Health Insurance Status of Pregnant Women and the Likelihood of Receipt of Antenatal Screening for HIV in Sub-Saharan Africa

Muhammad    Ragaa    Hussein; Deepa       Dongarwar; Rafeek    A.    Yusuf; Zenab       Yusuf; Gambo    Gumel    Aliyu; George    Ryan    Elmessan; Hamisu    M.    Salihu
Abstract

Background: We investigated if initiating preventive care against HIV vertical transmission by antenatal HIV screening is independent of the patients’ source of financial reimbursement for the care received in sub-Saharan Africa (SSA).
Methods: Using information from the WHO’s Global Health Expenditure Database and the Demographic Health Surveys Database for 27 sub-Saharan countries, we used Spearman’s correlation and adjusted survey logistic regression to determine the potential relationship between enrollment in health insurance and the likelihood that expectant mothers would be offered antenatal HIV screening.
Results: We found that expectant mothers covered by health insurance were more than twice as likely to be offered antenatal screening for HIV compared to the uninsured. The likelihood differed by the type of insurance plan the expectant mother carried.
Discussion: Health insurance is more of a financial tool that this study finds to be necessary to boost the uptake of preventive and therapeutic HIV care in SSA.
Conclusion: The ensuing disparity in receiving proper care could hinder the goals of 90-90-90 and the forthcoming 95-95-95 plan in SSA.
Keywords: Antenatal screening, health insurance, HIV, HIV screening, Sub-Saharan Africa, Demographic Health Survey (DHS).
Graphical Abstract

[1] 
World Health Organization Mother-to-child transmission of HIV.  Available from: https://www.who.int/hiv/topics/mtct/about/en/
[2] 
Kinuthia J, Kiarie JN, Farquhar C, et al. Cofactors for HIV-1 incidence during pregnancy and postpartum period. Curr HIV Res  2010; 8(7): 510-4.
[http://dx.doi.org/10.2174/157016210793499213] [PMID: 20946093] 
[3] 
Chandisarewa W, Stranix-Chibanda L, Chirapa E, et al. Routine offer of antenatal HIV testing (“opt-out” approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe. Bull World Health Organ  2007; 85(11): 843-50.
[http://dx.doi.org/10.2471/BLT.06.035188] [PMID: 18038074] 
[4] 
Byamugisha R, Tumwine JK, Ndeezi G, Karamagi CA, Tylleskär T. Attitudes to routine HIV counselling and testing, and knowledge about prevention of mother to child transmission of HIV in eastern Uganda: A cross-sectional survey among antenatal attendees. J Int AIDS Soc  2010; 13(1): 52.
[http://dx.doi.org/10.1186/1758-2652-13-52] [PMID: 21144037] 
[5] 
Torpey K, Kabaso M, Kasonde P, et al. Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting. BMC Health Serv Res  2010; 10(1): 29.
[http://dx.doi.org/10.1186/1472-6963-10-29] [PMID: 20109210] 
[6] 
Horwood C, Haskins L, Vermaak K, Phakathi S, Subbaye R, Doherty T. Prevention of mother to child transmission of HIV (PMTCT) programme in KwaZulu-Natal, South Africa: an evaluation of PMTCT implementation and integration into routine maternal, child and women’s health services. Trop Med Int Health  2010; 15(9): 992-9.
[http://dx.doi.org/10.1111/j.1365-3156.2010.02576.x] [PMID: 20561313] 
[7] 
UN Joint Programme on HIV/AIDS (UNAIDS). Global AIDS Update: Miles to go—closing gaps, breaking barriers, righting injustices. Report 2018.
[8] 
Mnyani CN, McIntyre JA. Preventing mother-to-child transmission of HIV. BJOG  2009; 116(Suppl. 1): 71-6.
[http://dx.doi.org/10.1111/j.1471-0528.2009.02312.x] [PMID: 19740178] 
[9] 
Chibwesha CJ, Giganti MJ, Putta N, et al. Optimal time on HAART for prevention of mother-to-child transmission of HIV. J Acquir Immune Defic Syndr  2011; 58(2): 224-8.
[http://dx.doi.org/10.1097/QAI.0b013e318229147e] [PMID: 21709566] 
[10] 
Stringer EM, Ekouevi DK, Coetzee D, et al. Coverage of nevirapine-based services to prevent mother-to-child HIV transmission in 4 African countries. JAMA  2010; 304(3): 293-302.
