Economic inequalities in health insurance subscription renewal: Evidence from Ghana's National Health Insurance Scheme.

Ghana's national health insurance scheme (NHIS) is considered a major step towards achieving Universal Health Coverage (UHC) in the country. However, over the years the scheme has faced challenges, including subscription non-renewal, that threaten its sustenance. In this study, we estimate and analyse the nature of economic inequalities in NHIS subscription renewal and determine factors that contribute to the observed inequality. Data from the seventh round of the Ghana Living Standard Survey (GLSS) was used for the study. A sample of 40,170 ever insured individuals was included in the analysis comprising 18,066 males and 22,104 females. We computed concentration indices (CIs) and used linear regression techniques to decompose the CIs. The results show that NHIS renewal is pro-rich [CI = 0.126; P < 0.01] and favored males [CI = 0.110; P < 0.01] and urban dwellers [CI = 0.066; p < 0.01]. Major contributors to the observed inequality in subscription renewal include premium and processing fees payment, access to information, and economic wellbeing. The observed rural-urban and male-female differences in subscription renewal were explained by differences in premium and processing fee payments, education outcomes, employment status and access to information. The findings suggest that interventions that reduce cost barriers to NHIS subscription for the poor, improve physical access to healthcare and improve sensitization efforts should be encouraged.

Billing the Insured: An Assessment of Out-of-Pocket Payment by Insured Patients in Ghana.

Background: The Ghana National Health Insurance Scheme was introduced in 2003 to provide financial protection to the population. While the Scheme has made strides in improving access to healthcare there have been a few challenges including out of pocket charges to insured patients with weak client power. The study investigated the catastrophic nature of the out-of-pocket charges, the factors affecting the charges and the client power. Methodology: We used primary data collected in 3 administrative regions: Greater Accra, Ashanti and the Northern regions, within the period April and June 2022 to compute catastrophic expenditure of the out-of-pocket healthcare expenditure on household expenditure on food and non-food. In addition, multivariate logistic regressions and a linear regression were run to examine the incidence of the practice and client power. Results: The results showed that on average the insured paid out-of-pocket charges with a probability of 66%. The probability was highest (80%) in the Greater Accra, followed by Ashanti region (66.6%) and (52.9%) in the Northern region. The out-of-pocket charges were found to be catastrophic with incidence rate between 48.2% and 26.1% for the 5% and 20% thresholds; the overshoots ranged between 34.1% and 26.9% for the thresholds; the poor were more disadvantaged than the rich. Patients reported the out-of-pocket charges to the NHIA with probability of 1.9%, but the NHIA did not respond to 81% of the reported cases. Knowledge of the benefit list is likely to motivate the insured to report out-of-pocket charges, while cordial relationship between the NHIA staff and the insured deters providers from charging out-of-pocket. Conclusion: The out-of-pocket charges occur extensively across health facilities and is impoverishing. A close collaboration between the NHIA and the insured is needed to reduce the incidence and hold providers accountable.

Effects of public and external health spending on out-of-pocket payments for healthcare in sub-Saharan Africa.

Financing healthcare in sub-Saharan Africa (SSA) is characterized by high levels of out-of-pocket (OOP) payments for healthcare. This renders many individuals vulnerable to poverty and deviates from the Universal Health Coverage (UHC) goal of providing financial protection for healthcare. We examined the relative effects of public and external health spending on OOP healthcare payments in SSA. We used the system generalized method of moments (GMM) estimator and data from the World Bank's World Development Indicators for 43 SSA countries from 2000 to 2017. The results show that reductions in OOP payments are higher with increases in public spending than external spending. This means increases in public health spending, compared with external health spending, will increase the pace towards achieving the financial protection goal of UHC in SSA. But since government spending is limited by fiscal space and parliamentary approval, public health spending through social health insurance might provide a regular means of financing healthcare to speed up achieving the financial protection goal in SSA countries.

Strategic Health Purchasing Progress Mapping: A Spotlight on Ghana's National Health Insurance Scheme.

