Does mobile renewal make health insurance more responsive to clients? A case study of the National Health Insurance Scheme in Ghana.

BACKGROUND: In 2018, Ghana's National Health Insurance Authority (NHIA) introduced a mobile strategy to enhance re-enrolment and improve client knowledge of their entitlements. This study investigated how Ghana's mobile strategy has influenced the NHIA's responsiveness to clients in terms of patient rights and entitlements, equity and satisfaction with health services. METHODS: We surveyed people (n=1700) in 6 districts who had renewed their insurance in the previous 12 months, using any strategy (mobile or manual). Multiple regression analysis examined correlation between individual characteristics and renewal modality. Policy documents on the mobile programme's design and focus group discussions (n=12) on people's experiences renewing their insurance were analysed thematically. RESULTS: While the mobile platform was designed for mobile National Health Insurance Scheme (NHIS) renewal and to provide information about insurance entitlements, few people surveyed (20%) knew about these informational features. Among those who renewed their NHIS coverage, 58% did so on the mobile renewal platform. Mobile renewal was high among those with tertiary education and those in the higher wealth quintiles. Mobile renewal was considered convenient, but required literacy in English, a phone and a mobile money wallet. For those who lacked some or all of these prerequisites but wanted to use mobile renewal, mobile vendors emerged as valued facilitators. CONCLUSION: The mobile platform has increased the responsiveness of Ghana's NHIS through offering clients a more convenient mechanism to renew their insurance policies. It does not, however, eliminate the one month waiting period for activating the card, does not provide prompts to reassure clients of their renewal and does not empower most clients with information on entitlements. To improve the adoption and use of the mobile renewal strategy, the NHIA should publicise the platform's information-sharing functions and explore formally engaging mobile vendors.

Role of actor networks in primary health care implementation in low- and middle-income countries: a scoping review.

BACKGROUND: Primary health care (PHC) improvement is often undermined by implementation gaps in low- and middle-income countries (LMICs). The influence that actor networks might have on the implementation has received little attention up to this point. OBJECTIVE: This study sought to offer insights about actor networks and how they support PHC implementation in LMICs. METHODS: We reviewed primary studies that utilised social network analysis (SNA) to determine actor networks and their influence on aspects of PHC in LMICs following the five-stage scoping review methodological framework by Arksey and O'Malley. Narrative synthesis was applied to describe the included studies and the results. RESULTS: Thirteen primary studies were found eligible for this review. Ten network types were identified from the included papers across different contexts and actors: professional advice networks, peer networks, support/supervisory networks, friendship networks, referral networks, community health committee (CHC) networks, inter-sectoral collaboration networks, partnership networks, communications networks, and inter-organisational network. The networks were found to support PHC implementation at patient/household or community-level, health facility-level and multi-partner networks that work across levels. The study demonstrates that: (1) patient/household or community-level networks promote early health-seeking, continuity of care and inclusiveness by enabling network members (actors) the support that ensures access to PHC services, (2) health facility-level networks enable collaboration among PHC staff and also ensure the building of social capital that enhances accountability and access to community health services, and (3) multi-partner networks that work across levels promote implementation by facilitating information and resource sharing, high professional trust and effective communication among actors. CONCLUSION: This body of literature reviewed suggests that, actor networks exist across different levels and that they make a difference in PHC implementation. Social Network Analysis may be a useful approach to health policy analysis (HPA) on implementation.

Associations between the stringency of COVID-19 containment policies and health service disruptions in 10 countries.

