inclusivity in the research cycle from conception (priority setting), funding, implementation, dissemination of findings, and scale up. We move on to provide a rationale for understanding the differences and similarities between research ethics and research integrity. Governments, research, and academic institutions must develop multifaceted approaches to promote compliance with principles of research integrity by developing and implementing clear research integrity policies and guidelines that foster responsible conduct of research and prioritize capacity building and empowerment of early career researchers, students, and other targeted key stakeholders.

Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life Years for 29 Cancer Groups From 2010 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019.

IMPORTANCE: The Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) provided systematic estimates of incidence, morbidity, and mortality to inform local and international efforts toward reducing cancer burden. OBJECTIVE: To estimate cancer burden and trends globally for 204 countries and territories and by Sociodemographic Index (SDI) quintiles from 2010 to 2019. EVIDENCE REVIEW: The GBD 2019 estimation methods were used to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) in 2019 and over the past decade. Estimates are also provided by quintiles of the SDI, a composite measure of educational attainment, income per capita, and total fertility rate for those younger than 25 years. Estimates include 95% uncertainty intervals (UIs). FINDINGS: In 2019, there were an estimated 23.6 million (95% UI, 22.2-24.9 million) new cancer cases (17.2 million when excluding nonmelanoma skin cancer) and 10.0 million (95% UI, 9.36-10.6 million) cancer deaths globally, with an estimated 250 million (235-264 million) DALYs due to cancer. Since 2010, these represented a 26.3% (95% UI, 20.3%-32.3%) increase in new cases, a 20.9% (95% UI, 14.2%-27.6%) increase in deaths, and a 16.0% (95% UI, 9.3%-22.8%) increase in DALYs. Among 22 groups of diseases and injuries in the GBD 2019 study, cancer was second only to cardiovascular diseases for the number of deaths, years of life lost, and DALYs globally in 2019. Cancer burden differed across SDI quintiles. The proportion of years lived with disability that contributed to DALYs increased with SDI, ranging from 1.4% (1.1%-1.8%) in the low SDI quintile to 5.7% (4.2%-7.1%) in the high SDI quintile. While the high SDI quintile had the highest number of new cases in 2019, the middle SDI quintile had the highest number of cancer deaths and DALYs. From 2010 to 2019, the largest percentage increase in the numbers of cases and deaths occurred in the low and low-middle SDI quintiles. CONCLUSIONS AND RELEVANCE: The results of this systematic analysis suggest that the global burden of cancer is substantial and growing, with burden differing by SDI. These results provide comprehensive and comparable estimates that can potentially inform efforts toward equitable cancer control around the world.

Breastfeeding and weaning practices among mothers in Ghana: A population-based cross-sectional study.

BACKGROUND: Children need good nutrition to develop proper immune mechanisms and psychosocial maturity, but malnutrition can affect their ability to realize this. Apart from the national demographic and health survey, which is carried out every 5 years, there have not been enough documented studies on child breastfeeding and weaning practices of caregivers in the Volta Region. We, therefore, examined child breastfeeding and weaning practices of mothers in the Volta Region of Ghana. METHODS: A sub-national survey method was adopted and a semi-structured questionnaire was used to collect data from 396 mothers and their children. Descriptive and inferential statistics comprising frequency, percentage, chi-square, and logistic regression were employed in analysing the data. We defined exclusive breastfeeding as given only breast milk to an infant from a mother or a wet nurse for six months of life except drops or syrups consisting of vitamins, minerals, supplements, or medicines on medical advice, and prolonged breastfeeding as breastfeeding up to 24 months of age. RESULTS: The prevalence of exclusive breastfeeding (EBF) was 43.7%. Mothers constituting 61.1% started breastfeeding within an hour of giving birth. In addition to breast milk, 5.1% gave fluids to their children on the first day of birth. About 66.4% started complementary feeding at 6 months, 22.0% breastfed for 24 months or beyond, while 40.4% fed their children on-demand. Child's age (AOR: 0.23, 95% CI:0.12-0.43, p<0.0001), prolonged breastfeeding (AOR: 0.41, 95%CI: 0.12-0.87, p = 0.001), mother's religion (AOR: 3.92, 95%CI: 1.23-12.61, p = 0.021), feeding practices counselled on (AOR: 1.72, 95%CI: 1.96-3.09, p = 0.023), mother ever heard about EBF (AOR: 0.43, 95%CI: 1.45-2.41, p = 0.039), child being fed from the bottle with a nipple (AOR: 1.53, 95%CI: 1.94-2.48, p = 0.003), and age at which complementary feeding was started (AOR: 17.43, 95%CI: 3.47-87.55, p = 0.008) were statistically associated with EBF. CONCLUSION: Breastfeeding education has been ongoing for decades, yet there are still gaps in the breastfeeding practices of mothers. To accelerate progress towards attainment of the sustainable development goal 3 of ensuring healthy lives and promoting well-being for all at all ages by the year 2030, we recommend innovative policies that include extensive public education to improve upon the breastfeeding and weaning practices of mothers.