Ghana is a lower-middle-income economy that has made significant efforts to improve its health system, in order to achieve universal health coverage. Ghana has adopted strategic health purchasing as an important tool for efficient utilization of resources. This paper focuses on Ghana's National Health Insurance Scheme (NHIS) analyzing its governance arrangements and purchasing functions; and providing recommendations for improvement. The study applied the Strategic Health Purchasing Progress Tracking Framework co-created by the Strategic Purchasing Africa Resource Center (SPARC) and its partners to collect data from secondary and primary sources between September 2019 and June 2020. A descriptive and narrative approach was used to synthesize information on the NHIS governance arrangements and purchasing functions based on the framework. Benchmarks were used to describe the NHIS on the continuum from passive to strategic purchasing and to identify steps to make purchasing more strategic. Strengths and weaknesses were found in governance and purchasing functions. Progress was seen in how the NHIS selects the services in the benefit package, regularly reviewing the package to respond to the health needs of the population, and in how it selectively contracts with providers, particularly private providers, to ensure that standards for quality of care are met. However, challenges remain in performance monitoring, due to claims being mostly processed manually, and provider payment, due to frequent unbundling and upcoding of services Ghana has made significant strides toward the achievement of universal health coverage, but there is room for improvement in provider payment and performance monitoring.

Political economy and the pursuit of universal health coverage in Ghana: a case study of the National Health Insurance Scheme.

The road to universal health coverage depends on resources committed to the health sector. In many cases, the political structure and strength of advocacy play an important role in setting budgets for health. However, this has, until recently, not been of interest to health system researchers and policymakers. In this study, we document the political path to the establishment of the Ghana National Health Insurance Scheme (NHIS) as well as continuous political interest in the scheme. To achieve our objectives, we used qualitative data from interviews with key stakeholders. These include stakeholders instrumental in the design and establishment of the NHIS. We also reviewed party manifestoes from the two main political parties in the country. Promises relating to the NHIS were extracted from the various manifestos and analysed. Other documents that account for the design and implementation of the scheme were reviewed. We found that the establishment of the NHIS was down to political commitment and effective engagement with relevant stakeholders. It was considered a solution to the political promise to remove user fees and make healthcare accessible to all. A review of the manifestos shows that in almost every election year after the NHIS was established, there has been some promise related to improving the scheme. There were several policy propositions repeated in different election years. The findings imply that advocacy to get health financing on the political agenda is crucial. This should start from the development of party manifestos. It is important to also ensure that proposed party policies are consistent with national priorities in the medium to long term.

COVID-19 in sub-Saharan Africa: impacts on vulnerable populations and sustaining home-grown solutions.

This commentary draws on sub-Saharan African health researchers' accounts of their countries' responses to control the spread of COVID-19, including social and health impacts, home-grown solutions, and gaps in knowledge. Limited human and material resources for infection control and lack of understanding or appreciation by the government of the realities of vulnerable populations have contributed to failed interventions to curb transmission, and further deepened inequalities. Some governments have adapted or limited lockdowns due to the negative impacts on livelihoods and taken specific measures to minimize the impact on the most vulnerable citizens. However, these measures may not reach the majority of the poor. Yet, African countries' responses to COVID-19 have also included a range of innovations, including diversification of local businesses to produce personal protective equipment, disinfectants, test kits, etc., which may expand domestic manufacturing capabilities and deepen self-reliance. African and high-income governments, donors, non-governmental organizations, and businesses should work to strengthen existing health system capacity and back African-led business. Social scientific understandings of public perceptions, their interactions with COVID-19 control measures, and studies on promising clinical interventions are needed. However, a decolonizing response to COVID-19 must include explicit and meaningful commitments to sharing the power-the authority and resources-to study and endorse solutions.

An Assessment of Domestic Financing for Reproductive, Maternal, Neonatal and Child Health in Sub-Saharan Africa: Potential Gains and Fiscal Space.

BACKGROUND: Reproductive, maternal, neonatal and child health (RMNCH) remains an important public health objective. In sub-Saharan Africa (SSA), inadequate financial commitment continues to pose a major challenge to improving RMNCH outcomes. Understanding financing gains and potential fiscal space for RMNCH can therefore not be overemphasized. OBJECTIVE: This study sought to analyse the potential gains from increased domestic financing as a source for improving RMNCH outcomes in SSA. We also assessed, in addition to the potential gains, the potential fiscal space available for financing RMNCH in SSA. METHODS: Our study used panel econometric techniques to estimate gains from increased health financing in terms of RMNCH. We also reviewed tax system performance as well as debt sustainability to identify fiscal space potentials across countries. RESULTS: We found significant gains from both domestic and external financing. The estimated elasticities suggest that the gains from domestic public financing were much stronger. The fiscal space options identified include tax revenue performance improvements, improved public financial management, and borrowing, at least in the short to medium term. The results show that fiscal space from improved tax systems ranged from US$34.6 per capita in Uganda to US$310.6 per capita in Nigeria. CONCLUSION: This result reinforces calls for increased domestic financing for health through innovations in domestic resource mobilization. Improving the performance of tax systems will be a step in the right direction, with possible long-term gains to the health sector.

