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

Document Type: Original Article

Authors

1 School of Public Health, University of Ghana, Legon, Ghana

2 Department of Sociology and Anthropology, University of Amsterdam, Amsterdam, The Netherlands

Abstract

Background
The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2004 with the goal of achieving universal coverage within 5 years. Evidence, however, shows that expanding NHIS coverage and especially retaining members have remained a challenge. A multilevel perspective was employed as a conceptual framework and methodological tool to examine why enrolment and retention in the NHIS remains low.

 
Methods
A household survey was conducted after 20 months educational and promotional activities aimed at improving enrolment and retention rates in 15 communities in the Central and Eastern Regions (ERs) of Ghana. Observation, indepth interviews and informal conversations were used to collect qualitative data. Forty key informants (community members, health providers and district health insurance schemes’ [DHISs] staff) purposely selected from two casestudy communities in the Central Region (CR) were interviewed. Several community members, health providers and DHISs’ staff were also engaged in informal conversations in the other five communities in the region. Also, four staff of the Ministry of Health (MoH), Ghana Health Service (GHS) and National Health Insurance Authority (NHIA) were engaged in in-depth interviews. Descriptive statistics was used to analyse quantitative data. Qualitative data was analysed using thematic content analysis.

 
Results
The results show that factors that influence enrolment and retention in the NHIS are multi-dimensional and cut across all stakeholders. People enrolled and renewed their membership because of NHIS’ benefits and health providers’ positive behaviour. Barriers to enrolment and retention included: poverty, traditional risk-sharing arrangements influence people to enrol or renew their membership only when they need healthcare, dissatisfaction about health providers’ behaviour and service delivery challenges.

 
Conclusion
Given the multi-dimensional nature of barriers to enrolment and retention, we suggest that the NHIA should engage DHISs, health providers and other stakeholders to develop and implement intervention activities to eliminate corruption, shortage of drugs in health facilities and enforce the compulsory enrolment stated in the NHIS policy to move the scheme towards universal coverage.

