Objective: A free maternal health policy was implemented under Ghana’s National Health Insurance Scheme to promote the use of maternal health services. Under the policy, women are entitled to free services throughout preg- nancy and at childbirth. A mixed methods study involving women, providers and insurance managers was carried out in the Kassena-Nankana municipality of Ghana. It explored the affordability, availability, acceptability and quality of services. In this manuscript, we present synthesised results categorised as facilitators and barriers to access as well as lessons learnt (implications). Results: Reasonable waiting times, cleanliness of facilities as well as good interpersonal relationships with providers were the facilitators to access. Barriers included out of pocket payments, lack of, or inadequate supply of drugs and commodities, equipment, water, electricity and emergency transport. Four lessons (implications) were identified. Firstly, out of pocket payments persisted. Secondly, the health system was not strengthened before implementing the free maternal health policy. Thirdly, lower level facilities were poorly resourced. Finally, the lack of essential inputs and infrastructure affected quality of care and therefore, access to care. It is suggested that the Government of Ghana, the Health Insurance Scheme and other stakeholders improve the provision of resources to facilities. Keywords: National Health Insurance, Free maternal health policy, Fee exemption, Maternal health services, Pregnancy, Childbirth, Lessons, Ghana Introduction constrained settings, it has been shown that there are A free maternal health policy was implemented in Ghana gaps in similar policy implementation, as these are often in July 2008 under the National Health Insurance Scheme implemented without careful planning and inadequate (NHIS). The policy allows all pregnant women to have infrastructure as well as resources in terms of workforce free registration with the NHIS after which they would be and funding [1–3]. Implementation is often affected by factors inside and outside the health system, which ulti entitled to free services throughout pregnancy, childbirth - and 3 months postpartum. The policy was one of Gha - mately affects access to services. na’s key strategies for the achievement of the Millennium Access to services is complex and multidimensional Development Goals (MDGs) and now, the Sustainable  and is determined by factors in the health system Development Goals (SDGs), specifically the reduction of as well as at the individual, household and commu- maternal and child deaths and the achievement of uni- nity level [5, 6]. The dimensions of access are classified versal health coverage (UHC). broadly as affordability, availability, acceptability and It is unclear whether the policy has achieved its quality of care. These affect the use and provision of desired outcomes in all parts of Ghana. In other resource services and are key for the successful implementation of policies. Therefore, we undertook a study to explore the affordability, availability, acceptability and quality *Correspondence: PhilipAyizem.Dalinjong@student.uts.edu.au of services under the free maternal health policy. Some Faculty of Health, University of Technology Sydney, Ultimo, Sydney, NSW, Australia of the results have been published in [7, 8], specifically © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Dalinjong et al. BMC Res Notes (2018) 11:341 Page 2 of 6 those relating to affordability. In this manuscript, we Results present the overall synthesised results in the form of The results have been synthesised and categorised as facilitators and barriers to access to services under the facilitators and barriers to access in terms of; affordabil - free maternal health policy. In addition, we highlight ity, availability, acceptability and quality of care. Figure 1 the key lessons (implications) drawn from the study. represents the overall synthesised results. Discussion Facilitators of access to services under the policy Main text The benefits of the free maternal health policy was Methods widely acknowledged as it promoted the use of services. The study was cross-sectional, combining quantitative Other reviews in low- and middle-income settings have and qualitative studies using the convergent parallel reported a significant positive relationship between mixed methods design. The study area was the Kas - health insurance including fee exemptions and the use of sena-Nankana municipality in rural Northern Ghana. services [9, 10]. Interestingly, in our study waiting times Quantitative data were collected from women (n = 406) were perceived not to impede the use of services. This is who gave birth in facilities and at home. In-depth inter- contrary to results from studies in Kenya , India  views were conducted among providers and insurance and Lao People’s Democratic Republic . The result managers (n = 28), while focus group discussions were may have been because women in this area expected to held with the same category of women (n = 10) who wait and had very few or limited expectations about what participated in the quantitative study. Details of the the service would provide. design, study area, sampling, data collection and analy- Equally, we found that the facilities were reported to sis are published in [7, 8]. be clean and providers to be respectful and friendly. The Fig. 1 Synthesis of