BACKGROUND: Disruptions in essential health services during the COVID-19 pandemic have been reported in several countries. Yet, patterns in health service disruption according to country responses remain unclear. In this paper, we investigate associations between the stringency of COVID-19 containment policies and disruptions in 31 health services in 10 low- middle- and high-income countries in 2020. METHODS: Using routine health information systems and administrative data from 10 countries (Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, South Korea, and Thailand) we estimated health service disruptions for the period of April to December 2020 by dividing monthly service provision at national levels by the average service provision in the 15 months pre-COVID (January 2019-March 2020). We used the Oxford COVID-19 Government Response Tracker (OxCGRT) index and multi-level linear regression analyses to assess associations between the stringency of restrictions and health service disruptions over nine months. We extended the analysis by examining associations between 11 individual containment or closure policies and health service disruptions. Models were adjusted for COVID caseload, health service category and country GDP and included robust standard errors. FINDINGS: Chronic disease care was among the most affected services. Regression analyses revealed that a 10% increase in the mean stringency index was associated with a 3.3 percentage-point (95% CI -3.9, -2.7) reduction in relative service volumes. Among individual policies, curfews, and the presence of a state of emergency, had the largest coefficients and were associated with 14.1 (95% CI -19.6, 8.7) and 10.7 (95% CI -12.7, -8.7) percentage-point lower relative service volumes, respectively. In contrast, number of COVID-19 cases in 2020 was not associated with health service disruptions in any model. CONCLUSIONS: Although containment policies were crucial in reducing COVID-19 mortality in many contexts, it is important to consider the indirect effects of these restrictions. Strategies to improve the resilience of health systems should be designed to ensure that populations can continue accessing essential health care despite the presence of containment policies during future infectious disease outbreaks.

Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium.

COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.

COVID-19 and resilience of healthcare systems in ten countries.

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Community perceptions of enrolment of indigents into the National Health Insurance Scheme in Ghana: a case study of the Livelihood Empowerment against Poverty Programme.

BACKGROUND: The Livelihood Empowerment against Poverty (LEAP) programme in Ghana as part of its beneficiary programme, identifies the poor/indigents for exemptions from premium payments in the National Health Insurance Scheme (NHIS). This paper sought to understand community perceptions of enrolling the poor in the NHIS through LEAP in order to inform policy. METHODS: The study adopted a descriptive cross-sectional study design by using a qualitative approach. The study was conducted in three geographical regions of Ghana: Greater Accra, Brong-Ahafo and Northern region representing the three ecological zones of Ghana between October 2017 and February 2018. The study population included community members, health workers, NHIS staff and social welfare officers/social development officers. Eighty-one in-depth interviews and 23 Focus Group Discussions were conducted across the three regions. Data were analysed thematically and verbatim quotes from participants were used to support the views of participants. RESULTS: The study shows that participants were aware of the existence of LEAP and its benefits. There was, however, a general belief that the process of LEAP had been politicized and therefore favours only people who were sympathizers of the ruling government as they got enrolled into the NHIS. Participants held the view that the process of selecting beneficiaries lacked transparency, thus, they were not satisfied with the selection process. However, the study shows the ability of the community to identify the poor. The study reports varying concepts of poverty and its identification across the three ecological zones of Ghana. CONCLUSION: There is a general perception of politicization and lack of transparency of the selection of the poor into the NHIS through the LEAP programme in Ghana. Community-based approaches in the selection of the indigent are recommended to safeguard the NHIS-LEAP beneficiary process.

Barriers to Quality Care in Medical Imaging at a Teaching Hospital in Ghana: Staff Perspective.

