Affordability of Healthcare Services in the Central Gonja District of Ghana

Affordability of healthcare services in the Central Gonja District of Ghana

Keywords: Affordability, Catastrophic health, Expenditure, Chemical Seller, Household, Out-of-Pocket Payment

ABSTRACT: Financial access to health care remains a challenge to the majority of people especially in the rural areas. In Ghana, it is estimated that four out of every ten persons are poor. In the Northern region of Ghana and the Central Gonja District, poverty level is 70% and 90% respectively. Over 50% of the residents of Central Gonja District are not insured and as a result the same proportion or more incur out of pocket health expenditure. The purpose of the study was to determine the affordability of healthcare services in Central Gonja District. A cross sectional study design and a mixed-method [quantitative and qualitative methods] were used. The two stage cluster sampling approach was used to draw the sample for the study. A sample of 403 household was interviewed using semi-structured questionnaires and three key informant interviews were conducted. The findings showed that in the Central Gonja District, 83.6% (337) of households were poor, 17.1% (N=204) of those who sought care from a formal or informal provider incurred catastrophic cost of care. Direct average cost of healthcare was US$ 21.40 (SD 30.14) while indirect average cost of care was US$ 28.50 (SD 40.98). In conclusion, healthcare is unaffordable to a good number of the people of Central Gonja District and therefore efforts at financial protection especially of the poor should be stepped up.

073-084| JRPH | 2014 | Vol 2 | No 1

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www.jhealth.info

Journal of Research in

Public Health An International

Scientific Research Journal

Authors:

Adam Soale1 and

Reuben K. Esena2.

Institution:

1. University of Ghana ,

SPH -HPPM, P. O. Box

LG 13 Legon-Accra Ghana.

2. University of Ghana,

School of Public Health,

P. O. Box LG 13

Legon-Accra Ghana.

Corresponding author:

Reuben K. Esena

Email:

Web Address:

http://www.jhealth.info/

documents/PH0017.pdf. Dates: Received: 20 Sep 2013 Accepted: 08 Nov 2013 Published: 06 Feb 2014

Article Citation: Adam Soale and Reuben K. Esena. Affordability of healthcare services in the Central Gonja District of Ghana. Journal of Research in Public Health (2014) 2(1): 073-084

Journal of Research in Public Health

Jou

rn

al of R

esearch

in

Pu

blic H

ealth

An International Scientific Research Journal

Original Research

INTRODUCTION

Background

The poverty-health status syndrome shows

spatial variation. The urban areas are better served with

modern health facilities by government, whilst the rural

areas suffer from acute lack of these facilities. (Bour,

1999). In most developing countries healthcare is usually

inaccessible to a large proportion of the population

especially those living in remote rural areas. In Ghana

the main cause of poor access to healthcare services

which result in poor health status is inability to bear

service cost (Takyi and Anamuah-Mensah, 1993).

The health system of the country has

communicable disease conditions, malnutrition, high

infant mortality and poor reproductive health. There are

also non-communicable diseases, such as, diabetes and

cardiovascular diseases. These health conditions are

largely worsened by poor access to health services and

the geographical and financial access to health care is a

challenge (Gyapong et al., 2007).

According to the 2009 Health Sector Programme

of work, maternal mortality ratio in 2008 stood at 451

per 100 000 live births (GHS, 2010) and one out of

every thirteen Ghanaian children died before the age of

five (GDHS, 2008). Anaemia which is said to be a major

threat to maternal and child health is said to be on the

increase. Among children, it is estimated that 78 per cent

have anaemia while in women it increased from 45 per

cent in 2003 to 59 per cent in 2008 (GDHS, 2008).

As a result of the widespread poverty in the

northern region, many cannot afford basic healthcare. It

is estimated that seven out of every ten persons is poor in

the region. Incidentally it is more deprived than the

southern sector of the country in terms health

infrastructure. The 2005 annual report of the Ghana

Health Service (GHS) of the northern region reveals that

maternal and under-five mortality are a major challenge

with under–five mortality as high as 137 per 1000 live

births (GDHS, 2008). The direct and indirect causes of

the maternal mortality are predominantly caused by

poverty, poor access to care, and poor quality of care,

which are preventable. Despite the fact that membership

of the National Health Insurance Scheme (NHIS) is

mandatory [unless one is enrolled to a private health

insurance] enrolment in NHIS is low among informal

sector workers especially in rural areas, posing a

challenge to access to health care.