Keywords

Main Subjects


  1. Nyonator F, Kutzin J. Health for some? The effects of user fees in the Volta Region of Ghana. Health Policy Plan. 1999;14(4):329-341.
  2. Asenso-Okyere WK, Anum A, Osei-Akoto I, Adukonu A. Cost recovery in Ghana: are there any changes in health care seeking behaviour? Health Policy Plan. 1998;13(2):181-188.  
  3. Waddington CJ, Enyimayew KA. A price to pay: The impact of user charges in the Ashanti-Akim district, Ghana. Int J Health Plann Manage.1989;4(1):17-47. doi:10.1002/hpm.4740040104
  4. Waddington CJ, Enyimayew KA. A price to pay, part 2: The impact of user charges in the Volta region of Ghana. Int J Health Plann Manage. 1990;5(4):287-312. doi:10.1002/hpm.4740050405
  5. Arhinful DK. The Solidarity of Self-interest: Social and Cultural Feasibility of Rural Health Insurance in Ghana. Leiden: African Studies Centre; 2003.
  6. Arhin-Tenkorang D. Health insurance for the informal sector in Africa: Design features, risk protection and resource mobilisation. Geneva: Commission on Macroeconomics and Health, World Health Organization; 2001.
  7. Agyepong IA, Adjei S. Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme. Health Policy Plan. 2008;23(2):150-160. doi:10.1093/heapol/czn002
  8. Government of Ghana. The National Health Insurance Act: Act 650. Accra: Ghana Government; 2003.
  9. Ministry of Health. Policy framework for the establishment of health insurance in Ghana. Accra: Ministry of Health; 2002.
  10. Ministry of Health. National Health Insurance Policy Framework for Ghana. Revised edition. Accra: Ministry of Health; 2004.
  11. National Health Insurance Scheme website. http://www.nhis.gov.gh/benefits.aspx.   Accessed September 3, 2016.
  12. Dzakpasu S, Soremekun S, Manu A, et al. Impact of free delivery care on health facility delivery and insurance coverage in Ghana's Brong Ahafo Region. PLoS One. 2012;7(11):e49430. doi:10.1371/journal.pone.0049430
  13. Government of Ghana. National Health Insurance Act: Act 852. Accra: Government of Ghana; 2012.
  14. National Health Insurance Regulations.       http://www.ilo.org/gimi/RessShowRessource.do?ressourceId=11967. Accessed 2 June 2008. pUblished 2004.
  15. National Health Insurance Authority. NHIA Annual Report 2009. Accra: National Health Authority; 2010.
  16. World Health Organisation. The World Health Report 2010: Health Systems Financing: The path to universal coverage. Geneva: World Health Organization; 2010.
  17. World Health Organization Global Health Expenditure database website. http://apps.who.int/nha/database.  Accessed May 20, 2017.
  18. Life expectancy at birth, total (years). The World Bank website. http://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=GH. Accessed May 31 2017.
  19. Tax revenue (% of GDP). The World Bank website.
    https://data.worldbank.org/indicator/GC.TAX.TOTL.GD.ZS?locations=GH&view=chart
    . Accessed September 6 2017.
  20. Ghana Statistical Service. 2010 Population and Housing Census: National Analytical Report. Accra: Ghana Statistical Service; 2013.
  21. Ghana Statistical Service. Trends and patterns of poverty in Ghana 2012-2013: Report of Ghana Living Standards Survey. Accra: Ghana Statistical Service; 2007.
  22. World Health Organisation Country Office For Ghana Annual Report 2014. http://www.afro.who.int/sites/default/files/2017-05/ghana-annual-report-2014-final.pdf.  Assessed October 4, 2017.
  23. Agyepong IA, Nagai RA. "We charge them; otherwise we cannot run the hospital" front line workers, clients and health financing policy implementation gaps in Ghana. Health Policy. 2011;99(3):226-233. doi:10.1016/j.healthpol.2010.09.018
  24. Ghana Statistical Service, Ghana Health Service, ICF International. Ghana Demographic Health Survey 2014.Rockville, Maryland, US: GSS, GHS and ICF International; 2015.
  25. Mensah J, Oppong JR, Schmidt CM. Ghana's National Health Insurance Scheme in the context of the health MDGs: an empirical evaluation using propensity score matching. Health Econ. 2010;19 Suppl:95-106. doi:10.1002/hec.1633
  26. Durairaj V, D’ameida S, Kirigia J. Ghana’s approach to social health protection. World Health Report Background, Paper No. 2. Geneva: WHO; 2010.
  27. National Health Insurance Authority Annual Report 2011, 2012. Status of implementation of the NHIS. http://www.nhis.gov.gh/files/annualreport2011.pdf.      Assessed September 2015.
  28. Asante F, Aikins M. Does the NHIS cover the poor? Accra: DANIDA Health Sector Support Office; 2008.
  29. Sarpong N, Loag W, Fobil J, et al. National health insurance coverage and socio-economic status in a rural district of Ghana. Trop Med Int Health. 2010;15(2):191-197. doi:10.1111/j.1365-3156.2009.02439.x
  30. Nguyen H, Knowles J. Demand for voluntary health insurance in developing countries: the case of Vietnam's school-age children and adolescent student health insurance program. Soc Sci Med. 2010;71(12):2074-2082. doi:10.1016/j.socscimed.2010.09.033
  31. Kusi A, Enemark U, Hansen KS, Asante FA. Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem? Int J Equity Health. 2015;14:2. doi:10.1186/s12939-014-0130-2
  32. Baer HA, Singer M, Johnsen JH. Toward a critical medical anthropology. Soc Sci Med. 1986;23(2):95-98. 
  33. Van der Geest S, Speckmann JD, Streefland PH. Primary health care in a multi-level perspective: towards a research agenda. Soc Sci Med. 1990;30(9):1025-1034.
  34. Press I. Levels of explanation and cautions for a critical clinical anthropology. Soc Sci Med. 1990;30(9):1001-1009.
