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An assessment of out of pocket payments in public sector health facilities under the free maternal healthcare policy in Ghana

Health Economics Review volume 13, Article number: 8 (2023) Cite this article

Abstract

Background

The free maternal healthcare policy was introduced in Ghana in 2008 under the national health insurance scheme as a social intervention to improve access to maternal health services. This study investigated the prevalence of out of pocket (OOP) payment among pregnant women with valid national health insurance who sought skilled delivery services at public sector health facilities in Ghana. The study also assessed the health system factors associated with OOP payment.

Methods

We used data from the Ghana Maternal Health Survey (GMHS), which was conducted in 2017. The study comprised 7681 women who delivered at a public sector health facility and had valid national health insurance at the time of delivery. We used multivariable logistic regression analysis to assess factors associated with OOP payment, whiles accounting for clustering, stratification, and sampling weights.

Results

The prevalence of OOP payment for skilled delivery services was 19.0%. After adjustment at multivariable level, hospital delivery services (adjusted Odds Ratio [aOR] = 1.23, 95% Confidence Interval [CI] = 1.00, 1.52), caesarean section (aOR = 1.73, 95% CI = 1.36, 2.20), and receiving intravenous infusion during delivery (aOR = 1.31, 95% CI = 1.08, 1.60) were associated with higher odds of OOP payment. Women who were discharged home 2 to 7 days after delivery had 19% lower odds of OOP payment compared to those who were discharged within 24 hours after delivery.

Conclusion

This study provides evidence of high prevalence of OOP payment among women who had skilled delivery services in public sector health facilities although such women had valid national health insurance. Government may need to institute measures to reduce OOP payment in public sector facilities especially at the hospitals and for women undergoing caesarean sections.

Background

The free maternal healthcare policy in Ghana was rolled out in 2008 under the national health insurance scheme [1]. This was part of the Government of Ghana’s social interventions to increase access to maternal healthcare services in the country. The national health insurance scheme is being funded by premiums, the national health insurance tax, social security and national insurance trust, government funding, and returns from investments [2, 3]. Since the inception of this policy, Ghana has had a significant improvement in maternal health service utilization such as antenatal care, skilled delivery, and postnatal care services [4,5,6]. The increase in utilization of maternal health services has consequently contributed to reduction in under-5 and maternal mortalities [7, 8].

Under the free maternal healthcare policy, pregnant women are exempted from paying premiums for registration or annual renewal for the national health insurance scheme [1]. Once the pregnancy is confirmed by a doctor/midwife/nurse, they are enrolled onto the national health insurance scheme without a fee to access maternal health services [1, 9]. The range of services covered under this program include antenatal care contacts, essential medicines, and essential laboratory services. It also covers skilled delivery services, including caesarean sections and postnatal services for the mother and newborn for up to 3 months [9, 10].

Pregnant women can access the free maternal health services from both the public and private sector health facilities with a valid national health insurance card provided such facilities are accredited by the national health insurance authority [11]. However, the public sector health facilities provide majority of the maternal health services in Ghana [12]. According to the recent Ghana Maternal Health Survey, public sector health facilities provide 85% of the skilled delivery services in Ghana [13]. Therefore, public sector health facilities play a critical role to the success of the free maternal healthcare services if they adhere to the policy guidelines of the national health insurance scheme [14, 15].

The Government of Ghana is solely responsible for managing the national health insurance scheme and has had some challenges, including their inability to timely reimburse funds to health facilities [15,16,17]. This has compelled some health facilities, including public sector health facilities to introduce OOP payments to pregnant women seeking maternal healthcare services [16, 18, 19]. The introduction of OOP payments for maternal health service utilization has the potential to defeat the purpose of the free maternal healthcare policy and possibly derail the gains made by Ghana towards improving maternal and child health outcomes [13]. This is because OOP payments are associated with low utilization of maternal health services, including skilled delivery services [20, 21].