Prevalence and predictors of depression, anxiety, and stress among adults in Ghana: A community-based cross-sectional study.

INTRODUCTION: Over the past two decades, there have been several global interventions including the Sustainable Development Goals (SDGs), aimed at improving health outcomes. Despite efforts by countries to achieve the SDG targets, mental health challenges remain major public health concerns globally. We examined the prevalence and predictors of depression, anxiety, and stress as well as the comorbidities of these mental health issues among adults. MATERIALS AND METHODS: This was a community-based cross-sectional study conducted among 2456 adults in four districts of the Volta Region of Ghana using data from the UHAS-Yonsei University Partnership Project. We analysed the data using frequency, percentage, mean, standard deviation, correlation, and binary logistic regression. RESULTS: Overall, 51.8% of the participants had at least one of the mental health issues examined. The prevalence of a mental health issue was 25.2%, 53.3%, and 9.7% for depression, anxiety, and stress respectively. Participants constituting 8.3% experienced all three mental health issues as comorbidities. Participants' level of formal education and income significantly predicted depression, anxiety, and stress respectively at the multivariable level. Adults with a tertiary level of education were, for instance, 68% (AOR = 0.32, 95%CI = 0.15-0.66), 65% (AOR = 0.35, 95%CI = 0.17-0.73), and 50% (AOR = 0.50, 95%CI = 0.33-0.76) less likely to experience depression, anxiety, and stress, respectively compared with those who had no formal education. CONCLUSION: The majority of our study participants either experienced depression, anxiety, or stress. There were quite high comorbidities of the mental health issues among the adult population. To accelerate progress towards the achievement of SDG 3.4 target of promoting mental health and wellbeing for all by the year 2030, there is a need for effective implementation of the country's 2012 Mental Health Act which makes provisions for the establishment of a Mental Health Fund. This could improve the financial circumstances of indigenes as income has been realised in the present study as an important factor influencing depression, anxiety, and stress among the adult population.

Management of chronic non-communicable diseases in Ghana: a qualitative study using the chronic care model.

BACKGROUND: While the burden and mortality from chronic non-communicable diseases (CNCDs) have reached epidemic proportions in sub-Saharan Africa (SSA), decision-makers and individuals still consider CNCDs to be infrequent and, therefore, do not pay the needed attention to their management. We, therefore, explored the practices and challenges associated with the management of CNCDs by patients and health professionals. METHODS: This was a qualitative study among 82 CNCD patients and 30 health professionals. Face-to-face in-depth interviews were used in collecting data from the participants. Data collected were analysed using thematic analysis. RESULTS: Experiences of health professionals regarding CNCD management practices involved general assessments such as education of patients, and specific practices based on type and stage of CNCDs presented. Patients' experiences mainly centred on self-management practices which comprised self-restrictions, exercise, and the use of anthropometric equipment to monitor health status at home. Inadequate logistics, work-related stress due to heavy workload, poor utility supply, and financial incapability of patients to afford the cost of managing their conditions were challenges that militated against the effective management of CNCDs. CONCLUSIONS: A myriad of challenges inhibits the effective management of CNCDs. To accelerate progress towards meeting the Sustainable Development Goal 3 on reducing premature mortality from CNCDs, the Ghana Health Service and management of the respective hospitals should ensure improved utility supply, adequate staff motivation, and regular in-service training. A chronic care management policy should also be implemented in addition to the review of the country's National Health Insurance Scheme (NHIS) by the Ministry of Health and the National Health Insurance Authority to cover the management of all CNCDs.

Health knowledge and care seeking behaviour in resource-limited settings amidst the COVID-19 pandemic: A qualitative study in Ghana.

