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Keywords:
Affordability, Catastrophic health, Expenditure, Chemical Seller, Household,
Out-of-Pocket Payment
ABSTRACT:
Financial access to health care remains a challenge to the majority of people
especially in the rural areas. In Ghana, it is estimated that four out of every ten
persons are poor. In the Northern region of Ghana and the Central Gonja District,
poverty level is 70% and 90% respectively. Over 50% of the residents of Central Gonja
District are not insured and as a result the same proportion or more incur out of
pocket health expenditure. The purpose of the study was to determine the
affordability of healthcare services in Central Gonja District. A cross sectional study
design and a mixed-method [quantitative and qualitative methods] were used. The
two stage cluster sampling approach was used to draw the sample for the study. A
sample of 403 household was interviewed using semi-structured questionnaires and
three key informant interviews were conducted. The findings showed that in the
Central Gonja District, 83.6% (337) of households were poor, 17.1% (N=204) of those
who sought care from a formal or informal provider incurred catastrophic cost of
care. Direct average cost of healthcare was US$ 21.40 (SD 30.14) while indirect
average cost of care was US$ 28.50 (SD 40.98). In conclusion, healthcare is
unaffordable to a good number of the people of Central Gonja District and therefore
efforts at financial protection especially of the poor should be stepped up.
073-084| JRPH | 2014 | Vol 2 | No 1
This article is governed by the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/2.0), which gives permission for unrestricted use, non-commercial, distribution and
reproduction in all medium, provided the original work is properly cited.
www.jhealth.info
Journal of Research in
Public Health
An International
Scientific Research Journal
Authors:
Adam Soale
1
and
Reuben K. Esena
2
.
Institution:
1. University of Ghana ,
SPH -HPPM, P. O. Box
LG 13 Legon-Accra Ghana.
2. University of Ghana,
School of Public Health,
P. O. Box LG 13
Legon-Accra Ghana.
Corresponding author:
Reuben K. Esena
Email:
Web Address:
http://www.jhealth.info/
documents/PH0017.pdf.
Dates:
Received: 20 Sep 2013 Accepted: 08 Nov 2013 Published: 06 Feb 2014
Article Citation:
Adam Soale
and Reuben K. Esena.
Affordability of healthcare services in the Central Gonja District of Ghana.
Journal of Research in Public Health (2014) 2(1): 073-084
Journal of Research in Public Health
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An International Scientific Research Journal
Original Research
INTRODUCTION
Background
The poverty-health status syndrome shows
spatial variation. The urban areas are better served with
modern health facilities by government, whilst the rural
areas suffer from acute lack of these facilities. (Bour,
1999). In most developing countries healthcare is usually
inaccessible to a large proportion of the population
especially those living in remote rural areas. In Ghana
the main cause of poor access to healthcare services
which result in poor health status is inability to bear
service cost (Takyi and Anamuah-Mensah, 1993).
The health system of the country has
communicable disease conditions, malnutrition, high
infant mortality and poor reproductive health. There are
also non-communicable diseases, such as, diabetes and
cardiovascular diseases. These health conditions are
largely worsened by poor access to health services and
the geographical and financial access to health care is a
challenge (Gyapong et al., 2007).
According to the 2009 Health Sector Programme
of work, maternal mortality ratio in 2008 stood at 451
per 100 000 live births (GHS, 2010) and one out of
every thirteen Ghanaian children died before the age of
five (GDHS, 2008). Anaemia which is said to be a major
threat to maternal and child health is said to be on the
increase. Among children, it is estimated that 78 per cent
have anaemia while in women it increased from 45 per
cent in 2003 to 59 per cent in 2008 (GDHS, 2008).