Studies in Ghana on OOP payments have focused on both public and private sector health facilities [18, 19, 22], but to the best of our knowledge none has assessed OOP payments in only public sector health facilities. It is therefore important to assess the prevalence of OOP payment in public sector facilities as these facilities are the bedrock of the free maternal healthcare policy. Furthermore, studies on OOP payments have not been nationally representative and may not be generalizable to the Ghanaian population [18, 22, 23]. There is also dearth of knowledge on health system factors that might be associated with OOP payments in public sector health facilities. Therefore, the aims of this study were 1) to assess the prevalence of OOP payment among pregnant women with a valid national health insurance who sought skilled delivery services in public sector health facilities and 2) to assess health system factors associated with OOP payment. These findings will be useful for policy makers to take steps towards improving maternal health utilization and avert any decline in the gains Ghana has made in improving maternal and child health outcomes.

Methods

Data sources

Data for the study was extracted from the Ghana Maternal Health Survey (GMHS), which was conducted in 2017. The survey was conducted by Ghana Statistical Service (GSS) with technical support from Inner City Fund (ICF) through the Demographic and Health Survey (DHS) program. GMHS used a multi-stage sampling where the first stage involved the selection of enumeration areas with probability proportional to the sizes of enumeration areas. In the second stage, households were selected from each enumeration area using systematic random sampling. Details of the sampling procedure is publicly available [24]. The 2017 GMHS was conducted among women aged 15–49 years who delivered a live birth or stillbirth from the period between 2012 to 2017.

Study population

Our study population were women aged 15–49 years who delivered at a public sector health facility in Ghana and had valid national health insurance at the time of delivery. Women who delivered at a private sector health facility or at home were excluded from the study. Pregnant women who had a private health insurance or did not have any health insurance at the time of delivery were also excluded from the study. Our total sample size was 7681 women.

Variable selection

Outcome variable

Our outcome variable of interest was OOP payment from a mother with a valid health insurance card during skilled delivery  at public sector health facility. A valid health insurance was an active health insurance with the national health insurance scheme at the time of receiving skilled delivery service. The outcome variable was generated out of three forms of OOP payment; payment to see a doctor/midwife/nurse, payment for laboratory services and payment for medicines. Pregnant women who paid for anyone of these three were categorized as OOP payment, otherwise they were categorized as not having made OOP payment. The outcome was coded as a dummy variable “1 for yes and 0 for no”.

Independent variables

The primary independent variables of interest were type of health facility, forceps or vacuum delivery, blood transfusion during delivery, intravenous infusion during delivery, delivery by caesarean section and length of stay after delivery. Type of health facility was categorized as (hospital, health center/clinic/Community-based Health Planning and Services (CHPS) compound); forceps or vacuum delivery (yes, no); blood transfusion during delivery (yes, no); intravenous infusion during delivery (yes, no); delivery by caesarean section (yes, no), and length of stay after delivery (24 hours, 2 to 7 days and more than a week). The secondary independent variables of interest were place of residence (urban, rural); age category (15–19, 20–34, 35–49); parity (primiparous, multiparous); education (no formal education, primary education, secondary education, higher education) and wealth (poor, middle, rich). The variable selection was based on literature review [19], and their availability in the GMHS dataset [13].

Data analysis

Data analysis was conducted using Stata/SE 14.0 (Stata Corp LLC, College Station, Texas USA). Descriptive statistics was used to assess the prevalence of OOP payment and characteristics of the study population. We conducted bivariate analysis using logistic regression to assess the relationship between independent variables and OOP payment. A statistical significance of p-value < 0.05 was set for inclusion of independent variables into the multivariable logistic regression model. Adjusted odds ratios (aORs) at 95% confidence interval (CI) were estimated. We accounted for clustering, stratification, and sampling weights in all our analysis because of the complex sampling design.

Results

Characteristics of study participants

The prevalence of OOP payment was 19.0%. Approximately, 70.0% of the women delivered at the hospital, 3.8% delivered through forceps or vacuum extraction and 16.1% delivered by a caesarean section. More than half (57.3%) received intravenous infusion during delivery, 5.4% had blood transfusion and 46.0% were discharged home within 24 hours after delivery. More than half (53.3%) of the women were resident in an urban area, 27.2% were primiparous, 56.0% had secondary education, and more than a third (36.1%) were in the poor wealth category (Table 1).

