How health facilities dealt with challenges in MiP policy implementation arrangement
Managers and health workers reported in interviews that the National Malaria Control Programme (NMCP) provides both government and faith-based facilities with malaria programme drugs and supplies such as SP, malaria test kits (RDT) and LLINs through the Central Medical Stores (CMS) and the district health directorate (ASFacility01, IDI, Facility Manager; VRFacility02, IDI, Facility Manager). They indicated that they frequently experience stock out of SP from the CMS and they are no longer being supplied with RDTs. However, they had experienced relatively few occasions of stock outs of LLINs from the NMCP. A general stock out was experienced in December 2018 and January 2019, which was as a result of a national mass distribution. Extensive discussion on this issue can be found in another paper (54).
Managers in ASFacility02, ASFacility03 and ASFacility04 in the Ashanti region reported that they decided to use internally generated funds (IGF) to procure SP from private manufacturing companies, whenever there was stock out. To recoup their money, they instituted co-payment dubbed ‘top up’, where SP, which was previously free of charge, was sold to clients. However, they added that whenever the facilities get SP from the CMS, it is given to pregnant women for free. Two study participants commented:
“We were giving the drug [SP] to pregnant women for free when the government used to provide the SP. But because the facility buys the drug [SP] from its internally generated funds (IGF), it will definitely come at a cost to pregnant women.” (ASFacility04, Conversation, Supply Officer, 20/05/2018).
“The district health directorate used to supply us with the SP. The district health directorate no longer supplies us with the SP. Sometimes, we go to the district pharmacy for the SP, but it is not forth coming, so I bought this one (pointing to a box containing SP on the table in the ANC consulting room) from outside market to avert stock out of the SP.” (ASFacility02, IDI, ANC manager)
The four study facilities in the Volta Region and one facility in the Ashanti region did not buy SP from the open market, so they run out of stock whenever they were not supplied SP, as a manager explained: “For medicines, those that we are supposed to get from the open market are always available, but the programme drugs like the SP…if it is not available at the District Medical Store or Regional Medical store, we cannot get it from anywhere. Sometimes it [unavailability of SP] affects our clients.” (ASFacility01, IDI, Facility manager 01). Other times clients were told that there was no SP and they were not given alternatives. Some of the facilities issued prescriptions to ANC attendees to buy SP from private outlets. Thus, such facilities could not enforce DOT on such occasions. However, some of the health providers in ASfacility02 and VRfacility04 compelled ANC attendees to return to the facility to take the purchased SP under DOT, by seizing their maternity records booklets, which was only given back to them, after they had returned to take the purchased SP under DOT.
VRFacility02 dealt with stock out of SP by asking clients to go and return at a later date. Some clients returned after a week or more and obtained SP (VRFacility02, Observation notes, 02/07/2019). Another strategy was to borrow SP from other sister government health facilities (VRFacility02, IDI, Facility manager). ASFacility04 dealt with stock outs by rationing SP to clients, such that some clients ended up taking 3 doses of SP by the time of delivering, instead of 5 or more.
Facilities used part of their IGF to buy RDT kits and reagents, so they charged fees in order to recoup the money. Thus the policy of fee free testing for malaria in pregnancy service was changed to a fee paying service.
In three facilities in the Ashanti Region clients paid for anti-malarials such as artesunate-amodiaquine, however in some of the facilities in the Volta Region such as VRFacility04, it was given to women free of charge. Managers explained that they were not readily available, so they had to buy them from the open market and sell them to clients. However quinine was administered free of charge.
Delayed reimbursement from the National Health Insurance Scheme and hidden cost of MiP and maternal health care impacting on access to MiP interventions
Delays in reimbursement of the cost of services provided and in the provision of medical supplies and consumables contributed to facility management instituting fees for some consumables and services. Most of the fees were paid at the pharmacy and most clients were issued receipts. The institution of fees contributed to the increasing cost of ANC services.
