Maternal health services utilisation among primigravidas in Uganda: what did the MDGs deliver?

BACKGROUND: Achieving maternal health outcomes in the SDGs requires the implementation of more targeted policies and strategies. While the MDGs may have deepened our understanding in this regard, we know little about the trends in maternal health services utilisation among primigravidas, and how age and geographical regions could have influenced these trends. In this study, we examined utilisation of antenatal and skilled delivery services among primigravidas in Uganda, a country with one of the highest maternal mortality ratios, and where early childbearing and its attendant challenges are common. METHODS: Guided by Andersen's Behavioural Model, we fitted multivariate regression models to a pooled dataset of the 2006, 2011 and 2016 Ugandan Demographic and Health Survey (n = 3477) to understand the dynamics in Antenatal Care (ANC) and Skilled Birth Attendance (SBAs) utilisation among primigravidas. Post-estimation margins were employed to further highlight the effect of age and geographical regions. RESULTS: The analyses show an improvement in access to maternal health services among primigravidas from 2006 to 2016. Compared to 2006, primigravidas in 2016 were 48%, 24% and 2.98 times more likely to have early ANC, four or more ANC visits, and SBAs, respectively. Altogether, a primigravida in 2016 relative to 2006 was 42% more likely to meet all three maternal health service indicators. Post-estimation margins analyses on age and geographical disparities revealed that younger primigravidas have lower probability, while primigravidas in Eastern Region, one of the most deprived in the country, have the lowest probability of accessing maternal health services. Also, the study found education, wealth, women's household decision-making power, place of residence as important determinants of ANC visits and SBAs. CONCLUSIONS: Based on our findings, it is important to address the vulnerabilities of primigravidas, particularly younger individuals, in accessing early ANC. Uganda should scale-up decentralisation and integration of maternal health delivery in local communities as a strategy of addressing lingering geographical disparities, and ultimately improve maternal health outcomes in the SDGs period.

Health insurance enrolment in the Upper West Region of Ghana: Does food security matter?

Toward achieving universal health coverage, Ghana's national health insurance has been acclaimed as a pro-poor scheme, yet been criticized for leaving the poor behind. Arising from this is how poverty has been operationalized and how poor people are targeted for enrolment into the scheme. We examine the role of food insecurity (not currently considered) as a multidimensional vulnerability concept on enrolment into Ghana's health insurance using binary logistics regression on cross-sectional survey of household heads (n = 1438) in the Upper West Region of Ghana. Our analyses show that heads of severely food-insecure households were significantly less likely to enroll in national health insurance scheme (NHIS) relative to households who reported being food-secure (OR = 0.36, P < .05). We also found education, occupation, and religion as significant predictors of health insurance enrolment. Based on our findings, it is crucial to incorporate food security status in the identification of vulnerable people for free enrolment in Ghana's health insurance.

Politics, economics, how about our health? Impacts of large-scale land acquisitions on therapeutic spaces and wellbeing in coastal Tanzania.

One question that has remained unexplored in the global land rush debate is how large-scale land acquisitions affect health and wellbeing of local populations. As part of a larger study, this study advances our understanding in this area by applying the concept of therapeutic landscapes to analyze interviews conducted in two coastal communities in Tanzania where land investments have been prevalent. Our analysis found that local populations perceived traditional lands with sacred sites as therapeutic spaces, which embodied cultural values, and promoted health and wellbeing when protected. Intrusion into these spaces through large-scale land investment is believed to remove their therapeutic attributes, thereby turning them into unhealthy landscapes. Dispossession of these spaces is perceived to heighten community distress resulting in poor psychosocial health. Based on our findings, we suggest that health consequences of land investments should move to the center of the large-scale land acquisition discourse. Health policy should refocus on the psychosocial health impacts of global land investments in Tanzania and other low-income countries. Ultimately local participation in land governance should be strengthened through land reforms in Tanzania and similar contexts, as this may provide a buffer to poor psychosocial health.

Factors associated with voluntary testing for HBV in the Upper West Region of Ghana.

This study examined the role of health facilities on testing for Hepatitis B virus in a policy context where screening is only available at a cost. We fitted multivariate multinomial logistic regression models to cross-sectional data (n = 1374) collected from Upper West Region of Ghana. The analysis showed that approximately 28% of respondents reported ever testing for HBV. Although source of healthcare influenced HBV testing, traders (RRR = 0.29, p ≤ 0.001) and farmers (RRR = 0.34, p ≤ 0.01) were significantly less likely to test voluntarily. Wealth generally predicted voluntary testing, although less so for mandatory testing. The findings highlight the need for free HBV services targeting the very poor, especially those who use community-level health facilities as their primary source of care.

Financial sustainability versus access and quality in a challenged health system: an examination of the capitation policy debate in Ghana.

Policy makers in low and middle-income countries are frequently confronted with challenges of increasing health access for poor populations in a sustainable manner. After several years of trying out different health financing mechanisms, health insurance has recently emerged as a pro-poor health financing policy. Capitation, a fixed fee periodically paid to health service providers for anticipated services, is one of the payment policies in health insurance. This article examines claims and counter-claims made by coalitions and individual stakeholders in a capitation payment policy debate within Ghana's National Health Insurance Scheme. Using content analysis of public and parliamentary proceedings, we situate the debate within policy making and health insurance literature. We found that the ongoing capitation payment debate stems from challenges in implementation of earlier health insurance claims payment systems, which reflect broader systemic challenges facing the health insurance scheme in Ghana. The study illustrates the extent to which various sub-systems in the policy debate advance arguments to legitimize their claims about the contested capitation payment system. In addition, we found that the health of poor communities, women and children are being used as surrogates for political and individual arguments in the policy debate. The article recommends a more holistic and participatory approach through persuasion and negotiation to join interests and core evidence together in the capitation policy making in Ghana and elsewhere with similar contexts.