Health literacy and health: rethinking the strategies for universal health coverage in Ghana

Highlights

• Most of the participants had limited access to healthcare although the majority of them had subscribed to the National Health Insurance Scheme.

• Only one-third of the population had sufficient health literacy.

• Poor health-related quality of life (HRQoL) was associated with low health literacy and lack of health insurance.

• Access to health care and health insurance subscription positively predicted HRQoL only when health literacy was high.

Abstract

Objectives

Health literacy (HL) is generally thought to be associated with positive health behaviour, appropriate health service utilisation and acceptance of interventions to maximise health outcomes. It is, therefore, increasingly suggested that evidence-based research should investigate how HL may operate in the context of universal health coverage (UHC). However, the role of HL in the relationships between elements of UHC such as access to health care and health insurance has not been widely explored. This applies in particular in Sub-Saharan Africa, although service coverage and health outcomes vary hugely between and within many countries. This article addresses this lacuna in Ghana, today one of the Africa's most promising health systems.

Study design

It is a cross-sectional study.

Methods

The study used structured interviews to gather data from 779 rural and urban adults using a multistage cluster sampling approach.

Results

In a three-step multiple hierarchical linear regression model, HL (B = −.09, standard error [SE] = .04) and health insurance subscription (B = −.15, SE = .04) were found to be inversely associated with poor health-related quality of life (HRQoL). Access to health care did not predict HRQoL (B = −.02, SE = .02). However, the interaction between access to health care and HL produced a negative effect on poor HRQoL (B = −.08, SE = .03). The interaction between HL and health insurance subscription also showed a similar effect on HRQoL (B = −.10, SE = .03). Further analysis depicted that access to health care (β = −.09, P = .05) and health insurance subscription (β = −.24, P = .00) related positively to HRQoL only when HL was high.

Conclusion

The article argues that where HL is low, even favourable policies for UHC are likely to miss set targets. While not losing sight of relevant sociocultural elements, enhancing HL should be a central strategy for policies aimed at bridging health inequalities and improving UHC.

Introduction

Universal health coverage (UHC) encapsulates efforts to ensure that ‘all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the uptake of these services does not expose the user to financial hardship’.¹ Indeed, the principle of aiming for UHC is stated in the Sustainable Development Goals (SDGs) as a target within the health goal, SDG 3, and attaining UHC implicitly underpins many other areas of the SDGs.1, 2, 3 UHC targets many aspects, including equity in health service coverage and financial protection. However, attaining UHC is predicated on specific, well-designed and functional policies and strategies.⁴ Previous attempts to develop similar concepts were often inadequate because of barriers of self-interest and poor understanding.⁵ In this context, this article attempts to address potential obstacles to achieving this important goal, in particular, the role of health literacy (HL) in UHC.

The authors argue that one often-neglected hindrance to achieve effective UHC in many developing countries is people's (restricted) ability to function efficiently in and make the best use of the health system. Indeed, the UHC principle has focussed mostly on the provider side rather than the users in most health systems.2, 6 UHC does aim to establish people-centred services to improve quality of services and patient safety,⁶ which implies that consumers' ability to understand health-related issues is crucial. Therefore, the present study investigates the ‘demand side’, concerning potential consumers' knowledge as defined below and their ability to use health services effectively. It addresses a fundamental question: what happens if people are ill-equipped to explore, understand and use existing opportunities to improve health outcomes? Consequently, the article focusses on the advantage of empowering targeted populations to take charge of their health within the framework of UHC through empirical evidence from Ghana.

The study proposes a comprehensive yet focussed approach to improving UHC through HL. HL has various definitions but principally refers to ‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health’.⁷ HL can be an asset for empowering people by enhancing the ability to access and use health services appropriately and can have direct positive physiological health effects.7, 8, 9 Without adequate attention to empowering the public in a health system, attempts to improve UHC through efforts such as enhancing access to health care and reducing financial barriers while well intentioned may yield lessened impact. Indeed, this may go some way to explaining the existing inadequacies in health outcomes in many developing countries and why some dub the mission for UHC as ‘a struggle’.⁵ While there is no specific target on HL in the SDGs, many in the field increasingly concur that efforts to raise HL will be crucial if the social, economic and environmentally sustainable development ambitions globally are to be fully realised.10, 11

Ghana's health system is one of the most well-developed and promising health systems in Sub-Saharan Africa and remains a model for many others in the continent.12, 13, 14 Access to health care has improved recently in Ghana.¹³ However, considerable discrepancies exist in access to health care among different population groups,¹⁵ including urban-rural, regional and intra-urban differences.¹⁶ Such discrepancies correlate with health outcomes across the globe.2, 6, 17, 18, 19 For instance, it is estimated that between 41% and 72% of all under-five mortality in Sub-Saharan Africa could be avoided through improved access to health care.²⁰ Conditions in Ghana are similar if not as severe as in some other countries.15, 21, 22, 23 Out of frustration about lack of availability or access, many, even the well educated, may resort to self-medication of dubious safety.²⁴

Health financing is also a relevant factor, and many countries in Sub-Saharan Africa have initiated social interventions to reduce direct healthcare expenses through risk-pooling approaches.¹⁴ Ghana's approach to achieving UHC through social health insurance (the National Health Insurance Scheme [NHIS]) is noted as one of the most coherent approaches in the subregion.¹⁴ Nevertheless, financial disincentives to healthcare access still exist due both to systemic weaknesses and household economic challenges in subscribing to the insurance scheme.¹² Global evidence demonstrates that adequate financing reduces inequalities in healthcare access and can improve population health.1, 25 In Ghana, a study using propensity score matching techniques found that women are more likely to receive prenatal care, deliver at a hospital and experience fewer birth complications if they are subscribed to the NHIS.²⁶ This is not dissimilar to findings in other contexts such as India where increased access to health insurance reduced mortality.²⁷

Having adequate HL has been linked to numerous direct and indirect health outcomes, including decreased morbidity and mortality as well as lower likelihood of using emergency room services.²⁸ A recent study in Ghana shows that even among marginalised groups such as street-involved youth, HL positively predicts the health status.²⁹ Similarly, Lori et al.⁷¹ found among some sections of Ghanaian women that low HL is associated with poor judgements regarding decisions about the use of health services and difficulty in interpreting and using health information. The role of HL is also linked to access to health care and healthcare expenditure. Low HL is associated with lack of access to health care because of inadequate knowledge about health and the health system.²⁸ For instance, in Ghana, a significant number of people fail to enrol onto social intervention such as health insurance, although they could afford it because of limited understanding of the scheme.³⁰ Some also attribute this to belief systems and perceptions which are linked to contextual health knowledge.³¹ People with low HL are likely to spend more on health because of indiscriminate use of emergency room services.32, 33 Actually, individuals with low HL are more liable to be hospitalised because of prior poor choices, which increases healthcare expenditure.28, 33

HL appears very likely to affect two of the major components of the UHC principle: access to health care and precepts of health financing. However, previous research in Ghana and many Sub-Saharan African countries has paid little attention to HL as a critical component to improving UHC. As a result, little is known from empirical studies about its potential moderating influence. Therefore, this article aims to broaden understanding on the role of HL by examining its role in the relationships between access to health care and health insurance subscription and health-related quality of life (HRQoL) among adults in Ghana. This is in response to the call by the World Health Organization for further studies to collate and distribute examples of best practice in HL intervention development and provide evidence of what works across contexts to attain the SDGs and UHC.¹⁰ It is hypothesised that the significance of elements of UHC such as access to health care and health insurance subscription to HRQoL are dependent on adequate HL.