The eight facilities explained that the NHIS frequently delays for over six months in reimbursing them for services that they provide. This assertion was confirmed by a senior official of the NHIS, who added that some facilities had only received reimbursement for services provided in early 2018 in 2019 (Conversation with a NHIA deputy director, Accra, 11/03/2019). Yet, managers had to service accumulating debts, buy drugs, pay contract staff and suppliers, buy and service equipment in order to keep their facilities functioning. So managers in all the facilities exercised power by instituting various forms of co-payment dubbed ‘top up’ for services that were previously free. Insured clients in three facilities in the Ashanti region paid half the price of routine drugs such as folic acid, ascorbic acid, fersolate and vitamin B complex, while uninsured clients paid the full cost (ASFacility02, Observation notes, 27/08/2018; ASFacility04, Observation notes, 16/08/2018; ASFacility03, IDI, Facility Manager). However, all the four facilities in the Volta Region offered routine drugs to ANC clients free in charge.
For clients to access fee free maternal health and MiP services, they had to undergo a urine in pregnancy test (UPT), which costs GH₵5 (1$). NHIS reimburses facilities for services provided to NHIS registrants and since majority of the women, who attend ANC for the first time are not insured, the facilities could not obtain reimbursement from the NHIS. The facilities thus passed this cost to the clients, as they could not afford to use their limited IGF to offer free UPT to the women. Health providers in interviews explained that a second reason for the mandatory pregnancy test was to prevent non pregnant women from exploiting the free maternal health care service (ASFaciility01, Conversation, Midwife, 19/11/2018; ASFaciility01, IDI, Facility Manager). Once women tested positive, they were registered on the NHIS and were expected to subsequently enjoy free maternal and MiP services.
In four facilities ANC clients paid 5GHS (1$) for a maternity record booklet. The facilities explained that maternity booklets were offered free of charge, when they were supplied by the MOH. However, the MOH had failed to supply any in the last six months. The facilities said that they did not want women to use ordinary books for ANC as it could compromise the quality of care, consequently the facilities paid for the cost of printing the books, which was passed on to clients (VRFacility03, conversation, Facility Manager, 30/11/2018; ASFacility01; IDI, Facility Manager 02). A manager explained:
“…those booklets used to be printed by the Ministry of Health and sent to us for them [clients] to take it for free. But over time those booklets don’t come… So you just print it at a cost… then the little money that they pay help you defray that cost. In essence it is supposed to ensure quality health care.” (VRFacility03, conversation with hospital administrator, 30/11/2018)
Women who were up to four months pregnant were due to receive SP. To access the service, women were required to undergo a Glucose-6-Phosphate Dehydrogenase (G6PD) test (the test assists in determining whether a client could be put on SP). In four facilities the test cost between GH₵15.00 and GH₵20.00 ($2.8 - $3.72). Three of these facilities said it was not covered by the NHIS. However, in VRFacility03 insured clients paid a top-up of 5GH (1$) for the test and the uninsured paid 15 GH₵ ($3). A facility manager explained that the charges were effected in 2019, because the government stopped reimbursing the facility for G6PD services provided to clients from the middle of 2018 (VRFacility03, IDI, Facility Manager).
In some facilities before women were given their first dose of SP, they were required to undertake a microscopic examination of blood for malaria parasites, utilising blood films (BFF test), which cost 5 GH₵ (1$).
Perceived negative influences of strategies adopted by health facilities on maternal and MiP health seeking behaviour of clients
Some women could not access comprehensive maternal health care, because they could not afford the fees charged for drugs, laboratory and ANC services. Observations in VRFacility04 and ASFacility0 illustrate the challenges that ANC clients experienced in paying for maternal and MiP services: Client Ajo*, a pregnant woman was referred to the laboratory for haemoglobin (Hb) test. However, she was reluctant to go, because her husband did not give her enough money to pay for the test, as she explained to the midwife (VRFacility04, observation notes, 30/07/2018). Client Cynthia, who was four months pregnant, complained of loss of appetite for a number of days, feeling weak and dizzy. So a midwife referred her to the resident obstetrician-gynecologist, on suspicion of malaria. Client Cynthia was seen sneaking out of the facility. When she was confronted by a research assistant, she explained that she would not be able to pay for the laboratory test and treatment, if the diagnoses confirmed that she had malaria, so she was going home to seek alternative treatment (ASFacility01, observation notes, 20/08/2018).
