Regaining policy attention for a health insurance capitation payment reform in Ghana: A prospective policy analysis.

Capitation as a provider payment mechanism gained policy attention by the Ghana National Health Insurance Scheme (NHIS) in 2012 and was piloted in the Ashanti Region, Ghana. Recent studies revealed that the policy was suspended in 2017 due to inappropriate policy framing, actor contestations, unclear policy design characteristics, and an unfavorable political context. However, the NHIS still has interest in capitation as a provider payment option. Using the modified political process model, a prospective policy analysis was conducted to explore how to: i) appropriately reframe policy debates; ii) create political opportunities; and iii) mobilize resources to reattract policy attention to capitation in Ghana. Cross-sectional qualitative data were gathered in December, 2019 from semi-structured interviews with a purposive sample of 18 stakeholders and complemented with four community-level focus group discussions with 41 policy beneficiaries in the pilot region. All data were tape-recorded and transcribed. The analysis was thematic, using the NVivo 12 software. The results revealed that an appropriate reframing of the policy requires policy renaming, refinement of certain policy design characteristics (emergency care, capitation rates, choice and assignment of providers) and refocusing policy communication and advocacy on the health benefits of capitation instead of its cost containment intent. To create political opportunities for policy re-implementation, a politically sensitive approach with broader stakeholder consultations should be adopted. Policy advocacy and communication should be evidenced-based and led by politically neutral agents. An equitable capitation policy implementation requires resourcing health facilities, especially the lower-level facilities, with improved infrastructure, consumables, improved information management systems and well-trained personnel to enhance their service delivery capacities. The study concludes that there exists stakeholder interest in the capitation policy in Ghana and calls for an effective reframing, creation of political opportunities, and mobilization of needed resources to regain policy attention.

A qualitative examination of factors influencing pregnancy-related anxiety in Northern Ghana.

INTRODUCTION: Despite high prevalence of anxiety among pregnant women in low- and -middle-income countries, research on context-specific conceptualisation, measurement, and predictors of pregnancy-related anxiety (PrA) is limited in these contexts. We explored local conceptualisations of factors influencing PrA in the Northern Region of Ghana. METHODS: We conducted 15 focus group discussions with antenatal care seekers in the Mion District, Savelugu Municipality, and Tamale Metropolis of the Northern Region, in July and August 2021. Multistage stratified purposive sampling was used to select respondents (n = 108). The data were audio-recorded and transcribed, and then we conducted a thematic analysis of the data. RESULTS: At the individual level, fear of anaemia; pre-existing health conditions; challenges with daily activities; and physical, emotional, and sexual abuses from spouses contributed to PrA. Health system failures resulting in unexpected out-of-pocket payments, negative health worker attitudes, diagnostic errors, constraints on birth preparation and birth process, and potential adverse birth outcomes were understood as driving PrA. Socio-cultural factors influencing PrA comprised beliefs and practices around baby naming/outdooring ceremonies, fear of spiritual attacks, social construction of gender roles, and contextual factors such as transportation challenges. CONCLUSION: Pregnant women in the region understood, experienced, and could identify perceived predictors of PrA. To address PrA, we recommend that mental health services should be integrated into the basic package of antenatal care and rural health services should be improved. Perceived predictors of PrA identified here could be included in the design of a context-specific PrA measure for use in the region.

Constraints on the functioning of Community-based Health Planning and Services facilities: A qualitative study in the Jirapa Municipality, Ghana.

The declaration of the Alma-Alta on primary health care (PHC) in 1978 enjoined nations to make health care accessible, affordable, and situated within their cultural contexts. The Ghana Community-based Health Planning and Services (CHPS), as a strategy to achieve the goal of PHC, has shown significant successes in communities where it has been implemented. However, a number of challenges continue to affect the effective functioning of CHPS. This study explored the community level and health system constraints on the effective functioning of CHPS in the delivering of PHC services in the Jirapa Municipality. A qualitative approach was implemented. A criterion-based purposive sampling technique was employed to recruit 51 managers and health service providers of CHPS for key informant interviews. The respondents included 25 community health management committee members, 25 health officers in charge of CHPS facilities, and one municipal CHPS coordinator. The interviews were held from September 18 to November 23, 2020. All interviews were face-to-face, audio-recorded and transcribed verbatim. Thematic analysis based on the constant comparative method was employed to analyse the data. The results showed that low community involvement in CHPS activities, disputes over the location and naming of CHPS zones, inadequate understanding of the CHPS concept and religious beliefs were the key community level factors which negatively affected the functioning of CHPS. Also, lack of logistics, financial constraints, poor attitude of health workers and inadequate staff motivation were the health sector constraints on the effective functioning of CHPS. In conclusion, concerted efforts are needed to tackle the community level and health system constraints to improve the overall functioning and effectiveness of the CHPS strategy. We recommend the strengthening of community sensitization, timely disbursement of funding, and provision of infrastructure and supplies to improve upon the effective functioning of CHPS as a strategy for delivery PHC in Ghana.

