Skip to main content

Main menu

  • Content
    • Current Issue
    • Advance Access
    • Archive
    • Supplements
      • The Challenge Initiative Platform
      • Call for Abstracts
      • The Responsive Feedback Approach
    • Topic Collections
  • For Authors
    • Instructions for Authors
    • Submit Manuscript
    • Publish a Supplement
    • Promote Your Article
    • Resources for Writing Journal Articles
  • About
    • About GHSP
    • Editorial Team
    • Advisory Board
    • FAQs
    • Instructions for Reviewers
  • Webinars
    • Local Voices Webinar
    • Connecting Creators and Users of Knowledge
    • Publishing About Programs in GHSP
  • Other Useful Sites
    • GH eLearning
    • GHJournal Search

User menu

  • My Alerts

Search

  • Advanced search
Global Health: Science and Practice
  • Other Useful Sites
    • GH eLearning
    • GHJournal Search
  • My Alerts

Global Health: Science and Practice

Dedicated to what works in global health programs

Advanced Search

  • Content
    • Current Issue
    • Advance Access
    • Archive
    • Supplements
    • Topic Collections
  • For Authors
    • Instructions for Authors
    • Submit Manuscript
    • Publish a Supplement
    • Promote Your Article
    • Resources for Writing Journal Articles
  • About
    • About GHSP
    • Editorial Team
    • Advisory Board
    • FAQs
    • Instructions for Reviewers
  • Webinars
    • Local Voices Webinar
    • Connecting Creators and Users of Knowledge
    • Publishing About Programs in GHSP
  • Alerts
  • Visit GHSP on Facebook
  • Follow GHSP on Twitter
  • RSS
  • Find GHSP on LinkedIn
PROGRAM CASE STUDY
Open Access

Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana

John Koku Awoonor-Williams, Stephen Apanga, Ayaga A. Bawah, James F. Phillips and Patrick S. Kachur
Global Health: Science and Practice September 2022, 10(Supplement 1):e2100763; https://doi.org/10.9745/GHSP-D-21-00763
John Koku Awoonor-Williams
aFormerly of Health Service, Accra, Ghana.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: kawoonor@gmail.com
Stephen Apanga
bUniversity for Development Studies, Tamale, Ghana.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ayaga A. Bawah
cRegional Institute for Population Studies, University of Ghana, Accra, Ghana.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
James F. Phillips
dMailman School of Public Health, Columbia University, New York, NY, USA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Patrick S. Kachur
dMailman School of Public Health, Columbia University, New York, NY, USA.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
PreviousNext
  • Article
  • Figures & Tables
  • Info & Metrics
  • Comments
  • PDF
Loading

Key Findings

  • Coordinated cycles of implementation research, planning, and testing innovations and policy reforms have contributed incrementally to the Community-based Health Planning and Services (CHPS) initiative achieving national scale and improving geographic access to primary health care services at the community level.

  • Achieving and maintaining high levels of financial access through the National Health Insurance Scheme (NHIS) has been more elusive, although research and evaluation evidence has also been utilized to support implementation reforms and refinements.

  • Although the NHIS contributed to increased use of CHPS services among the poorest, this increase is skewed toward curative care treatment, rather than comprehensive primary health services that include promotive and preventive care.

Key Implications

  • Achieving universal health coverage (UHC) in Ghana requires integrating the CHPS initiative and NHIS operations into a fully functional system of care.

  • A comprehensive system-learning approach should be adopted in addressing service readiness, geographic availability, and financial access all together.

  • Additional research such as a plausibility trial of systems solutions is needed to fully integrate NHIS reform with Ghana’s Roadmap for Attaining Universal Health Coverage, 2020–2030.

ABSTRACT

Ghana is positioned to become the first country in sub-Saharan Africa to implement universal health coverage based on nationwide expansion of geographic access through the Community-based Health Planning and Services initiative. This achievement is the outcome of 3 decades of implementation research that health authorities have used for guiding the development of its primary health care program. This implementation research process has comprised Ghana’s official endorsement of the 1978 Alma Ata Declaration, leading to the institutionalization of evidence relevant to the strategic design of primary health care and national health insurance policies and services. Rather than relying solely upon the dissemination of project results, Ghana has embraced a continuous and systemic process of knowledge capture, curation, and utilization of evidence in expanding geographic access by a massive expansion in the number of community health service points that has taken decades. A multisectoral approach has been pursued that has involved the creation of systematic partnerships that included all levels of the political system, local development officials, community groups and social networks, multiple university-based disciplines, external development partners, and donors. However, efforts to achieve high levels of financial access through the roll-out of the National Health Insurance Scheme have proceeded at a less consistent pace and been fraught with many challenges. As a result, financial access has been less comprehensive than geographical access despite sequential reforms having been made to both programs. The legacy of activities and current research on primary health care and national health insurance are reviewed together with unaddressed priorities that merit attention in the future. Factors that have facilitated or impeded progress with research utilization are reviewed and implications for health systems strengthening in Ghana and elsewhere in Africa and globally are discussed.

INTRODUCTION

The World Health Organization (WHO) emphasizes that achieving universal health coverage (UHC) requires that all individuals and communities receive the health services they need without suffering financial hardship. This global health objective is formalized by the United Nations Sustainable Development Goal (SDG) target 3.81:

Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

To achieve this goal, WHO’s Thirteenth General Program of Work prioritized expanding UHC to a billion more people worldwide by 2023.1 While UHC includes the full spectrum of essential, high-quality services, its foundation is the goal of achieving a strong and resilient people-centered health system with primary health care (PHC).1 This focus provided the rationale for Ghana’s Ministry of Health’s (MOH) recent review of its strategy toward achieving UHC that involved developing a national UHC roadmap for strengthening PHC delivery by improving service availability for the population through community health services and the expansion of public health interventions.2 In this case study, we review the evidence behind programs and mechanisms that have fostered the utilization of implementation and policy research in Ghana. By gathering and interpreting data at each level of the health care system, this study exemplifies comprehensive health systems implementation research. We describe the state of progress toward expanding geographic and financial access to PHC, with an emphasis on what has been achieved and what remains to be accomplished to reach Ghana’s UHC goals.

We describe the state of progress toward expanding geographic and financial access to PHC, with an emphasis on what has been achieved and what remains to be accomplished to reach Ghana’s UHC goals.

Trends in the coverage of UHC initiatives have progressed over the past 2 decades (Figure). After a period of trial and research in the 1990s, the Community-based Health Planning and Services (CHPS) initiative entered an implementation phase in 2000 that was very gradual until 2009, when implementation accelerated, with levels of coverage eventually approaching UHC goals within the decade that followed. The Figure indicates health insurance coverage, conducted in 2008,3 2014,4 2016,5 2017,6 and 2018,7 as reported in the national statistics and surveys. The observed trend was less consistent than CHPS coverage trends, despite initially impressive gains in uptake. Based on coverage estimates for women of reproductive age from repeated nationally representative surveys, the proportion of women with valid insurance coverage peaked at roughly 60% between 2014 and 2016 and declined thereafter, hovering around 50%, even though enrollment figures may have been higher.8 This article aims to explain these trends and the contrasting coverage of CHPS and the National Health Insurance Scheme (NHIS) over the post-2000 period.

FIGURE
  • Download figure
  • Open in new tab
  • Download powerpoint
FIGURE

National Coverage of CHPS Compounds and NHIS Active Enrollment, Ghana, 1998–2021a

Abbreviations: CHPS, Community-based Health Planning and Services; NHIS, National Health Insurance Scheme.

aCHPS coverage information taken from routine National Health Information System data (red dots represent actual numbers of CHPS compounds reported annually through the National Health Information System and the trend line projects the anticipated achievement of full coverage) and NHIS enrollment estimates (blue bars) are derived from nationally representative population surveys.3–7

THE ROLE OF RESEARCH IN ATTAINING UHC

Ghana’s UHC policy has 2 interlocking components: (1) the CHPS initiative that focuses on achieving geographic access to essential services in people’s communities,9–11 and (2) the NHIS that aims to overcome financial barriers through a national social insurance program.12 Because of the systematic application of implementation research evidence to policies that were pursued, CHPS and NHIS are uniquely Ghanaian solutions to the challenges of reaching a culturally diverse, geographically dispersed, and economically disadvantaged population.13 Both have been the subject of extensive pilot testing, replication trial, knowledge management, evaluation, reflection, and policy development and reform—to ultimately achieve nationwide UHC.14