Some ANC attendees skipped scheduled ANC appointments, because they could not afford the cost of care. The research team visited two case studies, a 17 year old adolescent and a woman of about 27 years old in VRCommunity02. Both of them were insured and their houses were a walking distance to facility VRFacility02. But they had missed their scheduled ANC visits, because they could not afford the charges that insured clients paid (VRCommunity02, conversation with two case studies, 19/07/2018).
Other ANC attendees who could not afford the cost of comprehensive ANC combined ANC visits with taking herbal medicine, visits to prayer camps and prayers. A respondent whose house was equally close to her preferred ANC facility (ASFacility02) stated:
“At the early stage of my pregnancy, I felt weak and I was unable to do anything that is why I am no longer working. When I asked my husband to give me money to go to hospital, he told me he doesn’t have money… So I was using my own money. I have been there [hospital] 3 times and now I don’t have money to go again. …I don’t go to hospital and I have been using local medicine. I pray to God to give me life, strength and protect my child and myself, so that nothing bad happens to us.” (ASCommunity02, IDI, Pregnant Woman 02).
Some women were happy to take the prescription forms, because once they left the hospital, the health workers ceased to have power to compel them to purchase the prescribed drugs. Sometimes such measures led to women visiting the same facility with the same complaints: “… those who want to buy will buy. Others will also leave the prescriptions in their ANC booklet and come with the same complaints on their next visit.” (VRFacility02, IDI, Maternity Department Manager).
Some women waited till they were nearly due to deliver before attending ANC. So they did not receive LLINs and the mandatory five doses of SP (ASFacility01, IDI, Health worker01). Others who had never attended ANC were informed by friends, acquaintances and relatives who had ever attended ANC that one had to make payments, which deterred them from starting ANC early. This contributed to late uptake of IPTp-SP and use of LLINs, as both are offered at the ANC clinics. An IDI with a pregnant 16 year old adolescent, who was seven months pregnant, but had never attended ANC revealed:
Interviewer: “Why don’t you go for ANC?”
Adolescent: “I don’t have money.”
Interviewer: “You said you haven’t started ANC, so how did you know you pay money there?”
Adolescent: “One of my sisters told me.”
Interviewer: “So if you had the money, would you have gone?”
Adolescent: “Yes, as for the ANC it is good. When you go they give drugs.”
(ASCommunity03, IDI, Pregnant Woman 12)
Several pregnant women who could not afford the cost of maternal health care services and those who were given prescriptions to purchase certain drugs from the open market, perceived that the health care system was not responsive to their health needs, thus they lost trust in it. Some engaged in health shopping such as visiting other health facilities when they were told that more drugs were being provided in those facilities. Others supplemented ANC visits with visits to prayer camps, herbal centres and some engaged in self-medication. A seventeen year old adolescent, who was six months pregnant explained to the research team that she skipped her last scheduled ANC visit, because she did not have money, yet she went to the prayer camp every Thursday. She shared her high trust in the prayer camps as follows:
“The hospital will only see the physical and the best that they can do for you is to prescribe drugs for you to go and buy and take. But the prophet can see both physical and spiritual. After consultation, he would give you herbs to go and take and after three days you will be well. He can also foresee and avert any misfortune that can happen in the course of the pregnancy. So for me I trust the prophet more.” (VRCommunity02, Conversation, Case Study, 19/09/2018)
Perceived positive aspects of initiatives taken to facilitate MiP and maternal health care delivery
It was observed that some women [at least one in five] in both regions, were happy to access maternal and malaria in pregnancy services. They included some of those who were gainfully employed, women whose husbands encouraged them or gave them financial support to access health care. Others received financial support and encouragement from extended family members such as mothers and fathers in-law, or encouragement from their social networks such as friends to use ANC services. An ANC attendee stated: “My friend who influenced me to come to ANC said something about the drug [SP] at the time she [her friend] was advising me to come for ANC.” (ASFacility02, Observation notes, 23/08/2018).
