In search of universal health coverage: the hidden cost of family planning to women in Ghana

Objective This study aims to estimate the cost of accessing FP services in Ghana. A cross-sectional design, involving quantitative methods were used to recruit 1194 women who accessed FP services in 336 primary health facilities, selected through a two-stage sampling. Descriptive statistics were used to estimate the cost, using STATA 13. Results The average age of the women was 29 ± 6.87. Most women had basic education. The sources of payment for FP services were self-finance, family and sponsorship. The average direct cost of accessing FP services was GHS 7.90 [US$ 1.76]. The cost of FP services was highest for consultation GHS 7.50 [US$ 1.67], Laboratory test/x-ray GHS 6.03 [US$ 1.34], Transportation GHS GHS5.50 [US$ 1.22], Contraceptive GHS 4.73 [US$ 1.05] and Client records Card GHS 3.30 [US$ 0.73]. The cost of FP services was higher for clients visiting private facilities, tertiary level as well as those in urban centers. Clients on average spent 54.21 min traveling at a distance of 3.49 km and wait averagely 18.11 min for each visit. Government stakeholders are encouraged to revise the existing maternal health policies, as well as increase the list of FP services within the exemption package of the NHIS policy.


Introduction
Improving family planning (FP) services and contraceptive uptake coverage in low-middle-income countries are topical public health concerns. Estimates suggest that access to modern contraceptives in developing countries could reduce the problem of unmet need for contraceptive uptake and reproductive health services, avert over 54 million unwanted pregnancies and 26 million abortions worldwide each year [1,2]. However, the projection on achieving 65% global coverage is yet to be realized [1]. With the current growth trends, the unmet needs for FP are expected to rise from 900 million women in 2010 to 962 million women by 2020 [3].
Past studies have shown that FP reduces the need for unsafe abortion [1,2]. Family planning reinforces people's rights to determine the number and spacing of their children. Attempts to achieve an increment in the number of FP users have been plagued with a number of access barriers, such as accessibility (e.g. proximity), availability (e.g. commodity stockout), awareness (e.g. socio-cultural issues, education and health literacy) and affordability of services [4][5][6][7][8][9][10][11][12]. These barriers progressively slow efforts to improve FP uptake and coverage [3,13]. The health systems in most developing economies rely on out of pocket payment for certain health services. Here, consumers sometimes bear as high as 80% of the total medical cost [14,15]. This high cost of care means that consumers may turn to other cost-saving and nonconventional way of care, which may later result in some undesirable outcomes [16][17][18]. This makes cost a major barrier to health-seeking behavior among consumers of FP services [17,[19][20][21][22].
In Ghana, contraceptive uptake has been projected to reach at least 50% coverage by the year 2020 [23]. The current contraceptive rate remains around 22-26% among married women [24]. The government of Ghana has made several attempts to improve access to FP services. For instance, the National Health Insurance Scheme (NHIS) policy was introduced in 2005 to remove financial barriers to health services including FP. In addition, free maternal health services were introduced in 2008 to increase access to maternal health services for pregnant women [20,25,26]. Notwithstanding that, a large number of women are unable to access FP services due to some cost burden. Several studies have recently been undertaken regarding universal health financing for health services, including FP. These studies have addressed largely general health services and maternal health services [26][27][28][29][30]. Despite this, little is known about the cost burden of accessing FP services among women. The few studies on cost burden target other public health issues such as occupational injuries [31,32] and malaria [33,34]. To our knowledge, no study has estimated the cost burden of family planning services in Ghana. This study, therefore, aims to contribute to the literature by estimating the direct and indirect cost of accessing FP services in Ghana.

Methodology
A facility-based cross-sectional survey was conducted among women seeking family planning services across selected health facilities in the administrative regions of Ghana from December 2017 to January 2018. The country has an estimated population of 30 million and operates a 3-tier health system, being the tertiary, secondary and primary levels [35,36]. Tertiary levels are the teaching hospitals whereas the regional and district hospitals belong to the secondary level, whiles all other service delivery points (SDPs) below the above mentioned are classified as primary level. Multi-Stage stratified sampling was used to recruit 1194 women seeking FP services.
The first stage involved stratification of each of the three health facility levels in the ten (10) administrative regions of Ghana, creating a total of 30 sampling stratum. Implicit stratification with proportional allocation was achieved at each level by using a probability proportional to size selection procedure (Additional file 1: Table S1).
A sample of 336 SDPs was independently selected. Sampling weights were computed for the analysis to ensure the actual representation of the population at both national and district levels. At the SDPs, exiting FP clients were enrolled and those who consented were interviewed.

Data collection
Data on the socio-demographics (e.g. age, sex, marital status, educational level and place of residence) and the cost incurred by clients (e.g. transportation cost, cost of FP method, and waiting time) seeking FP services were collected using a structured questionnaire by trained resident enumerators (RE). The questionnaire was programmed and loaded onto a smartphone with ODK (Open Data kit) [37,38]. A face-to-face interview was conducted in the respondent's preferred local dialects (English, Twi, Ga, Ewe, Dagbani, and Frafra). REs were trained on the use of ODK application for data collection and translation of the questions into their respective languages. The questionnaire was pre-tested at Ejisu-Jauben Municipality in a facility that was not sampled for the actual study.