Ghana’s commitment to achieving UHC commenced with its endorsement of the 1978 Alma Ata Accord.14 However, except for launching district hospitals and subdistrict health centers, the country’s economic crises in the 1980s prevented an effective implementation of this accord. While the district hospitals and subdistrict health centers provided essential services, they were intended to receive referrals from more peripheral levels of care because most such facilities were remotely located away from rural households. The MOH responded to this problem by creating a cadre of community-based workers, called community health nurses (CHNs), and deploying these workers as PHC providers at convenient community locations.15 However, the core cost of constructing community health posts, providing essential equipment, and providing essential pharmaceuticals for CHNs was unsustainable in most rural districts. CHNs were hired and trained, but because resources for health posts and equipment were inadequate, they were deployed to hospitals and subdistrict clinics where their presence was redundant with other paramedical staff. Moreover, their clinic locations were remote from most households. By the early 1990s, it was apparent to policy makers that “health for all by the year 2000,” as envisioned at Alma Ata, was unlikely to come to fruition soon for most Ghanaians unless reform was pursued.16

The geographic accessibility problem was compounded by financial challenges. To sustain the provision of care, the MOH embraced a “cash-and-carry” policy in the 1980s that charged all patients for PHC services. Practical problems with this policy’s provisions prevented families from acquiring essential care. In response to widespread discontent with this policy, an untested “exemption policy” was launched in the 1990s that aimed to provide free services to children aged 5 years and younger. But because this policy lacked the financial support it required, PHC operations were severely disrupted by shortages of essential drugs and supplies. As the year 2000 approached, it was apparent to the policy community that developing geographically accessible services at scale required further evaluation17 and a sustainable health insurance program that required careful investigation.18,19 Research stations that had been created by the MOH were commissioned for concerted investigation of solutions to the access and insurance challenges. The Navrongo Health Research Center (NHRC) in northern Ghana was tasked with addressing the access challenge. The Dodowa Health Research Center (DHRC) in Greater Accra Region was assigned responsibility for developing and testing approaches to sustainable health insurance.

By 2000, it was apparent to the policy community that developing geographically accessible services at scale required further evaluation and a sustainable health insurance program that required careful investigation.

DEVELOPING GEOGRAPHIC ACCESS: THE CHPS INITIATIVE

To generate evidence for guiding discussions on the appropriate strategic design of a program to improve access to PHC services, the MOH requested the NHRC to pilot the deployment of nurses and volunteers to 3 communities based on the WHO “Strategic Approach”20,21 and informed by participatory planning research methods.22 A steering committee, chaired by the MOH Director of Medical Services, ensured that research would be embedded into policy planning operations,23–25 with protocols reflecting the need to address strategic questions about the appropriate operational design of community-based PHC services.

The formative pilot and experimental efforts that created CHPS led to a series of implementation studies. When these studies identified problems, research on reform was undertaken that guided the process of improving program functioning. There were 5 critical program components of PHC organization in CHPS that were the direct outcome of implementation research: (1) community engagement; (2) financing; (3) nurse training, deployment, and management; (4) essential equipment procurement and operation; (5) volunteer recruitment, deployment, and management (Table 1).

View this table:
  • View inline
  • View popup
TABLE 1.

Pragmatic Observations Associated With the Navrongo Phase 1 Pilot to Increase Access to Primary Health Care Services, Ghana

As of 2021, the national implementation of CHPS has reached 6,277 of the 6,809 targeted service catchment areas. This achievement spans over 2 decades of implementation effort.

Phase 1: Developing a Community-Based Strategy

Advocacy, based on international agency initiatives elsewhere, suggested contrasting approaches to community-based operations. UNICEF’s experience with volunteer-based services in the Republic of Benin was translated into the Bamako Initiative,26,27 which involved convening community health committees for managing revolving accounts to sustain the financing of essential drugs. Unpaid volunteers were recruited and trained to provide primary care and referral services. Several international commentators viewed the Bamako Initiative as an affordable means of achieving health for all.28 Ghana’s experience with volunteer initiatives in the 1980s raised questions about the quality of care that volunteers were capable of providing as well as reasons to doubt the sustainability of unpaid volunteer approaches.29,30 In response to the view that paid professional workers were essential to the provision of PHC, the MOH launched a program that involved training CHNs for 18 months. However, the absence of evidence on the feasibility and effectiveness of CHN deployment at the community level could not justify investment in their training.

A pilot intervention was developed to assess the feasibility of volunteer versus CHN placement in 3 communities in Kassena-Nankana district in the Upper-East Region (UER) of Ghana. Operational problems were taken to community committees for discussion. All 3 communities expressed an interest in having resident nurse access and a willingness to assemble volunteer teams for constructing interim facilities using traditional methods and materials with the understanding that their effort to create locations for services would be rewarded with the posting of a resident nurse (Box 1).

BOX 1

Community-Constructed Interim Facilities in Ghana

Figure
  • Download figure
  • Open in new tab
  • Download powerpoint

The costly construction of permanent facilities where resident nurses can live and provide care is critical to launching community-based primary health care services. Participatory appraisal of this problem generated evidence that communities would contribute volunteer labor, material, and traditional methods for interim facility construction that would be replaced with permanent structures when financing became available. Initially demonstrated in Navrongo, and replicated in Nkwanta, community construction was adopted as a routine Community-based Health Planning and Services (CHPS) component when GEHIP demonstrated procedures for routinizing the method as a means of accelerating the launching of lifesaving CHPS. © 1996 James Phillips/Population Council

Volunteer deployment was also piloted, generating experience with the process of recruitment, training, and supervision for community health volunteers. The apparent feasibility of both strategies contributed to policy commitment to proceed with community-based program planning. The relative efficacy of the pilot was assessed as a phase 2 district experiment that focused on assessing health and demographic endpoints17 that have been extensively disseminated elsewhere.31,32

Practical experiential learning from the trial that profoundly affected national operational policy had garnered less attention in the formal literature on research outcomes. The phase 1 pilot was limited to 3 communities spanning only 18 months of qualitative participatory appraisal of community reactions to services for eliciting grassroots advice in strategic planning.22 Considerable experience was nonetheless gained that was relevant to addressing practical challenges associated with community engagement, worker deployment, and financing and sustaining operations (Table 1, column 1). To clarify operational strategies to be tested in a phase 2 experiment, practical learning was shared with the MOH oversight team (Table 1, column 2), which had a lasting impact on CHPS planning, implementation, and policy (Table 1, column 3).

Phase 2: Testing the Strategy

Despite important operational lessons that phase 1 provided, the efficacy of volunteer versus CHN deployment in the community could not be resolved by a 3-community pilot. A district-wide trial was required with study arms: nurse only, volunteer only, and combined nurse and volunteer deployment. These conditions could be tested relative to the effectiveness of care limited to subdistrict and hospital clinics.

This experiment, referred to as “the Navrongo Experiment,” was configured by assigning each of the 4 subdistricts of Kassena-Nankana district to one of the worker deployment conditions, whereby all communities were exposed to 1 or both of the conditions.17 Overall community-based care was found to be affordable (US$8.72 per capita per year) and the incremental cost of CHPS implementation—incorporating both resident nurses and volunteers—was only US$1.92 per capita. Work routines, supervisory arrangements, and other important administrative details provided an evidence base for the GHS to plan national scale-up.9 Most importantly, the basic staffing parameters of the national community-based program were clarified (Table 2).

View this table:
  • View inline
  • View popup
TABLE 2.

Pragmatic Observations and Policy Outcomes Associated With the Navrongo Experiment to Increase Access to Primary Health Care Services, Ghana

Phase 3: Setting the Stage to Scale Up the Strategy

In 1998, the MOH convened a National Health Forum with all district, regional, and national directors of health services to build consensus for scaling up the Navrongo Experiment generated evidence that is summarized in Tables 1 and 2. Consensus could not be reached as debate ensued about the feasibility of transferring the Navrongo system to other districts owing to diverse environmental, cultural, and economic circumstances (Box 2).

BOX 2

The Staffing Outcome of the Navrongo Initiative: Paid Nurses and Volunteers for Optimizing Community Engagement

Figure
  • Download figure
  • Open in new tab
  • Download powerpoint

Results from the Navrongo experiment showed that volunteer deployment had no impact as a stand-alone scheme. While nurse deployment had major child survival effects, family planning and fertility results depended upon community health nurses and volunteers talking to men in the community about family planning. The joint nurse and volunteer combined staffing model was adopted as national policy. ©1996 James Phillips/Population Council

The Nkwanta District Health Director from the Volta Region of Ghana offered to test the transfer of the Navrongo approach. A 1-year reprieve on action in Navrongo was agreed upon, whereby Navrongo pilot activity was transferred to Nkwanta district to be replicated and adapted.

Results of the Nkwanta replication process are summarized in Table 3. National policies for staffing, capacity building, scale-up, operational dissemination, support systems development, and knowledge generation and management were outcomes of the Nkwanta initiative. Initially viewed as a 1-year demonstration, Nkwanta became a sustained resource, whereby teams from various districts across the country undertook peer learning exchanges, which resulted in scaling up CHPS operations nationwide for a decade.

View this table:
  • View inline
  • View popup
TABLE 3.

Pragmatic Observations and Policy Outcomes Associated With the Nkwanta Replication Process, Ghana

The Nkwanta initiative resulted in national policies for staffing, capacity building, scale-up, operational dissemination, support systems development, and knowledge generation and management.

