Edward Nketiah-Amponsah Stephen Duku Christine Fenenga Robert Kaba Alhassan

1. ““Towardsa client-oriented health insurance system in Ghana”SomekeyfindingsNHIS 10th Anniversary Conference 5th November, 2013Accra, Ghana Edward Nketiah-Amponsah Stephen Duku Christine Fenenga Robert Kaba Alhassan Tobias Rinke de Wit, Inge Hutter, Menno Pradhan, Daniel Arhinful NHIS 10th Anniversary Conference

2. Background • Key question of this project derived from NHIS: 2010 enrolment about 64% , active membership 34% Retention problem => what are the barriers? • Anecdotal information and growing empirical evidence showing differences in enrolment rate among the population (Asante & Aikins, 2008) • This RCT project is a joint initiative between NHIA, GHS, CHAG and other health partners and the University of Ghana and 3 Universities in The Netherlands with an initiation workshop in 2011 • Funded by the Global Health Policy and Health Systems Research Fund 2010 of the Dutch Scientific Organization NWO-WOTRO NHIS 10th Anniversary Conference

3. Main Objective and Research Question • Main Objective: • To enhance and sustain health insurance participation in Ghana through improved client-oriented quality of care • Main research questions: • What are the main perceived barriers of health care clients to (re-)enroll in the NHIS? • Which are effective interventions that address these barriers? NHIS 10th Anniversary Conference

4. Client-Provider-Insurer Tripod FrameworkPerspectives of the 3 key stakeholder groups, allowing comparison and triangulation of data Client Client-Oriented NHIS System Insurer Provider NHIS 10th Anniversary Conference

5. Set up of research Selected Regions: GAR and WR NHIS 10th Anniversary Conference

6. Sampling Strategy NHIS 10th Anniversary Conference

7. Remaining content of this presentation • Health insurance perspectives by Stephen Duku • Client perspectivesby Christine Fenenga • Healthcare provider perspectives by Robert K. Alhassan NHIS 10th Anniversary Conference

8. Tripodwith Focus on the Insurer Client Client-Oriented NHIS System Provider Insurer NHIS 10th Anniversary Conference

9. Qualitative Research Methodology Location:Greater Accra and Western Regions In-depth Interviews (n=16) • 8 interviews in 4 NHIA districts offices (Dangme West, Ga West, Ahanta West and MpohorWassa), 2 interviews per district • 4 interviews, 2 each at the NHIA Regional offices of the Greater Accra and Western regions • 4 interview at the NHIA Headquarters in Accra Interviewees • NHIA District Office – District Scheme Managers and Claims Officers • NHIA Regional Office – Regional Managers and M&E Officers • NHIA Headquarters – Divisional Directors and Senior Officers Data management • Topic guides for all the interviews • All interviews were recorded and transcribed verbatim • Interviews were Coded, Categorized and conceptualized • Findings were validated in a feedback workshop in each region

10. Household Survey Methodology Location:Greater Accra and Western Regions Data collected with a semi-structured questionnaire on: • Socio-demographics • Social capital and Social schemas • Employment status • Health status and healthcare utilization behavior • NHIS enrolment status • Perceived quality of health care services • Perceived quality of NHIS services • Consumption expenditure patterns • Dwelling characteristics

11. Qualitative Research Findings Quality of NHIS Services to Clients 1. Determinants of Quality • Ease of Registration and registration time • Waiting period to acquire NHIS card and the accuracy of information on cards • Availability of information on benefit package • Attitude of NHIS staff. 2. Challenges in Providing High Quality Services • Delays by Registration Agents to submit registration forms to schemes. • Delays by district schemes to submit registration forms to region. • Inadequate staff at the scheme level to enter registration data into the system. • Low registration fees leading to inadequate administrative funds at schemes. • Misunderstanding and misinformation of clients on the NHIS registration process. • Education, infrastructural and environmental problems posses a huge challenge in the provision of high quality services.