Factors associated with anaemia in pregnancy: A retrospective cross-sectional study in the Bolgatanga Municipality, northern Ghana.

BACKGROUND: Anaemia in pregnancy (AIP) remains a severe public health problem associated with adverse outcomes. This study assessed haemoglobin levels and the prevalence of anaemia during antenatal care (ANC) registration, at 28 weeks and 36 weeks of gestation as well as the factors associated with AIP at the different stages of pregnancy. METHODS: A retrospective cross-sectional design was implemented. Using ANC registers as the sampling frame, 372 pregnant women, within 36 and 40 weeks of gestation were randomly sampled from 28 health facilities for the study. The participants were all receiving ANC in the Bolgatanga Municipality. Data were collected via clinical records review and a questionnaire-based survey between October and November, 2020. Using the Statistical Package for the Social Sciences (SPSS), descriptive analysis of haemoglobin levels and the prevalence of anaemia were performed. In addition, binary logistic regression was used to identify the factors associated with anaemia in pregnancy. AIP was determined using the national practice of 11.0g/dl haemoglobin cut-off point and the World Health Organisation's recommended adjustment for the 2nd trimester of pregnancy was made using the cut-off of 10.5g/dl to account for the effect of haemodilution. RESULTS: At booking, AIP prevalence was 35.8% (95%CI:30.9, 40.9) using a cut-off of 11.0g/dl and 25.3% (95%CI:20.9, 30.0) using a cut-off of 10.5g/dl for those in the 2nd trimester. At 28 weeks, AIP prevalence was 53.1% (95%CI:45.8, 60.3) and 37.5 (95%CI:30.6, 44.8) using a cut-off of 11.0g/dl and 10.5g/dl for those in the 2nd trimester, respectively. At 36 weeks, AIP prevalence was 44.8% (95%CI:39.2, 50.4) using a cut-off of 11.0g/dl. At p<0.05, registering after the first trimester (AOR = 1.87, 95%CI: 1.17, 2.98, P = 0.009) and at a regional hospital (AOR = 2.25, 95%CI: 1.02, 4.98, P = 0.044) were associated with increased odds of AIP but registering at a private hospital (AOR = 0.32, 95%CI: 0.11, 0.92, P = 0.035) was associated with decreased odds of AIP at booking. At 28 weeks, age group 26-35 years (AOR = 0.46, 95%CI: 0.21, 0.98, P = 0.044), Christianity (AOR = 0.32, 95%CI: 0.31, 0.89, P = 0.028.), high wealth (AOR = 0.27, 95%CI: 0.09, 0.83, P = 0.022) and tertiary education (AOR = 0.09, 95%CI:0.02, 0.54, P = 0.009) were associated with decreased odds of AIP. At 36 weeks, booking after first trimester of pregnancy was associated with increased odds (AOR = 1.72, 95%CI: 1.05, 2.84, P = 0.033) whilst high wealth (AOR = 0.44, 95%CI: 0.20, 0.99, P = 0.049), higher age groups-26-35 (AOR = 0.38, 95%CI: 0.21, 0.68, P = 0.001) and 36-49 years (AOR = 0.35, 95%CI: 0.13, 0.90, P = 0.024) and secondary education of spouse were associated with reduced odds (AOR = 0.35, 95%CI: 0.14, 0.88, P = 0.026) of AIP. CONCLUSION: AIP consistently increased from registration to 36 weeks of gestation. Given the observed correlates of AIP, we recommend that interventions geared towards early ANC registration, improved household wealth, and improved maternal education are required to reduce AIP.

Enablers and inhibitors of community participation in Ghana's Community-based Health Planning and Services programme: a qualitative study in the Builsa North Municipality.

