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Evaluation database

Evaluation report

2012 Ghana: Evaluation of the free maternal health care initiative in Ghana

Author: HERA, Belgium and Health Partners, Ghana

Executive summary


The Free Maternal Health Care Initiative provides subsidised health insurance to pregnant women, giving them access to an existing range of insurance benefits that includes comprehensive maternity care with some notable exceptions such as ambulance service and post-partum family planning counselling. It is supported from the general pool of resources of the National Health Insurance Fund, which includes contributions from international partners via the health sector budget support. The evaluation of the free maternal health care initiative in Ghana follows almost five years after it was launched in 2008.


The main objectives of the evaluation were: to evaluate the impact of the MoH‘s free maternal health care policy on utilisation of skilled delivery services in Ghana; and to evaluate the impact of the free maternal health care policy on quality of maternal health services.
Other objectives of the evaluation were:
• To ascertain the profile of beneficiaries of the free maternal health care policy. Indicate the profile of net beneficiaries in terms of geographical location and distance to nearest health facility, income and educational levels and how these variables influenced their health seeking behaviours.
• To describe the process and challenges in the implementation of the guidelines on free maternal health care policy at all levels of service delivery.
• To describe the process and challenges in the implementation of the guidelines on the free maternal health care policy within the NHIS and the MoH.
• To ascertain the perspectives of the beneficiaries (pregnant women and other stakeholders) of the policy including understanding reasons why women do not or are not able to take advantage of the policy.
• To draw lessons that will feed into the revision of the policy and for future initiatives.


In doing the evaluation, the following methods were used: systematic review of published and unpublished documents and databases; key informant interviews with 128 stakeholders in the Ghana health sector; review of maternity registers from 2007 to 2012 in 21 hospitals in 10 Regions; review of 2,420 individual maternity records in the same 21 hospitals; and 15 community group discussions in 11 different communities

Findings and Conclusions:

The findings of the assessment are as follows:
• Since inception of the initiative in 2008, there has been a steady increase in the number of facility-based deliveries from about 300,000 in 2007 to about 500,000 in 2011. The utilisation rate reported by the Ghana Health Service in 2011 was about 66% which is confirmed by population-based data of the 2011 Multiple Indicator Cluster Survey.
• The institutional maternal mortality ratio reported by the Ghana Health Service declined from 230 per 100,000 in 2007 to 170 in 2011.
• The 21 hospitals sampled were making an effort to cope with the growing number of maternity clients. Their main constraint was a severe shortage of human resources.
• The majority of hospitals faced challenges in providing an acceptable level of privacy and confidentiality for women during delivery.
• The referral system was affected by shortages and/or user fees for ambulance services.
• Supervision was not well documented and not conducted with the expected frequency.
• Most hospitals did not have regular plans or programmes for up-grading or refreshing the knowledge and skills of their staff.
• The main cost to the system is the increased recurrent cost reflected in increasing cost of insurance claims.
• NHIA tariffs for claim reimbursement were initially quite low, but were adjusted in 2013 to approach real costs. However major costs to facilities are generated by the time lag between service provision and claims payment.
• Barriers to facility-based deliveries cited were the distance and cost of transport, the attitudes and perceived hostility of maternity staff, a variety of local cultural practices and beliefs, and the cost of supplies requested by the midwives.


The main recommendations of the evaluation are:
• To continue the insurance premium exemption while further streamlining the NHIS registration process and while considering to expand the list of insured services, for instance by including ambulance transport and post-partum family planning services;
• To address the human resource bottlenecks for maternity care in order to match the service supply to the increasing demand created by the initiative;
• To further decentralise maternity services in order to bring them closer to communities by building the capacity of health centres and CHPS compounds for normal delivery services;
• To increase the efficiency of claims processing and payment, minimise the payment delays, and frequently review tariffs. At the same time, to institute tighter supervision and sanction providers who are passing costs of insured services on to clients;
• To increase the client-friendliness of maternity services through increased attention to privacy and confidentiality, and through training and supervision to improve client communications by maternity staff.

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