12. Quality of NHIS Services to Health Providers 1. Determinants of Quality • Health providers’ accreditation process • Prompt payment of claims • Monitoring of provider service quality to clients 2. Challenges in Providing High Quality Services • Inadequate education of health providers on claims processing and NHIS in general. • Providers borrowing staff and equipment for accreditation process. • Lack of right caliber of staff at health facilities for claims processing. • Inadequate staff at health facilities to process claims quickly. • Lack of ICT support to speed up claims verification and processing

13. Quantitative Household Survey Findings Summary of Descriptive Characteristics of Total Sample

14. Enrolment in Health Insurance

15. Reasons for Never Enrolling in the NHIS

16. Age Group, Sex and Locality of Residence per Percentage Enrolled of Sample 18+ Years

17. Sector of Employment and Wealth Quintile per percentage Enrolled

18. Health Status & Utilization per Percentage Enrolled

19. Perception on Quality of Services at Nearest Accredited Health Facility

20. Perception on Quality of NHIS Services

21. Determinants of Enrolment in the NHIS

22. Determinants of Enrolment in the NHIS Continued

23. Determinants of Enrolment in the NHIS Continued

24. Tripodwith Focus on the Clients Client Trust -Socio cultural schemas -Social capital Client-Oriented NHIS System Insurer Provider NHIS 10th Anniversary Conference

25. Methods Stakeholders Qualitative Quantitative Participatory Action Approach NHIA All Clients All Clients All IM All= clients, healthcare providers and insurance SDM 20 IHH Abbreviations: IM= Initiation meeting SDM =Stakeholder Design Meeting IHH =Individual Health Histories KII =Key Informant Interviews FGD =Focus Group Discussions RVM =Regional Validation Meeting SM =Stakeholder Meeting HHS =Household Survey IMC =Intervention MyCare 6 KII 20 FGD RVM SM HHS SM IMC NHIS 10th Anniversary Conference

26. NHIS 10th Anniversary Conference FGD Western Region 2011

27. NHIS 10th Anniversary Conference RVM Greater Accra 2011

28. NHIS 10th Anniversary Conference Stakeholder meeting 2012

29. Social Capital(Bourdieu 1986, Coleman 1988, Putnam 1993,Fukuyama 2000, Grootaert 2001) • social connections or social networks that catalyzes cooperation, coordination and reciprocity; • reduces incomplete or asymmetric information • reduces transaction costs in the absence of formal, enforced contracts. • can achieve improved social and economic outcomes. • Trust is seen as important determinant of SC. • SC at the community level can positively and significantly impact households’ decision in take up of health insurance (Donfouet et al 2011; Zangh et al 2006) NHIS 10th Anniversary Conference

30. Differentiating Social Capital Authorities i.e. Government, NHIS, Healthcare providers Vertical SC Client Family , friends , neighbors Groups and associations Horizontal SC NHIS 10th Anniversary Conference

31. Clients’ views on social networks and support structures If ‘you walk alone’ and keep things to yourself, nobody knows what is worrying you or what is in your heart but if you are part of a group, you can share what is bothering you. Someone who is knowledgeable about it will give you advice and help you. So the group is good’ (IHH female, Insured Western Region) ‘Why I realized that ‘health’ is not good is because most of my siblings and even my friends that I know have insurance, look disappointed when they go for treatment and come back’ (FGD female GAR) ‘Now the world has become difficult, family members are no more supporting anybody, (interjection by a participant: 'Everyone for himself, God for us all' that is the motto we have in this family’ (FGD Male/Female Western Region) What motivated me to join the NHIS is that I may not have money when I fall ill and that would make the illness worse. I have already paid and keep my card so when I fall ill without having any money I can access health care. (Female insured IHH GAR)

32. Social capital: membership of groups (n=3963) NHIS 10th Anniversary Conference

33. Social capital: Social cohesion and inclusion (n=3963) NHIS 10th Anniversary Conference

34. Social capital :Trust and solidarity (n-3963) NHIS 10th Anniversary Conference

35. Survey findings: Trust in the healthcare provider (N=3963) NHIS 10th Anniversary Conference

36. Tripodwith Focus on the Provider Client Client-Oriented NHIS System • Provider • Quality healthcare Insurer NHIS 10th Anniversary Conference