Problem statement

It has been established that 7 out of every 10

persons in the northern region is poor (GLSS-4,

1998/1999). Widespread poverty in the region makes

basic healthcare unaffordable to a large number of

people in the region (ACDEP, 2007).

Some intra regional disparities in the prevalence

of poverty are observed with some districts such as the

Central Gonja having poverty levels as high as 90%

(Nine out of every ten persons)- (CGDA, 2008).

In communities with such high level of poverty,

financial access to healthcare is a major challenge. This

poor financial access is manifested in the high under-five

mortality rate of 181 per 1000 live births in the district

(CGDA, 2008) exceeding both the regional and national

rates. There were also cases of increased malnutrition

among children under-five. The top ten ailments in the

District are malaria, diarrhea, Urinary Tract Infection

(UTI), skin diseases, pneumonia, typhoid, Kwashiorkor,

anemia, intestinal worms, and guinea-worm (DHMT,

2010).

In addition to the poor health status in the

district, Health Insurance coverage is said to range

between 30 to about 46 per cent (DMHIS, 2012). Out-of

–pocket payments are still a widespread phenomenon in

the district. In 2009 the proportion of uninsured patients

who visited a public health facility in the district was

57% of the total out–patient (OPD) visits (DHMT,

2010). A study in the northern region observed that

during periods of illness about 29 per cent resort to

borrowing, 31 per cent receive support from relatives,

Soale and Esena, 2014

074 Journal of Research in Public Health (2014) 2(1): 073-084

friends and community and 40 per cent rely on their own

internal resources to finance their healthcare (Apoya and

Maaweh, 2001).

This highlights the gap in health care access and

affordability of these services. It is unclear as to what

proportion of households cannot afford health care

services and what proportion of household incomes are

spent on health care. Therefore, the objective of this

study is to determine the affordability of health care to

households in the Central Gonja District.

Conceptual framework

The study seeks to use the framework [Fig 1] for

estimating household cost of illness, coping strategies

and their economic consequences at the household level

(Sauerborn, Adam, and Hien, 1996) to determine

affordability of healthcare services in the Central Gonja

District.

The framework is divided into three main parts:

Health System factors, Individual and Household level

factors and Social resources factors.

The type of illness and severity (perceived or

evaluated) determines the cost that will be involved in

treating the particular illness. Severe illness may be due

to delay in seeking early treatment which could be due to

treatment seeking behavior. It is known that households

or individuals may use home remedies first before

seeking further treatment and sometimes only when the

disease is severe. When distance to a health care facility

is far or service availability is poor this might lead to

delays in seeking care but will influence the costs of

care. However if there is a health insurance, the cost of

seeking care may not affect early treatment seeking. On

the other hand where user fees apply, this may lead to

high cost. Direct cost refers to household expenditure

associated with seeking healthcare. It includes medical

cost (cost of consultation, Medicines and laboratory test

etc.) and non-medical cost (Transport cost, cost of

special foods etc.). Indirect cost on the other hand

involves loss of household productive labor time by the

sick and the caregivers due to illness. Coping cost has to


Journal of Research in Public Health (2014) 2(1): 073-084 075

Source: (Sauerborn et al., 1996)

Figure 1: Conceptual Framework for Assessing Cost of Health Care

do with ways household are able to raise the needed

income to pay for the cost of treatment. Usually it

involves borrowing, relying on a network of relatives and

friends for support and sale of family assets. Borrowing

to pay for health care may lead to households cutting

down on their basic needs so as to afford health care

which may be detrimental to overall livelihood of the

individual or household.

Justification

By adopting health for all, countries have a

responsibility of ensuring that all enjoy good health

enable them to participate in social and economic

activities. Meanwhile poor health due to catastrophic

cost of illness continues to undermine efforts at

achieving the MDGs. Despite the introduction of health

insurance and the exemption policy, out-of-pocket

(OOP) payments still characterized the healthcare

delivery system in communities such as Central Gonja

District. Poverty and poor health are intricately linked

and mutually reinforcing and neither can be improved

without a corresponding improvement in the other.

Therefore, findings from this study will add to

existing knowledge on financial access to healthcare in

general and affordability in particular in Ghana and serve

as baseline information for the Central Gonja District. It

will also bring to the fore which of the cost components

forms the chunk of the total cost of healthcare and

specify areas for which programs of intervention by the

Ghana Health Service and other stakeholders could be

targeted at.

For instance it will inform policy makers to

re-align poverty reduction effort with the improvement in

financial access and general affordability of healthcare.

