Background to the policy
Most key informants pointed to concerns about statistics for maternal health and the need to reach the Millennium Development Goal 5 as the main driver behind the policy. The recognition that most women do not deliver with a skilled attendant was a major concern and the common perception was that removing financial barriers would facilitate access to health care service use by pregnant women. Many also raised other access barriers, including geographical, service availability, socio-cultural and informational barriers.
‘Basically, it was designed to reduce maternal mortality by improving access to women who do not use maternal health services because of financial reasons’ (respondent 3)
Most respondents showed very little awareness of the lessons learned from the earlier phase of maternal delivery exemptions, which were still technically in force when the new NHIS-based policy came in, although the application had collapsed due to lack of funding. Some referred to the earlier studies done by Immpact, but it was not clear whether these had influenced the new policy design.
The process of developing the policy
According to informants, the President announced free care for pregnant women through the NHIS in 2008. The announcement followed a visit by the President to the UK in April where it was agreed that UK funds would be used to support the policy. The guidelines had to be prepared quickly as it was announced by the President for a fixed date. It was to start from the 1st July (Republic Day – a public holiday). Maternal mortality was declared a national emergency by the Minister of Health. After this, a maternal mortality conference was held in July 2008, with representatives from across Ghana and also internationally, although the report of the meeting fails to mention the policy. A safe motherhood task force was also set up in September 2008.
The main stakeholders were the Ministry of Health (MoH), GHS, Christian Health Association of Ghana and the NHIS, who worked together on the guidelines. Policy guidelines were issued on the 27th July. They specified eligibility (all pregnant women, and newborns for the first three months of their lives) and benefits package (all health services which are normally provided within the NHIS package falling within the year, starting from the presentation of the pregnant woman to a health facility). The Ministry of Women and Children had done some advocacy for free maternal care.
Some complained that there was not enough stakeholder consultation and that the details had not been well articulated. It was generally believed that policy comes from the top down, and is developed administratively, without adequately involving implementers – for this and other policies.
‘We at the lower levels were not involved. As I said the stakeholder involvement was not good’ (respondent 6)
‘It’s political expediency - the politicians say that I want it done now, so you have to do it’ (respondent 11)
Communication of policy
Official stakeholders within the health services and the insurance scheme reported that they were informed about the policy through circulars, letters and memos. However, not all stakeholders were well informed. One of the key stakeholders, for example, was not aware that registration fees were waived for pregnant women. Not all the relevant departments in the MoH were able to recall receiving a written copy of the guidelines. Some stakeholders within the Ministry of Health were not fully aware of the details of earlier policies either. Respondents at district level also reported some lack of clarity on how to implement the policy due to different rules being applied.
‘There was some correspondence from national level sort of that tried to state what it is and what it’s not but it was not widely disseminated, there were some confusions about it and when insurance took over, the insurance started making their own rules about who qualifies and that you need to come to the hospital and get a pregnancy test and things before you go to the insurance’ (respondent 6)
Funds for training staff in how to implement the policy were said to be lacking, so communication with the health system was restricted to sending the guidelines to districts. For the public, the media, Members of Parliament and District Chief Executives took up and passed on the message of the President.
Budgeting & funding sources
Prior costing and budgeting of the policy was not done, however some estimates may have been made after the decision was taken, according to key informants. The Ministry of Finance allocates funds based on agreed annual priorities and work plans with the MoH but was not aware of any additional allocation to support this specific policy. Although the United Kingdom government supported the policy, the budget funding was already in place and the overall amount of aid was not increased, so in reality there was no new money for this policy, although a notional £4.5 million was allocated to the policy from the UK aid programme. In the first year, the MoH made a transfer to the NHIS to cover some of the costs. There continued to be some support to the implementation of the policy but it was not thought to be adequate.
‘No cost analysis was done to find out if this 4.5million, how many years it will take, how many women it’ll cover, no’ (respondent 11)
‘As up to today, nobody knows whether the money has been transferred to the health insurance or not’ (respondent 11)
There was a lack of understanding amongst these key informants of how the policy was being funded. It was assumed by many key informants to be funded separately by government (from external sources), whereas in reality the funding is internal to the NHIS, borne from its routine sources. Many informants believed that having a government budget line for the policy was important for its sustainability.
