Assessment of Bypass of the Nearest Primary Health Care Facility Among Women in Ghana
Authors: Griffith Bell, Erlyn K. Macarayan, Hannah Ratcliffe, June-Ho Kim, Easmon Otupiri, Stuart Lipsitz, Lisa Hirschhorn, John Koku Awoonor-Williams, Belinda Afriyie Nimako, Anthony Ofosu, Hannah Leslie, Asaf Bitton, Dan Schwarz
Journal: JAMA Network Open (2020)

<h3>Importance</h3> Recent reports have highlighted that expanding access to health care is ineffective at meeting the goal of universal health coverage if the care offered does not meet a minimum level of quality. Health care facilities nearest to patient's homes that are perceived to offer inadequate or inappropriate care are frequently bypassed in favor of more distant private or tertiary-level hospital facilities that are perceived to offer higher-quality care. <h3>Objective</h3> To estimate the frequency with which women in Ghana bypass the nearest primary health care facility and describe patient experiences, costs, and other factors associated with this choice. <h3>Design, Setting, and Participants</h3> This nationally representative survey study was conducted in 2017 and included 4203 households to identify women in Ghana aged 15 to 49 years (ie, reproductive age) who sought primary care within the last 6 months. Women who sought care within the past 6 months were included in the study. Data were analyzed from 2018 to 2019. <h3>Exposures</h3> Bypass was defined as a woman's report that she sought care at a health facility other than the nearest facility. <h3>Main Outcomes and Measures</h3> Sociodemographic characteristics, reasons why women sought care, reasons why women bypassed their nearest facility, ratings for responsiveness of care, patient experience, and out-of-pocket costs. All numbers and percentages were survey-weighted to account for survey design. <h3>Results</h3> A total of 4289 women met initial eligibility criteria, and 4207 women (98.1%) completed the interview. A total of 1993 women reported having sough health care in the past 6 months, and after excluding those who were ineligible and survey weighting, the total sample included 1946 women. Among these, 629 women (32.3%) reported bypassing their nearest facilities for primary care. Women who bypassed their nearest facilities, compared with women who did not, were more likely to visit a private facility (152 women [24.5%] vs 202 women [15.6%]) and borrow money to pay for their care (151 women [24.0%] vs 234 women [17.8%]). After adjusting for covariates, women who bypassed reported paying a mean of 107.2 (95% CI, 79.1-135.4) Ghanaian Cedis (US $18.50 [95% CI, $13.65-$23.36]) for their care, compared with a mean of 58.6 (95% CI, 28.1-89.2) Ghanaian Cedis (US $10.11 [95% CI, $4.85-15.35]) for women who did not bypass (<i>P</i> = .006). Women who bypassed cited clinician competence (136 women [34.3%]) and availability of supplies (93 women [23.4%]) as the most important factors in choosing a health facility. <h3>Conclusions and Relevance</h3> The findings of this survey study suggest that bypassing the nearest health care facility was common among women in Ghana and that available services at lower levels of primary care are not meeting the needs of a large proportion of women. Among the benefits women perceived from bypassing were clinician competence and availability of supplies. These data provide insights to policy makers regarding potential gaps in service delivery and may help to guide primary health care improvement efforts.