This can protect the poor from sinking into further

poverty.

Research questions

How much do households pay for healthcare?

Are households able to afford the cost of healthcare?

Objectives

General Objective

The general objective of this study is to

determine the affordability of healthcare services in the

Central Gonja District.

Specific objectives

The specific objectives were to:

Determine the proportion of household income

spent on healthcare in the District.

Estimate the direct cost of healthcare services to a

household in the District.

Determine the household indirect cost of healthcare

in the District.

Methods

Type of the study

The study was a cross-sectional design using a

mixed-method [quantitative and qualitative].

Study location/ area

The Central Gonja district [Figure 2] is one of

the newly created districts carved out from the West

Gonja District by legislative instrument 1750 under the

Local Government act, 1993 (Act462) in 2004 (CGDA,

2005). It lies between longitude 1°:5" and 2°:58" West

and Latitude 8°:32" and 10°: 2" north.

Variables

The dependent variable that was measured in the

study is Affordability of healthcare services to

households.

The independent variables included: Household

income, Employment, Cost of medical care, Cost of

transport, Health insurance, Length of illness and

chronicity and age.

Study population

The study population is the number of adult

household members in the District. The study unit

therefore is the household. The choice of the household

as the unit of analysis was informed by the fact that

negotiation about seeking care takes place in household

and cost of care which is usually borne by either the sick,



the caregiver or in extreme cases the community,

ultimately burdens the household’s resources.

Sample size

The sample size taken for the study [403

households] was determined according to Fischer et al

1998 [cited in Gichobi et al., 2010] and found to be:

384. A non-response rate was added to increase the

sample size to 403.

Sampling procedure

The sampling method used is the Two-stage

cluster sampling method. The community was divided

into three clusters namely: Bridge, Central Gonja District

right of road from Kintampo and Left respectively.

Given that the population of Central Gonja District is

8347 and an average household size of 6.8, the total

number of households was approximately 1228. It was

assumed that the population was fairly distributed among

the clusters; therefore each had about 409 households.

Within each cluster a systematic random sampling of 135

households [about 33%] in each cluster was done with a

sampling interval of 3 to participate in the study. In order

to avoid any bias in the sampling, it was started at the

middle of each cluster and the direction was determined

by spinning a bottle. The neck of the bottle served as the

pointer to the direction. Sampling was done in that

direction and then opposite direction until the desired

sample size was attained. Three key informants namely a

chemical seller, the in-charge of the health center in

Central Gonja District and a Traditional healer were

interviewed to elicit information about the cost of their

services.

Data collection techniques/method and tools

Data was collected in the field using a semi-

structured questionnaire and an interview guide. The

questionnaire collected information on age, sex, main

occupation of respondent, household consumption

expenditure (Food and utility), non-food for the last

month and remittances (Proxy for household income) on



Figure 2 : Map of Central Gonja District in Ghana

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9 0 9 18 Kilometers

HEALTH FACILITIES IN THE CENTRAL GONJA DISTRICT

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Health facilities in the Central Gonja District

one hand and expenditure on health (expenditure on self

medication, out-patient, in-patient and folk/traditional

healing) on the other. Information on whether a

household member was ill in the last six months before

the survey and where treatment was sought, mode of

payment for care, length of illness and health insurance

status were also collected.

The key informant interview was conducted to

elicit information on the services offered, the cost of the

various services offered by the facility/chemical seller/

traditional/folk healer, the type of conditions they see

and severity of illness and their opinion on the possible

reasons for the delay or otherwise.

Quality control

To ensure that the quality of the research is

enhanced, first of all the questionnaire was translated

into the local dialect (Gonja) with the assistance of a

teacher who teaches Gonja in Tamale College of

Education, Tamale was used to train the field workers to

ensure accuracy and uniformity in the administration of

the questionnaires.

In furtherance of quality assurance, all completed

questionnaire were checked for completeness and

inconsistencies. Besides the community wide survey,

information was collected from the in-charge of the

Central Gonja District health centre, Licensed chemical

seller and a traditional healer through a key informant

interview. This was to ensure the quality of data.

Data processing and analysis

The first part of the analysis of data involved

categorizing households into income quintiles and

calculating frequencies and the mean health expenditure

of households. Then using the health expenditure,

proportions of each household’s income that is spent on

health was calculated. Bar graph and tables were used to

display the results. This was done by coding the data and

inputting it into Statistical Package for Social Science

(SPSS) version 16.0. These statistics together with

explanatory notes were employed to enhance clarity and

aid understanding of outcome. This outcome formed the

basis for the conclusions and recommendations.