[http://dx.doi.org/10.1001/jama.2010.990] [PMID: 20639563] 
[11] 
Rollins N, Little K, Mzolo S, Horwood C, Newell ML. Surveillance of mother-to-child transmission prevention programmes at immunization clinics: the case for universal screening. AIDS  2007; 21(10): 1341-7.
[http://dx.doi.org/10.1097/QAD.0b013e32814db7d4] [PMID: 17545711] 
[12] 
Michaels D, Eley B. The HIV & AIDS and STI National Strategic Plan 2007-2011: a paediatric perspective. S Afr J Child Health  2007; 1(4): 135-9.
[13] 
World Health Organization. PMTCT strategic vision 2010-2015: preventing mother-to-child transmission of HIV to reach the UNGASS and Millennium Development Goals: moving towards the elimination of paediatric HIV. 2009.
[14] 
Vrazo AC, Sullivan D, Ryan Phelps B. Eliminating mother- to-child transmission of HIV by 2030: 5 strategies to ensure continued progress. Glob Health Sci Pract  2018; 6(2): 249-56.
[http://dx.doi.org/10.9745/GHSP-D-17-00097] [PMID: 29959270] 
[15] 
Forsythe SS, McGreevey W, Whiteside A. Twenty years of antiretroviral therapy for people living with HIV: global costs, health achievements, economic benefits. Health Affairs  2019; 38(7): 1163-72.
[16] 
Bekker LG, Alleyne G, Baral S, et al. Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society-Lancet Commission. Lancet  2018; 392(10144): 312-58.
[http://dx.doi.org/10.1016/S0140-6736(18)31070-5] [PMID: 30032975] 
[17] 
Buchanan AM, Cunningham CK. Advances and failures in preventing perinatal human immunodeficiency virus infection. Clin Microbiol Rev  2009; 22(3): 493-507.
[http://dx.doi.org/10.1128/CMR.00054-08] [PMID: 19597011] 
[18] 
Van Donk M. “Positive” urban futures in sub-Saharan Africa: HIV/AIDS and the need for ABC (A Broader Conceptualization). Environ Urban  2006; 18(1): 155-75.
[http://dx.doi.org/10.1177/0956247806063971] 
[19] 
Grede N, de Pee S, Bloem M. Economic and Social Factors are Some of the Most Common Barriers Preventing Women from Accessing Maternal and Newborn Child Health (MNCH) and Prevention of Mother-to-Child Transmission (PMTCT) Services: A Literature Review. AIDS Behav  2014; 18: 516-30.
[http://dx.doi.org/10.1007/s10461-014-0756-5] 
[20] 
Falnes EF, Moland KM, Tylleskär T, de Paoli MM, Msuya SE, Engebretsen IM. “It is her responsibility”: partner involvement in prevention of mother to child transmission of HIV programmes, northern Tanzania. J Int AIDS Soc  2011; 14(1): 21.
[http://dx.doi.org/10.1186/1758-2652-14-21] [PMID: 21521511] 
[21] 
Gourlay A, Birdthistle I, Mburu G, Iorpenda K, Wringe A. Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. J Int AIDS Soc  2013; 16(1): 18588.
[http://dx.doi.org/10.7448/IAS.16.1.18588] [PMID: 23870277] 
[22] 
Hodgson I, Plummer ML, Konopka SN, et al. A systematic review of individual and contextual factors affecting ART initiation, adherence, and retention for HIV-infected pregnant and postpartum women. PLoS One  2014; 9(11): e111421.
[http://dx.doi.org/10.1371/journal.pone.0111421] [PMID: 25372479] 
[23] 
Kagee A, Remien RH, Berkman A, Hoffman S, Campos L, Swartz L. Structural barriers to ART adherence in Southern Africa: Challenges and potential ways forward. Glob Public Health  2011; 6(1): 83-97.
[http://dx.doi.org/10.1080/17441691003796387] [PMID: 20509066] 
[24] 
Coetzee B, Kagee A, Vermeulen N. Structural barriers to adherence to antiretroviral therapy in a resource-constrained setting: the perspectives of health care providers. AIDS Care  2011; 23(2): 146-51.
[http://dx.doi.org/10.1080/09540121.2010.498874] [PMID: 21259126] 
[25] 
MacCarthy S, Rasanathan JJ, Ferguson L, Gruskin S. The pregnancy decisions of HIV-positive women: the state of knowledge and way forward. Reprod Health Matters  2012; 20(39): 119-40.