Oral melanomas in HIV-positive patients: Report of two cases and review of the literature.

Oral melanoma in HIV-positive patients is exceedingly rare, with only two cases reported in the literature published in English. Herein, we report two additional cases of oral melanomas which occurred as oral masses in the upper gingiva and hard palate in 35- and 27-year-old HIV-positive women. Significant thrombocytopenia, anemia, reduced CD4 cells, and high HIV load occurred in both patients. Microscopically, the lesions showed a variable proliferation of fusiform and epithelioid-pigmented cells, with cellular pleomorphism and high mitotic index. The diagnosis of melanoma was supported by positive immunoreactivity for S-100, MelanA, and HMB-45. Both cases had an unfavorable outcome, and the patients died a few months after the initial diagnosis. Because of its rarity, oral melanoma occurring in HIV-positive patients can pose problems in diagnosis and should be clinically distinguished from Kaposi's sarcoma, which is more common in the context of the immunodeficiency syndrome.

Smoking-Alcohol-Sex Exposure and Knowledge About Oral and Oropharyngeal Cancer Among Brazilian Adolescents: An Exploratory-Observational Approach

Abstract Objective: To investigate the involvement of young Brazilian students about five behaviors: tobacco use, alcohol consumption, sexual intercourse, knowledge about HPV, and knowledge about oral and oropharyngeal cancer. Material and Methods: Through a cross-section design, we explored some factors that might be associated with boys and girls. Statistical Regression methods were applied to identify differences, considering the estimation of the Odds Ratio. Results: Half of the sample had already consumed alcohol and at least 1 in 10 individuals had already tried smoking. One-third of adolescents have had sexual intercourse. Three factors related to boys were associated in the multiple regression analysis: have heard about HPV, have not heard about oral cancer, and think that HPV can cause oropharyngeal cancer. In conclusion, it seems that boys and girls were equally exposed to smoking-alcohol-sex; however, some differences were verified concerning the knowledge about HPV and oral / oropharyngeal cancer. Conclusion: Keep monitoring adolescents should be a priority to our study area, considering that those youngers had already being exposed to the risk factors for cancer.

Análise pericial das lesões situadas em cabeça e pescoço de mulheres vítimas de violência doméstica atendidas em um instituto médico legal de Maceió ­ AL / Forensic analysis of head and neck injuries of women victims of violence assisted in a Medical Legal Institute of Maceió ­ AL

Introdução: A violência contra a mulher continua sendo uma realidade no Brasil que traz à tona o cenário nacional de desigualdade de gênero, observada pelos altos índices de agressão, divulgados por meio de várias pesquisas que afirmam que a violência doméstica está em contínua progressão. No Brasil, a Lei Maria da Penha foi sancionada em 2006, estabelecendo medidas de assistência e proteção às mulheres em situação de violência doméstica e familiar. Objetivo: O estudo tem como objetivo conhecer os tipos de lesões em cabeça e pescoço identificadas em mulheres vítimas de violência doméstica que buscam o Instituto Médico Legal (IML) e, consequentemente, elevam as estatísticas de agressão feminina. Material e método: Consiste em uma pesquisa documental retrospectiva com abordagem quantitativa, e se enquadra na especialidade da Odontologia Legal. A coleta dos dados foi realizada no Instituto Médico Legal da cidade de Maceió - AL, referente aos anos de 2015 e 2016. Resultados: Dos 1698 laudos, os resultados mostram que mulheres entre 30 e 45 anos, da classe D, com vínculos afetivos com seus agressores prevalecem como agredidas por instrumentos contundentes e a região da cabeça foi a mais atingida. Conclusão: Conclui-se que os laudos fornecidos pelo odontolegista auxiliam no esclarecimento de incidências e na identificação dos tipos de lesões da cabeça e pescoço identificados em vítimas de agressão doméstica.