Services are repaid in a standard way for the NHIS, based on monthly claims. Reimbursement amounts are separated into service costs (based on agreed rates of fee per episode) and drugs, which are charged according to use. The fees per episode vary according to facility types, with higher level and private facilities paid at higher rates (reflecting their cost and subsidy structures).
The policy implementation is affected by the funding delays (said to average 5 months), which are more generally an issue within the NHIS, and which cause facilities to withhold free services.
‘If there are delays, it’s just the delays in payment of general health insurance claims and not on maternity alone’ (respondent 11)
‘My main concern is the arbitrariness with which the facilities can decide that this month I won’t do it because I haven’t been paid. These are some of the problems’ (respondent 3)
Some reported that reimbursements for maternal health care were handled more quickly than other general NHIS claims, but generally the process for vetting claims can be laborious and slow. Some regions within the NHIS system are currently piloting capitation, and this is reported to be causing additional problems with providers, who are resistant to this payment method.
The policy was perceived as having been kick-started by funds from the UK government. That raised concerns amongst some stakeholders about what would happen when the one-off grant ended. A number of respondents recognised that there is no dedicated longer term funding for the policy.
‘The policy is working, the only boring aspect of it is that, you know it’s for a period, when the funds are not there, how are we going to continue the policy?’ (respondent 9)
Given that the policy is implemented within the NHIS system, most stakeholders consider it is sustainable if the health insurance is sustainable and if there is political commitment.
‘It’s sustainable as much as we have the will to make it sustainable, and I can say that to the NHI as well - as long as Ghana decides that they want it to happen, it’ll happen’ (respondent 12)
However, others are sceptical about the something for nothing approach:
‘It’s not sustainable. People should contribute and I think we have the platform’ (respondent 6)
No analysis of financial impact has yet been conducted. However, in 2008 the fixed transfer to district schemes per exempted member of any type was 14 Ghanaian cedis (GhC). Overall figures for claims and expenditure were lacking to assess the adequacy of this subsidy, but in the case of pregnant women, the NHIS tariff for ANC, normal facility delivery and postnatal care at the lowest level of facility would cost just over GhC 14. Any additional complication, illness during pregnancy or seeking care at higher levels would therefore have been certain to push the cost over the subsidy level. Analysis carried out by the NHIS itself indicated that a growing deficit would accrue to the NHIS from the scheme, in the absence of additional support.
Implementation of the policy has reportedly varied due to different interpretation of the policy by various implementers. Some of these generated additional barriers for women. For example, some requirements for eligibility were imposed:
‘One day we heard that before you qualify, everybody must have a pregnancy test and then we had to go and complain that why a midwife should do a pregnancy test to tell you that this woman is pregnant, so there were certain problems. Some of them will demand a scan before you qualify for reimbursement … which was not free’ (respondent 3)
The card is given for a year and covers all care within that year (maternal and incidental, such as malaria), according to key informants. But there have been differences in local interpretation of the package of care: ‘Some of them by the mere word of abortion, then they won’t pay but if the doctor wrote miscarriage then they will pay’ (respondent 3)
‘The weaknesses are the misalignment between protocols where health insurance determine what they will pay irrespective of what the service is suppose to provide; we keep going back and f orth’ (respondent 3)
Registration was also a barrier initially. In theory people have to register, have their photo taken, get a card – all of which takes time and money and can delay access to care. At the start, there were said to be disputes over whether women could be treated without these, and how to best organise the registration process for them.
‘For example, if someone comes in Sunday, some of the insurance people say that if you treat them without being given authorisation, we won’t pay, so the person need to pay upfront’ (respondent 6)
Some of the measures were linked to trying to combat perceived fraudulent claims.
‘They say that the delivery side can be one of the weakest link that people can defraud them so they try to put in mechanisms to prevent them’ (respondent 6)
‘Human beings we are like that, we always find ways from eating from the pot. So there were some mutual suspicions on both sides and sometimes people also felt that the insurance people are not paying them their due, which is sometimes also true because they’ll take away some the money for not writing something on it so they’ll deduct something’ (respondent 6)
Certain facilities were more reluctant than others to implement the policy e.g. the teaching hospitals, which are autonomous institutions.
