DOMESTIC, POOLED BUT LATE: A MIXED-METHODS EVALUATION OF FINANCING MODELS FOR REPRODUCTIVE, MATERNAL, NEWBORN AND CHILD HEALTH IN SIX DISTRICTS OF NORTHERN GHANA, 2020 TO 2024

Background: In Ghana, several financing models pay for reproductive, maternal, newborn and child health (RMNCH) services, yet they have not been evaluated together at district level against explicit criteria. We evaluated them in six Northern Region districts from 2020 to 2024.
Methods: A convergent parallel mixed-methods design was guided by the health financing functions framework. We reviewed RMNCH financing records from 6 District Health Directorates (DHDs), 6 National Health Insurance Scheme (NHIS) district offices and 36 facilities (240 institution-years), and held 24 key informant interviews and 4 focus group discussions with 32 participants. Amounts were converted to constant 2020 cedis, and six financing models were rated on five criteria.
Results: Records were complete for 97.9% of institution-years. Facility RMNCH financing rose by 80.5% in nominal terms but fell by 26.3% in real terms. The NHIS share rose from 50.6% to 58.4%, while the donor share fell from 12.9% to 4.9%. DHDs received 86.6% of allocated government funds, a mean of 57 days late. The NHIS paid 85.3% of claimed value after a mean of 86 days, and no claim batch met the 28-day legal limit. Rural facilities waited 100 days and urban facilities 73 days. In real terms every model was rated weak on adequacy, and only the NHIS was strong on sustainability.
Conclusion: RMNCH financing became more domestic and pooled, but it shrank in real terms, and purchasing was slow and unequal. A fixed monthly NHIS payment calendar with a rural target is the most direct remedy.