[http://dx.doi.org/10.1016/S0968-8080(12)39641-9] 
[26] 
Messersmith LJ, Semrau K, Anh TL, et al. Women living with HIV in Vietnam: desire for children, use of sexual and reproductive health services, and advice from providers. Reprod Health Matters  2012; 20(39): 27-38.
[http://dx.doi.org/10.1016/S0968-8080(12)39640-7] 
[27] 
Jürgensen M, Tuba M, Fylkesnes K, Blystad A. The burden of knowing: balancing benefits and barriers in HIV testing decisions. a qualitative study from Zambia. BMC Health Serv Res  2012; 12(1): 2.
[http://dx.doi.org/10.1186/1472-6963-12-2] [PMID: 22222028] 
[28] 
Musheke M, Ntalasha H, Gari S, et al. A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa. BMC Public Health  2013; 13(1): 220.
[http://dx.doi.org/10.1186/1471-2458-13-220] [PMID: 23497196] 
[29] 
Olney JJ, Braitstein P, Eaton JW, et al. Evaluating strategies to improve HIV care outcomes in Kenya: a modelling study. Lancet HIV  2016; 3(12): e592-600.
[http://dx.doi.org/10.1016/S2352-3018(16)30120-5] [PMID: 27771231] 
[30] 
Mash R, Howe A, Olayemi O, et al. Reflections on family medicine and primary healthcare in sub-Saharan Africa. BMJ Glob Health  2018; 3(Suppl. 3): e000662.
[http://dx.doi.org/10.1136/bmjgh-2017-000662] [PMID: 29765778] 
[31] 
Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health  2016; 37: 395-412.
[http://dx.doi.org/10.1146/annurev-publhealth-032315-021507] [PMID: 26735432] 
[32] 
Chandra-Mouli V, McCarraher DR, Phillips SJ, Williamson NE, Hainsworth G. Contraception for adolescents in low and middle income countries: needs, barriers, and access. Reprod Health  2014; 11(1): 1.
[http://dx.doi.org/10.1186/1742-4755-11-1] [PMID: 24383405] 
[33] 
Merten S, Kenter E, McKenzie O, Musheke M, Ntalasha H, Martin-Hilber A. Patient-reported barriers and drivers of adherence to antiretrovirals in sub-Saharan Africa: a meta-ethnography. Trop Med Int Health  2010; 15(Suppl. 1): 16-33.
[http://dx.doi.org/10.1111/j.1365-3156.2010.02510.x] [PMID: 20586957] 
[34] 
Yusuf RA, Dongarwar D, Yusuf ZI, Salihu HM. Association between intimate partner violence, knowledge and use of contraception in Africa: comparative analysis across five African regions. Int J MCH AIDS  2020; 9(1): 42-52.
[PMID: 32123627] 
[35] 
Kieny MP, Evans TG, Scarpetta S, et al. Delivering quality health services: a global imperative for universal health coverage. The World Bank  2018; 1(127816): 1-100.
[36] 
World Bank. UHC in Africa: A Framework for Action. 2016; 1-56.
[37] 
Dieleman J, Campbell M, Chapin A, et al. Evolution and patterns of global health financing 1995-2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet  2017; 389(10083): 1981-2004.
[http://dx.doi.org/10.1016/S0140-6736(17)30874-7] [PMID: 28433256] 
[38] 
Lagarde M, Barroy H, Palmer N. Assessing the effects of removing user fees in Zambia and Niger. J Health Serv Res Policy  2012; 17(1): 30-6.
[http://dx.doi.org/10.1258/jhsrp.2011.010166] [PMID: 22096082] 
[39] 
Manthalu G, Yi D, Farrar S, Nkhoma D. The effect of user fee exemption on the utilization of maternal health care at mission health facilities in Malawi. Health Policy Plan  2016; 31(9): 1184-92.
[http://dx.doi.org/10.1093/heapol/czw050] [PMID: 27175033] 
[40] 
Zombré D, De Allegri M, Ridde V. Immediate and sustained effects of user fee exemption on healthcare utilization among children under five in Burkina Faso: A controlled interrupted time-series analysis. Soc Sci Med  2017; 179: 27-35.
[http://dx.doi.org/10.1016/j.socscimed.2017.02.027] [PMID: 28242542] 
[41] 
Ganle JK, Parker M, Fitzpatrick R, Otupiri E. Inequities in accessibility to and utilisation of maternal health services in Ghana after user-fee exemption: a descriptive study. Int J Equity Health  2014; 13(1): 89.