Phase 4: Scaling Up CHPS

Although policy pronouncements endorsed the scale-up of CHPS by the year 2000, initial progress was gradual for a decade (Figure 1). Rapid scale-up of CHPS ensued in 2009, however, with national coverage subsequently expanding until most districts were saturated with functioning zones within the following decade. By 2019, this saturation was a time of consolidation of gains, with policies directed to improving coverage by splitting zones and dispersing workers. Thus, by 2021, original coverage objectives had been met, with new goals defined by the need for CHPS refinement and following the creation of new administrative areas. We consider each of these eras, in turn.

Navrongo and Nkwanta field operations were used to expand national implementation capacity through field-based demonstration activities for visiting implementation teams. Rather than focusing on individual training, the orientation process was designed to develop team implementation capacity.

Participating districts were invited to assemble a complete CHPS implementation team comprised of district health management team representatives, a subdistrict supervisor, and at least 2 community health nurses called community health officers (CHOs) who had received additional in-service training and were scheduled to implement CHPS services. Participants observed the process of implementing the 6 Nkwanta implementation milestones (1) mapping, zone planning, and initial community leadership engagement; (2) community staff orientation and training; (3) local governance development; (4) community facility construction; (5) logistics mobilization and nurse deployment; and (6) volunteer mobilization, to equip implementation teams to establish at least 1 functioning zone where Nkwanta-like CHPS start-up and management procedures could be demonstrated. Equipped with this capability, participating teams could replicate the Nkwanta zone-by-zone process of rolling out CHPS as resources, capabilities, and community commitment emerged. This approach, termed “guided diffusion” was intended to foster the spread of CHPS among communities at the district level, even before national revenue was available to cover the district-level cost of starting the program.33

CHPS Reform: A Renewed 4-Phased Process of Implementation Research

The participatory orientation program had an immediate impact. By the end of 2008, 92% of all CHPS coverage was associated with implementation activities in 32 districts where implementation teams had experienced the team-based orientation visits. However, implementation in other districts was slowed by leaders’ lack of understanding of implementation milestones and the absence of resources for start-up costs. Reviews of capacity building,34 implementation leadership,35 and community engagement in districts that were not progressing with scale-up attested to the need for CHPS implementation reform. When elements of a possible reform package were clarified by a field review of CHPS implementation challenges,35 the GHS launched a trial of reform implementation in the Upper East Region (UER). Conducted in 2010–2015, this trial tested strategies for implementing elements of the 6 WHO health systems strengthening pillars.36

Known as the Ghana Essential Health Interventions Program (GEHIP), this initiative, located in 4 districts, commenced with a participatory community appraisal of the goals of national CHPS reform. Comprising a new phase 1 component of a research agenda, this investigation highlighted practical means of addressing problems that were hampering CHPS scale-up. Followed immediately with a 4-district trial of health systems strengthening activities, GEHIP tested means of involving communities in rapid implementation activities,37 improving the provision of emergency care,38 and reforming budgeting and financial mechanisms. These efforts expanded CHPS coverage from 20% to 100% in 4 years in treatment areas within the UER.

GEHIP applied lessons from the original phase 1 Navrongo pilot for the process of convening community-engaged construction of interim community care facilities. Rather than limiting action to 3 communities, however, GEHIP applied this strategy to 4 districts, leading to rapid expansion of CHPS coverage in treatment districts. GEHIP also addressed the problem of fragmentary emergency referral services with a community-engaged program of logistics support, emergency communication, and acute care development.37,38 Comparison district increases in coverage were also pronounced, but coverage impacts were half that of GEHIP.37,38 Mortality declined throughout the UER during the GEHIP period, but observed declines were significantly greater in treatment districts than in comparison districts.39

In response, several implementation lessons were adopted by the GHS. However, the continuing need for system learning led to further study and action. With support from the Korean International Cooperation Agency, GEHIP was expanded to cover all 13 UER districts to create a region of excellence for UHC achievement.40 A concomitant transfer experiment was launched to test the replicability of GEHIP in 2 districts each in the Northern and Volta regions. This ongoing process of operational learning is termed the Program for Strengthening the Implementation of the Community-based Health Planning and Services Initiative in Ghana or CHPS+.41 Taken as a set of learning activities, CHPS+ incorporates knowledge management operations as an integral component of its embedded system of project management, research, and utilization (Table 4).42 As Table 4, column 3 shows, CHPS+ has demonstrated that GEHIP methods for fostering community-driven construction of interim facilities could be replicated, thereby minimizing start-up costs and delays that arise from expensive and complex construction procurement procedures (Box 1).43

View this table:
  • View inline
  • View popup
TABLE 4.

Pragmatic Observations and Policy Outcomes Associated With Monitoring the Scaling Up Process

EXPANDING FINANCIAL ACCESS: THE NATIONAL HEALTH INSURANCE SCHEME

Out-of-pocket payments and the uncertainty around them have long been recognized as barriers to accessing needed health services in low- and middle-income countries, including Ghana. The application of user fees was commonly recognized as 1 factor exacerbating socioeconomic inequities in the uptake of health services.43 Before 2000, Ghana had addressed some of these through targeted user fee exemptions for specific groups including pregnant women, young children, health workers, patients with a limited range of conditions (e.g., TB, leprosy, mental illness), and the extreme poor. These exemptions were not consistently applied and therefore failed to resolve financial barriers or achieve equity.44,45 In some cases, research showed that health care providers and facility managers relied on user fees to maintain operations and did not want to apply the exemptions as required.46 There had also been limited experience with social health insurance programs for formal sector employees and others able to purchase coverage in the private sector.47 These efforts did not include the vast majority of Ghanaians who subsist on the informal economy and were not “pro” poor. To address these groups, small-scale public and private sector mutual health organizations arose in several settings. These efforts to establish a community-based health insurance scheme were limited in scope—reaching only 1% of the population,48 and their terms and coverage were not well coordinated and could not be used outside their limited geographic areas.49 Despite these developments, the highly unpopular system of user fees continued to dominate, and abolishing it became a political issue in the national elections of 2000.

The NHIS was established by an Act of Parliament and signed in September 2003 “to secure the provision of basic healthcare services.”50 The legislation also established the National Health Insurance Authority (NHIA) to implement a national health insurance policy, beginning in 2005. The move was widely celebrated as one of the very first efforts by a sub-Saharan African country to provide social health insurance for all.51 A main objective of the NHIS was to reduce financial barriers by providing enrollees with a standard package of health services intended to cover 95% of all health care needs. The NHIS benefits are portable and can be accessed at any accredited health facility nationwide. The NHIS is financed by a levy on value-added taxes, contributions to the Social Security and National Insurance Trust (SSNIT) from formally employed workers, individual premiums paid by informally employed members, and returns on investments made by the National Health Insurance Fund (NHIF) through Parliamentary allocation and donor contributions.

A main objective of the NHIS was to reduce financial barriers by providing enrollees with a standard package of health services intended to cover 95% of all health care needs.

To participate as beneficiaries, individuals and households must apply in person and pay an initial registration fee and annual premiums. Some groups are exempted from paying the annual premiums, including SSNIT contributors and pensioners, as well as some groups subject to user fee exemptions already: children younger than age 18 years (whose parents enroll), persons older than age 70 years, those with physical disabilities or mental illnesses, pregnant women and newborns (since 2008), and persons and households designated indigent by the Ministry of Social Welfare.53 However, despite these exemptions, some still face some form of financial hardships. For example, except for pregnant women and newborns who have immediate access to health care services after enrollment, the rest of those exempted have to serve a waiting period of 3 months as new registrants or 1 month for defaulting in paying their annual premiums.53 The annual premium charged can vary according to a person’s income or wealth, but a standard rate is most often applied.54

The proportion of the Ghanaian population enrolled in NHIS increased rapidly in its early years, growing from 25% to 42% between 2006 and 2007.55 However, the proportion who maintained coverage after initial enrollment, especially among those required to pay annual premiums has consistently lagged behind enrollment figures. Some individuals and families could not afford the annual premiums, while others prioritized other household expenses, planned to wait until they needed health care, or simply concluded that NHIS provided too little coverage to families to justify the expense of annual renewal.56 Evidence also suggests that a substantial portion of individuals were unaware of when their coverage expired, or the need to renew through annual premiums.57 In the face of declining NHIS coverage, research also indicated that the poorest individuals in remote areas were often the least likely to enroll or renew.58 Despite these challenges, there is evidence that the NHIS is reducing out-of-pocket payments for health services.58,59 Yet, the extent of this contribution to financial access has been less than expected.59 In 2008, a Maternal Exemption Policy was added to the NHIS. The idea is to eliminate premiums for women who were pregnant and to automatically cover neonates to remove any coverage gap between birth and registration.60