Table 1 Characteristics of study participants (n = 7681)
Full size table

Factors associated with OOP payment

Women who delivered at the hospital were 1.23 times as likely to make OOP payment compared to those who delivered at a health center/clinic/CHPS compound (aOR = 1.23, 95% Confidence Interval [CI] = 1.00, 1.52). Compared with women who did not receive intravenous infusion during delivery, those who received intravenous infusion were 1.31 times as likely to make OOP payment during skilled delivery services (aOR = 1.31, 95% CI = 1.08, 1.60). Women who were delivered by caesarean section had 1.73 times the odds of OOP payment compared to those who had vaginal delivery (aOR = 1.73, 95% CI = 1.36, 2.20). Women who were resident in urban areas (aOR = 1.28, 95% CI = 1.04, 1.59), had primary education (aOR = 1.47, 95% CI = 1.11, 1.93) or had secondary education (aOR = 1.63, 95% CI = 1.30, 2.10) also had higher odds of OOP payment during skilled delivery services. Duration of stay after delivery for 2 to 7 days was associated with 19% lower odds of OOP payment compared to women who were discharged within 24 hours after delivery (aOR = 0.81, 95% CI = 0.67, 0.97) (Table 2).

Table 2 Factors associated with out of pocket payment during skilled delivery services
Full size table

Discussion

Our study investigated the prevalence of OOP payment and its associated health system factors among pregnant women with valid national health insurance who sought skilled delivery services in public sector health facilities in Ghana. We found that one out of every five pregnant women made OOP payment during skilled delivery. Pregnant women who delivered at the hospital, delivered by caesarean section, and received intravenous infusion during delivery had higher odds of OOP payment. Women who were discharged home after 2 to 7 days after delivery had lower odds of OOP payment during skilled delivery services compared to those who were discharged home within 24 hours after delivery.

The Ghana national health insurance scheme comprehensively covers all maternal health services, including antenatal care, delivery services and postnatal care in public sector health facilities [9, 10]. However, our study found that about one-fifth of the women paid OOP to either see a practitioner (i.e., doctor/midwife/nurse), for medicines or laboratory service at a public healthcare facility. These OOP payments subtly introduced at some public sector health facilities may be a way to keep providing healthcare services amidst the lack of timely reimbursement of national health insurance funds from government [15,16,17]. This is a major challenge for health facilities as the main source of funding for health facilities is funds from the national health insurance reimbursement [25]. The lack of timely reimbursement of funds pose a threat to pregnant women having to pay OOP for skilled delivery services, which ideally should be free because the clients had a valid health insurance card [16, 18, 19]. These OOP payments have the potential to cause a decline in utilization of maternal health services, particularly skilled delivery services [26]. This may undermine the progress Ghana has made towards improving maternal and child health outcomes.

OOP payment was more prevalent among women who delivered at the hospital compared to those who delivered at other health facilities (i.e., health center/clinic/CHPS compounds). A similar finding has been reported in Burkina Faso [27]. A possible explanation for this finding is that hospitals have a higher prevalence of skilled delivery services, including referrals from health centers/clinics/CHPS compounds [24]. Furthermore, some of the medications used at the hospital level may not be covered under the national health insurance scheme essential medicines list [28]. The implication of this finding is that pregnant women who are referred to the hospital from other health facilities (i.e., health center/clinic/CHPS compounds) may be reluctant to honor such referrals because of the higher cost of OOP payment. This has the potential to reduce skilled delivery services in the hospital as well as maternal and child health outcomes [20, 21, 26].

We also found that women who delivered by caesarean section had higher odds of OOP payments compared to those who delivered per vagina. A number of reasons could have accounted for this finding. Some pregnant women may have opted to undergo elective caesarean section [29], which require them to pay for the service although it should be free under the free maternal healthcare policy [30]. Additionally, pregnant women who undergo caesarean section may likely use epidural anaesthesia for pain management [31], and some of these medicines are not included in the essential medicines list of the national health insurance scheme [28, 30]. This finding may also explain why our earlier finding on OOP payment being higher at the hospital because caesarean sections are mostly performed at the hospital level in Ghana.

Women who received intravenous infusion treatment during delivery also had higher odds of OOP payment compared to those who did not receive intravenous infusion. Intravenous infusions are mostly indicated as fluid replacement or as medicines to manage skilled delivery [32,33,34]. The use of intravenous infusions are more prevalent in hospitals, where OOP payments are also more common. We also found that women who were discharged home after 2 to 7 days after delivery had reduced odds of OOP payment compared to those who were discharged within 24 hours. This finding is surprising; however, a possible explanation could be that mothers who were unable to afford OOP cost stayed longer in the health facility until such debts were waived by the facility before they were discharged home.

