The potency of a free maternal healthcare policy in achieving universal health coverage a cross-sectional qualitative study

Study design

We conducted a cross-sectional study among women in their reproductive age (15-49) who received maternal health care services in three selected health facilities from the sub-district; Bekwai Health Centre, Chirano Health Centre, and Anwhiaso Health Centre in the Bibiani-Anuiaso-Bekwai Municipality from June 2021 to December 2021. The age of the women was confirmed by inspecting their national health insurance cards. A systematic sampling technique was used to select Women who were aged 15-49 years who were within their second and third trimesters as well as nursing mothers within their first three (3) months of birth were included in the study. The women were selected at an interval of three. As patients were admitted they were assigned with numbers up to three and the third person was selected. Women who fell within the reproductive age group and had children aged between three and 12 months were selected to participate in the study. This was repeated at the various health facilities until the required number of 72 was obtained.Women who fall within the reproductive age group but had children older than 12 months were excluded from the study. In addition, in-depth interviews (IDIs) were conducted on Nurses and Midwives within antenatal clinics (ANCs) and child welfare clinics (CWCs) of selected health facilities. Three (3) nurses/midwives from each selected health facility were interviewed, which made a total of nine (9) from all the selected health facilities. Also, a key informant interview (KII) was done on the manager of NHIS at the Bibiani-Anwhiaso-Bekwai municipal office to buttress the information taken from the women.

The aim was to ascertain the potency of the free maternal health policy under the national health insurance scheme on enhancing women access to maternal health care services thereby contributing to the attainment of UHC.

Sampling technique

The study adopted a multi-stage sampling technique. The health facilities in the municipality were stratified into three sub-districts. The names of the health facilities (Bekwai Health Centre, Chirano Health Centre, and Anwhiaso Health Centre) in each sub-district were written separately on pieces of a paper and folded and were put in a hat and one health facility was selected randomly (lottery) from each of the sub-districts.

Women who were in their reproductive age and have children aged between three (3) and twelve (12) months and have come to the health facilities to access maternal healthcare services were assigned numbers up to three (3) and every other third person was selected. This process was repeated at the various health facilities until the required number of 72 with 24 participants at each health facility across the three districts was attained.

A purposive sampling technique was used to select nurses, midwives and the municipal national health insurance manager after they have consented to be interviewed. The IDIs on Nurses and Midwives were conducted in enclosed areas of the health facilities, whereas the KII for the manager of the national health insurance scheme (NHIS) at the study area i.e., Bibiani-Anwhiaso-Bekwai municipal office was done in his office.

Inclusion and exclusion criteria

Women who were aged 15-49 years who were within their second and third trimesters as well as nursing mothers within their first three (3) months of birth were included in the study.

Women, who were 15-49 years but were not pregnant or were pregnant but were within their first trimesters, were excluded from the study. The reason for excluding pregnant women in their first trimester is that they have not had enough ANC visits and might not have the needed experience to answer most of the questions for the study.

Study variables

Questions for this study included socio-demographic characteristics of participants. The study also helped to find out the health insurance status of mothers. Questions for the study assessed health care services that were covered by the free maternal health care policy in Ghana and ascertained whether the FMHCP could be effective on maternal health-related outcomes. The study also identified some challenges that confronted mothers when they were accessing the FMHCP in Ghana and how these said challenges could be addressed in Ghana.

Data collection techniques and tools

A focus group discussion guide was prepared based on the study objectives.²⁴ A total of six focus group discussions (FGD) consisting of 12 participants each, were conducted, two in each of the three selected health facilities. The FGDs were done on women during antenatal and postnatal services within enclosed areas of the health facilities. Among the topics considered for discussion during the FGD session were participant’s knowledge about the free maternal healthcare policy in terms of services provided under the policy and how many of the women have registered and benefited from the policy. Matters relating to impact of the policy on maternal healthcare, sustainability and challenges confronting the programme. This allowed the women to freely but critically express their views about the subject matter of the study. It also afforded the researcher the opportunity to probe further on the understanding of the women on the socio-cultural as well as financial components of the policy. The use of a discussion guide also encouraged the researcher to work and engage with study participants rather than simply observing them. It further allowed for full and uncompromising recognition of how the study participants’ experiences create meaning for them and influences their maternal health seeking behaviour and life choices. Focus Group Discussions were audio-recorded, transcribed verbatim, and checked for completeness and accuracy.

