**1. Introduction**

Access to healthcare including maternal healthcare services drives public health policies across the globe [1–3]. According to Ribot [4], access connotes the ability to make use of a resource. In the field of maternal healthcare, access entails the ability of women to obtain prenatal, antenatal, facility-based delivery and postnatal services [5] since these services contribute to beneficial health outcome for both the baby, and mother. Hence, Krutilova [6] maintains that all individuals including women ought to have access to healthcare that meet their needs regardless of their economic, social and physical attributes. Yet, access to maternal healthcare services remains a major development challenge around the world and in Africa, the state of affairs is more disquieting [6]. In sub-Saharan Africa in particular, Twum et al. [7] posit that financial constraints tend to erect barriers to access healthcare for the less privileged, particularly women. As a result, Kibusi et al. [8] pointed out that

**10**

*Healthcare Access - Regional Overviews*

[1] Wang H et al. GBD 2015 mortality and causes of death collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: A systematic analysis for the global burden of disease study 2015. The Lancet. 2016;**388**(10053):1459-1544

[10] Spaan E et al. The impact of health insurance in Africa and Asia: A systematic review. Bulletin of the World Health Organization. 2012;**90**:685-692

[11] Smith KV, Sulzbach S. Communitybased health insurance and access to maternal health services: Evidence from three west African countries. Social Science & Medicine. 2008;**66**(12):2460-2473

[12] Otieno PO et al. Prevalence and factors associated with health insurance coverage in resource-poor urban settings in Nairobi, Kenya: A cross-sectional study. BMJ Open. 2019;**9**(12):1-2

[13] Abiiro GA, McIntyre D. Universal financial protection through National Health Insurance: A stakeholder analysis of the proposed one-time premium payment policy in Ghana. Health Policy and Planning. 2012;**28**(3):263-278

[14] Soors W et al. Community Health Insurance and Universal Coverage: Multiple Paths, Many Rivers to Cross. World Health Organization; 2010

[15] Tangcharoensathien V et al. Health-financing reforms in Southeast

[16] High Level Expert Group. Report on Universal Health Coverage for India: Submitted to the Planning Commission of India. New Delhi; 2011. pp. 3-4

[17] Lu C et al. Towards universal health coverage: An evaluation of Rwanda Mutuelles in its first eight years. PLoS

[18] WHO. The Abuja Declaration: Ten

Asia: Challenges in achieving universal coverage. The Lancet.

2011;**377**(9768):863-873

One. 2012;**7**(6):e39282

Years on; 2019

[2] Bollyky TJ et al. Lower-income countries that face the most rapid shift in noncommunicable disease burden are also the least prepared. Health Affairs.

[3] Daniels M, Donilon T, Bollyky TJ. The Emerging Global Health Crisis: Noncommunicable Diseases in Low-and Middle-Income Countries. Council on Foreign Relations Independent Task

[4] World health organization (WHO).

The World Health Report 2010: Health Systems Financing: The Path to Universal Coverage. World health

[5] Reich MR et al. Moving towards universal health coverage: Lessons from 11 country studies. The Lancet.

[6] World Bank. Financing Health in Middle-Income Countries; 2019

[7] World Health Organization and UNICEF. Countdown to 2015: Accountability for Maternal, Newborn and Child Survival: The 2013 Update. World Health Organization and UNICEF; 2013

[8] World Health Organization. Global Health Expenditure Database. Available from: http://apps.who.int/nha/database/

CompositionReportPage.aspx

[9] WHO. The World Health Report 2010: Health Systems Financing: The Path to Universal Coverage. World Health Organization (WHO); 2010;**1**:2-3

organization (WHO); 2010

2016;**387**(10020):811-816

2017;**36**(11):1866-1875

Force Report No. 72; 2014

**References**

maternal mortality ratio in Sub-Saharan Africa continues to rise despite the many interventions such as health insurance.

Health insurance, therefore, comes in handy as it provides a mechanism for pregnant women to access and utilise maternal healthcare services. Ho [9] elucidates that health insurance protects the poor in particular against the risk of incurring medical and related financial costs at the point of service utilisation. In addition, Dalinjong et al. [10] emphasise that health insurance coverage allows all pregnant women to access maternal health services throughout pregnancy, childbirth, and post-delivery. Further, health insurance plays a critical role in improving maternal mortality ratio and related health outcomes [8]. Thus, governments have the responsibility to capture all persons including women under a health insurance scheme [11] to protect them against incurring financial cost at the point of maternal health services utilisation as insinuated by the social justice theory.