Women living in urban areas and women who had primary or secondary education were more likely to incur OOP cost during skilled delivery services compared to women living in rural areas and women who had no formal education. Similar findings has been reported elsewhere [27]. Hospitals are predominantly found in urban areas in Ghana [35], and so pregnant women in urban areas are more likely to utilize hospitals during skilled delivery services, which tend to be associated with OOP payment compared to those in rural areas, where health centers/clinics/CHPS compounds are predominant. Educational attainment is associated with women living in urban areas [36, 37], and are therefore more likely to utilize hospital services. Moreover, educated women are more likely to be economically stable and may opt for elective caesarean section thereby incurring OOP cost for the services [30].

Our study had some limitations and strengths. We cannot infer causality because of the cross-sectional nature of the data. Furthermore, most of our variables were self-reported and recall bias could have been introduced. We could also not account for variables outside of the GMHS dataset (e.g., supply related factors). However, our study reports the national prevalence of OOP payment among pregnant women with valid national health insurance in public sector health facilities in Ghana. It is also the first study to assess the health system factors associated with OOP payments. Furthermore, the use nationally representative data makes our findings generalizable to Ghana.

Conclusion

One out of every five pregnant women incurred OOP payment for skilled delivery services in public sector health facilities despite having a valid national health insurance. Skilled delivery services at the hospital, caesarean section delivery and receiving intravenous infusion during delivery were associated with OOP payment. The high prevalence of OOP payment is a potential barrier to accessing skilled delivery services in Ghana. Government may need to institute measures to reduce OOP payment in public sector facilities especially at hospitals and for caesarean sections.

Availability of data and materials

Data is available upon request.

Abbreviations

OOP:

Out of Pocket

DHS:

Demographic and Health Survey

GMHS:

Ghana Maternal and Health Survey

CHPS:

Community-based Health Planning and Services

References

  1. Mensah J, Oppong JR, Schmidt C. Ghana’s National Health Insurance Scheme in the Context of the Health MDGs – An Empirical Evaluation Using Propensity Score Matching. 2009 [cited 2022 Mar 23]. Report No.: 157. Available from: https://econpapers.repec.org/paper/zbwrwirep/157.htm

    Google Scholar 

  2. Blanchet NJ, Fink G, Osei-Akoto I. The effect of Ghana’s National Health Insurance Scheme on health care utilisation. Ghana Med J. 2012;46(2):76–84.

    CAS  Google Scholar 

  3. Nguyen HT, Rajkotia Y, Wang H. The financial protection effect of Ghana National Health Insurance Scheme: evidence from a study in two rural districts. Int J Equity Health. 2011;10(1):4.

    Article  Google Scholar 

  4. Agbanyo R. Ghana’s national health insurance, free maternal healthcare and facility-based delivery services. Afr Dev Rev. 2020;32(1):27–41.

    Article  Google Scholar 

  5. Yaya S, Da F, Wang R, Tang S, Ghose B. Maternal healthcare insurance ownership and service utilization in Ghana: analysis of Ghana demographic and health survey. PLoS One. 2019;14(4):e0214841.

    Article  CAS  Google Scholar 

  6. Kumbeni MT, Apanga PA. Institutional delivery and associated factors among women in Ghana: findings from a 2017-2018 multiple indicator cluster survey. Int Health. 2021;13(6):520–6.

    Article  Google Scholar 

  7. Lambon-Quayefio M, Owoo NS. Determinants and the impact of the National Health Insurance on neonatal mortality in Ghana. Health Econ Rev. 2017;7(1):34.

    Article  Google Scholar 

  8. Nsiah-Boateng E. Reducing maternal and child mortality in Ghana: is National Health Insurance scheme’s free maternal care program helping? Value Health. 2015;18(3):A267.

