title: Ghana's National Health insurance scheme and maternal and child health: a mixed methods study.
abstract: BACKGROUND
  Ghana is attracting global attention for efforts to provide health insurance to all citizens through the National Health Insurance Scheme (NHIS). With the program's strong emphasis on maternal and child health, an expectation of the program is that members will have increased use of relevant services.
  
  
  METHODS
  This paper uses qualitative and quantitative data from a baseline assessment for the Maternal and Newborn errals Evaluation from the Northern and Central Regions to describe women's experiences with the NHIS and to study associations between insurance and skilled facility delivery, antenatal care and early care-seeking for sick children. The assessment included a quantitative household survey (n = 1267 women), a quantitative community leader survey (n = 62), qualitative birth narratives with mothers (n = 20) and fathers (n = 18), key informant interviews with health care workers (n = 5) and focus groups (n = 3) with community leaders and stakeholders. The key independent variables for the quantitative analyses were health insurance coverage during the past three years (categorized as all three years, 1-2 years or no coverage) and health insurance during the exact time of pregnancy.
  
  
  RESULTS
  Quantitative findings indicate that insurance coverage during the past three years and insurance during pregnancy were associated with greater use of facility delivery but not ANC. Respondents with insurance were also significantly more likely to indicate that an illness need not be severe for them to take a sick child for care. The NHIS does appear to enable pregnant women to access services and allow caregivers to seek care early for sick children, but both the quantitative and qualitative assessments also indicated that the poor and least educated were less likely to have insurance than their wealthier and more educated counterparts. Findings from the qualitative interviews uncovered specific challenges women faced regarding registration for the NHIS and other barriers such lack of understanding of who and what services were covered for free.
  
  
  CONCLUSIONS
  Efforts should be undertaken so all individuals understand the NHIS policy including who is eligible for free services and what services are covered. Increasing access to health insurance will enable Ghana to further improve maternal and child health outcomes.
authors.affiliation: Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. kavita_singh@unc.edu.|Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. kavita_singh@unc.edu.
authors.forename: Kavita
authors.initials: K
authors.lastname: Singh
authors.affiliation: Institute of Statistical, Social and Economic Research, University of Ghana, Accra, Ghana. ioseiak@ug.edu.gh.
authors.forename: Isaac
authors.initials: I
authors.lastname: Osei-Akoto
authors.affiliation: Institute of Statistical, Social and Economic Research, University of Ghana, Accra, Ghana. fkotcher@live.unc.edu.|Department of Public Policy, College of Arts and Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. fkotcher@live.unc.edu.
authors.forename: Frank
authors.initials: F
authors.lastname: Otchere
authors.affiliation: The Institute for Healthcare Improvement (IHI), Cambridge, MA, USA. ssodzi-tettey@IHI.org.
authors.forename: Sodzi
authors.initials: S
authors.lastname: Sodzi-Tettey
authors.affiliation: Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. cbarring@email.unc.edu.|Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. cbarring@email.unc.edu.
authors.forename: Clare
authors.initials: C
authors.lastname: Barrington
authors.affiliation: Department of Public Policy, College of Arts and Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. carhuang@email.unc.edu.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Huang
authors.affiliation: Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. corifordham@gmail.com.
authors.forename: Corinne
authors.initials: C
authors.lastname: Fordham
authors.affiliation: Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. speizer@email.unc.edu.|Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. speizer@email.unc.edu.
authors.forename: Ilene
authors.initials: I
authors.lastname: Speizer
mesh_terms: D000293:Adolescent; D000328:Adult; D000067576:Child Health; D036861:Delivery, Obstetric / Q000191:economics; D005190:Family; D005260:Female; D005869:Ghana; D006282:Health Personnel / Q000191:economics; D006291:Health Policy / Q000191:economics; D006801:Humans; D007231:Infant, Newborn; D019458:Insurance Coverage / Q000706:statistics & numerical data; D008875:Middle Aged; D009313:National Health Programs / Q000191:economics; D011247:Pregnancy; D011295:Prenatal Care / Q000191:economics; D011795:Surveys and Questionnaires; D055815:Young Adult