[http://dx.doi.org/10.1186/s12939-014-0089-z] [PMID: 25388288] 
[42] 
Hatt LE, Makinen M, Madhavan S, Conlon CM. Effects of user fee exemptions on the provision and use of maternal health services: a review of literature. J Health Popul Nutr  2013; 31(4)(Suppl. 2): 67-80.
[PMID: 24992804] 
[43] 
World Health Organization. Health insurance in sub-Saharan Africa: a call for subsidies.  Available from: https://www.who.int/bulletin/volumes/86/3/07-042135/en/
[44] 
De Allegri M, Kouyaté B, Becher H, et al. Understanding enrolment in community health insurance in sub-Saharan Africa: a population-based case-control study in rural Burkina Faso. Bull World Health Organ  2006; 84(11): 852-8. Available from: http://www.who.int/bulletin/volumes/84/11/06-031336.pdf
[http://dx.doi.org/10.2471/BLT.06.031336] [PMID: 17143458] 
[45] 
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.
[http://dx.doi.org/10.1186/1475-9276-10-4] [PMID: 21247436] 
[46] 
Ulrichs M. Informality, women and social protection: Identifying barriers to provide effective coverage. Overseas Development Institute, Working Paper 435  2016; 1-49.
[47] 
Alfers L. The Ghana National Health Insurance Scheme: Barriers to access for informal workers. 2013; 30: 1-22.
[48] 
Odeyemi IA. Community-based health insurance programmes and the National Health Insurance Scheme of Nigeria: Challenges to uptake and integration. Int J Equity Health  2014; 13(1): 20.
[http://dx.doi.org/10.1186/1475-9276-13-20] [PMID: 24559409] 
[49] 
Basaza R, Criel B, Van der Stuyft P. Community health insurance in Uganda: Why does enrolment remain low? A view from beneath. Health Policy  2008; 87(2): 172-84.
[http://dx.doi.org/10.1016/j.healthpol.2007.12.008] [PMID: 18280608] 
[50] 
Olugbenga EO. Workable Social Health Insurance Systems in Sub-Saharan Africa. Africa Dev.   Afr Dev  2017; 42: 147-75.
[51] 
Roubal T, Cherilova V, Maele N, Vande , et al. Methodology for the update of the Global Health Expenditure Database, 2000-2016. 2018.
[52] 
Alam N, Hajizadeh M, Dumont A, Fournier P. Inequalities in maternal health care utilization in sub-Saharan African countries: a multiyear and multi-country analysis. PLoS One  2015; 10(4): e0120922.
[http://dx.doi.org/10.1371/journal.pone.0120922] [PMID: 25853423] 
[53] 
Oyelola A. Adegboye DK a n d OAA. Multi-year trend analysis of childhood immunization uptake and coverage in Nigeria. J Biosoc Sci  2013; 225-39.
[54] 
Rutstein SO, Rojas G. Demographic and Health Survey Guide to DHS Statistics. 2006. Available from: https://dhsprogram.com/pubs/pdf/DHSG1/Guide_to_DHS_Statistics_29Oct2012_DHSG1.pdf
[55] 
Demographic and Health Surveys. DHS Program Methodology.  Available from: https://dhsprogram.com/What-We-Do/Methodology.cfm
[56] 
World Health Organization (WHO). Characteristics of community-based health insurance (CBHI) schemes.  Available from: https://www.who.int/health_financing/topics/community-based-health-insurance/key-characteristics/en/
[57] 
Vogel RJ. Health insurance in Sub-Saharan Africa: A survey and analysis. Policy, Research, and External Affairs Working Papers 476 World Bank  1990; 1: 1-45.
[58] 
Witter S, Adjei S, Armar-Klemesu M, Graham W. Providing free maternal health care: Ten lessons from an evaluation of the national delivery exemption policy in Ghana. Glob Health Action  2009; 2(1): 1881.
[http://dx.doi.org/10.3402/gha.v2i0.1881] [PMID: 20027275] 
[59] 
Degroote S, Ridde V, De Allegri M. Health Insurance in Sub-Saharan Africa: A scoping review of the methods used to evaluate its impact. Appl Health Econ Health Policy  2020; 18(6): 825-40.