BACKGROUND: The emergence of a pandemic presents challenges and opportunities for healthcare, health promotion interventions, and overall improvement in healthcare seeking behaviour. This study explored the impact of COVID-19 on health knowledge, lifestyle, and healthcare seeking behaviour among residents of a resource-limited setting in Ghana. METHODS: This qualitative study adopted an exploratory design to collect data from 20 adult residents in the Cape Coast Metropolis using face-to-face in-depth interviews. Data collected were analysed thematically and statements from participants presented verbatim to illustrate the themes realised. RESULTS: Health knowledge has improved due to COVID-19 in terms of access to health information and increased understanding of health issues. There were reductions in risky health-related lifestyles (alcohol intake, sharing of personal items, and consumption of junk foods) while improvements were observed in healthy lifestyles such as regular physical exercise and increased consumption of fruits and vegetables. COVID-19 also positively impacted health seeking behaviour through increased health consciousness and regular check-ups. However, reduced healthcare utilization was prevalent. CONCLUSION: The COVID-19 pandemic has presented a positive cue to action and helped improved health knowledge, lifestyle, and care seeking behaviour although existing health system constrains and low economic status reduced healthcare utilization. To improve health systems, health-related lifestyles and healthcare seeking behaviour as well as overall health outcomes even after the pandemic wades off, COVID-19 associated conscious and unconscious reforms should be systematically harnessed.

Mixed effects analysis of factors associated with health insurance coverage among women in sub-Saharan Africa.

INTRODUCTION: In the pursuit of achieving the Sustainable Development Goal targets of universal health coverage and reducing maternal mortality, many countries in sub-Saharan Africa have implemented health insurance policies over the last two decades. Given that there is a paucity of empirical literature at the sub-regional level, we examined the prevalence and factors associated with health insurance coverage among women in in sub-Saharan Africa. MATERIALS AND METHODS: We analysed cross-sectional data of 307,611 reproductive-aged women from the most recent demographic and health surveys of 24 sub-Saharan African countries. Bivariable and multivariable analyses were performed using chi-square test of independence and multi-level logistic regression respectively. Results are presented as adjusted Odds Ratios (aOR) for the multilevel logistic regression analysis. Statistical significance was set at p<0.05. RESULTS: The overall coverage of health insurance was 8.5%, with cross-country variations. The lowest coverage was recorded in Chad (0.9%) and the highest in Ghana (62.4%). Individual-level factors significantly associated with health insurance coverage included age, place of residence, level of formal education, frequency of reading newspaper/magazine and watching television. Wealth status and place of residence were the contextual factors significantly associated with health insurance coverage. Women with no formal education were 78% less likely to be covered by health insurance (aOR = 0.22, 95% CI = 0.21-0.24), compared with those who had higher education. Urban women, however, had higher odds of being covered by health insurance, compared with those in the rural areas [aOR = 1.20, 95%CI = 1.15-1.25]. CONCLUSION: We found an overall relatively low prevalence of health insurance coverage among women of reproductive age in sub-Saharan Africa. As sub-Saharan African countries work toward achieving the Sustainable Development Goal targets of universal health coverage and lowering maternal mortality to less than 70 deaths per 100,000 live births, it is important that countries with low coverage of health insurance among women of reproductive age integrate measures such as free maternal healthcare into their respective development plans. Interventions aimed at expanding health insurance coverage should be directed at younger women of reproductive age, rural women, and women who do not read newspapers/magazines or watch television.

Community utilisation and satisfaction with the community-based health planning and services initiative in Ghana: a comparative study in two system learning districts of the CHPS+ project.

BACKGROUND: To strengthen the implementation of the Community-based Health Planning and Services (CHPS) programme which is Ghana's key primary health care delivery strategy, the CHPS+ Project was initiated in 2017. We examined community utilisation and satisfaction with CHPS services in two System Learning Districts (SLDs) of the project. METHODS: This community-based descriptive study was conducted in the Nkwanta South Municipality and Central Tongu District of Ghana. Data were collected from 1008 adults and analysed using frequency, percentage, chi-square, and logistic regression models. RESULTS: While the level of utilisation of CHPS services was 65.2%, satisfaction was 46.1%. Utilisation was 76.7% in Nkwanta South and 53.8% in Central Tongu. Satisfaction was also 55.2% in Nkwanta South and 37.1% in Central Tongu. Community members in Nkwanta South were more likely to utilise (AOR = 3.17, 95%CI = 3.98-9.76) and be satisfied (AOR = 2.77, 95%CI = 1.56-4.90) with CHPS services than those in Central Tongu. Females were more likely to utilise (AOR = 1.75, 95%CI = 1.27-2.39) but less likely to be satisfied [AOR = 0.47, 95%CI = 0.25-0.90] with CHPS services than males. Even though subscription to the National Health Insurance Scheme (NHIS) was just 46.3%, NHIS subscribers were more likely to utilise (AOR = 1.51, 95%CI = 1.22-2.03) and be satisfied (AOR = 1.45, 95%CI = 0.53-1.68) with CHPS services than non-subscribers. CONCLUSION: Ghana may not be able to achieve the goal of universal health coverage (UHC) by the year 2030 if current levels of utilisation and satisfaction with CHPS services persist. To accelerate progress towards the achievement of UHC with CHPS as the vehicle through which primary health care is delivered, there should be increased public education by the Ghana Health Service (GHS) on the CHPS concept to increase utilisation. Service quality should also be improved by the GHS and other stakeholders in Ghana's health industry to increase satisfaction with CHPS services. The GHS and the National Health Insurance Authority (NHIA) should also institute innovative strategies to increase subscription to the NHIS since it has implications for CHPS service utilisation and satisfaction.

