Health insurance coverage and access to child and maternal health services in West Africa: a study protocol for a systematic review

In September of 2000, the 191 member states of the United Nations signed the Millennial Development Goals [1]. Included in these goals was the reduction of child mortality and improving maternal health by 2015. A decade and a half of efforts and investments that followed led to the decrease of maternal mortality rates (MMR) ratio and under-five deaths in children by more than half. Additionally, the number of women who benefited from skilled birth assistance rose by 59% between 1990 and 2014 [1]. Despite these efforts, by 2015, only about half of the women globally received the recommended amount of antenatal care [1]. Then came the 17 Sustainable Development Goals (SDG), signed by the United Nations in 2015 with the intention to continue the expansion of the work done in the previous 15 years. The third goal, Ensure Healthy Lives and Promote Well-Being at All Ages includes targets such as the continued reduction of the under-five mortality and MMR rates, as well as expansion of access to contraceptives, lowering the adolescent fertility rate and expanding access to immunization [2]. So far, billions of dollars have been pledged or invested towards these goals, including a $1.4 billion commitment over 10 years by the Canadian government [3]. Specifically, the SDG set out to achieve the following targets in relation to maternal and child health: the reduction of under-five mortality to less than 25 in 1000, neonatal mortality lowered to less than 12 in 1000, and MMR to 70 per 100 000 live births as targets [2].

Western Africa is known to have the world’s highest MMR rates in the world [4] and one of the highest rates for under-five mortality in children, including at the neonatal stage [5]. The MMR in Western Africa range from the low 300 in 100 000 live births in Benin and Ghana to around 500 in Cameroon and Niger to over 900 per 100 000 live births in Nigeria [6]. The unfortunate reality is that most deaths are preventable. When it comes to mothers, hemorrhage, exacerbation of pre-existing conditions by pregnancy, eclampsia, and sepsis are major causes of maternal deaths [7]. Whereas for children, specifically newborns, the main cause of death are complications during birth, such as intrapartum events, preterm births, or infections such as diarrhea and sepsis [8]. In both cases, appropriate and timely medical care is the solution through mostly low-tech and cost-effective technologies [8] that are often accessible when a mother is giving birth in the presence of trained and skilled health workers in government-approved health facilities.

UHC is defined as the ability for people to access and use all necessary health services at a substantial quality without incurring catastrophic financial costs [9]. Specifically, the World Health Organization (WHO) sets out equity in access, strong quality of health services, and protection against financial risk as important tenants of UHC [10]. Therefore, the goals of UHC include increased access to essential medical services, while decreasing the rate of catastrophic costs to consumers. A strong argument for UHC is its role in Malawi [11]. Malawi ranked 174 out of 187 on the Human Development Index, with a GDP of US$ 494.40 per capita [11]. The implementation of UHC was marked by policies targeting areas with poor indicators through increased funding, training, and retraining health care staff and human resources [12]. These efforts have led to an increase in overall coverage and stronger health indicators, such as lowering the under-five mortality rate [12].

The impact of health insurance coverage on access to maternal services has been considered in some regions of West African countries, though there are only a handful of studies available. As in most low- and middle-income countries, many West African countries have used community-based health insurance schemes or social schemes [13]. Two regions that have been studied are the Wa East and West regions of Northern Ghana [14] and Kawara State in Nigeria [15]. Further, one relevant study has been carried out in Mauritania [12]. In 2003, Ghana introduced a National Health Insurance Service [15]. To increase access to the services, the Ghanaian government exempted certain groups, including pregnant women, from paying premiums. The study focused on the Wa East and Wa West districts of Northern Ghana, two of the poorer regions of the country. In this study, over 90% of women were enrolled in the National Health Insurance Service. Of those enrolled, 98.6% utilized antenatal services, and the majority, 66.5%, gave birth in health facilities. Notably, these increases were shared among various social and economic classes. Furthermore, in Nigeria, an interrupted time-series study was conducted to determine the impact of the state health insurance scheme, one that was developed through a public-private partnership [15]. Findings from this study showed that when women had access to services and insurance, rates of insurance increased significantly, from 0 to 70.2% and in hospital deliveries increased by 62%. This study noted that it is not clear if health insurance coverage without the elimination of other barriers, such as distance to services, will be sufficient to guarantee access and utilization of health services. In 2002, Maurtiania developed an obstetrical risk insurance (ORI) [12]. Unique to other models, this scheme did not depend on risk pooling, but rather on pre-payment. Women could pay 16–18 USD to guarantee access to a core set of services. The study observed that only 58% of women interviewed knew ORI existed and of those who knew, two thirds enrolled. The study observed that for those insured, there was a moderate increase in pre-natal use of services. Yet, ORI had no meaningful impact on cesarean section rates, postnatal care, and neonatal mortality. This study would suggest that pre-payed schemes, a type of community-based scheme [13], may have their limitations, indicating that various schemes would have various implications on the rates of utilization of services. Further, efforts around recruitment into schemes, especially regional schemes, would impact the rates of adhesions to schemes, in turn impacting the rates of access and utilization of services.

Despite decades of targeted public health interventions, the West African region still has the most elevated MMR and under-five mortality rates in the world. The solution to this issue is widely believed to be the implementation of UHC [16, 17], as most causes of death could be effectively dealt with through primary care providers. Yet, little is known about the impact of current efforts in increasing access to services based on UHC programs. Hence, this study’s primary objective will be to conduct a systematic review of published studies that have examined the link between health insurance coverage and access and utilization of health care services for mothers and newborns in Western Africa. Secondary objectives are to identify evidence gaps relating to barriers in coverage.

Though many studies have discussed the impact of health insurance on access to medical services, few have considered Western Africa as a whole. Despite decades of investments and targeted work, this region continues to have the most elevated rates of MMR and under-five mortality in the world. Many countries or regions employ some variation of community-based and national insurance schemes [13], yet the evidence on their impact on access to services for mothers and children is scarce.

Based on previous literature that carried out similar investigations in other settings, it is expected that decreased exposition to catastrophic health expenditure is likely to increase access and utilization of health services. This review will be the first to link coverage status to the utilization of services in the whole of West Africa. This protocol outlines the methodology and rationale while presenting examples of the limited evidence available. The strength of this paper will be the broad search for evidence, from inception to August 2020, in many journals and platforms, in both French and English. Limitations include the underrepresentation or underreported data points due to the limited number of studies on this issue. This may result in publication bias and methodological quality issues. Therefore, we will assess meta-bias(es) to ensure rigidity in the findings.

This study is likely to face few practical or operational issues. Access to data is facilitated by the Demographic Health Statistics. The methodology uses software and databases easily accessible. The COVID-19 pandemic could impact the timeline of this study, though it is unlikely it will.

Any amendment to this protocol while conducting the study will be outlined in PROSPERO and in the final manuscript.

The completed review will be published in a journal in order to effectively communicate the results to a range of stakeholders such as policymakers including health economist on the value of continued efforts to provide UHC in West Africa and the presumed need to combine UHC with policies that improve other social and economic indicators. Any important changes to the protocol will be submitted to the journal in which it was published.