Access to maternal health services under the free maternal health policy in the Kassena-Nankana municipality of Northern Ghana

University of Technology Sydney. Faculty of Health.Introduction: Ghana implemented the National Health Insurance Scheme (NHIS) in 2005 to improve access to health services, for the achievement of universal health coverage. A free maternal health policy was implemented under the NHIS to enhance access for pregnant women. It is unknown if the policy has reduced access barriers regarding affordability, availability, acceptability and quality of care. Therefore the aim of the study was to explore factors affecting access in the form of affordability, availability, acceptability and quality of care under the NHIS policy. Methods: A cross-sectional survey was conducted in the Kassena-Nankana municipality of the Upper East region of Ghana. The study used parallel mixed methods; it collected and combined quantitative and qualitative data. Questionnaires were administered to women (n=406) who gave birth in facilities (n=353) and at home (n=53). In-depth interviews (IDIs) were carried out with health providers (n=25) and insurance managers (n=3), while focus group discussions (FGDs) were held with women (n=10). Descriptive statistics were used for the quantitative data. The qualitative data were analysed using a thematic analysis process. Results: Affordability – Women made out of pocket payments (OOP) under the policy, averaging GH¢17.50 (US$8.90) and GH¢33.50 (US$17.00) respectively, during pregnancy and childbirth. About 36% (n=145/406) of women incurred what was classified as ‘catastrophic’ OOP payments over 10% threshold of household income, affecting their welfare. Availability – Distance and time were barriers to care seeking. Infrastructure, laboratory services, accommodation, equipment, basic drugs and supplies were limited and often inadequate. The community-based health planning and services compounds were particularly challenged. Of the 14 study facilities, only two (14%) had a source of clean water, and five (36%) had a regular power supply. Emergency transport for referral was also unavailable. Acceptability – Women perceived facilities to be clean despite the limitations in infrastructure. Providers were perceived to be respectful and friendly. Eighty-nine percent (n=314/353) of women revealed a lack of privacy at childbirth, which was confirmed in IDIs. Quality of care – Overall, 74% (n=300/406) and 77% (n=272/353) of women were very satisfied or satisfied with quality of care during pregnancy and at childbirth respectively, which was supported in FGDs. Providers reported being dissatisfied, due to the challenges associated with service provision. Conclusion: Despite the policy, findings showed that out of pocket payments still existed and one third of women were significantly disadvantaged by the payments. Nevertheless, most women were satisfied with their care, although this could be because they were unaware of what high quality care might include. Providers were aware of the limitations of care provision and many reported being dissatisfied with the service they could provide. The government of Ghana, the National Health Insurance Scheme and other stakeholders should embark on resourcing facilities as well as infrastructural improvements. These would improve access to services and staff satisfaction, for the achievement of universal health coverage