Community-Based Health Planning and Services Plus programme in Ghana: A qualitative study with stakeholders in two Systems Learning Districts on improving the implementation of primary health care.

BACKGROUND: In 1999, Ghana introduced the Community-Based Health Planning and Services (CHPS) as the key primary health care strategy. In this study, we explored the challenges, capacity development priorities, and stakeholder perspectives on improving the CHPS concept as it has been fraught with a myriad of challenges since its inception. Our study is the outcome of the national programme for strengthening the implementation of CHPS Initiative in Ghana (CHPS+) introduced in 2017. METHODS: This exploratory research was a qualitative study conducted in two Systems Learning Districts (SLDs) of CHPS+ in the Volta Region of Ghana from March to May, 2018. Four focus group discussions and two general discussions were conducted among 60 CHPS+ stakeholders made up of health workers and community members. Data analyses were conducted using conceptual content analysis. Statements of the participants were presented as quotes to substantiate the views expressed. RESULTS: Negative attitude, high attrition, inadequacy and unavailability of health professionals at post when needed were challenges associated with the health professionals. Late referrals, lack of proper community entry and engagement, non-availability of essential logistics, distance of CHPS compounds from communities, and inadequate funding were challenges associated with the health system. Lack of community ownership of the CHPS programme, lack of security at CHPS compounds, and late reporting of cases by the community members were also realised as challenges emanating from the community members. Priority areas for capacity development of health workers identified included logistics management, community entry and engagement, emergency delivery, managing referrals at the CHPS level, and resuscitation of newborns. CONCLUSION: Health-worker, community, and health systems-based challenges inhibit the implementation of CHPS in Ghana. Capacity development of health professionals and continuous community engagement are avenues that can improve implementation of the programme.

Implications of COVID-19 for the management of chronic non-communicable diseases in sub-Saharan Africa: application of the chronic care model.

About 41 million people die of chronic non-communicable diseases (CNCDs) each year, accounting for 71% of all global deaths. The high prevalence of CNCDs is particularly problematic for sub-Saharan Africa (SSA) since CNCDs are already a major cause of mortality in the sub-region. While the case fatality rate of COVID-19 is quite low, it is worth noting that people with underlying CNCDs constitute the majority of those who die from this virus. Underpinned by the chronic care model (CCM), we present a commentary on the implications of COVID-19 for the management of CNCDs in SSA. We realized that despite the World Health Organisation's guidelines for countries to maintain essential services while putting necessary measures in place to prevent and control the spread of COVID-19, myriad of health systems and community-level factors militate against effective management of the CNCDs in SSA. This results in disruptions in management of the conditions as well as possible long-term effects such as the deterioration of the health status of CNCD patients and even deaths. Without immediate interventions to salvage the status quo, SSA countries may not be able to achieve the Sustainable Development Goal 3.4 target of reducing by one-third, premature mortality from CNCDs by the year 2030. We recommend that financial constraints could be ameliorated through short- and long-term loan facilities from the International Monetary Fund and the World Bank to augment national efforts at strengthening health systems while combating COVID-19. We also recommend increased community engagement and public education by COVID-19 response teams to enhance community support for persons living with CNCDs and to reduce social stigmatization.

Understanding the Socio-demographic Factors Surrounding Young Peoples' Risky Sexual Behaviour in Ghana and Kenya.

