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Background: The Ghana National Health Insurance Scheme was introduced in 2003 to provide financial protection to the population. While the Scheme has made strides in improving access to healthcare there have been a few challenges including out of pocket charges to insured patients with weak client power. The study investigated the catastrophic nature of the out-of-pocket charges, the factors affecting the charges and the client power. Methodology: We used primary data collected in 3 administrative regions: Greater Accra, Ashanti and the Northern regions, within the period April and June 2022 to compute catastrophic expenditure of the out-of-pocket healthcare expenditure on household expenditure on food and non-food. In addition, multivariate logistic regressions and a linear regression were run to examine the incidence of the practice and client power. Results: The results showed that on average the insured paid out-of-pocket charges with a probability of 66%. The probability was highest (80%) in the Greater Accra, followed by Ashanti region (66.6%) and (52.9%) in the Northern region. The out-of-pocket charges were found to be catastrophic with incidence rate between 48.2% and 26.1% for the 5% and 20% thresholds; the overshoots ranged between 34.1% and 26.9% for the thresholds; the poor were more disadvantaged than the rich. Patients reported the out-of-pocket charges to the NHIA with probability of 1.9%, but the NHIA did not respond to 81% of the reported cases. Knowledge of the benefit list is likely to motivate the insured to report out-of-pocket charges, while cordial relationship between the NHIA staff and the insured deters providers from charging out-of-pocket. Conclusion: The out-of-pocket charges occur extensively across health facilities and is impoverishing. A close collaboration between the NHIA and the insured is needed to reduce the incidence and hold providers accountable.

The road to universal health coverage depends on resources committed to the health sector. In many cases, the political structure and strength of advocacy play an important role in setting budgets for health. However, this has, until recently, not been of interest to health system researchers and policymakers. In this study, we document the political path to the establishment of the Ghana National Health Insurance Scheme (NHIS) as well as continuous political interest in the scheme. To achieve our objectives, we used qualitative data from interviews with key stakeholders. These include stakeholders instrumental in the design and establishment of the NHIS. We also reviewed party manifestoes from the two main political parties in the country. Promises relating to the NHIS were extracted from the various manifestos and analysed. Other documents that account for the design and implementation of the scheme were reviewed. We found that the establishment of the NHIS was down to political commitment and effective engagement with relevant stakeholders. It was considered a solution to the political promise to remove user fees and make healthcare accessible to all. A review of the manifestos shows that in almost every election year after the NHIS was established, there has been some promise related to improving the scheme. There were several policy propositions repeated in different election years. The findings imply that advocacy to get health financing on the political agenda is crucial. This should start from the development of party manifestos. It is important to also ensure that proposed party policies are consistent with national priorities in the medium to long term.

AbstractThis research estimated the impact of credit uptake (formal, informal, and family) on youth entrepreneurship performance in Benin using panel data from a World Bank survey on enterprise formalization. To address potential endogeneity and ensure the robustness of results, we employed multiple models and estimation techniques (fixed‐effects and Lewbel approach). Our results showed that, while formal credit was most important for larger firms, smaller firms benefited mainly from flexible (informal or family) credit. The impact of credit uptake was generally higher for female‐owned firms. There were also variations in uptake according to the firm owner's age. The impact of formal credit was relatively higher for older firm owners while informal credit impacted more younger owners. The findings highlight the importance of informal and family credit sources, especially for start‐ups and small firms.

Since the outbreak of the COVID-19 crisis, there is an increased interest to understand how social inequalities, discrimination, and inclusion are related to the pandemic. Sub-Saharan Africa has been comparatively resilient regarding the number of cases and fatalities per capita. At the same time, the region has high rates of multiple inequalities. Socioeconomic inequalities could adversely affect the fight against COVID-19 by influencing people's access to healthcare and eroding confidence and trust in public health institutions. This work investigates the effects of education, gender, income, and political inequalities on COVID-19 in Sub-Saharan Africa. The study also explores a country case study from Ghana to complement the systematic regional analysis. We find that pre-existing income inequality, along with some other dimensions of inequality, may have contributed to higher infection and mortality rates of COVID-19. We recommend that in the shortterm governments should consider outcomes of inequality in their fight against COVID-19. In the medium and long-term, and for the effectiveness of measures to fight future outbreaks, governments should strive to reduce various forms of inequalities.

In recent years, economic development discourse has moved beyond increasing economic growth to ensuring that growth also leads to reduction in poverty and inequality. This motivates the current study to examine the relationship between economic growth and poverty in Benin. We used data from the 2006 and 2011 Benin Demographic and Health Surveys and computed a multidimensional poverty index using multiple correspondence analysis. The distribution of growth pro‐poorness was analyzed using the Growth Incidence Curves and Non‐Income Growth Incidence Curve. Average multidimensional poverty rate was estimated to be about 55.3 percent. The findings show that while growth has generally been pro‐poor in Benin, there exist disparities across rural and urban households, and for women as well as the elderly. The findings reinforce the need for broader poverty measures and refocusing poverty reduction strategies to marginalized groups in Benin.

BACKGROUND: Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services. METHODS: We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities' service availability and readiness. RESULTS: We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points). CONCLUSIONS: We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors. TRIAL REGISTRATION: This study is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations (RIDIE-STUDY-ID-55942496d53af). SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at ...