Impact of universal health coverage on health service utilization: Evidence from Ghana

Abstract

clear and effective messages about safety of novel vaccines, community immunity, harmful effects of non-vaccination on children and community; Adequate dissemination on epidemiological and adverse event surveillance; A clear legal frame stating responsibilities, rights and obligations of medical staff, parents, health authorities; An informed consent for non-vaccination; Strategies for a better commitment, involvement, support of health care providers, community leaders, population , higher risk groups in implementing immunization. Key messages: There is a need for a higher commitment of health staff to support efforts to address parental hesitancy, reluctance towards early childhood vaccination. The parents' hesitancy is a combined effect of knowledge deficit, underground fears in population with non-involvement of medical staff and health authorities in facilitating adequate perceptions. Universal health coverage requires that families have access to quality health services appropriate to their needs. In Ghana, the National Health Insurance Scheme (NHIS) aims to improve access to health services unconditioned by capacity to pay. Despite impressive efforts to encourage the Ghanaian population's enrolment in the NHIS, evidence regarding the impact of health insurance on improved medical care utilization is scarce. This study examines the effect of insurance on health service utilization using data from the Ghana Living Standards Survey collected in 2012-2013. We investigate the effect of interest via fixed-effects probit analyses disaggregated by geographical proximity to care. We construct an outcome variable indicating use of medical services when an individual is ill or injured. To mitigate selection bias, we instrument participation in the NHIS via cluster insurance rate and construct matched datasets using propensity score methods. Our results show that enrolment in the NHIS significantly increases the probability of meeting medical needs (0.284, a = 0.001). The effect of health insurance on improved utilization is larger among individuals living outside a 1-hour radius to the nearest hospital (0.321, a = 0.035). Moreover, individuals in the poorest expenditure quintile have a significantly lower rate of utilization (0.149, a = 0.007) compared to their richest counterparts (0.205, a = 0.023). Our findings suggest that health insurance broadens access to needed health services. This is especially relevant for insured individuals living in geographically remote areas who would not have sought medical care otherwise. By identifying heterogenous insurance effects among vulnerable subpopula-tions, we reveal the urgency of reducing geographic barriers to care and ensuring that the poorest benefit equally from the NHIS. Findings are relevant to low and middle income countries with hard-to-serve rural populations seeking to broaden access to quality healthcare. Key messages: Universal health coverage significantly improves use of needed health services, especially among individuals living in geographically remote areas who would not have sought care otherwise. Insurance effects are heterogenous among subpopulations. Insured individuals in the poorest expenditure quintile have a lower rate of utilization compared to their richest counterparts. Addressing the gap between ANC service's intention and behavior with a focus on self-efficacy In order to encourage more women to use Antenatal Care (ANC) services, it is essential to understand how their behaviors can change and how the changes can sustain. Existing studies identify various factors influencing the use of ANC services and show that women have positive intentions to use ANC services. However, the reason for the inconsistency between intention and actual behavior still remains unclear. To address this concern, this study explores why intention does not fully translate into actual behavior, with a focus on self-efficacy, based on a qualitative study of an Maternal and Newborn Child Healthcare (MNCH) project in Ntoroko, Uganda. For this study, 11 qualitative in-depth and 14 focus group interviews were conducted with purposeful sampling. Interview data were thematically analyzed and the Health Action Process Approach (HAPA), which underlines the role of self-efficacy in the process between the motivational phase and volitional phase, informs the analytical process and discussion of the gap between intention and behavior in regard to ANC services. Our analysis shows that barriers working in the motivation phase include vague conceptualization of maternal healthcare services, negative experiences and word-of-mouth regarding unreadiness of health facilities, and ANC service systems that do not safeguard women's privacy. Unempowered women's roles in family decision-making, geographical and financial limitations, and legal regulation on husband's MNCH engagement were found to work as barrier factors in the volitional phase. Notably, these factors pertain to macro-sociocultural dimension, which limits the perceived self-efficacy in the individual dimension. To design and implement better-targeted projects, practitioners and researchers should take account of the role of self-efficacy in the process between intention and behavior. They need to understand that self-efficacy on an individual level is influenced by sociocultural levels. Key messages: To decrease the gap between MNCH service's intention and actual behavior, the role of self-efficacy has to be considered, which is interplayed with sociocultural factors. As there is no one size fits all in health behavior change, it is necessary to seek to utilize a diversity of theoretical approaches so as to understand the complex mechanisms resulting in change.