As a result of the widespread poverty in the
northern region, many cannot afford basic healthcare. It
is estimated that seven out of every ten persons is poor in
the region. Incidentally it is more deprived than the
southern sector of the country in terms health
infrastructure. The 2005 annual report of the Ghana
Health Service (GHS) of the northern region reveals that
maternal and under-five mortality are a major challenge
with underfive mortality as high as 137 per 1000 live
births (GDHS, 2008). The direct and indirect causes of
the maternal mortality are predominantly caused by
poverty, poor access to care, and poor quality of care,
which are preventable. Despite the fact that membership
of the National Health Insurance Scheme (NHIS) is
mandatory [unless one is enrolled to a private health
insurance] enrolment in NHIS is low among informal
sector workers especially in rural areas, posing a
challenge to access to health care.
Problem statement
It has been established that 7 out of every 10
persons in the northern region is poor (GLSS-4,
1998/1999). Widespread poverty in the region makes
basic healthcare unaffordable to a large number of
people in the region (ACDEP, 2007).
Some intra regional disparities in the prevalence
of poverty are observed with some districts such as the
Central Gonja having poverty levels as high as 90%
(Nine out of every ten persons)- (CGDA, 2008).
In communities with such high level of poverty,
financial access to healthcare is a major challenge. This
poor financial access is manifested in the high under-five
mortality rate of 181 per 1000 live births in the district
(CGDA, 2008) exceeding both the regional and national
rates. There were also cases of increased malnutrition
among children under-five. The top ten ailments in the
District are malaria, diarrhea, Urinary Tract Infection
(UTI), skin diseases, pneumonia, typhoid, Kwashiorkor,
anemia, intestinal worms, and guinea-worm (DHMT,
2010).
In addition to the poor health status in the
district, Health Insurance coverage is said to range
between 30 to about 46 per cent (DMHIS, 2012). Out-of
pocket payments are still a widespread phenomenon in
the district. In 2009 the proportion of uninsured patients
who visited a public health facility in the district was
57% of the total outpatient (OPD) visits (DHMT,
2010). A study in the northern region observed that
during periods of illness about 29 per cent resort to
borrowing, 31 per cent receive support from relatives,
Soale and Esena, 2014
074 Journal of Research in Public Health (2014) 2(1): 073-084
friends and community and 40 per cent rely on their own
internal resources to finance their healthcare (Apoya and
Maaweh, 2001).
This highlights the gap in health care access and
affordability of these services. It is unclear as to what
proportion of households cannot afford health care
services and what proportion of household incomes are
spent on health care. Therefore, the objective of this
study is to determine the affordability of health care to
households in the Central Gonja District.
Conceptual framework
The study seeks to use the framework [Fig 1] for
estimating household cost of illness, coping strategies
and their economic consequences at the household level
(Sauerborn, Adam, and Hien, 1996) to determine
affordability of healthcare services in the Central Gonja
District.
The framework is divided into three main parts:
Health System factors, Individual and Household level
factors and Social resources factors.
The type of illness and severity (perceived or
evaluated) determines the cost that will be involved in
treating the particular illness. Severe illness may be due
to delay in seeking early treatment which could be due to
treatment seeking behavior. It is known that households
or individuals may use home remedies first before
seeking further treatment and sometimes only when the
disease is severe. When distance to a health care facility
is far or service availability is poor this might lead to
delays in seeking care but will influence the costs of
care. However if there is a health insurance, the cost of
seeking care may not affect early treatment seeking. On
the other hand where user fees apply, this may lead to
high cost. Direct cost refers to household expenditure
associated with seeking healthcare. It includes medical
cost (cost of consultation, Medicines and laboratory test
etc.) and non-medical cost (Transport cost, cost of
special foods etc.). Indirect cost on the other hand
involves loss of household productive labor time by the
sick and the caregivers due to illness. Coping cost has to
Soale and Esena, 2014
Journal of Research in Public Health (2014) 2(1): 073-084 075
Source: (Sauerborn et al., 1996)
Figure 1: Conceptual Framework for Assessing Cost of Health Care
do with ways household are able to raise the needed
income to pay for the cost of treatment. Usually it
involves borrowing, relying on a network of relatives and
friends for support and sale of family assets. Borrowing
to pay for health care may lead to households cutting
down on their basic needs so as to afford health care
which may be detrimental to overall livelihood of the
individual or household.