The social justice theory's core arguments centre on fairness and equality. As such, all people have a right to fair treatment and an equal share of the benefits of society [12] including health insurance coverage and consequently access to maternal health services. Also, Jost and Kay [13] elucidate that social justice ensures that societal benefits and obligations are shared in accordance with acceptable procedures, norms and rules that promote basic rights, liberties and entitlement of individuals and or groups within a society. Furthermore, social justice involves a fair and equal access to primary goods such as maternal healthcare services [14]. Bankson [15] contributes that social justice encourages the redistribution of goods and resources such as maternal health services in a way that improves the situations of the disadvantaged. In a nutshell, social justice is predicated on equal access and in the view of Nussbaum [16], efforts should be geared towards removing the obstacles that perpetuate differences, marginalisation or discrimination based on geographical location. Thus, health insurance coverage appears to provide a window of opportunity to reduce Out-of-pocket expenditure [17] and ease access to maternal healthcare services.

Access theory is hinged on the ability of the individual/or group to benefits from resources such as health insurance through acceptable processes [4, 18]. Ribot and Peluso [18] conceive access to mean the ability of the individual/or group to benefit from such things as material objects, persons, institutions, and symbols. Therefore, the central tenets of access theory are maintenance, and control which are mediated by institutional structures and processes [4] within a social system. According to Ribot [4], maintenance concerns expending resources for individual/or collective benefit, whereas power over others constitutes control. In addition, Ribot and Peluso [18] intimate that power constitutes the material, cultural and politicaleconomic constituents within the social setup that spell out access to resources such as maternal healthcare. In brief, the expending of national resources in the form of free enrolment of pregnant women onto the national health insurance scheme [NHIS] seeks to guarantee access and utilisation of maternal healthcare services.

According to the World Health Statistics [19], 303, 000 women died as a result of pregnancy related causes in 2015. WHO further notes that 99% of the deaths occurred in low and middle-income countries (LMIC) and 64% of these deaths occurred in Africa. Previously, WHO [20] had estimated that Sub-Saharan Africa alone accounted for about 66% of global maternal related deaths. Specifically, Nigeria and India accounted for 19% and 15% respectively of global maternal deaths in 2015 [20]. Therefore, it is imperative for governments to ensure that women have access to quality care before, during and after childbirth since this will improve maternal mortality ratio [19]. Suffice it to say, the level of maternal mortality may have stimulated the formulation of sustainable development goals (SDGs)

**13**

*Access to Maternal Healthcare Services under the National Health Insurance Policy…*

since health is fundamentally linked to sustainable development. Specifically, goal 3 focuses on ensuring that all people including pregnant women enjoy healthy lives and wellbeing. Thus, governments are obliged to ensure the realisation of this

In 2003, Ghana introduced a NHIS as a measure to safeguard its population against out-pocket-payment at the point of accessing healthcare services [21] particularly maternal healthcare services. It is, however, important to note that the NHIS policy recognises that some sections of the society may not be able to make the minimum contribution to the scheme [22]. As a result, children under 18 years old, elderly above 70 years old, Social Security and National Insurance Trust (SSNIT) pensioners, pregnant women, and extreme poor do not pay the premium [22]. This signals that exemption of pregnant women from paying the premium seeks to do away with financial barriers to maternal healthcare services and thus, to

However, in Ghana, a total of 955 women died from pregnancy related causes in 2016 [23]. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF [24] also report that pregnancy-related mortality ratio for Ghana hovers around 343 deaths per 100,000 live births. GHS [23] had earlier noted that Greater Accra recorded the highest number of maternal deaths and this can be attributed to the concentration of referral facilities in Accra. GHS adds that the Upper West Region accounted for only 2% of the total maternal deaths in Ghana [23]. Nevertheless, GHS [23] posits that the Upper West Region is characterised by scattered health facilities which contribute to poor access to healthcare. This begs the question of whether enrolment and exemption of pregnant women from the payment of the NHIS's premium guarantees access and utilisation of maternal healthcare service in the region. The Wa West and Wa East districts are among the underprivileged in Ghana. In terms of health infrastructure and personnel, for instance, the Wa-West District is disadvantaged [25]. The District has one health centre and 27 community health planning services (CHPS) compounds that serve 81,348 people [25, 26] living in the 208 communities. The Wa East district also has its fair share of challenges. The district suffers from limited health facilities, insufficient health personnel, inaccessible communities, and poor road network [27]. This hints that perhaps the people and in particular pregnant women living in these districts may suffer deprivation