For the qualitative data, responses from the key

informant interviews were transcribed and reported in the

text according the objective they answer.

Ethical considerations/issues

Ethical approval was sought from the Ghana

Health Service Ethical Review Committee [Research and

Development Division]. The study subjects included

household heads or any adult member of the household

present at the time of the survey. There was no conflict

of interest on the part of the researchers. Permission was

sought from the Acting District Director of Health

Services of the Central Gonja District.

Pre-testing of questionnaire

Questionnaire for the study were pre-tested at

Benkrom, a community in the extreme northern end of

the Kintampo north Municipality separated from Central

Gonja District by the Black Volta whose residents

constantly interact with the people of Central Gonja

District and share similar characteristics with them.

Issues that were considered during the pre-testing

included: respondents willingness to co-operate by

answering questions, the reliability and validity of the

data collecting tool and acceptability of the method used

by the people, how to reach the study population and

what time of day was appropriate for the administration

of questionnaires and any other such unexpected issues

that arose and had the potential of interfering with the

study process as well as the outcome.

RESULTS

Demographic characteristics of respondents

A total of 403 respondents were interviewed in a

community wide survey which was divided into three

clusters approximately of equal size 409 households. The

minimum household size was one (1) and a maximum of

twenty-five (25) with mean household size of 7.46 (SD

3.27). Out of the total number of respondents



interviewed, 51.2% (206) were males while the

remaining 48.8% (197) were females. The age of

respondents ranged from 18 to 62 years and above. They

were categorized into age groups of ten (10) years

interval [Figure 3]. Age group 18-28 was the largest

representing 33.5 % (135) of the respondents. The least

was the 62 and above age group which constituted 8.7%

(35). Those who were married formed 52.1% (210),

30.3% (122) were single, 3.5% (14) were separated while

9.7% (39) were widowed. In regard to their religious

affiliations, 81.6% (329) were Moslems, 15.9% (64)

Christians and 2.5% (10) Traditional believers. Trading

was the leading economic activity in the community

forming 33.0% (133). The least was nursing which

accounted for 2.2% (9). For their levels of education,

32.3% (130) have never been to school, 2.0% (8) had

University education while 18.1% (73) had College/

Polytechnic and Secondary/Vocational/ Technical

education respectively [Fig. 3].

Respondents were asked about the household’s

consumption expenditure for the last thirty days before

the survey, illness profile of household which was

recorded as a dichotomous response, and chronic illness

were defined as illness that lasted for one year or is

expected to last for one year, where care was sought

during period of illness, how healthcare was paid for,

direct cost of care which is a composite of medical and

non-medical cost. Respondents were also asked about

how illness affected them and how much in monetary

terms they estimated they lost due to illness or giving

care to an ill household member. They were also

questioned if they were registered with the national

health insurance scheme, how many of their household

members were registered and how household mobilizes

resources to pay for the healthcare of a household

member who is not registered with the national health

insurance scheme.

The survey also looked at household’s choice of

healthcare and how households transported their sick

member to the facility.

Proportion of household income spent on healthcare

This study sought to find out the affordability of

healthcare services in Central Gonja District in the

Central Gonja District (Figure 4). Of the 403

respondents, the minimum household consumption

expenditure for the month prior to the surveys was US$

4.61 and the maximum was US$ 351.56 with an average

household consumption expenditure of US$ 73.35 (SD.

101.17). Households were grouped into five income

quintiles using the consumption expenditure ranging

from poorest (1 '<= 109’), very poor (2 '110 - 209’), poor

(3 '210 - 309’), less poor (4 '310 - 409') and least poor



Figure. 3: Demographic Characteristics of Respondents during the survey.

(5 '410+'). As shown in fig 4, the poorest were 29.5%

(119), the very poor were 54.1% (218), poor were

10.4% (42), less poor were 2.7% (11) and least poor

were 3.2% (13).

The findings further showed that 204 households

had at least one household member who was ill in the

last [previous] six months prior to the survey; a total

direct household healthcare expenditure ranging from

US$ 0 US$ 250.98 with a mean of US$ 21.40 (SD.

