title: Perspectives of frontline health workers on Ghana's National Health Insurance Scheme before and after community engagement interventions.
abstract: Barely a decade after introduction of Ghana's National Health Insurance Scheme (NHIS), significant successes have been recorded in universal access to basic healthcare services. However, sustainability of the scheme is increasingly threatened by concerns on quality of health service delivery in NHIS-accredited health facilities coupled with stakeholders' discontentment with the operational and administrative challenges confronting the NHIS. The study sought to ascertain whether or not Systematic Community Engagement (SCE) interventions have a significant effect on frontline health workers' perspectives on the NHIS and its impact on quality health service delivery.
  
  
  
  The study is a randomized cluster trial involving clinical and non-clinical frontline health workers (n = 234) interviewed at baseline and follow-up in the Greater Accra and Western regions of Ghana. Individual respondents were chosen from within each intervention and control groupings. Difference-in-difference estimations and propensity score matching were performed to determine impact of SCE on staff perceptions of the NHIS. The main outcome measure of interest was staff perception of the NHIS based on eight (8) factor-analyzed quality service parameters.
  
  
  
  Staff interviewed in intervention facilities appeared to perceive the NHIS more positively in terms of its impact on "availability and quality of drugs (p < 0.05)" and "workload on health staff/infrastructure" than those interviewed in control facilities (p < 0.1). Delayed reimbursement of service providers remained a key concern to over 70 % of respondents in control and intervention health facilities.
  
  
  
  Community engagement in quality service assessment is a potential useful strategy towards empowering communities while promoting frontline health workers' interest, goodwill and active participation in Ghana's NHIS.
authors.affiliation: Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana. arkabason@gmail.com.|Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands. arkabason@gmail.com.
authors.forename: Robert Kaba
authors.initials: RK
authors.lastname: Alhassan
authors.affiliation: Department of Economics, University of Ghana, Legon, Ghana.
authors.forename: Edward
authors.initials: E
authors.lastname: Nketiah-Amponsah
authors.affiliation: PharmAccess Foundation, Amsterdam, Netherlands.
authors.forename: Nicole
authors.initials: N
authors.lastname: Spieker
authors.affiliation: Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana.
authors.forename: Daniel Kojo
authors.initials: DK
authors.lastname: Arhinful
authors.affiliation: PharmAccess Foundation, Amsterdam, Netherlands.|Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands.
authors.forename: Tobias F
authors.initials: TF
authors.lastname: Rinke de Wit
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D016000:Cluster Analysis; D003695:Delivery of Health Care / Q000592:standards*; D005260:Female; D005869:Ghana; D006268:Health Facilities; D006282:Health Personnel; D006801:Humans; D007348:Insurance, Health / Q000592:standards; D008297:Male; D009313:National Health Programs / Q000458:organization & administration / Q000592:standards*; D010465:Perception; D011795:Surveys and Questionnaires
keywords: Frontline health workers; Ghana; National Health Insurance Scheme; Perspectives; Quality service; Systematic community engagement interventions