Assessment of Direct and Indirect Health Cost of Women Seeking Maternal Health Care Services Under Free Maternal Health Care Policy in Eastern Region of Ghana

Abstract

Background To improve maternal health service utilization, Ghana introduced a free maternal health care policy (FMHCP) in 2008, which enrolls pregnant women in the National Health Insurance Scheme (NHIS) for free, covering antenatal, delivery and post-natal services. Despite the introduction of the free maternal care policy, many women still have to bear out-of-pocket costs when receiving maternal health care services. Objective To identify and categorize the types of household cost incurred by women seeking maternal health care services under the free maternal care policy, estimate the magnitude of these costs and associated financial burden on women seeking maternal health care and add on a few patients’ experiences and health providers and managers perspectives on household cost in accessing maternal health care in Abuakwa South and Nsawam Adoagyiri Municipalities of the Eastern Region of Ghana. Methods A cross-sectional mixed-methods design was used. The quantitative study recruited 393 women receiving maternal healthcare in the two health facilities. A structured questionnaire was used to collect data from mothers. An interview guide was used to collect qualitative data. The qualitative data was collected from 12 mothers, 17 healthcare providers and 10 staff from the National Health Insurance Authority. Qualitative data analysis was done using Microsoft Excel. Thematic analysis was used to identify recurring themes and patterns in views on the free maternal healthcare policy. The cost data was analyzed descriptively using STATA 17. Results The total economic cost of maternal health care services incurred during the study was GHS231,737.07 (US$14,950.78). On average, each woman incurred GHS590 (US$38.00) per pregnancy cycle. Direct costs (medications, laboratory tests, transportation, and consumables) accounted for 53% of the total, while indirect costs (mainly productivity losses) constituted 47%. Productivity loss due to absenteeism emerged as the major cost driver, representing 42% of the total expenditure. On average, households spend between 5% and 6% of their monthly income on maternal health services, despite the policy’s intent to eliminate financial burdens. Out-of-pocket expenses were mostly reported for laboratory tests, drugs, ultrasound scans, and transportation. Conclusion Although the FMHCP has significantly improved access and utilization of maternal health services, women continue to bear notable direct and indirect costs, undermining the policy’s goal of financial risk protection. Persistent OOP payments highlight systemic gaps in implementation, including stock-outs, delays in reimbursement, and limited coverage of essential services.