65.31). Of the 204 households, 82.8 % (169) spent <=

39% of their household expenditure on healthcare and

are less likely to face catastrophic cost of care, thus for

these households healthcare can be said to be affordable

to them. About 13.2 % (27) of households spent between

40%-100% of their household expenditure on healthcare

while 3.9 % (8) spent more than 100% of their household

expenditure on healthcare (Table 1). These two groups

of people face catastrophic cost of care and are likely to

be pushed into further poverty and ill health because

3.9% (8) were observed to have spent more than their

income and were likely to have borrowed to complement

the payment for healthcare. About 28.9 % (116) of the

respondents indicated that they borrow money to pay for

the care of household members who are not insured.

In response to a question about “how often they

encounter people who cannot pay for their treatment”,

the in-charge of the Central Gonja District Health Centre

said:

“Not very often, but sometimes you finish treating

somebody and the person starts to cry. If you ask why

she buried her husband last week, then you will come to

know that she can’t pay anymore; in the past she could

have paid for them now exhausted. As for RTA (Road

Traffic Accident) it happens a lot.”

The traditional healer on the other hand in an

answer to a question as to how much he charges and

whether clients are able to pay? This was what he said:



Frequency Percentage

Valid <= 39% 169 82.8

40% – 100% 27 13.2

101% + 8 3.9

Total 204 100.0

Not Applicable 199

Total 403

Table 1: Proportion of Household income spent on

healthcare.

Figure 4 : Household Consumption expenditure of respondents.

“I charge US$ 46.14 or US$ 92.28 depending on

the way the client approach me. But you see, not all of

them are able to pay promptly so I usually allow them go

and come back to pay when they get the money but some

of them go and don’t come back”

Direct cost of health to households

Total direct cost of care was estimated by

aggregating direct medical cost [Cost of consultation,

drugs, laboratory investigations and other therapies] and

direct non-medical cost [Cost of transportation, special

foods and other cost associated with seeking treatment].

Out of the sample, the number of households who had at

least one sick [ill] member sought some form of care

either from the hospital/public clinic or other sources

incurred cost ranging from US$ 0.00 to US$ 250.98 and

an average of US$ 21.40 (SD. 65.31). Only 180 of the

204 respondents who mentioned that a household

member with illness were able to recall the cost they

incurred when seeking care for the sick member. Out of

the 180, 88.9 % (160) spent US$ 45.67 or less for

healthcare, 6.7 % (12) spent from US$ 6.14 to US$ 91.81

on healthcare while 4.4 % ( 8) spent US$ 92.28 or more

on healthcare [Table 2].

Cost of special food appears to have contributed

to the total cost of healthcare than cost of transport

besides the medical cost. About 24.2 % (N=91) of the

respondents spent more than 50% of their healthcare

expenditure on special food and at the same time 7.1 %

(N=98) incurred more that 50% of their healthcare

expenditure on transport.

Indirect cost of healthcare

Indirect cost of healthcare was estimated using

the human capital approach by asking respondents to

estimate the value of time lost seeking treatment,

productivity losses, and absenteeism in monetary terms.

Out the sample 90.3 % (215) estimated they lost US$

91.81 or less, 8.4 % (20) estimated they lost from US$

92.28 to US$ 184.1 and 1.3 % (3) lost US$ 184.54 or

more [Table 3]. The estimated monetary losses ranged

from no effect to a maximum of US$ 369.09 and an

average of US$ 28.51 (SD. 88.81).

During the survey 58.2 % (139) indicated

productivity Labour Day losses as the effect of ill health

on the household while 38.1 % (91) indicated loss of

household income. About 34.7 % (83) of sick household

members were cared for by their parents.

DISCUSSION

Catastrophic cost of care does not mean incurring

high healthcare expenditure. Relatively low medical cost

could be catastrophic to a poor household; for example,

compelling them to cut down on their food, shelter and

children’s education expenses. In the same vein large

healthcare payments could lead to financial catastrophe

and bankruptcy for even richer households (Xu et al.,

2007).

Cost of healthcare estimated from the providers’

perspective only takes into account services provided and

paid for. These services are typically consultation fees,

laboratory tests and diagnostic expenses, medications

purchase and hospital bills. This study however,

estimated cost from the client/patient’s perspective

which goes beyond just the medical cost but includes non

-medical cost such as cost of transport, special foods and

other cost incurred during the period of seeking

healthcare.