study results Dalinjong et al. BMC Res Notes (2018) 11:341 Page 3 of 6 environment of facilities as well as the attitudes of pro- While women reported being satisfied with care, this viders are important predictors of service usage. A review was not the case for the providers. Providers recognised on the determinants of women’s satisfaction with services that the situation meant that the care they were providing in low- and middle-income countries has shown that the was sub-standard. Providers often know what ‘good’ care interpersonal relationships of providers dominated fac- should be even if their clients are willing to accept less tors influencing women’s use of services . It is encour - than ‘good’. Other studies have highlighted similar issues, aging that women in this rural region were positive about for example, in Bangladesh; while women reported satis- their relationships with providers but this may again be faction with services, providers were unhappy with care attributed to low expectations. provision due to staff and logistics challenges, the lack of Women interviewed indicated that they were very sat- laboratory services and insufficient supervision . isfied or satisfied with quality of care. This result is in line with studies conducted in India and Bangladesh where Lessons learnt (implications) from the results women were reportedly satisfied with services provided Although the Government of Ghana has prioritised under the Chiranjeevi and the Maternal Health Voucher maternal health by implementing the policy a decade Schemes respectively [15, 16]. However, the result runs ago, the results of our study raise critical questions about contrary to other studies, for example from Bangladesh the ability of the policy to meet its goals. Our study high- where women expressed dissatisfaction with quality of lighted four useful lessons for policy makers and other services received . Satisfaction is a difficult concept stakeholders in Ghana. These lessons are relevant to and is dependent on expectations and the outcome . other countries who have implemented or are planning For example, many women report being ‘satisfied’ at the to implement fee free policies. time of care merely because they and their babies sur- vived the experience and sometime later, they articulate Lesson number one: OOP payments persisted a more nuanced, usually negative, experience. This is the despite the NHIS halo effect of maternity care [19–21] and may be respon - OOP payments were common. The cost of transport, sible for our positive results. Despite the high rates of sat- laboratory services, drugs and supplies made service uti- isfaction, many women in our study also reported a lack lisation difficult especially for poor women. The lack of of privacy during labour and birth suggesting that per- funds in facilities was a result of the delay in payments haps their ‘satisfaction’ was actually limited. by the NHIS, partly caused by the claims process and to some extent the lack of adequate funds for the scheme. Barriers for access to services under the policy The establishment of the electronic claims submission Our study demonstrated that, despite the policy, women system by the NHIS is a step in the right direction as still made out of pocket (OOP) payments for drugs, sup- this will reduce fraud and abuse, help contain costs and plies, laboratory services including ultrasound scans and promote the financial sustainability of the NHIS [27, 28]. transport as well as the purchase of other items for child- The system also allows for the early settlement of claims, birth. The results corroborate findings from similar set - thereby encouraging them to continue to provide services tings. For instance, despite a policy in Ethiopia to provide to clients of the NHIS. free services for women, 65% of facilities required women Sustainable sources of funding to ensure funds are to make payments for some services  and in Senegal, available for claims payment within the stipulated time where women made payments for transport and drugs (1 month following submission to the NHIS). Currently, under the Free Delivery and Caesarean Policy . These the NHIS relies on a 2.5% value added tax (Health Insur- highlight the challenges with implementing fee exemp- ance Levy) on some categories of goods and services as tion policies in many countries. one of its main sources of funding . An additional 1% Distance and time taken to reach the nearest facil- increase in the levy is suggested to raise more money for ity were perceived in our study to be impediments to the smooth operation of the NHIS. The greatest need is care seeking. The result is not isolated. In South Africa to ensure efficiency, as more funding does not necessarily and Zambia, women revealed long distances to facilities imply the success of the NHIS. Measures should be put in which hindered access [24, 25]. Likewise, basic essential place to identify poor women as a priority for the reim- inputs such as infrastructure, laboratory tests, drugs and bursement of the cost of transport to facilities, although supplies, equipment, water, electricity and emergency the process of prioritisation for reimbursement will need transport were either inadequate or unavailable in many attention. Reimbursing the transport cost for women of the lower level facilities; that is, the community-based who are poor, in addition to the benefit package of the health planning