BACKGROUND: Community participation is essential for the successful implementation of primary health care programmes across the globe, including sub-Saharan Africa. The Community-based Health Planning and Services (CHPS) programme is one of the primary health care interventions in Ghana which by design and implementation heavily relies on community participation. However, there is little evidence to establish the factors enabling or inhibiting community participation in the Ghanaian CHPS programme. This study, therefore, explored the enabling and inhibiting factors influencing community participation in the design and implementation of the CHPS programme in the Builsa North Municipality in the Upper East Region of Ghana. METHODS: A qualitative approach, using a cross-sectional design, was employed to allow for a detailed in-depth exploration of the enabling and inhibiting factors influencing community participation in the design and implementation of the CHPS programme. The data were collected in January 2020, through key informant interviews with a stratified purposive sample of 106 respondents, selected from the 15 functional CHPS facilities in the Municipality. The data were audio-recorded, transcribed and manually analysed using thematic analysis. RESULTS: The results showed that, public education on the CHPS concept, capacity of the community to contribute material resources towards the construction of CHPS facilities, strong and effective community leadership provided by community chiefs and assembly persons, the spirit of volunteerism and trust in the benefits of the CHPS programme were the enablers of community participation in the programme. However, volunteer attrition, competing economic activities, lack of sense of ownership by distant beneficiaries, external contracting of the construction of CHPS facilities and illiteracy constituted the inhibiting factors of community participation in the programme. CONCLUSION: Extensive public education, volunteer incentivization and motivation, and the empowerment of communities to construct their own CHPS compounds are issues that require immediate policy attention to enhance effective community participation in the programme.

Understanding the policy dynamics of COVID-19 vaccination in Ghana through the lens of a policy analytical framework.

BACKGROUND: Ghana became the first African country to take delivery of the first wave of the AstraZeneca/Oxford vaccine from the COVAX facility. But why has this promising start of the vaccination rollout not translated into an accelerated full vaccination of the population? To answer this question, we drew on the tenets of a policy analytical framework and analysed the diverse interpretations, issue characteristics, actor power dynamics and political context of the COVID-19 vaccination process in Ghana. METHODS: We conducted a rapid online review of media reports, journal articles and other documents on debates and discussions of issues related to framing of the vaccination rollout, social constructions generated around vaccines, stakeholder power dynamics and political contentions linked to the vaccination rollout. These were complemented by desk reviews of parliamentary reports. RESULTS: The COVID-19 vaccination was mainly framed along the lines of public health, gender-centredness and universal health coverage. Vaccine acquisition and procurement were riddled with politics between the ruling government and the largest main opposition party. While the latter persistently blamed the former for engaging in political rhetoric rather than a tactical response to vaccine supply issues, the former attributed vaccine shortages to vaccine nationalism that crowded out fair distribution. The government's efforts to increase vaccination coverage to target levels were stifled when a deal with a private supplier to procure 3.4 million doses of the Sputnik V vaccine collapsed due to procurement breaches. Amidst the vaccine scarcity, the government developed a working proposal to produce vaccines locally which attracted considerable interest among pharmaceutical manufacturers, political constituents and donor partners. Regarding issue characteristics of the vaccination, hesitancy for vaccination linked to misperceptions of vaccine safety provoked politically led vaccination campaigns to induce vaccine acceptance. CONCLUSIONS: Scaling up vaccination requires political unity, cohesive frames, management of stakeholder interests and influence, and tackling contextual factors promoting vaccination hesitancy.

Facilitators and Barriers to the Use of Sexual and Reproductive Health Services among Adolescents in a Rural Ghanaian District.

Using the Andersen and Newman model, we explored the facilitators and barriers to the use of sexual and reproductive health (S&RH) services by in-school adolescents in Ghana. Thematic analysis of interviews revealed that parental support and a good peer network predispose adolescents to use S&RH services, while religious prejudice predisposes adolescents not to use S&RH services. Adolescent-friendly social clubs, S&RH corners, and well-trained health workers enable S&RH service use while parental disapproval, poor health workers' attitudes, and inconvenience of health facilities inhibit S&RH service use. Adolescents' perceptions of the severity of S&RH conditions create the need for S&RH care, while societal perception of sexual pleasure and perceived side effects of S&RH services are need-based barriers to the use of S&RH services. We recommend that adolescent-focused S&RH interventions should build the competence of health workers, promote religious and community tolerance, and strengthen family relationships that facilitate parent-child S&RH communication.

Measurement of pregnancy-related anxiety worldwide: a systematic review.