Accredited health facilities that provide covered services to individuals with valid NHIS credentials can submit claims for reimbursement to recover the cost of the services provided. However, there have been challenges with ensuring timely remittances in response to these claims. At times, the NHIF has not been replenished sufficiently quickly or completely to manage all of the claims. Delays of 6 to 12 months or more have become commonplace.61 At the start of the scheme, NHIA required providers to submit itemized billing without specification of standardized fees. This process was cumbersome and contributed to the inefficient processing of claims; it also resulted in wide-ranging claim amounts for the same services. By 2008, the NHIA had introduced the Ghana Diagnosis Related Groups (GDRG) schedule that standardized fees for specific conditions at all levels of service.62 This created some additional challenges, including incentives for providers to bill for the maximum allowable, whether a full range of services was actually provided to each client.63 An investigation in 2010 demonstrated that the GDRG had failed to contain costs, particularly for outpatient services, which accounted for the majority of claims.62

Over the past decade, the sustainability of the NHIS has raised concerns for the government mainly due to the rising volume of claims and the associated unrecovered cost. As the volume and cost of claims increased, replenishment of NHIF was slower than expected.64 In 2010, as a cost containment strategy, the NHIA began exploring a capitation payment system, through which providers would be afforded a single fee per individual, meant to cater to the whole range of covered services that the beneficiary would be expected to require over the course of the year.65 The system was piloted in the Ashanti Region in 2012; however, shortly after, political enthusiasm waned, and it was never expanded nationwide.66

A major reform of the NHIS is that it provides a single benefit package to everyone nationwide who registers regardless of employment, income, or age. The package is intended to cover the majority of diseases and conditions that afflict Ghanaians67 and includes outpatient services, including diagnostic testing and operations; all maternity care services, including cesarean deliveries; most inpatient care, including surgeries, specialist services, and hospital accommodations; oral health services; emergency care; and all drugs on the essential medicines list.54 Some major surgeries, cancer treatments, and cosmetic surgeries are excluded. Some of the challenges and barriers experienced have included: adding to the demands on health infrastructure and human resources, long delays in reimbursement for covered services which affected the financial sustainability of service provision at health facilities, the costs to the population of enrolling and renewing, required copayments, and the lack of coverage for some specific services, treatments, and procedures.

A major reform of the NHIS is that it provides a single benefit package to everyone nationwide who registers regardless of employment, income, or age.

A particular challenge for achieving UHC for preventive health components of PHC is that many basic preventive services are not specifically covered.61 Initial plans earmarked at least 10% of the NHIF for preventive services, but this has yet to be realized. Instead, in the early years, NHIF covered the country’s copayment for immunizations procured through Gavi, the Global Vaccine Alliance.68 As a result of this omission, CHPS compounds—which provide the majority of preventive services and a critical amount of basic curative care—have not benefited from the NHIS to the extent of subdistrict health centers and district hospitals. In fact, some district managers have deliberately staffed CHPS compounds to be able to provide a greater volume of reimbursable curative care, potentially neglecting the CHPS initiative’s fundamental preventive and community health focus.61 Moreover, reimbursement schemes fail to address the need for CHPS outreach and community mobilization costs. The focus on care reimbursement has had a dysfunctional tendency to divert CHPS from its community-oriented care origins by emphasizing instead its role as a community-based clinical program for curative care.

A 2016 presidential technical committee reviewed the challenges associated with NHIS implementation since its inception. While this review recommended that the scheme be restricted to a compulsory primary health care and maternal and child health care provision,69 thereby enabling the scheme to be more focused and serve as a vehicle for UHC, multiple operational problems persist.

DISCUSSION

It is the goal of UHC that all people obtain the health services they need without risking financial hardship arising from unaffordable out-of-pocket payments. This involves quality health services coverage ranging from health promotion to prevention, treatment, rehabilitation, and palliation as well as coverage with a form of financial risk protection. The role of the CHPS initiative toward achieving UHC in Ghana cannot be overemphasized. Whereas the NHIS has a wide range of service packages that it pays for, these are concentrated more on treatment to the detriment of the other service coverage areas of UHC especially health promotion and prevention including outreach services which are core functions of CHPS. Current evidence suggests that the existence of the NHIS has led to increased use of the CHPS services by the poorest who are insured.70,71 However, under the current dispensation of the NHIS, this increase is only skewed toward treatment or curative care, which could negatively impact Ghana’s roadmap to achieving UHC. Even though the determinants of enrollment into the NHIS have been extensively researched, empirical evidence to determine the effect of a strengthened health system, especially the CHPS initiative, on NHIS enrollment deserves further research. This should be complemented with a new round of implementation research that addresses complete UHC integration of the NHIS with CHPS. The complementary ability of a strengthened PHC system such as CHPS and a social pool health financing mechanism such as the NHIS with a focus on PHC could serve as the best pathway toward achieving UHC.

Thus, with the development of a national UHC roadmap, continuous efforts at ensuring that Ghanaians have timely access to quality health services irrespective of their ability to pay at the point of use should be a national priority. Key strategies in operationalizing the UHC roadmap must therefore include increasing NHIS enrollment and keeping members active and making CHPS functional throughout the country.

LESSONS LEARNED

UHC in Ghana is imminent. This achievement is the consequence of 4 decades of policy formation, public investment, and action that has been grounded in Ghana’s commitment to the 1978 Alma Ata Declaration and later emphasized by Astana 2018. Research has been critical to implementing strategies that work. When scaling up rapidly progressed without research grounding, several operational problems arose. Fortunately, the process has also led to 7 key learnings based on what has worked well.

Research has been critical to implementing strategies that work toward achieving UHC.

  1. No single project or initiative has had UHC as the outcome. Rather, Ghana has instituted a process for sequential research to build on accumulated learning. Progress achieved will not end the continuous learning process; research for developing PHC will continue. The process of sequential implementation learning has been sustained by CHPS, with an apparent effect on the sustainability of CHPS itself.65,66 In contrast, the NHIS was launched based on pilot implementation. Research that ensued focused on diagnosing operational problems rather than testing implementation improvements. Results indicate a need to reverse research priorities: CHPS should have a new research agenda focused on problems and quality of care, and the NHIS should prioritize implementation research for achieving sustainable mass coverage as well as complete integration of NHIS and CHPS.

  2. The CHPS learning process constitutes an example of embedded implementation science,23,72,73 while NHIS research has been planned, conducted, and disseminated by researchers. CHPS research directions and findings are owned by the government GHS leadership structure, while NHIS research is external to the system that it aims to improve. The CHPS integrated and comanaged approach maximizes prospects that research outcomes will serve as program implementation inputs.

  3. Key policy-relevant evidence has been institutionalized through deliberate knowledge management—through active and ongoing engagement between policy makers, implementation authorities, and researchers—and not merely passively disseminated. Research has used mixed methods, always with a theoretical grounding that permits rigorous inference, and scaling up has been the subject of research, not just a decree at the end of each project phase or research episode. Carefully designed mixed method research has provided valuable insights into NHIS functioning, coverage, and impact.

  4. External financing has been critical to the conduct of NHIS research but not controlling. Multiple donors have been involved in NHIS research, but none directed or financed operations on these initiatives. In general, the NHIS research has benefited from avoiding cooperating agency implementation activities. Several donors that have been engaged in CHPS implementation have often used their own systems of operations and procurement that have been dysfunctional to the GHS administrative procedures, processes, and ownership.

  5. CHPS and NHIS research operated at all levels of the system, unified by a system-thinking perspective. In both the NHIS and CHPS development domains, political leadership engagement contributed to UHC's impact when the research system policy system engaged all levels of the political system. All aspects of the intervention are integrated: no particular modality, service strategy, or technical input has dominated the research operation; for the health insurance system, all levels of the health care operation have been the focus of research.

  6. Learning takes time, especially in complex systems contexts. Projects can have artificial timelines; processes must be sustained beyond the duration of any particular project. Even as UHC approaches, the need for system learning continues. Both the NHIS and CHPS have complex implementation challenges to address in the future.

  7. For both the NHIS and CHPS, failure and setbacks have been the focus of learning and corrective action rather than an outcome that terminates investigation. Diagnostic research has been a continuous component of the learning process. Problems that persist will now be the subject of forthcoming investigation and action. Achieving UHC involves integrating the CHPS initiative and NHIS operations into a combined fully functional system of care. While the concomitant presence of CHPS with NHIS represents progress to this end, operational details of this partnership merit further implementation research. Cost recovery arrangements support the provision of CHPS clinical services, but inadequately address links between NHIS reimbursement mechanisms and CHPS outreach, preventive services, and community engagement operations. Accessible services will fail to achieve UHC if achieving financial accessibility remains elusive. For this reason, a comprehensive system-learning approach should not be limited to addressing service readiness, geographic availability, and financial access in isolation.

For the NHIS and CHPS, failure and setbacks have been the focus of learning and corrective action rather than an outcome that terminates investigation.

