Factors That Influence Enrolment and Retention in Ghana' National Health Insurance Scheme

Is enrolment in the national health insurance scheme in Ghana pro-poor? Evidence from the Ghana Living Standards Survey

OBJECTIVES

This article examines equity in enrolment in the Ghana National Health Insurance Scheme (NHIS) to inform policy decisions on progress towards realisation of universal health coverage (UHC).

DESIGN

Secondary analysis of data from the sixth round of the Ghana Living Standards Survey (GLSS 6).

SETTING

Household based.

PARTICIPANTS

A total of 16 774 household heads participated in the GLSS 6 which was conducted between 18 October 2012 and 17 October 2013.

ANALYSIS

Equity in enrolment was assessed using concentration curves and bivariate and multivariate analyses to determine associated factors.

MAIN OUTCOME MEASURE

Equity in NHIS enrolment.

RESULTS

Survey participants had a mean age of 46 years and mean household size of four persons. About 71% of households interviewed had at least one person enrolled in the NHIS. Households in the poorest wealth quintile (73%) had enrolled significantly (p<0.001) more than those in the richest quintile (67%). The concentration curves further showed that enrolment was slightly disproportionally concentrated among poor households, particularly those headed by males. However, multivariate logistic analyses showed that the likelihood of NHIS enrolment increased from poorer to richest quintile, low to high level of education and young adults to older adults. Other factors including sex, household size, household setting and geographic region were significantly associated with enrolment.

CONCLUSIONS

From 2012 to 2013, enrolment in the NHIS was higher among poor households, particularly male-headed households, although multivariate analyses demonstrated that the likelihood of NHIS enrolment increased from poorer to richest quintile and from low to high level of education. Policy-makers need to ensure equity within and across gender as they strive to achieve UHC.

Determinants of paying national health insurance premium with mobile phone in Ghana: a cross-sectional prospective study

INTRODUCTION

In an effort to increase Ghana's National Health Insurance Scheme (NHIS) enrollment and retention rates, the NHIS introduced membership renewal and premium payment by mobile phone. The success of such an innovation dependents on many factors including personal and community characteristics of members.

OBJECTIVE

The objective of the study is to investigate the determinants of renewing membership and paying the NHIS premium through a mobile phone.

METHODOLOGY

The prospective cross-sectional survey was used to solicit the required information from about 1192 respondents living in Kumasi Metropolis, Atwima Nwabiaya and Sekyere Central Districts of Ghana. Logistic regression model was employed to estimate the determinants of paying the NHIS premium with the mobile phone.

RESULTS

The study found that factors including residing in an urban area (Kumasi metropolis), senior high education, tertiary education and informal employees are the determinants of paying the NHIS premium with the mobile phone.

CONCLUSION

It is recommended that the NHIS consider making the mobile payment as simple as possible for the less educated and the rural members to access it.

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study

BACKGROUND

Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers' ability to serve poorer patient populations with quality health services?

METHODS

In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials' experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically.

RESULTS

Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers' abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.

CONCLUSIONS

Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study

Background

Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers’ ability to serve poorer patient populations with quality health services?

Methods

In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials’ experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically.

Results

Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers’ abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.

Conclusions

Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.

Examining equity in health insurance coverage: an analysis of Ghana's National Health Insurance Scheme

Background

Following years of out-of-pocket payment for healthcare, some countries in Africa including Ghana, Kenya and Rwanda have instituted social health protection programs through health insurance to provide access to quality and affordable healthcare especially for the poor. This paper examines equity in coverage under Ghana’s National Health Insurance Scheme (NHIS).

Methods

Secondary data from the 2008 Ghana Demographic and Health Survey based on an analytical sample of 4821 females (15–49 years) and 4568 males (15–59 years) were analysed using descriptive, bivariate and multivariate methods. Concentration curves and indices were used to examine equity in coverage on the NHIS.

Results

As at 2008, more than 60% of Ghanaians aged 15–59 years were not covered under the NHIS with slightly more females (38.9%) than males (29.7%) covered. Coverage was highest among the highly educated, professionals, those from households in the richest wealth quintile and urban residents. Lack of coverage was most concentrated among the poor.

Conclusions

Universal coverage under the NHIS is far from being achieved with marked exclusion of the poor. There is the need for deliberate action to enrol the poor under the NHIS.