*DOI: http://dx.doi.org/10.5772/intechopen.88982*

reduce or eradicate pregnancy-related deaths.

and injustice as a result of the persistence of these challenges.

as important ingredients of access to maternal healthcare.

Still, studies that relate to access to maternal healthcare under Ghana's NHIS appear to ignore rural idiosyncrasies associated with access to maternal healthcare services. Using 2008 DHS data, Wang et al. [28] examine the impact of NHIS coverage on access to maternal healthcare services in Ghana and came to the conclusion that majority of pregnant women reported at least one antenatal care visit and facility-based delivery. The study presented a national picture but fell short of a discussion of access to maternal healthcare services in rural areas. In a related study, Twum et al. [7] investigated access to maternal healthcare services under NHIS's free maternal healthcare policy in relatively well-endowed urban towns of Kintampo and Jema. The authors reported that pregnant women who were covered under the free maternal healthcare policy completed the recommended four antenatal care visits and delivered in a health facility but did not go for postnatal care. Yet the study ignored rural anomalies, distance and waiting time at the facility

This study contributes to knowledge, first, by shifting the fulcrum of analysis of access from property to maternal healthcare and secondly, it sheds light on how enrolment onto the NHIS contributes to access to maternal healthcare in the two rural districts in the Upper West Region. Therefore, the study seeks to address the

important goal.

*Access to Maternal Healthcare Services under the National Health Insurance Policy… DOI: http://dx.doi.org/10.5772/intechopen.88982*

since health is fundamentally linked to sustainable development. Specifically, goal 3 focuses on ensuring that all people including pregnant women enjoy healthy lives and wellbeing. Thus, governments are obliged to ensure the realisation of this important goal.

In 2003, Ghana introduced a NHIS as a measure to safeguard its population against out-pocket-payment at the point of accessing healthcare services [21] particularly maternal healthcare services. It is, however, important to note that the NHIS policy recognises that some sections of the society may not be able to make the minimum contribution to the scheme [22]. As a result, children under 18 years old, elderly above 70 years old, Social Security and National Insurance Trust (SSNIT) pensioners, pregnant women, and extreme poor do not pay the premium [22]. This signals that exemption of pregnant women from paying the premium seeks to do away with financial barriers to maternal healthcare services and thus, to reduce or eradicate pregnancy-related deaths.

However, in Ghana, a total of 955 women died from pregnancy related causes in 2016 [23]. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF [24] also report that pregnancy-related mortality ratio for Ghana hovers around 343 deaths per 100,000 live births. GHS [23] had earlier noted that Greater Accra recorded the highest number of maternal deaths and this can be attributed to the concentration of referral facilities in Accra. GHS adds that the Upper West Region accounted for only 2% of the total maternal deaths in Ghana [23]. Nevertheless, GHS [23] posits that the Upper West Region is characterised by scattered health facilities which contribute to poor access to healthcare. This begs the question of whether enrolment and exemption of pregnant women from the payment of the NHIS's premium guarantees access and utilisation of maternal healthcare service in the region.

The Wa West and Wa East districts are among the underprivileged in Ghana. In terms of health infrastructure and personnel, for instance, the Wa-West District is disadvantaged [25]. The District has one health centre and 27 community health planning services (CHPS) compounds that serve 81,348 people [25, 26] living in the 208 communities. The Wa East district also has its fair share of challenges. The district suffers from limited health facilities, insufficient health personnel, inaccessible communities, and poor road network [27]. This hints that perhaps the people and in particular pregnant women living in these districts may suffer deprivation and injustice as a result of the persistence of these challenges.