FUTURE DIRECTIONS

Further systems trials and investigations are needed that aim to develop a fully functional UHC system in trial districts, using Ghana’s recently implemented CHPS+ project with its functioning PHC system as a platform for implementation research on developing and testing NHIS reform.

What would such an investigation entail? To progress toward UHC, a new phased implementation research initiative is needed that builds on the successes of the CHPS process of sequential investigation and that addresses the deficiencies of the NHIS program highlighted in insightful studies. This research program should use the informative strategy of NHIS research on diagnosing operational problems to investigate CHPS quality and operational problems associated with functionality. The following 4 overlapping phases could be pursued.

To progress toward UHC, a new phased implementation research initiative is needed that builds on the successes of past research and addresses deficiencies.

  1. A strategic crossover approach would commence with a rapid qualitative systems appraisal of health care worker, supervisor, and district manager reactions to investigator-posited improvements in the total system of care, focusing primarily on possible NHIS reform.

  2. Based on the lessons learned, stakeholders could launch a new plausibility trial in districts that have achieved advanced coverage with CHPS operations but where possible flaws in the regimen of CHPS services require investigation.

  3. In response to phase 2 continuous observation of the district trial, knowledge management and systems research inference could be managed in conjunction with replication activities, designed to assess the scaling up potential of the NHIS reforms that are under investigation.

  4. When phase 3 scale-up procedures have evidence to guide action, a national reform of NHIS and CHPS could proceed with evidence to guide the national reform process.

The role of research in guiding UHC remains crucial and would evolve as health system changes and programs mature over time. Achieving UHC will require incremental operational learning and a flexible research and program paradigm to ensure that findings from embedded IR can be incorporated into policy implementation processes as they arise, even when the coverage of the NHIS and CHPS is complete. Research strategies that have contributed to CHPS and NHIS development in the past merit review and utilization for addressing UHC development needs in the future.

Acknowledgments

We wish to acknowledge the support provided for this study by the Doris Duke Charitable Foundation and express our thanks to the Ghana Health Service and Ministry of Health as well as the participants and other partners whose collaboration was key to the lessons reported in this article.

Author contributions

All coauthors contributed to conceptualizing this article. Original drafts were prepared by JKAW with contributions from SA, AAB, SPK, and JFP. All authors approved the final submission.

Competing interests

None declared.

Notes

Peer Reviewed

Cite this article as: Awoonor-Williams JK, Apanga S, Bawah AA, et al. Using health systems and policy research to achieve universal health coverage in Ghana. Glob Health Sci Pract. 2022;10(4)(Suppl 1): e2100763. https://doi.org/10.9745/GHSP-D-21-00763

  • Received: December 8, 2021.
  • Accepted: May 31, 2022.
  • Published: September 15, 2022.
  • © Awoonor-Williams et al.

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit https://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-21-00763