and services (CHPS compounds). policy, may encourage their use of services. Dalinjong et al. BMC Res Notes (2018) 11:341 Page 4 of 6 Lesson number two: a weak health system challenged access Lesson number four: lack of essential inputs The inadequacy or unavailability of drugs and sup - and infrastructure impeded quality care plies, equipment, transport and infrastructure meant Quality of care is compromised by the lack of essential the health system was unable to support the success- inputs and infrastructure in facilities. Poor quality of ful implementation of the policy. This is synonymous care not only discourages women from service usage, with settings in low- and middle-income countries, but does not permit the achievement of good health where the outbreak of epidemics and other emergen- outcomes. For instance, implementing fee free policies cies, for example, the outbreak of the Ebola Virus in may lead to an increase in the use of services but mater- West Africa, exposed the vulnerability and weaknesses nal deaths may not reduce proportionately if the qual- of the health system [30, 31]. Strong health systems are ity of care is poor . All pregnant women need to be required to attain health goals [32, 33], provide routine provided with quality care at pregnancy, labour, birth or usual services and to contain disease outbreaks [34, and beyond [40, 41]. The WHO’s framework for quality 35]. Such strong health systems provide the assurance of care stipulates the need for continuous assessment, that the required workforce, equipment, drugs and sup- improvement and monitoring within the health sys- plies, transport, information, monitoring and super- tem. It is crucial to ensure the availability of the neces- vision, affordable and responsive services as well as sary inputs for quality care provision , including an good provider relations exist in the process of service adequate workforce and skilled, regulated and educated delivery . The success of Ghana’s policy requires an midwives . ongoing investment in drugs and supplies, equipment In conclusion, lessons from our study included the and transport as well as improvement in the infrastruc- persistence of OOP payments, a vulnerable health sys- ture of facilities. tem, poorly resourced lower level facilities and low quality of care due to the lack of essential inputs and infrastructure. These negatively affect the drive towards Lesson number three: lower level facilities are poorly reducing maternal and child deaths and the attainment resourced of UHC. It is suggested that the Government of Ghana, Lower level facilities (CHPS compounds) in the study the NHIS and other stakeholders improve the provision are poorly resourced for the provision of services to of resources to facilities, especially lower level ones. people living in distant and remote communities. Nev- ertheless, these play a crucial role, acting as gatekeepers to the health system and as the first point of care for Limitations of the study women, including the poor. These facilities also provide The study has its limitations. Firstly, the estimated lev - basic preventive and curative services. Thus, strength - els of OOP payments might be underestimated, as pro- ening peripheral health systems is key to the achieve- ductivity losses for women and their caregivers were ment of good health outcomes as well as the attainment not determined. Secondly, recall bias on the part of the of UHC. Our study highlights the need for an expan- women cannot be ruled out since the interviews and sion in the infrastructure of the CHPS compounds, discussions were held after women had given birth. including the provision of emergency transport at the community level, as well as the provision of water and electricity in the facilities. Abbreviations CHPS: community-based health planning and services; MDGs: Millennium Water and electricity are crucial for the effective Development Goals; NHIS: National Health Insurance Scheme; OOP: out of operation of facilities. Water helps maintain hygiene pocket; UHC: universal health coverage; SDGs: Sustainable Development and sanitation in facilities, while electricity facilitates Goals; WASH: Water, Sanitation and Hygiene; WHO: World Health Organization. the sterilisation of equipment as well as storage of Authors’ contributions drugs, vaccines and associated adjuvants [37, 38]. The PAD AYW CSEH conceived and conceptualized the study. PAD collected data. World Health Organization (WHO) considers WASH PAD carried out the data analysis. PAD wrote the manuscript and AYW and CSEH critically reviewed it. All authors read and approved the final manuscript. (Water, Sanitation and Hygiene) services in facilities as very necessary for the attainment of the SDGs, espe- cially those relating to maternal and child health . Acknowledgements We thank all participants for their participation in the study. This explains the inclusion of WASH services in the framework for quality of care for maternal and child Competing interests health. The authors declare that they have no competing interests. Dalinjong et al. BMC Res Notes (2018) 11:341 Page 5 of 6 Availability of data and materials a qualitative study. BMC Pregnancy Childbirth. 2015;15(1):26. https ://doi. The dataset supporting the conclusions of this article is included within the org/10.1186/s1288 4-015-0453-z. article. 12. Patel R, Ladusingh L. 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