Some women attended ANC regularly, because they had built trust in the health care system, resulting from having experienced positive effects of utilising health care in previous pregnancies. Others had trust in the health care system and voluntarily accessed health care and so did not complain about the cost of MiP and other maternal health services. A respondent stated: “I decided to start attending ANC by my own will, but not for economic, or distance factors.”(VRCommunity04, IDI, Pregnant Woman 05)
An initiative known as “last mile” was introduced in the second quarter of 2019. The CMS sends medical commodities to the door steps of the health facilities every two months. Facilities are offered their requisitioned commodities to last for three months, so that they do not run short of supplies before the next visit. So a facility makes a requisition and the CMS uses tally cards to distribute them according to requests made. The initiative is to ensure that far off facilities or hard-to-reach facilities do not run short of medical supplies including MiP drugs and other maternal health drugs (VRFacility02, IDI, Facility Manager; VRFacility04, IDI, Facility Manager). However facilities are still in shortfall of medical consumables such as gloves, gauze etcetera.
Effects of initiatives on managers and health workers’ experiences in maternal health and MiP services provision
Managers perceived the initiative of cost-sharing such as clients buying maternal health care products, SP, and other malaria drugs as beneficial, for it contributed greatly to the facilities’ internally generated funds. Facilities could thus afford to buy requisite drugs, medical supplies and consumables for effective and uninterrupted service delivery.
However, department managers and workers felt frustrated, as these initiatives affected clinical decision making and adherence to treatment. Some of the midwives reported in interviews that pregnant women who visited the ANC were always reluctant to undertake laboratory tests, because of the fees involved. On one occasion, when a client was reluctant to undergo an hb test, because of the cost involved a health provider stated: “…the pregnant women in this town [VRCommunity04] … do not like paying at all for health care services.” (VRFacility04, observation notes, 30/07/2019). Health providers lamented that it made their work difficult, because refusal to conduct necessary lab tests, hampered health providers’ ability to diagnose the medical conditions of clients, in order to provide appropriate medical care (VRFacility04, observation notes, 30/07/2018).
Health providers perceived that clients distrusted them and believed that they benefitted from the payments. They perceived that was the reason for the reluctance towards any payment, as evidenced in a conversation with two midwives: “They think that we use the money for ourselves.” (VRFacility04, conversation with two midwives, 29/08/2019)
Health managers and workers felt frustrated that sometimes the women ended up buying the wrong drugs or were offered expired drugs by drug stores who exploited the women (VRFacility02, IDI, ANC Manager; VRFacility02, IDI, Facility Manager). An ANC manager lamented: ‘You write for them to go and buy [drugs] and when they go they come back with another drug, so it’s a serious thing (VRFacility02, IDI ANC Manager 01). Such actions compromised adherence to treatment.
Some health workers believed that the reason for the shortage of drugs and supplies was because the district health directorate, which they perceive has power to ensure their availability was not responsive to the facilities’ needs. An ANC Manager expressed her frustration:
…you know the routine drugs are not available all the time (folic acid, multivite and ferrox and iron capsules… It’s a challenge, but unless the authority get up, because we have been complaining and since they [district health directorate] are not on the ground, I don’t know if they don’t feel the pain, but we do feel the pains of the pregnant women. You can’t get up and do what you want to do, because they said all initiatives should come from the directorate (VRFacility02, IDI, ANC Manager).
Two ANC managers in VRFacility04, reported in interviews that they did not trust that their facility manager was responsive to health providers’ needs for resources to work with. They believed that she did not always include the requisition for drugs and medical consumables made by the ANC to the DHA and the CMS.
Facility managers on the other hand explained that the stock outs and unavailability of medical supplies were a result of failure to reimburse facilities and delays from the CMS (VRFacility02, IDI, Facility Manager; VRFacility04, IDI, Facility Manager).