BACKGROUND: The perinatal period is often characterized by specific fear, worry, and anxiety concerning the pregnancy and its outcomes, referred to as pregnancy-related anxiety. Pregnancy-related anxiety is uniquely associated with negative maternal and child health outcomes during pregnancy, at birth, and early childhood; as such, it is increasingly studied. We examined how pregnancy-related anxiety is measured, where measures were developed and validated, and where pregnancy-related anxiety has been assessed. We will use these factors to identify potential issues in measurement of pregnancy-related anxiety and the geographic gaps in this area of research. METHODS: We searched the Africa-Wide, CINAHL, MEDLINE, PsycARTICLES, PsycINFO; PubMed, Scopus, Web of Science Core Collection, SciELO Citation Index, and ERIC databases for studies published at any point up to 01 August 2020 that assessed pregnancy-related anxiety. Search terms included pregnancy-related anxiety, pregnancy-related worry, prenatal anxiety, anxiety during pregnancy, and pregnancy-specific anxiety, among others. Inclusion criteria included: empirical research, published in English, and the inclusion of any assessment of pregnancy-related anxiety in a sample of pregnant women. This review is registered on PROSPERO (CRD42020189938). RESULTS: The search identified 2904 records; after screening, we retained 352 full-text articles for consideration, ultimately including 269 studies in the review based on the inclusion and exclusion criteria. In total, 39 measures of pregnancy-related anxiety were used in these 269 papers, with 18 used in two or more studies. Less than 20% of the included studies (n = 44) reported research conducted in low- and middle-income country contexts. With one exception, all measures of pregnancy-related anxiety used in more than one study were developed in high-income country contexts. Only 13.8% validated the measures for use with a low- or middle-income country population. CONCLUSIONS: Together, these results suggest that pregnancy-related anxiety is being assessed frequently among pregnant people and in many countries, but often using tools that were developed in a context dissimilar to the participants' context and which have not been validated for the target population. Culturally relevant measures of pregnancy-related anxiety which are developed and validated in low-income countries are urgently needed.

Promoting male participation in maternal healthcare in the Jaman North District in Ghana: Strategies and implementation challenges.

Promoting male participation in maternal healthcare is essential for improved maternal health outcomes. This study explored existing strategies to promote male participation in maternal healthcare and assessed their implementation challenges within healthcare facilities in the Jaman North District in Ghana. A qualitative approach was implemented in April 2020. Interviews were administered to a stratified purposive sample of 18 respondents comprising six midwives and 12 male partners of postnatal mothers. All interviews were audio-recorded, transcribed, and manually analysed using thematic analysis. The findings revealed early service, male partner invitation, male partner incentivisation, public sensitization, and male informed education, as strategies to promote male participation in the district. The implementation of these strategies has been constrained by socio-cultural and health system factors, namely, perception of pregnancy as non-illness, perceived experiences gained by women during previous births, cultural stereotypes, unconducive environment of healthcare facilities, inappropriate timing of facility attendance and unexpected costs associated with male participation. Promoting male participation, therefore, requires dedicated policy attention to the existing socio-cultural and health system constraints. The Ghana Health Service and other stakeholders should consider both community-level and targeted sensitization on the benefits of male participation in maternal healthcare and a general improvement in maternal healthcare infrastructure.

Is value-based payment for healthcare feasible under Ghana's National Health Insurance Scheme?

BACKGROUND: Effective payment mechanisms for healthcare are critical to the quality of care and the efficiency and responsiveness of health systems to meet specific population health needs. Since its inception, Ghana's National Health Insurance Scheme (NHIS) has adopted fee-for-service, diagnostic-related groups and capitation methods, which have contributed to provider reimbursement delays, rising costs and poor quality of care rendered to the scheme's clients. The aim of this study was to explore stakeholder perceptions of the feasibility of value-based payment (VBP) for healthcare in Ghana. Value-based payment refers to a system whereby healthcare providers are paid for the value of services rendered to patients instead of the volume of services. METHODS: This study employed a cross-sectional qualitative design. National-level stakeholders were purposively selected for in-depth interviews. The participants included policy-makers (n = 4), implementers (n = 5), public health insurers (n = 3), public and private healthcare providers (n = 7) and civil society organization officers (n = 1). Interviews were audio-recorded and transcribed. Data analysis was performed using both deductive and inductive thematic analysis. The data were analysed using QSR NVivo 12 software. RESULTS: Generally, participants perceived VBP to be feasible if certain supporting systems were in place and potential implementation constraints were addressed. Although the concept of VBP was widely accepted, study participants reported that efficient resource management, provider motivation incentives and community empowerment were required to align VBP to the Ghanaian context. Weak electronic information systems and underdeveloped healthcare infrastructure were seen as challenges to the integration of VBP into the Ghanaian health system. Therefore, improvement of existing systems beyond healthcare, including public education, politics, data, finance, regulation, planning, infrastructure and stakeholder attitudes towards VBP, will affect the overall feasibility of VBP in Ghana. CONCLUSION: Value-based payment could be a feasible policy option for the NHIS in Ghana if potential implementation challenges such as limited financial and human resources and underdeveloped health system infrastructure are addressed. Governmental support and provider capacity-building are therefore essential for VBP implementation in Ghana. Future feasibility and acceptability studies will need to consider community and patient perspectives.