Still, studies that relate to access to maternal healthcare under Ghana's NHIS appear to ignore rural idiosyncrasies associated with access to maternal healthcare services. Using 2008 DHS data, Wang et al. [28] examine the impact of NHIS coverage on access to maternal healthcare services in Ghana and came to the conclusion that majority of pregnant women reported at least one antenatal care visit and facility-based delivery. The study presented a national picture but fell short of a discussion of access to maternal healthcare services in rural areas. In a related study, Twum et al. [7] investigated access to maternal healthcare services under NHIS's free maternal healthcare policy in relatively well-endowed urban towns of Kintampo and Jema. The authors reported that pregnant women who were covered under the free maternal healthcare policy completed the recommended four antenatal care visits and delivered in a health facility but did not go for postnatal care. Yet the study ignored rural anomalies, distance and waiting time at the facility as important ingredients of access to maternal healthcare.

This study contributes to knowledge, first, by shifting the fulcrum of analysis of access from property to maternal healthcare and secondly, it sheds light on how enrolment onto the NHIS contributes to access to maternal healthcare in the two rural districts in the Upper West Region. Therefore, the study seeks to address the

*Healthcare Access - Regional Overviews*

nal healthcare services.

interventions such as health insurance.

maternal mortality ratio in Sub-Saharan Africa continues to rise despite the many

Health insurance, therefore, comes in handy as it provides a mechanism for pregnant women to access and utilise maternal healthcare services. Ho [9] elucidates that health insurance protects the poor in particular against the risk of incurring medical and related financial costs at the point of service utilisation. In addition, Dalinjong et al. [10] emphasise that health insurance coverage allows all pregnant women to access maternal health services throughout pregnancy, childbirth, and post-delivery. Further, health insurance plays a critical role in improving maternal mortality ratio and related health outcomes [8]. Thus, governments have the responsibility to capture all persons including women under a health insurance scheme [11] to protect them against incurring financial cost at the point of maternal

The social justice theory's core arguments centre on fairness and equality. As such, all people have a right to fair treatment and an equal share of the benefits of society [12] including health insurance coverage and consequently access to maternal health services. Also, Jost and Kay [13] elucidate that social justice ensures that societal benefits and obligations are shared in accordance with acceptable procedures, norms and rules that promote basic rights, liberties and entitlement of individuals and or groups within a society. Furthermore, social justice involves a fair and equal access to primary goods such as maternal healthcare services [14]. Bankson [15] contributes that social justice encourages the redistribution of goods and resources such as maternal health services in a way that improves the situations of the disadvantaged. In a nutshell, social justice is predicated on equal access and in the view of Nussbaum [16], efforts should be geared towards removing the obstacles that perpetuate differences, marginalisation or discrimination based on geographical location. Thus, health insurance coverage appears to provide a window of opportunity to reduce Out-of-pocket expenditure [17] and ease access to mater-

Access theory is hinged on the ability of the individual/or group to benefits from resources such as health insurance through acceptable processes [4, 18]. Ribot and Peluso [18] conceive access to mean the ability of the individual/or group to benefit from such things as material objects, persons, institutions, and symbols. Therefore, the central tenets of access theory are maintenance, and control which are mediated by institutional structures and processes [4] within a social system. According to Ribot [4], maintenance concerns expending resources for individual/or collective benefit, whereas power over others constitutes control. In addition, Ribot and Peluso [18] intimate that power constitutes the material, cultural and politicaleconomic constituents within the social setup that spell out access to resources such as maternal healthcare. In brief, the expending of national resources in the form of free enrolment of pregnant women onto the national health insurance scheme [NHIS] seeks to guarantee access and utilisation of maternal healthcare services. According to the World Health Statistics [19], 303, 000 women died as a result of pregnancy related causes in 2015. WHO further notes that 99% of the deaths occurred in low and middle-income countries (LMIC) and 64% of these deaths occurred in Africa. Previously, WHO [20] had estimated that Sub-Saharan Africa alone accounted for about 66% of global maternal related deaths. Specifically, Nigeria and India accounted for 19% and 15% respectively of global maternal deaths in 2015 [20]. Therefore, it is imperative for governments to ensure that women have access to quality care before, during and after childbirth since this will improve maternal mortality ratio [19]. Suffice it to say, the level of maternal mortality may have stimulated the formulation of sustainable development goals (SDGs)

health services utilisation as insinuated by the social justice theory.

**12**

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 constitute the final section.
