**3. Empirical review**

*Healthcare Access - Regional Overviews*

tute the final section.

**2. Conceptual discussions**

quently during delivery.

crucial role in the utilisation of these services.

of membership and processing fees [7].

following objectives: (1) assess how NHIS underwrites access to maternal healthcare services, and (2) examine the utilisation of maternal healthcare services under the NHIS policy. The paper is divided into six sections. The section following this discusses the concepts that underpin the study. Next, a review of some empirical studies that relate to the subject matter of the paper is presented. The fourth section presents the methodology adopted for the study and the fifth section presents the empirical evidence of the study, while conclusions and policy implications consti-

WHO [29] describes maternal health as the wellbeing of women before, during pregnancy, at childbirth and post-delivery. Therefore, maternal healthcare is concerned with providing pregnancy-related services to women and teen-age girls [24, 29]. Accordingly, maternal healthcare services include antenatal care (ANC), delivery care, and postnatal care (PNC) [24]. ANC denotes the care provided by skilled health workers to pregnant women and adolescent girls to ensure the best health conditions for the mother and baby [30]. Also, WHO notes that the uptake of ANC services enables skilled health personnel to identify risk, prevent risk and manage pregnancy-related diseases as well as engage in health education and promotion among pregnant women. Rutaremwa et al. [5] add that ANC attendance appears to help reduce stillbirths and neonatal death. Lincetto et al. [31] had earlier recommended that four ANC visits at specific intervals enable care givers to make essential interventions during pregnancy and subse-

Delivery care means attention given to mother during labour and delivery to respond to problems that may arise during the process. The care provided to women and new-borns until discharge is crucial for their health after they leave the health facility [20]. Further, WHO [30] noted that delivery care reduces illness and death in mothers and their new-borns babies. PNC, on the other hand, involves the provision of a supportive environment in which a woman, her baby and the wider family can begin their new life together [32]. According to Charlotte et al. [33], PNC ensures continuity of care for mother and baby as well as help to support healthy behaviours. Thus, PNC contributes to the beneficial health outcome for the baby as well as the mother [5]. Timilsina and Dhakal [34] also note that PNC helps to assess the health status of mother and new-born so as to be able to institute a remedy to any defect and to formulate preventive measure that may become necessary. It is, however, important to state that access to maternal healthcare services plays a

Access to healthcare refers to the ability of a given individual or group to enter into a health care delivery facility [35] and utilise the available services. In other words, access to health care describes the relationship between need, provision and utilisation of health services [36]. Therefore, access to maternal healthcare entails the entry into and use of skilled services during pregnancy, delivery and post-delivery [37]. However, the costs associated with seeking maternal healthcare services may discourage pregnant women, particularly the poor, from receiving healthcare services promptly [38]. As such, in 2003, the NHIS was introduced in Ghana and subsequently, in 2008, a free maternal healthcare programme (FMHCP) was set in motion to alleviate the cost burden associated with seeking maternal healthcare [7]. As a result, pregnant women do not pay a premium for fresh registration or renewal

**14**

So far, our discussion is centred on the concepts that underpin the study. This section considers some empirical studies that have been carried out on health insurance and access to maternal healthcare services. Kibusi et al. [8] sought to find out whether health insurance coverage enabled pregnant women to utilise maternal health services in Tanzania. The study revealed that a small percentage of the respondents were covered by health insurance. Further, the results showed that the timing of the first ANC visit was also low and few women completed the recommended ANC visits. Yet, the authors found that majority of the respondents delivered at health facilities under skilled attendants and concluded that health insurance coverage was associated with the recommended timing of the first ANC visit as well as increases the chances for facility-based delivery. In Bangladesh, Banik [38] had earlier found that majority of pregnant women had their nearest health centre within a one-kilometre distance but had to wait for about an hour before being seen by the nurses or doctors. Also, decisions about seeking maternal healthcare services made by both husband and wife were higher compared to those made by husband or wife alone [38].

In a related study, Twum et al. [7] assessed the effectiveness of a free maternal healthcare programme under the NHIS in Ghana. The social justice and access theory undergird the study. The authors discovered that health insurance status of respondent played an important function in the use of maternal healthcare services and women with health insurance coverage had a better opportunity to use antenatal care, deliver at the facility and postnatal care compared with those who are not registered. Similarly, Dalinjong et al. [10] assessed the implementation of the free maternal health policy in rural Northern Ghana using the qualitative approach. The study found that women still paid for drugs, supplies, laboratory services including ultrasound scans and transport as well as the purchase of other items for childbirth. They also reported that distance and time taken to reach the nearest facility were impediments to seeking maternal healthcare. The next section of the paper discusses the study locations, sampling, data collection methods and instruments as well as data analysis techniques deployed in the study.

### **4. Study methods**

The study was conducted in Wa West and Wa East Districts in the Upper West Region. The Wa West District is home to 81,348 people with 50.5% being females and the rest being males with a Total Fertility Rate of 4.1. The district is entirely rural and is located in the western part of the Upper West Region. The district lies between longitudes 9°40′N and 10°10′N and latitudes 2°20′W and 2°50′W. The southern part of the district is bordered by Northern Region, Nadowli-Kaleo District to the north-west, Wa Municipal to the east and Burkina Faso to the west [25]. The District occupies nearly 1492.0 km2 and its capital, Wechiau is about 15.0 km away from Wa the regional capital. On the other hand, the Wa East district lies between latitudes 9°55′N and 10°25′N and longitude 1°10′W and 2°5′W and covers a land area of about 4297.1 km2 . The district capital, Funsi is about 115 km away from Wa and shares boundaries with West Mamprusi, West Gonja and the Sissala East district to the northwest, southeast and north, respectively. The district host about 72,074 inhabitants and 50.5% of them are males while the rest are females with a Total Fertility Rate of 3.9 [39]. **Figure 1** shows the zonal centres selected for the study.

**Figure 1.** *Map of Wa East and Wa West show zonal centres sampled for the study. Source: adapted from GSS [25, 39].*

The mixed research approach with the aid of the cross-sectional design which requires taking a snapshot of the phenomenon under consideration. However, the study was tilted towards the quantitative approach. The total number of households in the four sampled communities was 454. The sample size was computed using Yamane's statistical formula: n = \_N 1 + N(e) 2 ; where n is the sample size, N is the size of the study population, and e is the margin of error [40]. In this study, N = 454 and e = 0.05. The sample size was computed as: n = \_\_\_\_\_\_\_\_\_\_\_\_ <sup>454</sup> 1 + 454(0.05) 2 = 212. Therefore, the samples size for the study was 212 households.

The multi-stage sampling technique was deployed in selecting zonal centres, communities and households. First, Wa East district has four zonal centres: Funsi, Bulenga, Kulkpong, and Baayiri, whereas Ga, Gurungu, Vieri and Wechiau constitute the zonal centres for the Wa West District. Two zonal centres from each district (Bulenga, Baayiri, Vieri and Ga) (see **Figure 1**) were randomly selected to participate in the study. In each zonal centre, the names of the communities were compiled and one community was randomly selected. In all, four communities (Guonuo, Tampala, Ga, and Berenyasi) were randomly sampled for the study. Following on that one house was randomly selected and the subsequent houses were then systematically sampled after every fourth house. Finally, women within the reproductive ages of 15–49 years [41] who have had children between 2015 and 2019 were identified and interviewed. Interviewing was the method used to collect the data with the aid of an interview schedule which contained both open-ended and closed-ended questions. Descriptive statistics, chi-square test for independence, Man-Witney test and thematic analysis were deployed in the analysis of the data. The results were presented in tables, text and narration.