Globally, young people in sub-Saharan Africa continue to be the population at the greatest risk for sexually transmitted infections (STIs) such as HIV and AIDS, Syphilis, and Gonorrhoea. Research has shown significant relationship between young peoples risky sexual behaviours and their vulnerability to these STIs. The study examined risky sexual behaviours among the youth in Ghana and Kenya in relation to socio-demographic characteristics. The paper uses data from the 2014 Demographic and Health Surveys of Ghana and Kenya. Young people between the ages of 15 to 24 years who were not married or living with a man/woman were included in the study. They comprised 2545 females and 1437 males from Ghana and 3546 females and 4317 males from Kenya. Descriptive analyses and binary logistic regression estimation technique were used to analyse the data. While awareness of AIDS was universal among the youth of both countries, utilisation of condoms on last penetrative sex was low. Risky sexual behaviour among young people was significantly associated with age, level of education, wealth status and religion. Among males and females in Ghana, the odds of sexual risk taking behaviour were higher among those who were employed than those who were unemployed. The reverse of this, however, occurred in Kenya, where males and females who were employed were less likely to engage in risky sexual behaviours than their counterparts who were unemployed. Our findings underscore the need for the relevant stakeholders in the two countries; Ministries of Health, Ghana/KenyaHealth Service, and NGOs concerned with sexual and reproductive health of young people, to intensify education on consistent and proper use of condoms and, position condom use as an acceptable behaviour especially among young people who are sexually active; with multiple partners and who may have STIs. Health literacy, which is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions, should be given priority. The governments of the two countries, especially Kenya, should promote youth entrepreneurship to reduce unemployment and strengthen job creation as a way of ensuring that young people engage on productive economic activities. With productive economic activities, females for instance may not have to engage in transactional multiple sexual relationships which is risky and, therefore, predisposes them to STIs such as gonorrhoea and HIV.

Understanding variations in health insurance coverage in Ghana, Kenya, Nigeria, and Tanzania: Evidence from demographic and health surveys.

BACKGROUND: Realisation of universal health coverage is not possible without health financing systems that ensure financial risk protection. To ensure this, some African countries have instituted health insurance schemes as venues for ensuring universal access to health care for their populace. In this paper, we examined variations in health insurance coverage in Ghana, Kenya, Nigeria, and Tanzania. METHODS: We used data from demographic and health surveys of Ghana (2014), Kenya (2014), Nigeria (2013), and Tanzania (2015). Women aged 15-49 and men aged 15-59 years were included in the study. Our study population comprised 9,378 women and 4,371 men from Ghana, 14,656 women and 12,712 men from Kenya, 38,598 women and 17,185 men from Nigeria, and 10,123 women and 2,514 men from Tanzania. Bivariate and multivariate techniques were used to analyse the data. RESULTS: Coverage was highest in Ghana (Females = 62.4%, Males = 49.1%) and lowest in Nigeria (Females = 1.1%, Males = 3.1%). Age, level of education, residence, wealth status, and occupation were the socio-economic factors influencing variations in health insurance coverage. CONCLUSIONS: There are variations in health insurance coverage in Ghana, Kenya, Nigeria, and Tanzania, with Ghana recording the highest coverage. Kenya, Tanzania, and Nigeria may not be able to achieve universal health coverage and meet the sustainable development goals on health by the year 2030 if the current fragmented public health insurance systems persist in those countries. Therefore, the various schemes of these countries should be harmonised to help maximise the size of their risk pools and increase the confidence of potential subscribers in the systems, which may encourage them to enrol.

Barriers and motivations for health insurance subscription in Cape Coast, Ghana: a qualitative study.

BACKGROUND: One of the main objectives of the Ghana National Health Insurance Scheme, at its establishment in 2003, was to ease financial burden of the full cost recovery policy, particularly on the poor. However, currently, majority of the scheme's subscribers are individuals in the upper wealth quintile, as the poor in society rather have not subscribed. We explored the motivational factors as well as the barriers to health insurance subscription in the Cape Coast Metropolis of Ghana. METHODS: This study collected qualitative data from 30 purposively selected subscribers and non-subscribers to the National Health Insurance Scheme using an in-depth interview guide. RESULTS: Major motivational factors identified were; affordable health insurance premium, access to free drugs, and social security against unforeseen health challenges. Encouragement by friends, family members, and colleagues, was also found to motivate subscription to the health insurance. The major barriers to health insurance subscription included; long queues and waiting time, perceived poor quality of drugs, and negative attitude of service providers both at the healthcare facilities and the health insurance office. The study underscores the need for the National Health Insurance Authority to conduct intensive education to change the negative perception people have regarding the quality of health insurance drugs. Efforts should also be made to reduce the waiting time in accessing healthcare with the National Health Insurance Scheme card. This would motivate more people to subscribe or renew their membership. CONCLUSIONS: The implication of barriers found is that people may not subscribe to the scheme in subsequent years. This would, therefore, consequently defeat the objective of achieving universal healthcare coverage with the scheme.