Introduction: Violence against women is still a reality in Brazil that brings to the national scenario of gender inequality, observed by the high levels of aggression registered through alarming data, disseminated through several research that affirm that domestic violence is in continuous progression. In Brazil, the Maria da Penha's Law was sanctioned in 2006, establishing assistance and protection measures for women in situations of domestic and family violence. Objective: The objective of this study is to know the types of head and neck injuries identified in women victims of domestic violence who look for the Medical Legal Institute (IML) and, consequently, raise the data of the victims of aggressions. Material and method: Consists in research of retrospective documentary with quantitative approach, and it fits in the specialty of Legal Dentistry. Data collection was done at the Legal Medical Institute in the city of Maceió - AL, referring to the years 2015 and 2016. Results: The results shows that women between 30 and 45 years of age, low income, with affective bonds with their aggressors prevail as aggressive instruments and the region of the head was the most affected. Conclusion: It is concluded that the reports provided by the legal dentist helps in the clarification of incidences and in the identification of the types of lesions of the head and neck identified in victims of domestic aggression.

Treatment of Hyperkalemia With a Low-Dose Insulin Protocol Is Effective and Results in Reduced Hypoglycemia.

INTRODUCTION: Complications associated with insulin treatment for hyperkalemia are serious and common. We hypothesize that, in chronic kidney disease (CKD) and end-stage renal disease (ESRD), giving 5 units instead of 10 units of i.v. regular insulin may reduce the risk of causing hypoglycemia when treating hyperkalemia. METHODS: A retrospective quality improvement study on hyperkalemia management (K+ ≥ 6 mEq/l) from June 2013 through December 2013 was conducted at an urban emergency department center. Electronic medical records were reviewed, and data were extracted on presentation, management of hyperkalemia, incidence and timing of hypoglycemia, and whether treatment was ordered as a protocol through computerized physician order entry (CPOE). We evaluated whether an educational effort to encourage the use of a protocol through CPOE that suggests the use of 5 units might be beneficial for CKD/ESRD patients. A second audit of hyperkalemia management from July 2015 through January 2016 was conducted to assess the effects of intervention on hypoglycemia incidence. RESULTS: Treatments ordered using a protocol for hyperkalemia increased following the educational intervention (58 of 78 patients [74%] vs. 62 of 99 patients [62%]), and the number of CKD/ESRD patients prescribed 5 units of insulin as per protocol increased (30 of 32 patients [93%] vs. 32 of 43 [75%], P = .03). Associated with this, the incidence of hypoglycemia associated with insulin treatment was lower (7 of 63 patients [11%] vs. 22 of 76 patients [28%], P = .03), and there were no cases of severe hypoglycemia compared to the 3 cases before the intervention. CONCLUSION: Education on the use of a protocol for hyperkalemia resulted in a reduction in the number of patients with severe hypoglycemia associated with insulin treatment.

Chronic kidney disease stages among diabetes patients in the Cape Coast Metropolis.

Diabetes patients worldwide are at a high risk of chronic kidney disease (CKD) which affects their quality of life and increases the risk of early death. This study used the new kidney disease improving global outcomes (KDIGO) guidelines to establish the prevalence and also identify the factors associated with CKD among diabetes patients in the Cape Coast Metropolis. Two hundred (200) diabetes patients were randomly recruited from the diabetic clinic of the Cape Coast Teaching Hospital from January to April 2014. Blood and urine samples were collected for the estimation of serum creatinine and urine protein, respectively. The estimated glomerular filtration rate (eGFR) was calculated using the chronic kidney disease epidemiology collaboration (CKD-EPI) equation; the 2012 KDIGO guidelines was used to assess CKD. Based on these guidelines, 37% of our participants had CKD. Sixteen percent (16%) of the participants had Stage 1 CKD and 17% had an eGFR <60 mL/min/1.73 m 2 . Albuminuria was higher among female diabetic patients compared to males (69.2% vs. 30.8%, P = 0.017). CKD was present in participants on oral hypoglycemic agents (OHAs) alone or both OHA and insulin. Duration of diabetes, systolic blood pressure, older age, and use of OHA were associated with CKD (P <0.05).

Effect of timely initiation of breastfeeding on child health in Ghana.

