title: The complex association of health insurance and maternal health services in the context of a premium exemption for pregnant women: a case study in Northern Ghana.
abstract: BACKGROUND
  Health insurance premium exemptions for pregnant women are a strategy to increase coverage of maternal health services in sub-Saharan countries. We examine health insurance registration among pregnant women before or after the introduction of a premium exemption, and test whether registration increases utilization of maternal health services.
  
  
  METHODS
  Data were drawn from a retrospective cohort study of 1641 women having given birth between January 2008 and August 2010 in two impoverished districts of Northern Ghana. Among those, 1411 became pregnant after premium exemption was adopted in July 2008. We compared registration rates before and after the exemption. We used logistic regressions to measure the association between insurance registration and receipt of essential maternal health interventions in the context of the premium exemption. We tested whether this association varied across levels of the health system [e.g. hospitals and health centres (HCs) vs community health compounds (CHC)].
  
  
  RESULTS
  Health insurance registration increased significantly among pregnant women after adoption of the premium exemption. Coverage of clinical and diagnostic services was high, but antenatal care (ANC) clients received only partial counselling about safe motherhood (e.g. pregnancy-related danger signs). Three out of four clients who sought ANC in hospitals and HCs delivered at a health facility vs. slightly more than 50% among clients of CHC. In hospitals and HCs, National Health Insurance Scheme (NHIS) registration was associated with higher quality of services. In CHCs, NHIS registrants received fewer diagnostic tests, were less extensively counselled about safe motherhood and were less likely to be vaccinated against tetanus toxoid than non-registered clients. Among CHCs clients, being a NHIS registrant was however associated with an increased likelihood of delivering at a health facility.
  
  
  CONCLUSIONS
  In the context of premium exemptions, association of health insurance with use of maternal health services, and quality of services received, depends on place where pregnant women seek ANC.
authors.affiliation: Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana jf2584@columbia.edu.
authors.forename: Jemima A
authors.initials: JA
authors.lastname: Frimpong
authors.affiliation: Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Helleringer
authors.affiliation: Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana.
authors.forename: John Koku
authors.initials: JK
authors.lastname: Awoonor-Williams
authors.affiliation: Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana.
authors.forename: Thomas
authors.initials: T
authors.lastname: Aguilar
authors.affiliation: Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana.
authors.forename: James F
authors.initials: JF
authors.lastname: Phillips
authors.affiliation: Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana.
authors.forename: Francis
authors.initials: F
authors.lastname: Yeji
mesh_terms: D000328:Adult; D005260:Female; D005869:Ghana; D006293:Health Promotion / Q000191:economics; D006801:Humans; D007348:Insurance, Health / Q000191:economics*; D008427:Maternal Health Services / Q000191:economics* / Q000706:statistics & numerical data*; D011247:Pregnancy; D018873:Pregnancy Rate; D011295:Prenatal Care / Q000191:economics / Q000706:statistics & numerical data; D012189:Retrospective Studies
keywords: Ghana; Health insurance; health facilities; health systems; maternal health; premium exemption; user fees