    Article  Google Scholar 

  9. HERA-Health Partners Ghana. Evaluation of the free maternal health care initiative in Ghana. 2013 [cited 2022 Mar 26]. Available from: https://www.moh.gov.gh/wp-content/uploads/2016/02/2013-Summit-REPORT-Evaluation-of-the-free-maternal-health-care-initiative-in-Ghana.pdf

    Google Scholar 

  10. Dixon J, Tenkorang EY, Luginaah IN, Kuuire VZ, Boateng GO. National health insurance scheme enrolment and antenatal care among women in Ghana: is there any relationship? Trop Med Int Health TM IH. 2014;19(1):98–106.

    Article  Google Scholar 

  11. Lamptey AA, Nsiah-Boateng E, Agyemang SA, Aikins M. National health insurance accreditation pattern among private healthcare providers in Ghana. Arch Public Health. 2017;75(1):36.

    Article  Google Scholar 

  12. Kumbeni MT, Apanga PA, Chanase MAW, Alem JN, Mireku-Gyimah N. The role of the public and private health sectors on factors associated with early essential newborn care practices among institutional deliveries in Ghana. BMC Health Serv Res. 2021;21:621.

    Article  Google Scholar 

  13. Ghana Statistical Service. Ghana Maternal Health Survey 2017. 2018 [cited 2022 Jan 28]. Available from: https://www.dhsprogram.com/publications/publication-fr340-other-final-reports.cfm

    Google Scholar 

  14. Kipo-Sunyehzi DD, Ayanore MA, Dzidzonu DK, AyalsumaYakubu Y. Ghana’s journey towards universal health coverage: the role of the national health insurance scheme. Eur J Investig Health Psychol Educ. 2019;10(1):94–109.

    Article  Google Scholar 

  15. Aikins M, Tabong PTN, Salari P, Tediosi F, Asenso-Boadi FM, Akweongo P. Positioning the National Health Insurance for financial sustainability and universal health coverage in Ghana: a qualitative study among key stakeholders. PLoS One. 2021;16(6):e0253109.

    Article  CAS  Google Scholar 

  16. Ashigbie PG, Azameti D, Wirtz VJ. Challenges of medicines management in the public and private sector under Ghana’s National Health Insurance Scheme - a qualitative study. J Pharm Policy Pract. 2016;9:6.

    Article  Google Scholar 

  17. Dalinjong PA, Laar AS. The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana. Health Econ Rev. 2012;2(1):13.

    Article  Google Scholar 

  18. Dalinjong PA, Wang AY, Homer CSE. Has the free maternal health policy eliminated out of pocket payments for maternal health services? Views of women, health providers and insurance managers in northern Ghana. PLoS One. 2018;13(2):e0184830.

    Article  Google Scholar 

  19. Dalinjong PA, Wang AY, Homer CSE. The operations of the free maternal care policy and out of pocket payments during childbirth in rural northern Ghana. Health Econ Rev. 2017;7(1):41.

    Article  Google Scholar 

  20. Lee WY, Shaw I. The impact of out-of-pocket payments on health care inequity: the case of National Health Insurance in South Korea. Int J Environ Res Public Health. 2014;11(7):7304–18.

    Article  Google Scholar 

  21. Onah MN, Govender V. Out-of-pocket payments, health care access and utilization in south-eastern Nigeria: a gender perspective. PLoS One. 2014;9(4):e93887.

    Article  Google Scholar 

  22. Akweongo P, Aikins M, Wyss K, Salari P, Tediosi F. Insured clients out-of-pocket payments for health care under the national health insurance scheme in Ghana. BMC Health Serv Res. 2021;21(1):440.

    Article  Google Scholar 

  23. Ekholuenetale M, Barrow A. Inequalities in out-of-pocket health expenditure among women of reproductive age: after-effects of national health insurance scheme initiation in Ghana. J Egypt Public Health Assoc. 2021;96(1):6.

    Article  Google Scholar 

  24. GSS. Ghana - Maternal Health Survey 2017. 2019 [cited 2022 Feb 13]. Available from: https://microdata.worldbank.org/index.php/catalog/3186

    Google Scholar 

  25. Akortsu MA, Abor PA. Financing public healthcare institutions in Ghana. J Health Organ Manag. 2011;25(2):128–41.

    Article  Google Scholar 

  26. Gitobu CM, Gichangi PB, Mwanda WO. The effect of Kenya’s free maternal health care policy on the utilization of health facility delivery services and maternal and neonatal mortality in public health facilities. BMC Pregnancy Childbirth. 2018;18(1):77.