37. Methodology (Qualitative & quantitative) • Qualitative • Individual in-depth interviews (IDIs) in private and public facilities in WR & GAR • Cadre of health providers • Managers at national, regional, district levels (n=4) • Clinical staff at service delivery point (n=18) • Grounded theory=>qualitative findings informed structuring of quantitative tool • Total sample size=22 IDIs • Quantitative • Medical technical quality assessment • Tools (Essentials, and SA+) • Total of 41 questions grouped into 5 major components • Staff perceptions data • Structured questionnaires on the ff: • Socio-demographic features of staff • Perspectives on client-centered quality care • Perspectives on the NHIS and QHC • Perceptions on workplace incentives and constraints NHIS 10th Anniversary Conference

38. Profile of Health Facilities Surveyed (n=64) NHIS 10th Anniversary Conference

39. Quality care and patient safety situation in clinics and health centresMean percentage scores in NHIA core standard areas (n=64) Source: Analyzed NHIA Accreditation Data on selected 64 clinics and health centres (2009/2010) NHIS 10th Anniversary Conference

40. Mean percentage scores on Essentials Risk Areas (n=64) NHIS 10th Anniversary Conference

41. NHIS 10th Anniversary Conference

42. Profile of Health Staff Interviewed (n=324) NHIS 10th Anniversary Conference

43. Percentage of staff satisfied with working conditions in NHIA accredited facilities (n=64) *p<0.05

44. Experiences and overall perceptions of health workers on the NHIS (n=324) (*p<0.05)

45. Perspectives health staff on the effects of NHIS on quality care

46. Comparing and triangulating Client and Provider Perspectives on Quality Care HC Providers: Quality is good but need for more staff, equipment & logistics Clients: Relational aspects quality are poor Facility to file complaints Qualitative Attitude of staff Rational use of drugs Availability of drugs Quality of care Quantitative Fair queuing system Sufficient trained staff Transparent information Adequate equipment Availability of staff HH survey: Quality is good except for Facility to file complaints (80% dissatisfied) and queuing time (40% diss. ) NHIA and ESS: low quality standards NHIS 10th Anniversary Conference

47. Concluding remarks (1): We found a positive association between enrolment in the NHIS and existing social capital in the target population (social trust and social participation). There is positive association between enrolment in the NHIS (formal institution) and trust factors such as information provision, reliable delivery of benefit package and client perceived quality of services and facility to file suggestions or complaints (significant) There is also a positive association between enrolment in the NHIS and socio-economic attributes such as health status, educational level, sector of employment and wealth status. Clients’ views of HC quality is largely based on inter-relational factors. This contrasts with providers views, which relates quality to medical technical aspects, creating a gap between perceptions of clients and providers. Our qualitative findings of client perceptions on quality of services generally show a more negative trend than survey findings. We argue that a mixed methods lead to more reliable, precise and valid data. NHIS 10th Anniversary Conference

48. Concluding remarks (2): • Essentials tool results positively correlate with the NHIA accreditation scores suggesting the former could be a complementary assessment tool for quicker assessment over shorter time by the NHIA. • Overall quality situation per Essentials*and NHIA accreditation data in sampled facilities is generally low even though all these facilities are accredited. Regular post accreditation monitoring is therefore imperative to ensure quality care standards are maintained after facilities are given accreditation. • Providers perceive medical technical quality indicators as benchmarks for quality service delivery; client-centered indicators not emphasized. Client-centered care modules should therefore be integrated into the training curricula of health training institutions in Ghana. • Interventions to reduce barriers and enhance enrolment should focus on improving interpersonal relations and information sharing at the health facilities (community level). NHIS 10th Anniversary Conference

49. Thank you NHIS 10th Anniversary onference