REFERENCES

  1. 1.↵
    World Health Organization (WHO). Promote Health, Keep the World Safe, Serve the Vulnerable: Thirteenth General Programme of Work, 2019–2023. WHO; 2018. Accessed June 16, 2022. https://apps.who.int/iris/bitstream/handle/10665/324775/WHO-PRP-18.1-eng.pdf
  2. 2.↵
    Republic of Ghana. Ministry of Health (MOH). Ghana’s Roadmap for Attaining Universal Health Coverage, 2020–2030. MOH; 2021. Accessed June 16, 2022. https://www.moh.gov.gh/wp-content/uploads/2021/08/UHC-Roadmap-2020-2030.pdf
  3. 3.↵
    Ghana Statistical Service (GSS); Ghana Health Service (GHS); ICF Macro. Ghana Demographic and Health Survey 2008. GSS/GHS/ICF Macro; 2009. Accessed June 16, 2022. https://dhsprogram.com/pubs/pdf/FR221/FR221[13Aug2012].pdf
  4. 4.↵
    Ghana Statistical Service (GSS); Ghana Health Service (GHS); ICF International. Ghana Demographic and Health Survey 2014. GSS/GHS/ICF International; 2015. Accessed June 16, 2022. https://dhsprogram.com/pubs/pdf/FR307/FR307.pdf
  5. 5.↵
    Ghana Statistical Service (GSS); Ghana Health Service (GHS); ICF International. Ghana Malaria Indicator Survey 2016. GSS/GHS/ICF International; 2017. Accessed June 16, 2022. https://dhsprogram.com/pubs/pdf/MIS26/MIS26.pdf
  6. 6.↵
    Ghana Statistical Service (GSS); Ghana Health Service (GHS); ICF International. Ghana Maternal Health Survey 2017: Key Indicators Report. GSS/GHS/ICF International; 2018. Accessed June 16, 2022. https://www2.statsghana.gov.gh/docfiles/PR95.pdf
  7. 7.↵
    Ghana Statistical Service (GSS); ICF. Ghana Malaria Indicator Survey 2019. GSS/ICF; 2020. Accessed June 16, 2022. https://dhsprogram.com/pubs/pdf/MIS35/MIS35.pdf
  8. 8.↵
    Ghana Statistical Service (GSS). Ghana Multiple Indicator Cluster Survey With an Enhanced Malaria Module and Biomarker, 2011, Final Report. GSS; 2011. Accessed June 16, 2022. https://www.dhsprogram.com/pubs/pdf/FR262/FR262.pdf
  9. 9.↵
    Ghana Health Service (GHS). The Community-Based Health Planning and Services (CHPS) Initiative. GHS; 1999.
  10. 10.
    Ghana Health Service (GHS). Community Health Planning and Services (CHPS): The Operational Policy. Ghana Health Service Policy Document No. 20. GHS; 2005.
  11. 11.↵
    Ghana Health Service (GHS). Ghana Health Service 2016 Annual Report. GHS; 2017. Accessed June 16, 2022. https://www.moh.gov.gh/wp-content/uploads/2017/09/2016-Annual-Report.pdf
  12. 12.↵
    1. Wang H,
    2. Otoo N,
    3. Dsane-Selby L
    . Ghana National Health Insurance Scheme: Improving Financial Sustainability Based on Expenditure Review. World Bank; 2017. Accessed June 16, 2022. https://openknowledge.worldbank.org/bitstream/handle/10986/27658/9781464811173.pdf
  13. 13.↵
    1. Awoonor-Williams JK,
    2. Appiah-Denkyira E
    . Bridging the intervention-implementation gap in primary health care delivery: the critical role of integrated implementation research. BMC Health Serv Res. 2017;17(Suppl 3):772. doi:10.1186/s12913-017-2663-8. pmid:29297396
    OpenUrlCrossRefPubMed
  14. 14.↵
    1. Bishai D,
    2. Schleif M
    Phillips JF Binka FN Williams JKA Bawah AA Awoonor-Williams JK Bawah AA. Four decades of community-based primary health care development in Ghana. In: Bishai D, Schleif M, F, eds. Achieving Health for All: Primary Health Care in Action. Johns Hopkins University Press; 2020:225–257. Accessed June 16, 2022. https://muse.jhu.edu/chapter/2715639/pdf
    OpenUrl
  15. 15.↵
    1. Awoonor-Williams JK,
    2. Sory EK,
    3. Nyonator FK,
    4. Phillips JF,
    5. Wang C,
    6. Schmitt ML
    . Lessons learned from scaling up a community-based health program in the Upper East Region of northern Ghana. Glob Health Sci Pract. 2013;1(1):117–133. doi:10.9745/GHSP-D-12-00012. pmid:25276522
    OpenUrlAbstract/FREE Full Text
  16. 16.↵
    World Health Organization (WHO). Progress Towards Health for All: Statistics of Member States, 1994. WHO; 1994. Accessed June 16, 2022. https://apps.who.int/iris/bitstream/handle/10665/61755/WHO_HST_GSP_94.1.pdf
  17. 17.↵
    1. Binka FN,
    2. Nazzar A,
    3. Phillips JF
    . The Navrongo community health and family planning project. Stud Fam Plann. 1995;26(3):121–139. doi:10.2307/2137832. pmid:7570763
    OpenUrlCrossRefPubMed
  18. 18.↵
    Republic of Ghana. Ministry of Health (MOH). National Health Insurance Policy Framework. MOH; 2002.
  19. 19.↵
    1. Agyepong IA,
    2. Adjei S
    . Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme. Health Policy Plan. 2007;23(2):150–160. doi:10.1093/heapol/czn002. pmid:18245803
    OpenUrlCrossRefPubMed
  20. 20.↵
    1. Fajans P,
    2. Simmons R,
    3. Ghiron L
    . Helping public sector health systems innovate: the strategic approach to strengthening reproductive health policies and programs. Am J Public Health. 2006;96(3):435–440. pmid:16449594
    OpenUrlCrossRefPubMed
  21. 21.↵
    1. Bawah A,
    2. Welaga P,
    3. Azongo DK,
    4. Wak G,
    5. Phillips JF,
    6. Oduro A
    . Road traffic fatalities - a neglected epidemic in rural northern Ghana: evidence from the Navrongo demographic surveillance system. Inj Epidemiol. 2014;1(1):22. doi:10.1186/s40621-014-0022-3. pmid:27747657
    OpenUrlCrossRefPubMed
  22. 22.↵
    1. Baum F,
    2. MacDougall C,
    3. Smith D
    . Participatory action research. J Epidemiol Community Health. 2006;60(10):854–857. doi:10.1136/jech.2004.028662. pmid:16973531
    OpenUrlAbstract/FREE Full Text
  23. 23.↵
    1. Koon AD,
    2. Nambiar D,
    3. Rao KD
    . Embedding of Research Into Decision-Making Processes. Alliance for Health Policy and Systems Research; 2012. Accessed June 16, 2022. https://assets.publishing.service.gov.uk/media/57a08a68e5274a31e00005b2/alliancehpsr_backgroundpaperembeddingresearch.pdf
  24. 24.
    1. Ghaffar A,
    2. Langlois EV,
    3. Rasanathan K,
    4. Peterson S,
    5. Adedokun L,
    6. Tran NT
    . Strengthening health systems through embedded research. Bull World Health Organ. 2017;95(2):87. pmid:28250505
    OpenUrlCrossRefPubMed
  25. 25.↵
    1. Varallyay NI,
    2. Bennett SC,
    3. Kennedy C,
    4. Ghaffar A,
    5. Peters DH
    . How does embedded implementation research work? Examining core features through qualitative case studies in Latin America and the Caribbean. Health Policy Plan. 2020;35(Suppl 2):ii98–ii111. doi:10.1093/heapol/czaa126. pmid:33156937
    OpenUrlCrossRefPubMed
  26. 26.↵
    1. Chabot J
    . The Bamako initiative. Lancet. 1988;332(8624):1366–1367. doi:10.1016/S0140-6736(88)90903-8. pmid:2904082
    OpenUrlCrossRefPubMed
  27. 27.↵
    1. Knippenberg R,
    2. Levy-Bruhl D,
    3. Osseni R,
    4. Drame K,
    5. Soucat A,
    6. Debeugny C
    . The Bamako initiative: primary health care experience. Child Trop. 1990;n184–185.
  28. 28.↵
    1. Ridde V
    . Is the Bamako Initiative still relevant for West African health systems? Int J Health Serv. 2011;41(1):175–184. doi:10.2190/HS.41.1.l. pmid:21319728
    OpenUrlCrossRefPubMed
  29. 29.↵
    1. Ward WB,
    2. Neumann AK,
    3. Pappoe ME
    . Community health education in rural Ghana: the Danfa Project—an assessment of accomplishments. Int Q Community Health Educ. 1981;2(2):143–155. doi:10.2190/Q5L9-K74B-8UP6-MQMD. pmid:20841082
    OpenUrlCrossRefPubMed
  30. 30.↵
    1. Ampofo DA,
    2. Nicholas DD,
    3. Ofosu-Amaah S,
    4. Blumenfeld S,
    5. Neumann AK
    . The Danfa family planning program in rural Ghana. Stud Fam Plann. 1976;7(10):266–274. doi:10.2307/1966342. pmid:973241
    OpenUrlCrossRefPubMed
  31. 31.↵
    1. Phillips J,
    2. Bawah AA,
    3. Binka FN
    . Accelerating reproductive and child health programme impact with community-based services: the Navrongo experiment in Ghana. Bull World Health Organ. 2006;84(12):949–955. pmid:17242830
    OpenUrlCrossRefPubMed
  32. 32.↵
    1. Binka FN,
    2. Bawah AA,
    3. Phillips JF,
    4. Hodgson A,
    5. Adjuik M,
    6. MacLeod B
    . Rapid achievement of the child survival millennium development goal: evidence from the Navrongo experiment in Northern Ghana. Trop Med Int Health. 2007;12(5):578–593. doi:10.1111/j.1365-3156.2007.01826.x. pmid:17445125
    OpenUrlCrossRefPubMed
  33. 33.↵
    1. Nyonator FK,
    2. Awoonor-Williams JK,
    3. Phillips JF,
    4. Jones TC,
    5. Miller RA
    . The Ghana Community-based Health Planning and Services Initiative for scaling up service delivery innovation. Health Policy Plan. 2005;20(1):25–34. doi:10.1093/heapol/czi003. pmid:15689427
    OpenUrlCrossRefPubMed
  34. 34.↵
    1. Adjei S,
    2. Seddoh A,
    3. de-Graft Aikins A,
    4. et al
    . Evaluation of Capacity Development at District Level of the Health Sector in Ghana (2006-2009): Evidence-Based Case Study. Ghana Ministry of Health; 2010. Accessed June 16, 2022. https://docplayer.net/1170730-Evaluation-of-capacity-development-at-district-level-of-the-health-sector-in-ghana-2006-2009-evidence-based-case-study.html
  35. 35.↵
    1. Binka FN,
    2. Aikins M,
    3. Sackey SO,
    4. et al
    . In-depth Review of the Community-Based Health Planning Services (CHPS) Programme: A Report of the Annual Health Sector Review, 2009. Ghana Ministry of Health; 2009.
  36. 36.↵
    World Health Organization (WHO). Everybody’s Business – Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for Action. WHO; 2007. Accessed June 16, 2022. https://apps.who.int/iris/handle/10665/43918
  37. 37.↵
    1. Awoonor-Williams JK,
    2. Bawah AA,
    3. Nyonator FK,
    4. et al
    . The Ghana essential health interventions program: a plausibility trial of the impact of health systems strengthening on maternal & child survival. BMC Health Serv Res. 2013;13(Suppl 2):S3. doi:10.1186/1472-6963-13-S2-S3. pmid:23819518
    OpenUrlCrossRefPubMed
  38. 38.↵
    1. Awoonor-Williams JK,
    2. Patel S,
    3. Hammond E,
    4. Phillips J
    . Lessons learned from a community-engaged emergency referral systems-strengthening initiative in a remote, impoverished setting of northern Ghana. J Transp Health. 2016;3(2):S48. doi:10.1016/j.jth.2016.05.103
    OpenUrlCrossRef
  39. 39.↵
    1. Bawah AA,
    2. Awoonor-Williams JK,
    3. Asuming PO,
    4. et al
    . The child survival impact of the Ghana Essential Health Interventions Program: a health systems strengthening plausibility trial in Northern Ghana. PLoS One. 2019;14(6):e0218025. doi:10.1371/journal.pone.0218025. pmid:31188845
    OpenUrlCrossRefPubMed
  40. 40.↵
    Republic of Ghana. Ministry of Health (MOH); Ghana Health Service; Korean International Cooperation Agency. Project for Improving Community-Based Primary Healthcare Through CHPS Strengthening (CHPS+). MOH; 2016.
  41. 41.↵
    1. Phillips JF,
    2. Awoonor-Williams JK,
    3. Bawah AA,
    4. et al
    . What do you do with success? The science of scaling up a health systems strengthening intervention in Ghana. BMC Health Serv Res. 2018;18(1):484. doi:10.1186/s12913-018-3250-3. pmid:29929512
    OpenUrlCrossRefPubMed
  42. 42.↵
    1. Awoonor-Williams JK,
    2. Phillips JF
    . Developing organizational learning for scaling-up community-based primary health care in Ghana. Learn Health Syst. 2021;6(1):e10282. doi:10.1002/lrh2.10282. pmid:35036554
    OpenUrlCrossRefPubMed
  43. 43.↵
    1. Awoonor-Williams JK,
    2. Schmitt ML,
    3. Patel SN,
    4. Asuru R,
    5. Phillips JF
    . Making the System Work: Lessons Learned on Strengthening Ghana’s Community-Based Health Planning and Services (Part A). UNICEF; 2017.
  44. 44.↵
    1. Nyonator F,
    2. Kutzin J
    . Health for some? The effects of user fees in the Volta Region of Ghana. Health Policy Plan. 1999;14(4):329–341. doi:10.1093/heapol/14.4.329. pmid:10787649
    OpenUrlCrossRefPubMed
  45. 45.↵
    1. Novignon J,
    2. Atakorah YB,
    3. Chijere Chirwa G
    . Exemption for the poor or the rich? An assessment of socioeconomic inequalities in Ghana’s national health insurance exemption policies. Health Policy Plan. 2021;36(7):1058–1066. doi:10.1093/heapol/czab059. pmid:34050736
    OpenUrlCrossRefPubMed
  46. 46.↵
    1. Agyepong IA,
    2. Nagai RA
    . “We charge them; otherwise we cannot run the hospital” front line workers, clients and health financing policy implementation gaps in Ghana. Health Policy. 2011;99(3):226–233. doi:10.1016/j.healthpol.2010.09.018. pmid:21071106
    OpenUrlCrossRefPubMed
  47. 47.↵
    1. Huff-Rousselle M,
    2. Akuamoah-Boateng J
    . The first private sector health insurance company in Ghana. Int J Health Plann Manage. 1998;13(2):165–175. doi:10.1002/(SICI)1099-1751(199804/06)13:2%3c165::AID-HPM505%3e3.0.CO;2-X. pmid:10185507
    OpenUrlCrossRefPubMed
  48. 48.↵
    1. Atim C,
    2. Grey S,
    3. Apoya P,
    4. Anie SJ,
    5. Aikins M
    . A Survey of Health Financing Schemes in Ghana. Partners for Health Reformplus, Abt Associates; 2001. Accessed June 16, 2022. http://hubrural.org/IMG/pdf/ghana_survey_health_financing_schemes.pdf
  49. 49.↵
    1. Baltussen R,
    2. Bruce E,
