Insured but Still Paying: Out-of-Pocket Payments, Catastrophic Expenditure and Forgone Care among Women Using Reproductive, Maternal, Newborn and Child Health Services in Six Districts of Northern Ghana
Abdul-Fatahi Adam *
School of Public Health, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria.
Mohammed Ali
College of Community and Organizational Development, Tamale, Ghana.
Foluke Adeniji
School of Public Health, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria.
Adam Haliq
School of Public Health, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria.
Mohammed Ali Ibrahim
School of Public Health, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria.
Tiimob Gideon Likida
School of Public Health, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria.
*Author to whom correspondence should be addressed.
Abstract
Aims: To estimate out-of-pocket (OOP) payments, catastrophic health expenditure (CHE) and forgone care among women using reproductive, maternal, newborn and child health services in Northern Ghana, and to compare CHE by financing model.
Study Design: Community-based cross-sectional household survey.
Place and Duration of Study: 36 communities in Tamale Metropolis, Yendi, Sagnarigu, Savelugu, Gushegu and Karaga, Northern Region, Ghana, from 10 February to 14 April 2026.
Methodology: We interviewed 864 women aged 15 to 49 years who had been pregnant, had given birth or had cared for a child under five in the previous year. CHE was defined as household health spending above 10% or 25% of consumption; the revised Sustainable Development Goal (SDG) indicator 3.8.2 was a sensitivity measure. The analysis used design-weighted proportions, Rao-Scott tests and cluster-robust logistic regression. The null hypothesis that the incidence of CHE among women does not differ by financing model was tested with a joint Wald test.
Results: A medical OOP payment was reported by 57.4% (95% confidence interval [CI] 52.8 to 61.8) of women, including 42.5% (36.9 to 48.3) of those with an active National Health Insurance Scheme (NHIS) card. CHE at 10% affected 7.5% (5.8 to 9.6) of households, 14.7% in rural districts and 19.4% in the poorest quintile. CHE did not differ by financing model (χ²(4) = 3.29, P = .51), so the null hypothesis was not rejected. Wealth was the strongest observed correlate (richest vs poorest quintile adjusted odds ratio [AOR] 0.08, 0.02 to 0.31). Being uninsured was associated with forgone care (AOR 4.33, 2.09 to 8.97). Revised SDG hardship affected 32.1% of rural and 3.6% of urban households.
Conclusion: An active NHIS card was more closely associated with whether women obtained care than with how much households spent. Continuous cover for mothers and children, reliable medicine supply and targeting by need could protect the poorest households.
Keywords: Out-of-pocket payment, catastrophic health expenditure, forgone care, financial protection, free maternal care, national health insurance Scheme, universal health coverage, Ghana