‘Officially, they will say they are included but unofficially they don’t give free maternal care’ (respondent 10)
Some of these issues were however resolved over time (e.g. the NHIS was now reported to be paying for scans and allows palpation to confirm pregnancy).
‘At all levels in the district, by them trying to work together, they improved their working so that it facilitated care for the women’ (respondent 6)
Management, monitoring and evaluation
Within the MoH, the policy is supposed to be monitored by the Family Health Division, but there are some organisational problems, as the midwives who are implementing the policy fall under the Institutional Care Division (ICD). In reality, this division is said to be more concerned with managing doctors and nurses, so the midwives and this policy are to some extent falling between two stools.
‘Under ICD or either safe motherhood, there is no champion midwife in either ICD or safe motherhood… maybe they need Director Midwifery Services so somebody who is the champion of midwifery services based in ICD’ (respondent 8)
The lack of champions of the policy, from national down to local level, was raised by some informants.
‘There is no champion at the regional level, there is no champion at the district, it’s only the midwife at the facility level who is managing and the one who is supervising is the medical assistant, who half of the time is a male who has done no midwifery so he can’t talk about that’ (respondent 8)
Although the policy is monitored through routine NHIS systems, no plan was elaborated from the start to monitor or evaluate this policy specifically, although one is now planned, with UNICEF support, in 2012.
‘It was part of the routine. It was integrated into the system’ (respondent 6)
The Ministry of Women and Children are meant to represent the interests of women and children in relation to other ministries, feeding back information on priority areas and problems on the ground. However, they are not well resourced and have not been able to fulfil this role very effectively over the past few years. Technical departments are also not involved in monitoring the policy per se, though they do monitor changes to coverage which may result. The NHIS keeps records of numbers of women enrolled under the policy.
Perceptions of the effects on household costs
There are various costs which are not covered by the policy, including transport and minor personal items which are required for a delivery, according to KI.
‘The financial access issue has been sorted out but it still depends, it may not be covering everything. It will not cover for instance your transport cost to the hospital and back. It will not cover the food you’ll eat and so on and so forth and certain petty things. When you are going to deliver, you need to go with a pad and all those things; it is not covering those ones but the major things done for you are covered’ (respondent 7)
The NHIS has a list of approved drugs, so drugs which are off this list are charged, though these should not generally be necessary.
‘They say it’s proprietary drug so you have to buy it and maybe they’ll say buy this or do this. I mean some of the facilities they’ll always find some excuse and take some cedis from you. In the ward, they’ll collect ward fees and they’ll ask you to bring some soap and dettol and some things’ (respondent 6)
There are also reports by informants of additional or informal charging, either opportunistic or related to delays in reimbursements by the NHIS. This is not specific to the free care policy but applies across all sorts of services. There are even cited instances of double-billing (to the patients and the NHIS).
‘You get to a facility and you are entitled to some medications, they say we don’t have and they write it for you, what do you do? You have to go and buy’ (respondent 11)
‘Some of the answers we get from some of the facilities: if I have not received reimbursement and I’m running on my own resources, then sometimes some of the things, you have to write it for the client to go and buy’ (respondent 7)
The culture of giving gifts to midwives is also cited as a factor driving informal payments, which can come to a significant cost for women.
‘They say it’s the custom of midwives that when you come and deliver, you’ll come and say thank you to the midwife… and they determine what they should bring to thank them, so they tell you they want this soap, they want this perfume, they want this piece of cloth, so in the end the money the woman spends in buying things to say thank you to the midwife is more than the fee she would have paid if she were being charged’ (respondent 8)
Perception of the effects on access
Despite these concerns, there was a feeling that the policy has reduced delays in accessing care for women.
‘The strength is that it provides access and one good thing was that even if you are not registered or on admission for complications or anything, the hospital initiates the process of getting you registered and so you don’t have to go and register before you come’ (respondent 3)
‘Breaking the financial barrier is a very big strength. Then we used to hear of children or mothers being detained because they couldn’t pay their fees, now there’s nothing like that’ (respondent 5)
However, some services seem to have increased more than others:
‘Antenatal uptake has gone up very dramatically. Assisted delivery has not gone up that much and there are service provision reasons for this, and I believe one of the reasons is certain demands that are made on the women especially when they are going to deliver’ (respondent 12)
Policy makers acknowledged that there are other barriers (financial and non-financial) to the use of health care services beside payment at the point of care. Other access barriers include distance to facilities, socio-cultural barriers, and supply-side barriers, such as the lack of availability of critical equipments and drugs at the point of need, lack of availability of skilled staff and poor attitude of providers. Other policies are in place to improve the situation – e.g. the policy of placing midwives in each community – however, these are also facing implementation challenges.
