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
This article is governed by the Creative Commons Attribution License (http://creativecommons.org/
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www.jhealth.info
Journal of Research in
Public Health
An International
Scientific Research Journal
Authors:
Adam Soale
1
and
Reuben K. Esena
2
.




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
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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 underfive 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 outpatient (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
Soale and Esena, 2014
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,
Soale and Esena, 2014
076 Journal of Research in Public Health (2014) 2(1): 073-084
the caregiver or in extreme cases the community,
ultimately burdens the households 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
Soale and Esena, 2014
Journal of Research in Public Health (2014) 2(1): 073-084 077
Figure 2 : Map of Central Gonja District in Ghana
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Yala
Chama
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San kpa la
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Mpah a
Yap ei
Tu luwe
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Distr ict b ou nda ry
Vol ta l ake
Road
# Yap ei Su b- dist rict commu nit ie s
# Mpah a Su b-d ist rict commu nit ie s
# Bui pe Sub- dist rict comm uni tie s
# Tu luwe S ub -di str ict co mmun it ies

CHPS Co mpo und

Sub -di str ict Ca pit al s

9 0 9 18 Kilometers
HEALTH FACILITIES IN THE CENTRAL GONJA DISTRICT
W
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TAMALE METROPOLIS
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KINTAMPO NORTH
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 households 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
Soale and Esena, 2014
078 Journal of Research in Public Health (2014) 2(1): 073-084
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 households
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 households 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
Soale and Esena, 2014
Journal of Research in Public Health (2014) 2(1): 073-084 079
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 cant 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:
080 Journal of Research in Public Health (2014) 2(1): 073-084
Soale and Esena, 2014
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 dont 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
childrens 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/patients 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
Journal of Research in Public Health (2014) 2(1): 073-084 081
Soale and Esena, 2014
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 months 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.



082 Journal of Research in Public Health (2014) 2(1): 073-084
Soale and Esena, 2014
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 caregivers 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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