Why do women attend antenatal care but give birth at home? a qualitative study in a rural Ghanaian District.

BACKGROUND: The Sustainable Development Goal Three has prioritised reducing maternal, under-5 and neonatal mortalities as core global health policy objectives. The place, where expectant mothers choose to deliver their babies has a direct effect on maternal health outcomes. In sub-Saharan Africa, existing literature has shown that some women attend antenatal care during pregnancy but choose to deliver their babies at home. Using the Andersen and Newman Behavioural Model, this study explored the institutional and socio-cultural factors motivating women to deliver at home after attending antenatal care. METHODS: A qualitative, exploratory, cross-sectional design was deployed. Data were collected from a purposive sample of 23 women, who attended antenatal care during pregnancy but delivered their babies at home, 10 health workers and 17 other community-level stakeholders. The data were collected through semi-structured interviews, which were audio-recorded, transcribed and thematically analysed. RESULTS: In line with the Andersen and Newman Model, the study discovered that traditional and religious belief systems about marital fidelity and the role of the gods in childbirth, myths about consequences of facility-based delivery, illiteracy, and weak women's autonomy in healthcare decision-making, predisposed women to home delivery. Home delivery was also enabled by inadequate midwives at health facilities, the unfriendly attitude of health workers, hidden charges for facility-based delivery, and long distances to healthcare facilities. The fear of caesarean section, also created the need for women who attended antenatal care to deliver at home. CONCLUSION: The study has established that socio-cultural and institutional level factors influenced women's decisions to deliver at home. We recommend a general improvement in the service delivery capacity of health facilities, and the implementation of collaborative educational and women empowerment programmes by stakeholders, to strengthen women's autonomy and reshape existing traditional and religious beliefs facilitating home delivery.

Knowledge, attitude and practice of hepatitis B infection prevention among nursing students in the Upper West Region of Ghana: A cross-sectional study.

INTRODUCTION: Hepatitis B infection remains a public health threat associated with undesirable statistics of morbidity and mortality. Good knowledge, attitude and practice (KAP) of hepatitis B infection (HBI) prevention are essential for HBI control. However, there is limited evidence concerning the KAP of HBI prevention among nursing students, who are significantly exposed to HBI. We assessed the KAP of HBI prevention and the factors associated with the practice of HBI prevention among nursing students in the Upper West Region of Ghana. METHODS: We administered an online cross-sectional survey in November 2020 to a stratified random sample of 402 nursing students in two nursing training colleges in the Upper West Region. Using STATA version 13, we computed composite scores of KAP of HBI prevention with maximum scores of 18 for knowledge and 8 each for attitude and practice. A generalised ordered logistic regression model was run to assess the factors associated with the practice of HBI prevention. RESULTS: The students had moderate median scores for knowledge (12.00; IQR = 10-13) and attitude (6.00; IQR = 5.00-7.00) but a poor median score (5.00; IQR = 4.00-6.00) for the practice of HBI prevention. High knowledge (aOR = 2.05; p = 0.06), good attitude, being a male, second year student and having parents with tertiary education were significantly associated with higher likelihoods (aOR >1; p < 0.05) of demonstrating good practice of HBI prevention. Students who had never married were significantly (aOR = 0.34; p = 0.010) less likely to exhibit good practice of HBI prevention. CONCLUSION: The KAP scores of HBI prevention among the students were sub-optimal. We recommend institution-based policies and regular education on HBI prevention, free/subsidised HBI prevention services, and the enforcement of proper professional ethics on HBI prevention in nursing training colleges. Such interventions should predominantly target female, non-married and first year nursing students.

