Free Health Care: How effective do Ghanaian stakeholders think it will be?
From February 2008 to March 2009, HB conducted 71 interviews
with a range of stakeholders interested in maternal health
in Ghana (including national Ministry of Health employees,
Ghana Health Service staff at national, regional and
district levels, researchers and staff from donors and
NGOs). Following the president’s announcement of the
exemption policy for national health insurance for pregnant
women in May 2008, interviewees were asked how effective
they thought the policy would be in improving maternal
health.
Although most interviewees felt the new policy may help to
some extent, there were two main issues that were expected
to prevent it from having any substantial beneficial effect.
The first was that, although the policy removed direct
financial barriers to health service utilisation, other
barriers remained which were sufficient to prevent the use
of services for many women. These include preferences for
home births and/or traditional birth attendants, lack of
transportation to facilities, as well as opportunity and
other costs associated with health service use. For this
reason some believed that the removal of fees would not lead
to increased health service utilisation, particularly for
delivery care.
“I do not think that the free maternal health exemption will
lead to reduction in maternal mortality, because there are
other things that result in maternal deaths.” 031, MoH staff
“for those who were not attending because of cost, health
insurance and the free maternal health services work, to an
extent. But…it can [only] help up to a point. But I don’t
see it as a solution to maternal health problems.” 045,
national GHS staff
The second issue was that if the policy did increase service
use, it would also increase workloads and create
overcrowding. This was believed to have two consequences.
Firstly, quality of care would suffer, as staff and
equipment would be even more overstretched than they were
before the policy. This would have a direct negative effect
on the maternal health of those attending facilities.
Secondly, as women became aware of the poor quality of care
received, they would be less likely to attend in future. As
one hospital doctor stated,
“So…when you just ask them to come…and they see the
congestion and they see the difficulty, when they go home
they will not come back. So really the problem has not been
tackled head on. Some of us will have preferred situations
which we have advocated…If we change the service, improve
the quality…Quality service is attractive and if you make it
fairly affordable, or if we improve the quality first before
we open it to be free, then people will come. But now, they
crowd on us but we are not able to delivery quality service
and so therefore we are not seeing the impact. If there is
going to be any impact it will be negative.” 029, GHS doctor
Interviewees recognised the need to increase the demand for
and use of maternal health services, but also noted that
increased workloads should be prepared for. Facilities,
equipment and staffing numbers should be expanded and
improved first, otherwise the effect may be
counterproductive. Issues of quality of care, workload and
staff attitude, as well as physical access to facilities and
community education were also considered important.
Some also pointed out that it would be more effective to
target the ‘exemptions policy’ to those who could not afford
to pay for care and the introduction of this targeted
approach was being planned, prior to the policy
announcement.
Finally it should be pointed out that the money donated by
the British government was not ‘new’, extra funds. As the
quote from a government employee shows below, the amount had
previously been agreed but was expected to be used for
general health sector support, to be decided by the
government of Ghana.
“for this year for instance we were expecting, we had an
agreement with…DfID…the £60 million was supposed to support
certain areas of the budget, not maternal health. Then
suddenly, er, the president travelled to the UK and the UK
government decided to reallocate that money to free maternal
health… it was not additional money.“ 031, MoH staff
By suddenly redirecting the funds without warning to pay for
pregnant women’s national health insurance, the planned
budget for the Ghana Health Service was left with gaping
holes which civil servants rushed to try to fill.
Competing interests:
None declared
Competing interests:
No competing interests
12 August 2009
Helen E. D. Burchett
Research Degree Student
Susannah H. Mayhew
London School of Hygiene and Tropical Medicine, WC1E 7HT
Rapid Response:
Free Health Care: How effective do Ghanaian stakeholders think it will be?
From February 2008 to March 2009, HB conducted 71 interviews
with a range of stakeholders interested in maternal health
in Ghana (including national Ministry of Health employees,
Ghana Health Service staff at national, regional and
district levels, researchers and staff from donors and
NGOs). Following the president’s announcement of the
exemption policy for national health insurance for pregnant
women in May 2008, interviewees were asked how effective
they thought the policy would be in improving maternal
health.
Although most interviewees felt the new policy may help to
some extent, there were two main issues that were expected
to prevent it from having any substantial beneficial effect.
The first was that, although the policy removed direct
financial barriers to health service utilisation, other
barriers remained which were sufficient to prevent the use
of services for many women. These include preferences for
home births and/or traditional birth attendants, lack of
transportation to facilities, as well as opportunity and
other costs associated with health service use. For this
reason some believed that the removal of fees would not lead
to increased health service utilisation, particularly for
delivery care.
“I do not think that the free maternal health exemption will
lead to reduction in maternal mortality, because there are
other things that result in maternal deaths.” 031, MoH staff
“for those who were not attending because of cost, health
insurance and the free maternal health services work, to an
extent. But…it can [only] help up to a point. But I don’t
see it as a solution to maternal health problems.” 045,
national GHS staff
The second issue was that if the policy did increase service
use, it would also increase workloads and create
overcrowding. This was believed to have two consequences.
Firstly, quality of care would suffer, as staff and
equipment would be even more overstretched than they were
before the policy. This would have a direct negative effect
on the maternal health of those attending facilities.
Secondly, as women became aware of the poor quality of care
received, they would be less likely to attend in future. As
one hospital doctor stated,
“So…when you just ask them to come…and they see the
congestion and they see the difficulty, when they go home
they will not come back. So really the problem has not been
tackled head on. Some of us will have preferred situations
which we have advocated…If we change the service, improve
the quality…Quality service is attractive and if you make it
fairly affordable, or if we improve the quality first before
we open it to be free, then people will come. But now, they
crowd on us but we are not able to delivery quality service
and so therefore we are not seeing the impact. If there is
going to be any impact it will be negative.” 029, GHS doctor
Interviewees recognised the need to increase the demand for
and use of maternal health services, but also noted that
increased workloads should be prepared for. Facilities,
equipment and staffing numbers should be expanded and
improved first, otherwise the effect may be
counterproductive. Issues of quality of care, workload and
staff attitude, as well as physical access to facilities and
community education were also considered important.
Some also pointed out that it would be more effective to
target the ‘exemptions policy’ to those who could not afford
to pay for care and the introduction of this targeted
approach was being planned, prior to the policy
announcement.
Finally it should be pointed out that the money donated by
the British government was not ‘new’, extra funds. As the
quote from a government employee shows below, the amount had
previously been agreed but was expected to be used for
general health sector support, to be decided by the
government of Ghana.
“for this year for instance we were expecting, we had an
agreement with…DfID…the £60 million was supposed to support
certain areas of the budget, not maternal health. Then
suddenly, er, the president travelled to the UK and the UK
government decided to reallocate that money to free maternal
health… it was not additional money.“ 031, MoH staff
By suddenly redirecting the funds without warning to pay for
pregnant women’s national health insurance, the planned
budget for the Ghana Health Service was left with gaping
holes which civil servants rushed to try to fill.
Competing interests:
None declared
Competing interests: No competing interests