    3. Rhodes G,
    4. Narh-Bana SA,
    5. Agyepong I
    . Management of mutual health organizations in Ghana. Trop Med Int Health. 2006;11(5):654–659. doi:10.1111/j.1365-3156.2006.01621.x. pmid:16640618
    OpenUrlCrossRefPubMed
  50. 50.↵
    National Health Insurance Act, 2003, Act 650. Parliament of Ghana (2003). Accessed June 16, 2022. https://acts.ghanajustice.com/actsofparliament/national-health-insurance-act-2003-act-650/
  51. 51.↵
    1. Kirigia JM,
    2. Preker A,
    3. Carrin G,
    4. Mwikisa C,
    5. Diarra-Nama AJ
    . An overview of health financing patterns and the way forward in the WHO African Region. East Afr Med J. 2006;83(9)(Suppl):S1–S28. doi:10.4314/eamj.v83i9.9492. pmid:17476860
    OpenUrlCrossRefPubMed
  52. 52.
    1. Witter S,
    2. Garshong B,
    3. Ridde V
    . An exploratory study of the policy process and early implementation of the free NHIS coverage for pregnant women in Ghana. Int J Equity Health. 2013;12(1):16. doi:10.1186/1475-9276-12-16. pmid:23446355
    OpenUrlCrossRefPubMed
  53. 53.↵
    About us. National Health Insurance Scheme. Accessed June 16, 2022. http://www.nhis.gov.gh/about.aspx
  54. 54.↵
    1. Blanchet NJ,
    2. Fink G,
    3. Osei-Akoto I
    . The effect of Ghana’s National Health Insurance Scheme on health care utilisation. Ghana Med J. 2012;46(2):76–84. pmid:22942455
    OpenUrlPubMed
  55. 55.↵
    Ghana Statistical Service (GSS); Ghana Health Service (GHS); Macro International. Ghana Maternal Health Survey, 2007. GSS/GHS/Macro International; 2008. Accessed June 16, 2022. https://dhsprogram.com/pubs/pdf/FR227/FR227.pdf
  56. 56.↵
    1. Nsiah-Boateng E,
    2. Aikins M
    . Trends and characteristics of enrolment in the National Health Insurance Scheme in Ghana: a quantitative analysis of longitudinal data. Glob Health Res Policy. 2018;3(1):32. doi:10.1186/s41256-018-0087-6. pmid:30460332
    OpenUrlCrossRefPubMed
  57. 57.↵
    1. Kanmiki EW,
    2. Bawah AA,
    3. Akazili J,
    4. et al
    . Unawareness of health insurance expiration status among women of reproductive age in Northern Ghana: implications for achieving universal health coverage. J Health Popul Nutr. 2019;38(1):34. doi:10.1186/s41043-019-0190-4. pmid:31775904
    OpenUrlCrossRefPubMed
  58. 58.↵
    1. Akazili J,
    2. Welaga P,
    3. Bawah A,
    4. et al
    . Is Ghana’s pro-poor health insurance scheme really for the poor? Evidence from Northern Ghana. BMC Health Serv Res. 2014;14(1):637. doi:10.1186/s12913-014-0637-7. pmid:25494816
    OpenUrlCrossRefPubMed
  59. 59.↵
    1. Kanmiki EW,
    2. Bawah AA,
    3. Phillips JF,
    4. et al
    . Out-of-pocket payment for primary healthcare in the era of national health insurance: evidence from northern Ghana. PLoS One. 2019;14(8):e0221146. doi:10.1371/journal.pone.0221146. pmid:31430302
    OpenUrlCrossRefPubMed
  60. 60.↵
    1. Bonfrer I,
    2. Breebaart L,
    3. Van de Poel E
    . The effects of Ghana’s National Health Insurance Scheme on maternal and infant health care utilization. PLoS One. 2016;11(11):e0165623. doi:10.1371/journal.pone.0165623. pmid:27835639
    OpenUrlCrossRefPubMed
  61. 61.↵
    1. Awoonor-Williams JK,
    2. Tindana P,
    3. Dalinjong PA,
    4. Nartey H,
    5. Akazili J
    . Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of Primary Health Care? Perspectives of key stakeholders in northern Ghana. BMC Int Health Hum Rights. 2016;16(1):21. doi:10.1186/s12914-016-0096-9. pmid:27595842
    OpenUrlCrossRefPubMed
  62. 62.↵
    1. Koduah A,
    2. van Dijk H,
    3. Agyepong IA
    . Technical analysis, contestation and politics in policy agenda setting and implementation: the rise and fall of primary care maternal services from Ghana’s capitation policy. BMC Health Serv Res. 2016;16(1):323. doi:10.1186/s12913-016-1576-2. pmid:27473662
    OpenUrlCrossRefPubMed
  63. 63.↵
    1. Agyepong IA,
    2. Aryeetey GC,
    3. Nonvignon J,
    4. et al
    . Advancing the application of systems thinking in health: provider payment and service supply behaviour and incentives in the Ghana National Health Insurance Scheme – a systems approach. Health Res Policy Syst. 2014;12(1):35. doi:10.1186/1478-4505-12-35. pmid:25096303
    OpenUrlCrossRefPubMed
  64. 64.↵
    National Health Insurance Authority. National Health Insurance Scheme Annual Report 2011. National Health Insurance Authority; 2011. Accessed June 16, 2022. https://www.nhis.gov.gh/files/annualreport2011.pdf
  65. 65.↵
    1. Andoh-Adjei FX,
    2. Spaan E,
    3. Asante FA,
    4. Mensah SA
    , Van der Velden K. A narrative synthesis of illustrative evidence on effects of capitation payment for primary care: lessons for Ghana and other low/middle-income countries. Ghana Med J. 2017;50(4):207–219. doi:10.4314/gmj.v50i4.3. pmid:28579626
    OpenUrlCrossRefPubMed
  66. 66.↵
    1. Abiiro GA,
    2. Alatinga KA,
    3. Yamey G
    . Why did Ghana’s national health insurance capitation payment model fall off the policy agenda? A regional level policy analysis. Health Policy Plan. 2021;36(6):869–880. doi:10.1093/heapol/czab016. pmid:33956959
    OpenUrlCrossRefPubMed
  67. 67.↵
    1. Witter S,
    2. Garshong B
    . Something old or something new? Social health insurance in Ghana. BMC Int Health Hum Rights. 2009;9(1):20. doi:10.1186/1472-698X-9-20. pmid:19715583
    OpenUrlCrossRefPubMed
  68. 68.↵
    National Health Insurance Authority. National Health Insurance Authority 2013 Annual Report. National Health Insurance Authority; 2014. Accessed June 16, 2022. https://www.nhis.gov.gh/files/2013%20Annual%20Report-Final%20ver%2029.09.14.pdf
  69. 69.↵
    NHIS Review Committee recommends free primary healthcare for all. National Health Insurance Scheme. April 20, 2021. Accessed June 16, 2022. https://www.nhis.gov.gh/News/nhis-review-committee-recommends-free-primary-healthcare-for-all--4083
  70. 70.↵
    1. Sakeah E,
    2. Doctor HV,
    3. McCloskey L,
    4. Bernstein J,
    5. Yeboah-Antwi K,
    6. Mills S
    . Using the community-based health planning and services program to promote skilled delivery in rural Ghana: socio-demographic factors that influence women utilization of skilled attendants at birth in Northern Ghana. BMC Public Health. 2014;14(1):344. doi:10.1186/1471-2458-14-344. pmid:24721385
    OpenUrlCrossRefPubMed
  71. 71.↵
    1. Dalinjong PA,
    2. Welaga P,
    3. Akazili J,
    4. et al
    . The association between health insurance status and utilization of health services in rural Northern Ghana: evidence from the introduction of the National Health Insurance Scheme. J Health Popul Nutr. 2017;36(1):42. doi:10.1186/s41043-017-0128-7. pmid:29237493
    OpenUrlCrossRefPubMed
  72. 72.↵
    1. Langlois EV,
    2. Mancuso A,
    3. Elias V,
    4. Reveiz L
    . Embedding implementation research to enhance health policy and systems: a multi-country analysis from ten settings in Latin America and the Caribbean. Health Res Policy Syst. 2019;17(1):85. doi:10.1186/s12961-019-0484-4. pmid:31615511
    OpenUrlCrossRefPubMed
  73. 73.↵
    1. Olivier J,
    2. Whyle E,
    3. Gilson L
    . Embedded Health Policy and Systems Research: A Rapid Scoping Review. Report for the Alliance for Health Policy and Systems Research. Alliance for Health Policy and Systems Research; 2018.
  74. 74.
    1. Tindana PO,
    2. Rozmovits L,
    3. Boulanger RF,
    4. et al
    . Aligning community engagement with traditional authority structures in global health research: a case study from northern Ghana. Am J Public Health. 2011;101(10):1857–1867. doi:10.2105/AJPH.2011.300203. pmid:21852635
    OpenUrlCrossRefPubMed
  75. 75.
    1. Nazzar A,
    2. Adongo PB,
    3. Binka FN,
    4. Phillips JF,
    5. Debpuur C
    . Developing a culturally appropriate family planning program for the Navrongo experiment. Stud Fam Plann. 1995;26(6):307–324. doi:10.2307/2138097. pmid:8826071
    OpenUrlCrossRefPubMed
  76. 76.
    1. Bawah AA,
    2. Akweongo P,
    3. Simmons R,
    4. Phillips JF
    . Women’s fears and men’s anxieties: the impact of family planning on gender relations in northern Ghana. Stud Fam Plann. 1999;30(1):54–66. doi:10.1111/j.1728-4465.1999.00054.x. pmid:10216896
    OpenUrlCrossRefPubMed
  77. 77.
    1. Debpuur C,
    2. Phillips JF,
    3. Jackson EF,
    4. Nazzar A,
    5. Ngom P,
    6. Binka FN
    . The impact of the Navrongo Project on contraceptive knowledge and use, reproductive preferences, and fertility. Stud Fam Plann. 2002;33(2):141–164. doi:10.1111/j.1728-4465.2002.00141.x. pmid:12132635
    OpenUrlCrossRefPubMed
  78. 78.
    1. Wells Pence B,
    2. Nyarko P,
    3. Phillips JF,
    4. Debpuur C
    . The effect of community nurses and health volunteers on child mortality: the Navrongo Community Health and Family Planning Project. Scand J Public Health. 2007;35(6):599–608. doi:10.1080/14034940701349225. pmid:17852975
    OpenUrlCrossRefPubMed
  79. 79.
    1. Awoonor-Williams JK,
    2. Feinglass ES,
    3. Tobey R,
    4. Vaughan-Smith MN,
    5. Nyonator FK,
    6. Jones TC
    . Bridging the gap between evidence-based innovation and national health-sector reform in Ghana. Stud Fam Plann. 2004;35(3):161–177. doi:10.1111/j.1728-4465.2004.00020.x. pmid:15511060
    OpenUrlCrossRefPubMed
  80. 80.
    1. Awoonor-Williams JK,
    2. Sory EK,
    3. Phillips JF,
    4. Nyonator FK
    . A Case Study in Successful Health System Development in a Challenging Environment: Rapid Progress With Scale-Up of Community-Based Primary Health Care in an Impoverished Region of Northern Ghana. World Health Organization; 2013.
  81. 81.
    1. Malarcher S
    1. Awoonor-Williams JK,
    2. Vaughan-Smith MN,
    3. Phillips JF
    . Scaling up health system innovations at the community level: a case study of the Ghana experience. In: Malarcher S, ed. Social Determinants of Sexual and Reproductive Health: Informing Future Research and Programme Implementation. World Health Organization; 2010:51–69. Accessed June 16, 2022. https://apps.who.int/iris/handle/10665/44344
  82. 82.
    1. Awoonor-Williams JK,
    2. Phillips JF,
    3. Bawah AA
    . The application of embedded implementation science to developing community-based primary health care in Ghana. Int J Popul Dev Reprod Health. 2017;1(1):66–81. doi:10.7916/D85F08BV
    OpenUrlCrossRef
  83. 83.
    1. Awoonor-Williams JK,
    2. Phillips JF,
    3. Bawah AA
    . Scaling down to scale-up: Ghana’s strategy for achieving health for all at last. J Glob Health Sci. 2019;1(1):e9. doi:10.35500/jghs.2019.1.e9
    OpenUrlCrossRef
  84. 84.
    1. Bellerose M,
    2. Alva S,
    3. Magalona S,
    4. Awoonor-Williams K,
    5. Sacks E
    . Supervision of community health nurses in Ghana: a mixed-methods study on experiences and mentorship needs. Health Policy Plan. 2021;36(5):720–727. doi:10.1093/heapol/czaa167. pmid:33351910
    OpenUrlCrossRefPubMed
  85. 85.
    1. Assan A,
    2. Takian A,
    3. Aikins M,
    4. Akbarisari A
    . Challenges to achieving universal health coverage through community-based health planning and services delivery approach: a qualitative study in Ghana. BMJ Open. 2019;9(2):e024845. doi:10.1136/bmjopen-2018-024845. pmid:30798313
    OpenUrlAbstract/FREE Full Text
  86. 86.
    1. Archer L,
    2. Awoonor-Williams JK
    . A Qualitative Systems Appraisal of Approaches to Barriers to the Introduction of Community-Based Primary Health Care in a Rural Locality of Northern Ghana. Columbia University; 2014.
  87. 87.
    1. Frimpong JA,
    2. Helleringer S,
    3. Awoonor-Williams JK,
    4. Yeji F,
    5. Phillips JF
    . Does supervision improve health worker productivity? Evidence from the Upper East Region of Ghana. Trop Med Int Health. 2011;16(10):1225–1233. doi:10.1111/j.1365-3156.2011.02824.x. pmid:21729221
    OpenUrlCrossRefPubMed
  88. 88.
    1. Aikins M,
    2. Laar A,
    3. Nonvignon J,
    4. et al
    . Evaluation of facilitative supervision visits in primary health care service delivery in Northern Ghana. BMC Health Serv Res. 2013;13(1):358. doi:10.1186/1472-6963-13-358. pmid:24063365
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Global Health: Science and Practice: 10 (Supplement 1)
Global Health: Science and Practice
Vol. 10, No. Supplement 1
September 15, 2022
  • Table of Contents
  • About the Cover
  • Index by Author
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about Global Health: Science and Practice.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana
(Your Name) has forwarded a page to you from Global Health: Science and Practice
(Your Name) thought you would like to see this page from the Global Health: Science and Practice web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana
John Koku Awoonor-Williams, Stephen Apanga, Ayaga A. Bawah, James F. Phillips, Patrick S. Kachur
Global Health: Science and Practice Sep 2022, 10 (Supplement 1) e2100763; DOI: 10.9745/GHSP-D-21-00763