BACKGROUND: Early initiation of breastfeeding and exclusive breastfeeding practices have been argued to be one of the important ways of ensuring child health. Unfortunately, owing to modernization, most nursing mothers fail to adhere to such practices. This is believed to be a factor contributory to poor child health in Ghana. Thus, this study investigated the effect of timely initiation of breastfeeding on child health in Ghana. METHODS: Cross sectional data using secondary data based on the positivism approach to research was employed. The Ordinary least squares and the Instrumental variables approach were used in estimating the effect of breastfeeding and other socio demographic indicators on the health of the child. Data for the study was sourced from the 2008 round of the Ghana Demographic and Health Survey. RESULTS: The results indicate that timely initiation of breastfeeding, both immediately and hours after birth are important factors that influence the child's health. Additionally, factors such as the wealth of the household, mother's education, age and size of the child at birth and age of the mother are important factors that also influence the health of the child in Ghana. CONCLUSION: The findings imply that efforts should be made on encouraging appropriate breastfeeding practices among nursing mothers to ensure proper child development and growth in Ghana.

Socioeconomic Correlates and the Choice of Treatment for Childhood Fever in Ghana

The study investigated the effect of household socioeconomic factors on the choice of treatment for childhood fever among children under age five in Ghana. Data from the 2008 Ghana Demographic and Health survey was used employing the multinomial probit model. Three treatment choices were considered: Government facility; Private facility and traditional/self-medication. The results suggest that the treatment of childhood fever is related to household wealth; health insurance status and residence. Government health facilities are mostly used by household's with higher wealth and household's with health insurance. Rural households are more likely to use traditional/self-medication; except those with health insurance who use government facilities. The age of the mother and birth order of the child were also found to influence the choice of treatment facility for childhood fever

Wealth and antenatal care use: implications for maternal health care utilisation in Ghana.

The study investigates the effect of wealth on maternal health care utilization in Ghana via its effect on Antenatal care use. Antenatal care serves as the initial point of contact of expectant mothers to maternal health care providers before delivery. The study is pivoted on the introduction of the free maternal health care policy in April 2005 in Ghana with the aim of reducing the financial barrier to the use of maternal health care services, to help reduce the high rate of maternal deaths. Prior to the introduction of the policy, studies found wealth to have a positive and significant influence on the use of Antenatal care. It is thus expected that with the policy, wealth should not influence the use of maternal health care significantly. Using secondary data from the 2008 Ghana Demographic and Health survey, the results have revealed that wealth still has a significant influence on adequate use of Antenatal care. Education, age, number of living children, transportation and health insurance are other factors that were found to influence the use of Antenatal care in Ghana. There also exist considerable variations in the use of Antenatal care in the geographical regions and between the rural and urban dwellers. It is recommended that to improve the use of Antenatal care and hence maternal health care utilization, some means of support is provided especially to women within the lowest wealth quintiles, like the provision and availability of recommended medication at the health center; secondly, women should be encouraged to pursue education to at least the secondary level since this improves their use of maternal health services. Policy should also target mothers who have had the experience of child birth on the need to use adequate Antenatal care for each pregnancy, since these mothers tend to use less antenatal care for subsequent pregnancies. The regional disparities found may be due to inaccessibility and unavailability of health facilities and services in the rural areas and in some of the regions. The government and other service providers (NGOs, religious institutions and private providers) may endeavor to improve on the distribution of health facilities, human resources, good roads and necessary infrastructure among other things in order to facilitate easy access to health care providers especially for the rural dwellers.

Correlates of contraceptive use among Ghanaian women of reproductive age (15-49 years).

Though fertility in Ghana has declined from an average of 8 children per woman over the past three decades to 4 per woman in recent times, the current rate of population growth is still unmatched by the requisite economic growth. Recent evidence suggests that the use of contraceptives have increased marginally despite the considerable decline in fertility rate. This paper revisits the determinants of contraceptive use among Ghanaian women, aged 15-49 using the 2008 GDHS. Empirically, the logistic and multinomial logistic regressions are used. Our results indicate that wealth status, level of education, ownership of health insurance, number of surviving children, marital status, location and geographical area of residence, religion and women autonomy are significant correlates of contraceptive use in Ghana. The finding reveals that, women who take health decisions jointly with their partners are more likely to use modern contraceptives as compared to women who take health decisions alone.