    Article  CAS  Google Scholar 

  27. Meda IB, Baguiya A, Ridde V, Ouédraogo HG, Dumont A, Kouanda S. Out-of-pocket payments in the context of a free maternal health care policy in Burkina Faso: a national cross-sectional survey. Health Econ Rev. 2019;9(1):11.

    Article  Google Scholar 

  28. Anabah TW. Investigating determinants for Woman’s choice to accept an epidural for labor analgesia at the delivery unit of the tamale teaching hospital. J Clin Anesth Pain Manag. 2021;5(2):235–40.

    Google Scholar 

  29. Aminu M, Utz B, Halim A, van den Broek N. Reasons for performing a caesarean section in public hospitals in rural Bangladesh. BMC Pregnancy Childbirth. 2014;14(1):130.

    Article  Google Scholar 

  30. Dankwah E, Kirychuk S, Zeng W, Feng C, Farag M. Socioeconomic inequalities in the use of caesarean section delivery in Ghana: a cross-sectional study using nationally representative data. Int J Equity Health. 2019;18(1):162.

    Article  Google Scholar 

  31. Kerai S, Saxena KN, Taneja B. Post-caesarean analgesia: what is new? Indian J Anaesth. 2017;61(3):200–14.

    Article  CAS  Google Scholar 

  32. Bailey JM, Bell C, Zielinski R. Timing and outcomes of an indication-only use of intravenous cannulation during spontaneous labor. J Midwifery Womens Health. 2020;65(3):309–15.

    Article  Google Scholar 

  33. Cecilia M, Vijayaselvi R, Bansal R, Lakshmi L, Jose R. Ten units intravenous oxytocin over 2–4 h is as effective as 30 units over 8–12 h in preventing postpartum hemorrhage after cesarean section: a randomized controlled trial. Indian J Pharmacol. 2018;50(5):279–83.

    Article  CAS  Google Scholar 

  34. Torloni MR, Siaulys M, Riera R, Martimbianco ALC, Pacheco RL, Latorraca OC, et al. Route of oxytocin administration for preventing blood loss at caesarean section: a systematic review with meta-analysis. BMJ Open. 2021;11(9):e051793.

    Article  Google Scholar 

  35. Statista. Ghana: availability of basic healthcare facilities by area 2021 [Internet]. Statista. [cited 2022 Mar 26]. Available from: https://www.statista.com/statistics/1278075/availability-of-basic-healthcare-facilities-in-ghana-by-area/

  36. Ginsburg C, Bocquier P, Béguy D, Afolabi S, Derra K, Augusto O, et al. Human capital on the move: education as a determinant of internal migration in selected INDEPTH surveillance populations in Africa. Demogr Res. 2016;34:845–84.

    Article  Google Scholar 

  37. Saaka M, Akuamoah-Boateng J. Prevalence and determinants of rural-urban utilization of skilled delivery Services in Northern Ghana. Scientifica. 2020;2020:9373476.

    Article  Google Scholar 

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Acknowledgements

We thank the Demographic and Health Survey (DHS) for making the data available to us.

Funding

Authors did not receive any financial support for the study.

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Authors and Affiliations

  1. Department of Health Management and Policy, College of Public Health and Human Sciences, Oregon State University, Corvallis, USA

    Maxwell Tii Kumbeni

  2. Mo Im Kim Nursing Research Institute, College of Nursing, Yonsei University, Seoul, South Korea

    Agani Afaya

  3. Department of Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana

    Agani Afaya

  4. Kentucky Department for Public Health, Frankfort, USA

    Paschal Awingura Apanga

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Contributions

MTK, AA and PAA conceived and designed the study. MTK performed data analysis. MTK, AA and PAA reviewed literature and drafted the initial manuscript. All authors reviewed and approved the final manuscript.

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Correspondence to Maxwell Tii Kumbeni.

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Kumbeni, M.T., Afaya, A. & Apanga, P.A. An assessment of out of pocket payments in public sector health facilities under the free maternal healthcare policy in Ghana. Health Econ Rev 13, 8 (2023). https://doi.org/10.1186/s13561-023-00423-0

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Health Economics Review

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