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana
John Koku Awoonor-Williams, Stephen Apanga, Ayaga A. Bawah, James F. Phillips, Patrick S. Kachur
Global Health: Science and Practice Sep 2022, 10 (Supplement 1) e2100763; DOI: 10.9745/GHSP-D-21-00763
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Statistics from Altmetric.com

Jump to section

  • Article
    • ABSTRACT
    • INTRODUCTION
    • THE ROLE OF RESEARCH IN ATTAINING UHC
    • DEVELOPING GEOGRAPHIC ACCESS: THE CHPS INITIATIVE
    • EXPANDING FINANCIAL ACCESS: THE NATIONAL HEALTH INSURANCE SCHEME
    • DISCUSSION
    • LESSONS LEARNED
    • FUTURE DIRECTIONS
    • Acknowledgments
    • Author contributions
    • Competing interests
    • Notes
    • REFERENCES
  • Figures & Tables
  • Info & Metrics
  • Comments
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Addressing the Need for a Preexposure Prophylaxis Monitoring and Evaluation Implementation Guide: Experience From Zambia
  • Innovations in Public Financing for Family Planning at Subnational Levels: Sustainable Cofinancing Strategies for Family Planning With Nigerian States
  • Improving State Government’s Responsiveness to Family Planning Interventions in Nigeria Using an Innovative Reflection and Action Tool
Show more PROGRAM CASE STUDY

Similar Articles

Subjects

  • Cross-Cutting Topics
    • Health Systems
    • Universal Health Coverage
US AIDJohns Hopkins Center for Communication ProgramsUniversity of Alberta

Follow Us On

  • Twitter
  • Facebook
  • LinkedIn
  • RSS

Articles

  • Current Issue
  • Advance Access Articles
  • Past Issues
  • Topic Collections
  • Most Read Articles
  • Supplements

More Information

  • Submit a Paper
  • Instructions for Authors
  • Instructions for Reviewers
  • GH Journals Database

About

  • About GHSP
  • Advisory Board
  • FAQs
  • Privacy Policy
  • Contact Us

© 2023 Creative Commons Attribution 4.0 International License. ISSN: 2169-575X

Powered by HighWire