BACKGROUND: The goal of quality care is to ensure that the health care services provided to individuals and patient populations improve desired health outcomes. However, as medical imaging services increase in Ghana, empirical evidence show a low level of care. Despite this, there exists no study in the public domain on the barriers to quality care. This study, therefore, sought to identify barriers to quality care in medical imaging at a teaching hospital to provide evidence that will enable optimization of care and in improving the overall medical imaging care delivery system. METHODS: This research was a descriptive, cross-sectional study using a mixed method approach based on the dimensions of quality of care of medical imaging services from medical imaging professionals' perspective: capacity and sustainability, timeliness, safety, equity, patient-centeredness, effective communication, and appropriateness of examination. QUANTITATIVE METHOD: A 5-point Likert scale questionnaire was used. The study population included all medical imaging professionals (n = 47) at the imaging department of the hospital. However, a total of 36 agreed to participate in the study. Data were analyzed using Stata Version 13. Descriptive analyses were carried out. QUALITATIVE METHODS: Purposive sampling strategy was applied to recruit 12 management team members and key staff with vast experience in medical imaging for the study. Data collection was done using a reflective in-depth interview guide. Data were analyzed using thematic analysis. QUANTITATIVE RESULTS: The quantitative findings show more than half of the respondents (n = 23, 63.9%) currently play supervisory roles, 10 (27.8%) work more than 40 hours a week, a minority group (n = 7, 19.4%) examine more than 100 patients per week, and 21 (58.5%) reported quality improvement programs are not carried out. Overall, half (50.0%) of the respondents are unaware of the availability of standard operating procedures, 28 (77.7%) reported imaging machines are not always functional, 34 (94.5%) reported lack of adherence to equipment servicing practices, and 27 (75%) agreed that broken-down equipment are left for more than 3 months before being fixed. In addition, 26 respondents (80.5%) reported staff number is inadequate compared with the workload, whereas only 11 (30.6%) stated supervision by management is adequate. Furthermore, 12 respondents (33.4%) reported management seem interested in quality of care only after adverse event, only 5 (38.5%) of the radiologists stated they are able to meet image reporting deadlines for clients, and only 8 (22.2%) of the respondents reported the availability of means of communicating results to referring clinicians aside the normal report. QUALITATIVE RESULTS: The qualitative findings show a lack of commitment to equipment servicing, frequent nonfunctionality of imaging machines, and an undue delay in repairs of broken-down machines. In addition, there exists inadequate human resource, inadequate supervision, a lack of quality improvement programs, and educational advancement opportunities for staff. The findings further show inadequacy of hospital gowns for patients, a lack of equity, and a poor organizational culture. In addition, the study identified a lack of means of communicating urgent imaging findings and a lack of promptness and timeliness to care from the consultant radiologists. CONCLUSION: The low level of care of medical imaging services observed in Ghana is reflected in the large number of barriers to quality care identified in this study. Most barriers identified are in the capacity and sustainability, timeliness, and effective communication dimensions of quality of care. The findings have important implications for policy makers. Improvement in these areas will enable optimization of care and in improving the overall medical imaging care delivery system.

Quality of Care of Medical Imaging Services at a Teaching Hospital in Ghana: Clients' Perspective.

BACKGROUND: The Ministry of Health of Ghana is committed to delivering client-focused, quality-driven, and results-oriented medical imaging services. However, there remained a lack of empirical evidence regarding the state of the various dimensions of quality needed to establish evidence-based strategies to strengthen the medical imaging system. This study assessed the quality of care of medical imaging services from clients' perspective at a teaching hospital in order to inform policy. METHODS: This research was a descriptive cross-sectional study using a mixed method approach based on the dimensions of quality of care in medical imaging: capacity and sustainability, timeliness, safety, equity, patient centeredness, and effective communication. QUANTITATIVE METHOD: A 5-point Likert scale questionnaire was used. A total of 191 clients aged ≥18 years were recruited during medical imaging services at the imaging department of the hospital. A simple random sampling technique was used to select participants. Data were analyzed using Stata version 13. Descriptive analyses were carried out. QUALITATIVE METHODS: Purposive sampling strategy was applied to recruit 12 in-depth interview participants. Reflective interview guide starting with demographic characteristics and followed by the dimensions of quality of care was used. Qualitative data were analyzed using thematic analysis. QUANTITATIVE RESULTS: Overall, there is low quality of care 2.8 (standard deviation [SD] = 0.6). There is low quality with regards to timeliness 2.8 (SD = 0.4), patient centeredness 2.7 (SD = 0.7), equity 2.8 (SD = 0.2), effective communication 2.7 (SD = 0.7), and safety 2.5 (SD = 0.3). Quality of care in relation to capacity and sustainability is high 3.4 (0.6). Only 73 (38.2%) of the clients are currently satisfied with the quality of care, and only 39.8% will recommend others to access care at the imaging department. Only 66 (34.6%) of clients are of the view that staff behavior instills confidence. QUALITATIVE RESULTS: The qualitative study shows a lack of equity, timeliness, and patient-centeredness in terms of care and privacy. There is a perceived lack of compliance with radiation protection protocols, and there exist wide communication gaps between clients and staff. Furthermore, there is a lack of capacity and sustainability in relation to the reliability and availability of functional equipment. There is, however, high appraisal from clients regarding the neatness and availability of staff. CONCLUSION: A majority of clients are not satisfied with the quality of care of the medical imaging services. Improved interaction with clients, availability of functional equipment, and effective communication during the care process between the patients and the imaging professionals such as provision of timely information during the waiting period and explanation of procedure will help enhance the quality of care.