Data analysis
A prevalence-based cost of illness approach focusing on direct cost and lost time value was employed to estimate the cost of seeking family planning services. This method has widely been adopted in estimating the cost of under-reported public health issues in several studies [31,39]. Data were analyzed using Microsoft Excel and STATA version 14. Data were summarized into means, frequencies, median and percentiles. The direct cost was estimated using approaches adopted in earlier studies on birth-related mortalities and occupational injuries [31,[40][41][42]. It was estimated by summing all cost incurred by clients in seeking FP service at the SDP: • Direct cost = folder fee + consultation fee + laboratory/X-ray charges + commodity purchased + transportation cost. • Indirect Cost (Time value loss) = summation of traveling time, distance traveled and waiting time at SDP for FP services.
The time value lost was estimated on the assumption that every hour lost owing to seeking FP services contributes to productivity loss.
All monetary estimates were expressed in Ghanaian Cedis and US dollars at an exchange rate of GHS 4.50 = US$ 1 as published by the central bank in December 2017.

Results
The mean age of the clients was 29.1 ± 6.9, more than half (53.3%) were in the age range of 25-34 years. Almost all clients were female (99.6%) and about 58.0% were currently married, while 3.94% were divorced. About 53.4% of the clients had up to junior high school level, 3-in-4 were urban residents and 47.7% access the SDPs by walking. Fifty-six percent of clients were required to visit the SDPs once every 3 months, while a few others had to visit every 5 years (6.8%). The majority of the clients (88.4%) paid for the methods received and this payment was made by themselves (56.8%), spouse (68.8%) and other family members (1.3%) ( Table 1).

Cost burden for accessing family planning services
The study disaggregated the burden of accessing FP by the difference in residential patterns, SDP ownership, level of SDP visited and the means of transportation used (

Direct cost incurred for assessing family planning services
The total monetary cost for assessing FP services for the study population was estimated to be GHS (Table 3).

Indirect cost (e.g. time value lost)
Several productivity hours were lost in the course of accessing FP services. For instance, 46.8% stayed off paid work, 40.8% were not able to perform household chores, 11.5% lost relaxation time and 0.9% also had to forego other social engagement. The clients on average spent 54.21 min traveling at a distance of 3.49 km to SDPs and wait for 18.11 min before they are served (Additional file 1: Table S2).

Discussion
The study aimed at estimating the hidden cost burden in accessing family planning services in Ghana. The findings  contribute to the existing literature and discussed according to the direct and indirect costs.

Direct cost in accessing family planning
The cost of family planning services is relevant to clients, service providers and government policy implementers. Such a costing data could inform stakeholders to develop policies that aim to promote universal health financing, and subsequently promote universal health coverage. The study findings showed that clients spent an average direct cost of GHS 7.90 ± 5.7 [$1.76 ± 1.27] when accessing family planning services. The direct cost appears to be relatively high when compared with the standard of living and economic indicators. More specifically, the direct constitutes about 81% of the daily minimum wage of the Ghanaian working population (GHS 9.68 [$2.15]) in 2018 [43]. More specifically, the average expenditure on contraceptives and transportation to the facility was about 50% of the daily minimum wage. This suggests that a client spent relatively a daily income for FP services, a situation that could place a significant financial burden on the household economies of the ordinary Ghanaian. In most instance, users of modern contraceptives may feel reluctant and turn to traditional methods which have a high failure rate to delay pregnancies. This finding is consistent with previous studies in many LMICs countries, like Pakistan [44], India [17] and Bangladesh [19]. In these settings, the cost of health services (e.g. family planning) constitutes a major barrier in seeking care. In particular, the high cost of healthcare discourages clients with lowincome status from seeking regular care and eventually opting for other cost-saving alternatives [6,17,18]. Given this challenge, National Health Insurance is increasingly introduced in many developing countries to remove outof-pocket payments for clients. For instance, NHIS has been introduced into the Ghanaian health systems, yet the cost of FP is not covered under this policy. To achieve universal health financing, our study recommends that the current NHIS benefit should incorporate all family planning services. Future research should employ qualitative methods to explore the subjective effects of the cost burden on the pathways to FP. Further, the study findings showed that there are differences in the cost burden of FP services according to the cost components. For instance, FP services at the tertiary level were higher above the average minimum wage compared to primary level facilities. Similarly, FP services were higher in private own facilities compared with public settings. Generally, the high cost of FP services at tertiary and private own facilities could be attributed to several reasons. Consistent with previous literature in LMICs, like India [19,45], tertiary level and private own facilities are perceived to have adequate human resources and equipment to provide comprehensive services. Therefore, service providers at these settings intend to charge higher to improve the quality of FP services. The study recommends that government regulatory bodies should employ a universal fee across all levels of service provision for FP services. Future research should use interventional design to identify innovative ways of achieving equity in health financing for FP services.

Indirect cost of family planning
The study findings showed that consumers of the FP services lose a total of 73 min on each visit to SDP owing to traveling and waiting time. On each visit, the consumer travels an average distance of 3.5 km. Consistent with earlier studies [4,5], FP services are unequally distributed across districts. Therefore, clients from rural communities may have to travel long distances to access FP services. The long traveling time to SDP could mean a loss in productive time for the clients. The study findings recommend that the government should employ innovative approaches such as telemedicine to improve access to FP services in rural districts. Also, future research should employ intervention studies to measure the effectiveness of telemedicine to promote FP services in rural districts.

Limitations
The study was limited in terms of the data collection instrument. The data collection tool was self-developed and did not use any existing validated tool. Nevertheless, several scientific scrutinies such as pre-testing of tools, sampling facilities and respondents randomly, development of tools based on previous literature reviews of standard costing questionnaire, discussion of findings with relevant literature were employed.