Justification
By adopting health for all, countries have a
responsibility of ensuring that all enjoy good health
enable them to participate in social and economic
activities. Meanwhile poor health due to catastrophic
cost of illness continues to undermine efforts at
achieving the MDGs. Despite the introduction of health
insurance and the exemption policy, out-of-pocket
(OOP) payments still characterized the healthcare
delivery system in communities such as Central Gonja
District. Poverty and poor health are intricately linked
and mutually reinforcing and neither can be improved
without a corresponding improvement in the other.
Therefore, findings from this study will add to
existing knowledge on financial access to healthcare in
general and affordability in particular in Ghana and serve
as baseline information for the Central Gonja District. It
will also bring to the fore which of the cost components
forms the chunk of the total cost of healthcare and
specify areas for which programs of intervention by the
Ghana Health Service and other stakeholders could be
targeted at.
For instance it will inform policy makers to
re-align poverty reduction effort with the improvement in
financial access and general affordability of healthcare.
This can protect the poor from sinking into further
poverty.
Research questions
How much do households pay for healthcare?
Are households able to afford the cost of healthcare?
Objectives
General Objective
The general objective of this study is to
determine the affordability of healthcare services in the
Central Gonja District.
Specific objectives
The specific objectives were to:
Determine the proportion of household income
spent on healthcare in the District.
Estimate the direct cost of healthcare services to a
household in the District.
Determine the household indirect cost of healthcare
in the District.
Methods
Type of the study
The study was a cross-sectional design using a
mixed-method [quantitative and qualitative].
Study location/ area
The Central Gonja district [Figure 2] is one of
the newly created districts carved out from the West
Gonja District by legislative instrument 1750 under the
Local Government act, 1993 (Act462) in 2004 (CGDA,
2005). It lies between longitude 1:5" and 2:58" West
and Latitude 8:32" and 10: 2" north.
Variables
The dependent variable that was measured in the
study is Affordability of healthcare services to
households.
The independent variables included: Household
income, Employment, Cost of medical care, Cost of
transport, Health insurance, Length of illness and
chronicity and age.
Study population
The study population is the number of adult
household members in the District. The study unit
therefore is the household. The choice of the household
as the unit of analysis was informed by the fact that
negotiation about seeking care takes place in household
and cost of care which is usually borne by either the sick,
Soale and Esena, 2014
076 Journal of Research in Public Health (2014) 2(1): 073-084
the caregiver or in extreme cases the community,
ultimately burdens the households resources.
Sample size
The sample size taken for the study [403
households] was determined according to Fischer et al
1998 [cited in Gichobi et al., 2010] and found to be:
384. A non-response rate was added to increase the
sample size to 403.
Sampling procedure
The sampling method used is the Two-stage
cluster sampling method. The community was divided
into three clusters namely: Bridge, Central Gonja District
right of road from Kintampo and Left respectively.
Given that the population of Central Gonja District is
8347 and an average household size of 6.8, the total
number of households was approximately 1228. It was
assumed that the population was fairly distributed among
the clusters; therefore each had about 409 households.
Within each cluster a systematic random sampling of 135
households [about 33%] in each cluster was done with a
sampling interval of 3 to participate in the study. In order
to avoid any bias in the sampling, it was started at the
middle of each cluster and the direction was determined
by spinning a bottle. The neck of the bottle served as the
pointer to the direction. Sampling was done in that
direction and then opposite direction until the desired
sample size was attained. Three key informants namely a
chemical seller, the in-charge of the health center in
Central Gonja District and a Traditional healer were
interviewed to elicit information about the cost of their
services.
Data collection techniques/method and tools
Data was collected in the field using a semi-
structured questionnaire and an interview guide. The
questionnaire collected information on age, sex, main
occupation of respondent, household consumption
expenditure (Food and utility), non-food for the last
month and remittances (Proxy for household income) on
Soale and Esena, 2014
Journal of Research in Public Health (2014) 2(1): 073-084 077
Figure 2 : Map of Central Gonja District in Ghana
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