Nine in-depth interviews and 6 key informant interviews were conducted. The FGD guide was pre-tested in the Atwima Mponua District. This was done to ensure validity, reliability and to check ambiguities. The choice of the district was informed by the fact that it has similar characteristics of the study districts. The results of this pre-test revealed weaknesses in the guide which were subsequently addressed before its application on the field.

Questions for this study included socio-demographic characteristics of participants. The study also helped to find out the health insurance status of mothers. Questions for the study assessed health care services that were covered by the free maternal health care policy in Ghana and ascertained whether it could enhance women access to maternal healthcare and further help in the attainment of universal health coverage.

Data analysis

Qualitative data that emerged from key informant interviews were transcribed verbatim and checked for completeness and accuracy by checking punctuations. Also the focus group discussions were audio recorded, transcribed verbatim and checked for completeness and accuracy. Familiarisation of the data was done by listening to the tape recordings repeatedly to ensure that the correct transcription²³ and coding have been done. This was followed by preliminary coding of data by identifying how the respondents conceptualised certain key phrases and words. The document was analysed by using content analysis through identification of general themes that emerged taken into consideration the objectives of the study. All data analysis was completed using NVivo 12 (QSR International, 2020) (RRID:SCR_014802). From the various themes and categories that emerged, the data was analysed thoroughly. The results were presented in a table.¹⁶

Ethical statement

Ethical clearance was obtained from the committee of Human Research, Publications, and Ethics, (CHRPE) of Kwame Nkrumah University of Science and Technology (KNUST) with (Ref: CHRPE/AP/268/21). Written informed consent and permission to participate in the study was obtained from each participant. In the case of those under 18 years, consent was sought from their parents/guardians. The respondents were at liberty to withdraw from the study anytime they deemed it necessary. Moreover, participants were also at liberty to choose not to answer particular questions they were uncomfortable with. Strict confidentiality of the identity of respondents was maintained using unique numeric codes, which were available only to the principal investigator.

Women knowledge about FMHCP and its coverage

The in-depth interview (IDIs) and FGDs revealed that most of the women were knowledgeable about the FMHCP. FMHCP was perceived as a free means by which pregnant women could access NHIS cards, antenatal care, postnatal care, drugs, and other important maternal health services. The following are excerpts from a midwife (Respondent 1) and a pregnant woman attending antenatal care (ANC) (FGD 2):

One other midwife stated emphatically how pregnant women are given priority to obtain NHIS cards for free, which then helps them to have access to free maternal care. According to her:

Participants were also able to mention some of the services and drugs covered under the FMHCP. Most of them were aware of the fact that without the NHIS card, one could not access these services or obtain routine drugs for free. Regarding the services that pregnant women are given at ANC, most of the respondents affirmed that they were given for free.

The interview with the key informant revealed how awareness was created for the FMHCP within the Municipality. It is therefore not surprising that most of the maternal health clients were appreciably knowledgeable about the FMHCP. According to the key informant:

Payment of fees under FMHCP

Informal payments were also reported among respondents. It was found that such payments were made for reasons such as the unavailability of drugs at the time the client was at the facility. For some clients, the prescribed drug had to be bought elsewhere. Additionally, both formal and informal fees were charged for services such as laboratory examinations and scans. Some participants made the following complaints during the discussions:

Although most of the health staff mentioned that clients are not charged any fees, they also affirmed that sometimes, clients are asked to buy drugs elsewhere. This usually occurs when those drugs are not available. According to one midwife:

Impact of FMHCP

Both participants of the focus group and interviewees alluded to the immense benefits of the FMHCP. Cognizance was given to how the policy has improved ANC attendance and reduced mortality. Overall, participants also remarked that, through the FMHCP, women who could not afford to pay for certain services were able to access those services without charge. FGD discussants for instance explained that:

According to one midwife, the free access to maternal health care came with the benefit of helping pregnant women seek care early enough. According to her, this helped to diagnose some obstetrically important conditions, as well as treat them at their onset to forestall complications. She said:

Another midwife also recounted how the policy has helped reduce maternal deaths in the district since the time of its implementation. She said:

Furthermore, the response of the key informant corroborated all that had been said. The informant indicated that since the implementation of the FMHCP, a downward trend of maternal mortality had been observed over the years. He said:

Sustainability of FMHCP

Respondents indicated mixed views regarding the sustainability of the FMHCP. Thus, while some thought that it could be sustained for years to come, others highlighted that there are still gaps that need to be addressed. Otherwise, the sustainability of the policy may dwindle. However, respondents generally of the view that the policy is sustainable. One of the longest-serving midwives indicated that:

Another health staff added that:

Other respondents, were of a contrary view. According to them, the fact that some services were still being paid for was enough to conclude that the policy is not sustainable.

The key informant also mentioned that:

Challenges of FMHCP

Several challenges regarding the FMHCP were raised during discussions and interviews. It was noticed that the challenges were particular to the category of respondents. For instance, ANC clients mostly complained about informal fees, preferential treatment, and lack of laboratory and scan services. Discussants revealed that:

Unavailability of drugs was also commonly reported as indicated in Table 1. As a result, most of the participants had purchased them from elsewhere. Clients mentioned that sometimes they could not afford those prescribed medications. Two clients lamented that:

Additionally, clients complained of preferential treatment that was exhibited by health staff. According to them, student nurses who visit ANC are treated better as compared to other clients.

Interestingly, one of the student nurses agreed to the earlier claim. She recalled:

For health staff, the main challenges of the FMHCP ranged from stock-outs to a low level of education among pregnant women. Some midwives explained:

The key informant interview revealed an interesting challenge that was not mentioned at all before. The respondents revealed that some pregnant women have the belief that bad people can cause pregnancy complications for them if they go for their card early. He explained that:

Measures to address FMHCP challenges

Participants gave recommendations to help address the presently identified challenges of the FMHCP as shown in Table 1. The majority called on the government to do its part to ensure that the needed resources to keep services running are provided. Some clients recommended the following:

Some ANC clients also recommended that all clients be treated irrespective of whether they are student nurses or uninsured.

Additionally, clients indicated that there is a need to ensure that resources for running maternal health services are always available. This is because stock-outs of drugs and other items such as ANC booklets disrupt the effective running of services. In such instances, staff resort to the use of improvised methods to keep services running. Some clients intimated that:

From the viewpoint of health staff, it was recommended that apart from communicating with the Health Directorate to do their part, more health staff need to be recruited by the government to match the growing number of maternal health attendants. By doing so, no client will be left untreated. She added again that it is important to educate mothers to know what the FMHCP is about to increase awareness. The following is an excerpt from the interview:

From the key informant’s perspective, the problem of informal fees collected during maternal health care sessions could be addressed by lodging formal complaints. He explained as follows:

Limitations of the study

The majority of the respondents were illiterate and could not read nor write hence, there was the need to translate the questions from English to the local language (Twi). The interpretation of the questionnaire to the local language (Twi) might have affected the intended meaning of the questions and could lead to inaccurate result. This however did not affect the findings of the study as effective training was given to field workers.

Underlying data

OSF: Potency of Health Insurance in Achieving Universal Health Coverage, https://doi.org/10.17605/OSF.IO/2QTZM.²³

This project contains the following underlying data:

Extended data

OSF: Potency of Health insurance in achieving universal health coverage, https://doi.org/10.17605/OSF.IO/4R63E.²⁴

This project contains the following extended data:

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).