  35. Jehu-Appiah C. Reaching the poor in Ghana’s National Health Insurance Scheme: Equity aspects and strategies to improve enrolment [PhD Thesis]. Nijmegen: Radboud University; 2012.  
  36. Kotoh AM. Improving health insurance coverage in Ghana: A case study. Leiden: African Studies Centre; 2013.
  37. Jehu-Appiah C, Aryeetey G, Spaan E, Agyepong I, Baltussen R. Efficeincy, equity and feasibility of strategies to identify the poor: An application to premium exemptions under National Health Insurance Scheme in Ghana. Health Policy Plan. 2010;95:166-73.
  38. Aryeetey GC, Jehu-Appiah C, Spaan E, D'Exelle B, Agyepong I, Baltussen R. Identification of poor households for premium exemptions in Ghana's National Health Insurance Scheme: empirical analysis of three strategies. Trop Med Int Health. 2010;15(12):1544-1552. doi:10.1111/j.1365-3156.2010.02663.x
  39. McKenzie DJ. Measuring inequality with asset indicators. J Popul Econ. 2005;18(2):229-260. doi:10.1007/s00148-005-0224-7
  40. Vyas S, Kumaranayake L. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan. 2006;21(6):459-468. doi:10.1093/heapol/czl029
  41. Emerson RM, Frits RI, Shaw LL. Writing ethnography field notes. Chicago: University of Chicago Press; 2005.
  42. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-112. doi:10.1016/j.nedt.2003.10.001
  43. Sulzbach S, Garshong B, Owusu-Banahene G. Effect of National Health Insurance Act in Ghana: Baseline report. Bethesda: ABT associates Inc; 2005.
  44. Jütting JP. Do Community-based Health Insurance Schemes Improve Poor People’s Access to Health Care? Evidence From Rural Senegal. World Dev. 2004;32(2):273-288. doi:10.1016/j.worlddev.2003.10.001
  45. 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):172-184. doi:10.1016/j.healthpol.2007.12.008
  46. Save the Children U.K. Helping children survive. Supporting poor families to overcome barriers to maternal, new born and child health services. 2008. http://www.savethechildren.org.uk/sites/default/files/docs/Helping_Children_Survive_1.pdf. Accessed 2 March 12. Published 2008.
  47. Witter S, Garshong B. Something old or something new? Social health insurance in Ghana. BMC Int Health Hum Rights. 2009;9:20. doi:10.1186/1472-698x-9-20
  48. World Health Organisation. Community-based health insurance schemes in developing countries: Facts, problems and perspectives. Geneva: WHO; 2003.
  49. Badasu DM. Implementation of Ghana’s health user fee policy and the exemption of the poor: Problems and prospects. African Population Studies.2004;19:285-302.
  50. Aikins M, Arhinful D. Review of exemption policy: A report on the annual health sector review 2005. Ghana: Ministry of Health; 2006.
  51. Kanchebe Derbile E, van der Geest S. Repackaging exemptions under National Health Insurance in Ghana: how can access to care for the poor be improved? Health Policy Plan. 2013;28(6):586-595. doi:10.1093/heapol/czs098
  52. Blanchet NJ, Fink G, Osei-Akoto I. The effect of Ghana's National Health Insurance Scheme on health care utilisation. Ghana Med J. 2012;46(2):76-84.
  53. Platteau JP. Mutual insurance as an elusive concept in traditional rural communities. J Dev Stud. 1997;33(6):764-796. doi:10.1080/00220389708422495
  54. van der Geest S. Is paying for health care culturally acceptable in Sub-Sahara Africa? Money and tradition. Soc Sci Med. 1992;34(6):667-673.
  55. Agyepong IA. Reforming health service delivery at district level in Ghana: the perspective of a district medical officer. Health Policy Plan. 1999;14(1):59-69.
  56. Aikins M, Okang G. Utilisation and cost of healthcare under district health insurance: A case study of Brong Ahafo and Eastern Regions. Accra: JSA Consultants; 2006.
  57. Aryee JRA. Public sector management in Africa. Economic research working paper series. No. 82. Tunisia: African Development Bank; 2005.
  58. van der Geest S, Finkler K. Hospital ethnography: introduction. Soc Sci Med. 2004;59(10):1995-2001. doi:10.1016/j.socscimed.2004.03.004
  59. van der Geest S, Whyte SR, Hardon A. The anthropology of pharmaceuticals: A biographical approach. Annu Rev Anthropol. 1996;25:153-178. doi:10.1146/annurev.anthro.25.1.153
  60. Ekman B. Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy Plan. 2004;19(5):249-270.
  61. D’Ambruoso L, Achadi A, Adisasmita A, Izati Y, Makowiecka K, Hussein J. Assessing quality of care provided by Indonesian village midwives with a confidential enquiry. Midwifery. 2009;25(5):528-539. doi:10.1016/j.midw.2007.08.008
  62. Rajkotia Y. The political development of the Ghanaian National Health Insurance System: Lessons in health governance. Bethesda, MD: Abt Associates Inc; 2007.
  63. Brinkerhoff DW. Accountability and health systems: toward conceptual clarity and policy relevance. Health Policy Plan. 2004;19(6):371-379. doi:10.1093/heapol/czh052
  64. National Democratic Congress. NDC Manifesto. A better Ghana: Investing in people, jobs and the economy. 2nd ed. Accra: National Democratic Congress; 2008.
  65. National Health Insurance Authority. Delivery on the NHIS promise of one-time premium payment, financial sustainability of the NHIS based on recent financial assessment of the NHIS. A presentation to stakeholders Elmina. Ghana: National Health Insurance Authority; 2010.
  66. Abiiro GA, McIntyre D. Universal financial protection through National Health Insurance: a stakeholder analysis of the proposed one-time premium payment policy in Ghana. Health Policy Plan. 2013;28(3):263-278. doi:10.1093/heapol/czs059