Preferences for long-term care insurance in China: Results from a discrete choice experiment.

Rapid population aging has led countries to consider the introduction of long-term care insurance (LTCI) as an essential component of a comprehensive social health protection package. Limited evidence, however, exists on people's preferences for such insurance products, especially in countries where their availability is still restricted. Using a discrete choice experiment (DCE), we investigated preferences, willingness to pay, and heterogeneity in preferences for attributes of a social LTCI among community members in China. We adopted a multi-methods approach, combining information across different data sources to identify five DCE attributes: individual premium, benefit package, coverage ceiling, government subsidy for participants, and reimbursement of home-based care provided by family caregivers. We constructed our experiment using a D-efficient design and ran the DCE survey among 1067 community members in urban and rural areas in Shenyang and Dalian, Liaoning Province from Dec 2019 to Jan 2020. We relied on a panel mixed logit model to analyze the data. Our findings indicated that people had significantly higher preferences for the LTCI product with a higher coverage ceiling, a lower individual premium, a higher government subsidy, a reimbursement of home-based care provided by family caregivers, and an expansion of the benefit package to also include necessary daily assistance. The coverage ceiling was found to be the most important attribute, followed by the reimbursement of home-based care provided by family caregivers and the individual premium. Our findings also revealed that the area of residence, prior commercial insurance ownership, age, having children, and income were the factors that drove heterogeneity in preferences for LTCIs. These findings bear important policy implications, as they provide clear guidance on product design, enabling decision-makers to increase the attractiveness and sustainability of LTCI.

Bypassing primary healthcare facilities for maternal healthcare in North West Ghana: socio-economic correlates and financial implications.

BACKGROUND: Bypassing primary health care (PHC) facilities for maternal health care is an increasing phenomenon. In Ghana, however, there is a dearth of systematic evidence on bypassing PHC facilities for maternal healthcare. This study investigated the prevalence of bypassing PHC facilities for maternal healthcare, and the socio-economic factors and financial costs associated with bypassing PHC facilities within two municipalities in Northwestern Ghana. METHODS: A quantitative cross-sectional design was implemented between December 2019 and March 2020. Multistage stratified sampling was used to select 385 mothers receiving postnatal care in health facilities for a survey. Using STATA 12 software, bivariate analysis with chi-square test and binary logistic regression models were run to determine the socio-economic and demographic factors associated with bypassing PHC facilities. The two-sample independent group t-test was used to estimate the mean differences in healthcare costs of those who bypassed their PHC facilities and those who did not. RESULTS: The results revealed the prevalence of bypassing PHC facilities as 19.35 % for antenatal care, 33.33 % for delivery, and 38.44 % for postnatal care. The municipality of residence, ethnicity, tertiary education, pregnancy complications, means of transport, nature of the residential location, days after childbirth, age, and income were statistically significantly (p < 0.05) associated with bypassing PHC facilities for various maternal care services. Compared to the non-bypassers, the bypassers incurred a statistically significantly (P < 0.001) higher mean extra financial cost of GH₵112.09 (US$19.73) for delivery, GH₵44.61 (US$7.85) for postnatal care and ₵43.34 (US$7.65) for antenatal care. This average extra expenditure was incurred on transportation, feeding, accommodation, medicine, and other non-receipted expenses. CONCLUSIONS: The study found evidence of bypassing PHC facilities for maternal healthcare. Addressing this phenomenon of bypassing and its associated cost, will require effective policy reforms aimed at strengthening the service delivery capacities of PHC facilities. We recommend that the Ministry of Health and Ghana Health Service should embark on stakeholder engagement and sensitization campaigns on the financial consequences of bypassing PHC facilities for maternal health care. Future research, outside healthcare facility settings, is also required to understand the specific supply-side factors influencing bypassing of PHC facilities for maternal healthcare within the study area.

Why did Ghana's national health insurance capitation payment model fall off the policy agenda? A regional level policy analysis.