Affordability of healthcare services in this study

is operationalized as the ability of a household to pay for

healthcare from its non-subsistence expenditure and was



Amount in US$ Frequency Percentage

Valid <= 99 160 88.9

100 – 199 12 6.7

200 + 8 4.4

Total 180 100.0

Missing System 24 11.76

Total 204

Table 2: Total direct cost of healthcare

measured as household spending less than 40% of their

household expenditure on healthcare. Survey showed

that over 80% of the households were poor. At the same

time 82.2% spent 39% or less of their household

expenditure on healthcare and are less likely to face

catastrophic cost while 17.1% spent about 40% on

healthcare. This was probably susceptible to financial

catastrophe and even bankruptcy. This interpretation

however, could be misleading. For poor households, a

threshold of 5% or 10% could be catastrophic which

would not be the same for the rich household since they

can afford to cut down on their luxuries without resorting

to sacrificing some of their basic needs.

A threshold of 5%-20% and 40% has been

noted for low income societies (WHO, 2006). The

choice of 40% however, was to ensure that it captures

household in all the income quintiles since different

thresholds are not set for the different income groups. It

might also be the case that people simply delayed or

avoided seeking care even though they may be unwell

just to avoid the financial catastrophe. In recognition of

this limitation [the distribution of the burden of direct

cost of care across households] Russell (2004) asserted

that direct cost of care were regressive to poor families

than better-off families. Therefore the incidence of

catastrophic cost of care could be more than the 17.1%

reported in the study. The same can be said of

affordability.

Somkotra and Lagrada (2009) mentioned that:

“in Thailand, households in the higher quintiles

[especially the richest] are more likely than the poorest

to incur very high health expenditures. These

expenditures often cross the threshold into

“catastrophic,” but because they result from a voluntary

choice to seek care from more costly private providers,

they are unlikely to have catastrophic consequences such

as permanent impoverishment after the implementation

of universal coverage”.

Despite the high Health Insurance enrollment

(79.7%), respondents who reported that a household

member was ill, still incurred high direct health cost.

Special foods were found to have significantly

influenced the total direct healthcare cost. Russell (2004)

comparing the direct cost of treating malaria to

households in developing countries, found that in Sri

Lanka and Zambia special foods were important

accounting for 46% and 44% respectively of the total

direct cost of healthcare. Russell (2004) mentioned that

“for Tuberculosis (TB) therapy, patients spent an

average of $ 21.00 per month (44% of a month’s income)

on meat, eggs, vegetables, oranges and orange-flavored

soft drinks. This cost to the patient is often ignored but

very critical to households’ ability to pay”.

In the case of Ghana, 62% and 70% of direct cost

of healthcare were spent on pharmaceuticals for mild and

severe malaria respectively. Indirect cost of care was not

found to be high. Over 90% estimated the loss to be less

than US$ 200 due to illness or giving care to a sick

household member. About 34.7% of household members

were cared for by their parents who invariably are the

bread winners of the households resulting in high

financial losses to the households. In the light of the

foregoing, indirect cost could be higher than what was

estimated.



Frequency Percentage

Valid <= 199.00 215 90.3

200.00 - 399.00 20 8.4

400.00 + 3 1.3

Total 238 100.0

Missing System 165

Total 403

Table 3: Indirect cost of Healthcare to Household in

Central Gonja District

CONCLUSION

The following conclusion can be made about the

affordability of healthcare services the District:

More than 80% of the people are poor.

There is an increased utilization of public healthcare

facilities in Central Gonja District as a result of

health insurance.

Over 17% of the people in the District spend 40% or

more of the household income on healthcare and are

therefore facing catastrophic cost of healthcare. In

the light of this, healthcare can be said to be

unaffordable to this group of people.

Transport and special foods in particular contribute

significantly to the total direct cost of healthcare.

Over 90% incur less than US$ 92.28 indirect cost.

RECOMMENDATIONS

From the findings of the study, the following

actions are recommended:

Conscious effort should be made at integrating

activities of health delivery with poverty alleviation

efforts such as registering beneficiaries for the

National Health Insurance or renewing the

membership of those who were registered but whose

cards were expired and improving upon general

livelihoods ensure better access and financial

protection especially of the disadvantaged groups

through support for the assets and strategies that the

people use to cope during illness.

The benefit package of the National Health

Insurance Scheme should be expanded to include

more services such as the laboratory investigations

because patients normally pay for laboratory

services even though they are insured.

A District hospital is needed so as to cut down on

the transportation cost, cost on caregiver’s upkeep

and ultimately the direct non-medical cost of care.

The various departments and agencies within the

District such as Ghana Education Service, District

Assembly and Health Directorate could work to

improve the road network, health education and

poverty alleviation.

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Affordability of Healthcare Services in the Central Gonja District of Ghana