[http://dx.doi.org/10.1007/s40258-019-00499-y] [PMID: 31359270] 
[60] 
Etiaba E, Onwujekwe O, Honda A, Ibe O, Uzochukwu B, Hanson K. Strategic purchasing for universal health coverage: examining the purchaser-provider relationship within a social health insurance scheme in Nigeria. BMJ Glob Health  2018; 3(5): e000917.
[http://dx.doi.org/10.1136/bmjgh-2018-000917] [PMID: 30483406] 
[61] 
Mebratie AD, Sparrow R, Yilma Z, Alemu G, Bedi AS. Enrollment in ethiopia’s community-based health insurance scheme. World Dev  2015; 74: 58-76.
[http://dx.doi.org/10.1016/j.worlddev.2015.04.011] 
[62] 
Grigorov V. Healthcare in Africa. Cardiovasc J Afr  2009; 20(5): 275-7.
[PMID: 19907798] 
[63] 
Nageso D, Tefera K, Gutema K. Enrollment in community based health insurance program and the associated factors among households in Boricha district, Sidama Zone, Southern Ethiopia; a cross-sectional study. PLoS One  2020; 15(6): e0234028.
[http://dx.doi.org/10.1371/journal.pone.0234028] [PMID: 32484840] 
[64] 
Wiesmann D, Jütting J. The emerging movement of community based health insurance in sub-Saharan Africa: Experiences and lessons learned. Afr Spectr  2000; 193-210.
[65] 
Fenny AP, Yates R, Thompson R. Social health insurance schemes in Africa leave out the poor. Int Health  2018; 10(1): 1-3.
[http://dx.doi.org/10.1093/inthealth/ihx046] [PMID: 29325056] 
[66] 
Sieverding M, Onyango C, Suchman L. Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya. PLoS One  2018; 13(2): e0192973.
[http://dx.doi.org/10.1371/journal.pone.0192973] [PMID: 29470545] 
[67] 
Gunn JKL, Asaolu IO, Center KE, et al. Antenatal care and uptake of HIV testing among pregnant women in sub-Saharan Africa: A cross-sectional study. J Int AIDS Soc  2016; 19(1): 20605.
[http://dx.doi.org/10.7448/IAS.19.1.20605] [PMID: 26787516] 
[68] 
Ernst & Young LLP. Global analysis of health insurance in SubSaharan Africa. 2018. Available from: https://www.ey.com/Publication/vwLUAssets/EY-global-analysis-of-health-insurance-in- sub-saharan-africa/$File/ey-global-analysis-of-health-insurance-in-sub-saharan-africa.pdf
[69] 
Grépin KA. HIV donor funding has both boosted and curbed the delivery of different non-HIV health services in sub-Saharan Africa. Health Aff (Millwood)  2012; 31(7): 1406-14.
[http://dx.doi.org/10.1377/hlthaff.2012.0279] [PMID: 22778329] 
[70] 
Remme M, Siapka M, Sterck O, Ncube M, Watts C, Vassall A. Financing the HIV response in sub-Saharan Africa from domestic sources: Moving beyond a normative approach. Soc Sci Med  2016; 169: 66-76.
[http://dx.doi.org/10.1016/j.socscimed.2016.09.027] [PMID: 27693973] 
[71] 
ILO. Improving Social Protection for the Poor : Health Insurance in Ghana The Ghana Social Trust pre-Pilot Project Final Report. 2005. Available from:http://www.ilo.int/public/english/protection/secsoc/downloads/policy/999sp1.pdf
[72] 
UNAIDS. Prevention GAP Report. 2016. Available from: https://www.unaids.org/sites/default/files/media_asset/2016-prevention-gap-report_en.pdf
[73] 
UN Joint Programme on HIV/AIDS (UNAIDS). UNAIDS AIDSInfo.  Available from: http://aidsinfo.unaids.org/
[74] 
Tudor Car L, van-Velthoven MH, Brusamento S, et al. Integrating prevention of mother-to-child HIV transmission (PMTCT) programmes with other health services for preventing HIV infection and improving HIV outcomes in developing countries. Cochrane Database Syst Rev  2011; (6): CD008741.
[http://dx.doi.org/10.1002/14651858.CD008741.pub2] [PMID: 21678382] 
[75] 
WHO & The World Bank. Tracking Universal Health Coverage: 2017 Global Monitoring Report. 2017.
Cite As
Current HIV Research

Health Insurance Status of Pregnant Women and the Likelihood of Receipt of Antenatal Screening for HIV in Sub-Saharan Africa

Abstract

Graphical Abstract