Provider payment reforms, such as capitation, are very contentious. Such reforms can drop off the policy agenda due to political and contextual resistance. Using the Shiffman and Smith (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. Lancet 2007; 370 1370-9) framework, this study explains why Ghana's National Health Insurance capitation payment policy that rose onto the policy agenda in 2012, dropped off the agenda in 2017 during its pilot implementation in the Ashanti region. We conducted a retrospective qualitative policy analysis by collecting field data in December 2019 in the Ashanti region through 18 interviews with regional and district level policy actors and four focus group discussions with community-level policy beneficiaries. The thematically analysed field data were triangulated with media reports on the policy. We discovered that technically framing capitation as a cost-containment strategy with less attention on portraying its health benefits resulted in a politically negative reframing of the policy as a strategy to punish fraudulent providers and opposition party electorates. At the level of policy actors, pilot implementation was constrained by a regional level anti-policy community, weak civil society mobilization and low trust in the then political leadership. Anti-policy campaigners drew on highly contentious and poorly implemented characteristics of the policy to demand cancellation of the policy. A change in government in 2017 created the needed political window for the suspension of the policy. While it was technically justified to pilot the policy in the stronghold of the main opposition party, this decision carried political risks. Other low- and middle-income countries considering capitation reforms should note that piloting potentially controversial policies such as capitation within a politically sensitive location can attract unanticipated partisan political interest in the policy. Such partisan interest can potentially lead to a decline in political attention for the policy in the event of a change in government.

Is the presence of an adolescent reproductive health corner associated with adolescent knowledge and use of reproductive health services in Ghana?

OBJECTIVE: This study assessed the association between the presence of an adolescent reproductive health corner and adolescents' knowledge and use of reproductive health services (RHS) in Ghana. METHODS: A survey was administered in May-June 2018 to 392 adolescents in Junior High Schools within two communities in the Asunafo South District. One community had an adolescent reproductive health corner and the other did not. Chi-square test and binary logistic regression were used to assess the associations between the presence of the corner and adolescents' knowledge and use of RHS. RESULTS: After controlling for the influence of socio-demographic characteristics, relative to those in the other community, adolescents in the community with the health corner were statistically significantly more likely to know contraceptive counseling (AOR = 8.57, p < 0.01), injectables (AOR = 6.08, p < 0.01), pills (AOR = 2.39, p < 0.01), implants (AOR = 1.86, p < 0.05) but less likely to know withdrawal (AOR = 8.57, p < 0.01), antenatal care (AOR = 0.10, p < 0.01) and postnatal care (AOR = 0.12, p < 0.01). Covariates such as sex, age, religion and sexual relationship status were also associated (p < 0.05) with knowledge of RHS. RHS use was generally low, however, comparatively; there was a significantly higher use of contraceptive counseling (χ2 = 85.963; p = 0.000), STIs screening (χ2 = 41.783, p = 0.000), male condoms (χ2 = 9.956, p = 0.001) and pills (χ2 = 8.665, p = 0.003) in the community with the health corner than in the other community. CONCLUSION: The existence of an adolescent reproductive health corner is associated with higher knowledge and use of modern methods of pregnancy and disease prevention services. However, management of such corners should also provide adequate information on pregnancy and post-pregnancy management services.

Exploring factors influencing adverse birth outcomes in a regional hospital setting in Ghana: A configuration theoretical perspective.

BACKGROUND: Understanding the complexity of factors that influence adverse childbirth outcomes at health facilities can be enhanced by the theoretical articulation of the interplay between external socio-structural and internal technical dynamics of the birthplace in context. Guided by configuration theory, this study explored the factors that influence adverse birth outcomes at a regional hospital setting in Ghana. METHODS: Qualitative data were collected from the Upper West regional hospital in Ghana. In-depth interviews were administered to 30 purposively selected respondents comprising 20 postpartum mothers and 10 midwives. The data was electronically audio-recorded, transcribed and analysed using thematic analysis. FINDINGS: The study revealed three key dimensions of socio-technical configurations shaping adverse birth outcomes within the hospital setting. These are mother-midwife personality and behavioral dynamics including personality clashes and poor communication; birth process dynamics consisting of diverse paradigms of safe birthing process and socio-technical conflicts on caesarean section; and birthplace context, comprising nature of the birthing environment, confidence in the safety of the birthplace and national health policy implementation challenges. These socio-technical interactions result in late reporting at facilities by mothers and delay in care delivery by midwives, contributing to adverse birth outcomes. CONCLUSION: In line with configuration theory, our study positions the influences of adverse birth outcomes in hospital settings in alignment with a subtle and iterative interplay of socio-technical factors. To comprehensively address adverse birth outcomes in hospital settings, health policymakers and practitioners need to understand and contextualise the socio-technical interactions that shape notable outcomes at specific hospital settings.