Differences in physical access to facilities also means that better off women are able to benefit disproportionately, according to some key informants.
‘One of the major weaknesses of that policy was that, it was supposed to be a pro- poor policy but it didn’t work out because of the way the facilities are sited. The facilities in our country are sited more skewed towards the urban that have money and so those who were benefitting from the free care were those who did not really need to benefit’ (respondent 6)
Perception of the effects on facilities and staff
Facilities and staff were reported to have faced increasing workloads as a result of the policy, especially in urban areas.
‘The initial problem was congestion. I think now people have come out with contingency measures and they have reorganised themselves to be able to deal with the increasing numbers, especially in the urban areas where there was serious increase’ (respondent 3)
‘It did increase the workload tremendously. The antenatals were crazy’ (respondent 6)
For the private sector, it is also reported as having driven up business:
‘The private, they are happy because it’s increased the numbers because the private used not to get many but now if they are accredited, they have those numbers’ (respondent 11)
Some comment on the inadequate resources for providers, though it is not clear whether there is any difference between this policy and others services refunded by the NHIS. (Facilities are now paid for all services using a fixed cost per episode, but with variable charging for permitted drugs, according to actual usage). The tertiary facilities are reported to be particularly unhappy with the tariffs. Others point to discrepancies in payments made to different facility types.
‘From the provider side, they also complain about the tariffs they get from health insurance. They think it’s inadequate, health insurance also thinks that whatever we put in is also inadequate so for money, it’s never enough, we just have to manage and see that the policy is carried out’ (respondent 5)
However, it is also important to note that the increase in workload had meant a reported growth in revenue for providers, which was reported to have fed into some improvement in some of the facilities.
‘The overall effect, because it was channelled through the insurance, capital influx in terms of IGF [ revenues from user fees and insurance payments] increased for facilities’ (respondent 6)
However, at individual staff level, the incentives embodied within the policy may be less encouraging, leading to some evidence of ‘passive resistance’ from providers.
‘A circular was issued to all midwives to stop collecting anything because insurance was going to pay for it but after that, in some areas, some midwives at the periphery will no longer take a labour case after eight pm’ (respondent 11)
Perceived effects on quality of care, utilisation and health outcomes
Some key informants report concerns that the increase in workload has affected quality of care negatively. Some also mentioned that there were incentives not to refer, so as to keep the full reimbursement and cost cutting by providers.
‘People were keeping patients to deliver to the end so that they also benefit or you pay for their bill before they leave, so those were some of the challenges’ (respondent 3)
‘They don’t give the necessary medications they are supposed to do because they are doing more of capitation within the program because all these cases get a certain package’ (respondent 3)
There are also some fears that the policy provides an incentive to increase fertility, and for women to make frivolous use of services, though equally others protest that both of these are not plausible. Most perceive an increase in supervised delivery rates, in caesareans in particular, and a reduction in maternal mortality.
Overall views of the policy and stakeholders’ recommendations
Key informants were positive about the policy as a whole and about the need to address financial barriers – only one advocated for a major change, involving a shift to means-tested support.
‘For the future, this policy should stay; the government should find a way to support it and all the players, everybody who has something to do with it should make sure it stays’ (respondent 2)
They made a variety of recommendations to strengthen and supplement it, including:
Better public education, to increase demand for the service
Improving access and transport, so that all can benefit, and in a timely way
Some suggest conditional cash transfers to cover transport costs
The more general cultural barriers also need to be addressed for the policy to meet its goals
Complementary measures are needed on the supply side, including ensuring that there are enough midwives.
Ensuring that the health system has the necessary supplies and facilities to provide the services
There should be good general monitoring, but also focussed on equity
In order to sustain and extend the policy, longer term funding sources need to be identified
Family planning services should be added to the package, as this is cost effective and saves lives