Preferences of healthcare providers for capitation payment in Kenya: a discrete choice experiment.

Provider payment mechanisms (PPMs) are important to the universal health coverage (UHC) agenda as they can influence healthcare provider behaviour and create incentives for health service delivery, quality and efficiency. Therefore, when designing PPMs, it is important to consider providers' preferences for PPM characteristics. We set out to uncover senior health facility managers' preferences for the attributes of a capitation payment mechanism in Kenya. We use a discrete choice experiment and focus on four capitation attributes, namely, payment schedule, timeliness of payments, capitation rate per individual per year and services to be paid by the capitation rate. Using a Bayesian efficient experimental design, choice data were collected from 233 senior health facility managers across 98 health facilities in seven Kenyan counties. Panel mixed multinomial logit and latent class models were used in the analysis. We found that capitation arrangements with frequent payment schedules, timelier disbursements, higher payment rates per individual per year and those that paid for a limited set of health services were preferred. The capitation rate per individual per year was the most important attribute. Respondents were willing to accept an increase in the capitation rate to compensate for bundling a broader set of health services under the capitation payment. In addition, we found preference heterogeneity across respondents and latent classes. In conclusion, these attributes can be used as potential targets for interventions aimed at configuring capitation to achieve UHC.

Attribute development and level selection for a discrete choice experiment to elicit the preferences of health care providers for capitation payment mechanism in Kenya.

BACKGROUND: Stated preference elicitation methods such as discrete choice experiments (DCEs) are now widely used in the health domain. However, the "quality" of health-related DCEs has come under criticism due to the lack of rigour in conducting and reporting some aspects of the design process such as attribute and level development. Superficially selecting attributes and levels and vaguely reporting the process might result in misspecification of attributes which may, in turn, bias the study and misinform policy. To address these concerns, we meticulously conducted and report our systematic attribute development and level selection process for a DCE to elicit the preferences of health care providers for the attributes of a capitation payment mechanism in Kenya. METHODOLOGY: We used a four-stage process proposed by Helter and Boehler to conduct and report the attribute development and level selection process. The process entailed raw data collection, data reduction, removing inappropriate attributes, and wording of attributes. Raw data was collected through a literature review and a qualitative study. Data was reduced to a long list of attributes which were then screened for appropriateness by a panel of experts. The resulting attributes and levels were worded and pretested in a pilot study. Revisions were made and a final list of attributes and levels decided. RESULTS: The literature review unearthed seven attributes of provider payment mechanisms while the qualitative study uncovered 10 capitation attributes. Then, inappropriate attributes were removed using criteria such as salience, correlation, plausibility, and capability of being traded. The resulting five attributes were worded appropriately and pretested in a pilot study with 31 respondents. The pilot study results were used to make revisions. Finally, four attributes were established for the DCE, namely, payment schedule, timeliness of payments, capitation rate per individual per year, and services to be paid by the capitation rate. CONCLUSION: By rigorously conducting and reporting the process of attribute development and level selection of our DCE,we improved transparency and helped researchers judge the quality.

Factors associated with optimal antenatal care use in Northern region, Ghana.

The objective of this study was to investigate the factors associated with the optimal use of antenatal care (ANC) during pregnancy. A facility-based cross-sectional survey was conducted between February and August 2014 among nursing mothers (n = 578) attending postnatal and child welfare clinics in three districts in Northern Ghana, representing urban, peri-urban, and rural zones. The developed questionnaire aided the collection of information on maternal demographic characteristics, health status, household assets, and ANC attendance. Binary logistic regression was modeled to estimate the association between optimal ANC use and mothers' characteristics. Approximately 81% of the respondents had ≥4 ANC visits during pregnancy, and coverage was over 99%. Mothers who had any formal education (adjusted odds ratio [AOR] = 1.7, 95% confidence interval [CI] = 1.0-2.8, P = 0.040) lived in middle class socioeconomic households (AOR = 2.6, 95%CI = 1.4-4.8, P = 0.003) and resided in urban areas (AOR = 2.0, 95%CI = 1.2-3.3, P = 0.006) were significantly more likely to report the optimal ANC use. Mothers' education, socioeconomic status, and proximity to a health facility were positively associated with the optimal ANC use. Education of females and policy initiatives aimed at improving the rural-urban divide are essential to optimize the use of ANC.