GHANA HEALTH INC. NHIS COUNTRY CASE STUDY REPORT 27th June 2013

GHANA HEALTH INC.
NHIS COUNTRY CASE STUDY REPORT
By
Ghana Health Inc Team
(Felix A. Asante
Daniel K. Arhinful
Ama P. Fenny
Anthony Kusi)
27th June 2013
Acknowledgements
The research leading to these results has received funding from the European
Commission's Seventh Framework Programme FP7/2007 under grant agreement No.
261440.
The views expressed in this document are the sole responsibility of the author and do
not necessarily reflect the views of the European Commission.
i
TABLE OF CONTENTS
ACRONYMS / ABBREVIATIONS.............................................................................iv
1.
INTRODUCTION .................................................................................................. 1
2.
BACKGROUND .................................................................................................... 2
3.
2.1
Country/State context........................................................................................ 2
2.2
Health systems context ..................................................................................... 7
2.3
Social Health Protection ................................................................................. 12
2.4
National Health Insurance Scheme (NHIS) .................................................... 14
2.5
Gaps in evidence ............................................................................................. 16
2.6
Research objectives, questions and hypotheses .............................................. 17
METHODOLOGY ............................................................................................... 18
3.1
Selection of study sites.................................................................................... 18
3.2
Mixed methods approach ................................................................................ 19
3.3
Quantitative method: household survey.......................................................... 20
3.3.1
Sampling strategy and size....................................................................... 20
3.3.2
Design of the questionnaire ..................................................................... 20
3.3.3
Data collection process ............................................................................ 20
3.3.4
Identification of households for study ..................................................... 21
3.3.5
Mapping and listing ................................................................................. 21
3.3.6
Supervision skills ..................................................................................... 21
3.3.7
Data entry, processing and analysis ......................................................... 22
3.3.8
Methodological challenges faced ............................................................. 22
3.4
4.
5.
Qualitative methods ........................................................................................ 22
3.4.1
Sampling strategy..................................................................................... 23
3.4.2
Design of the topic guides........................................................................ 24
3.4.3
Data collection process ............................................................................ 24
3.4.4
Data entry, processing and analysis ......................................................... 25
3.4.5
Methodological challenges faced ............................................................. 25
ETHICAL CONSIDERATIONS .......................................................................... 26
4.1
Ethical clearance ............................................................................................. 26
4.2
Consent forms and permissions ...................................................................... 26
RESULTS ............................................................................................................. 27
5.1
Description and overview of data collected (all methods).............................. 27
ii
5.2
SPEC-by-STEP adopted by Ghana ................................................................. 29
5.2.1
Level 1: Targeted population ................................................................... 31
5.2.2
Level 2: Never insured ............................................................................. 33
5.2.3
Level 3: Previously insured household members .................................... 40
5.2.4
Level 4: Registered with the NHIS but yet to receive membership card. 46
5.2.5
Level 5: Active NHIS members (valid NHIS card holders) .................... 49
5.3
Access to educational, health and transport infrastructural services ...... Error!
Bookmark not defined.
6.
DISCUSSION ....................................................................................................... 55
6.1
Discussion of Results ...................................................................................... 57
7.
CONCLUSION ..................................................................................................... 59
8.
RECOMMENDATIONS ...................................................................................... 60
REFERENCES ............................................................................................................ 61
ANNEX........................................................................................................................ 64
1.
SPEC Framework: Dimensions, Domains, Variables and Indicators ............... 64
2.
SPEC Step-by-Step: Ghana............................................................................... 77
List of Tables
Table 2.1: Macroeconomic Indicators (2007-2011) ...................................................... 3
Table 2.2: Selected Human Development Indicators for Ghana ................................... 4
Table 2.3: Trends in Poverty Incidence by Region and Location, 1990-2006 .............. 4
Table 2.4: Health Sector Output Indicators, 2005-2010 ................................................ 8
Table 2.5: Top Ten Causes of Outpatient Morbidity (2002-2009) ................................ 9
Table 2.6: Doctor to Population Ratio ........................................................................... 9
Table 2.7: Nurse to Population Ratio........................................................................... 10
Table 2.8: Selected Social Protection Instruments in Ghana ....................................... 13
Table 3.1: Districts for the Household Survey............................................................. 18
Table 3.2: Stakeholder Analysis – Part I ..................................................................... 22
Table 3.3: Stakeholder Analysis – Part II .................................................................... 23
Table 3.4: Potential Target Groups for the Formation of Focused Groups ................. 23
Table 5.1: Summary Description of the Sample .......................................................... 27
Table 5.2: Characteristics of household members who responded to the .................... 29
iii
Table 5.3: Total Registered (cumulative) and Active Membership by Region, 2011 . 32
Table 5.4: Aggregate NHIS Subscribers by Category, 2010 and 2011 ....................... 32
Table 5.5: Perception about the NHIS by Respondents to the SPEC Pull-Out
Questionnaire ............................................................... Error! Bookmark not defined.
Table 5.6: Access to Educational, Health and Infrastructural Services by Insurance
Status ............................................................................ Error! Bookmark not defined.
Table 5.7: Perception on Access to Health Care.......................................................... 54
List of Figures
Figure 2.1: Map of Ghana: Administrative Regions/Capitals........................................2
Figure 2.2: NHIS Total Inflow as at 31 December,
2009............................................Error! Bookmark not defined.6
Figure 5.1: Current health insurance status 2012; Household members......................32
ACRONYMS / ABBREVIATIONS
AAK
Abura-Asebu-Kwamamkese
ANC
Antenatal Care
BMC
Budget Management Committee
CHPS
Community-based Health Planning Services
CSO
Civil Society Organisation
CSPS
Centre for Social Policy Studies
DMHIS
District Mutual Health Insurance Scheme
DSW
Department of Social Welfare
EA
Enumeration Area
ERP
Economic Recovery Programme
FGD
Focus Group Discussion
GDP
Gross Domestic Product
GHS
Ghana Health Service
GoG
Government of Ghana
iv
GPRS I
Ghana Poverty Reduction Strategy
GPRS II
Growth and Poverty Reduction Strategy
GSS
Ghana Statistical Service
HDI
Human Development Index
HIPC
Heavily Indebted Poor Countries
IRB
Institutional Review Board
ISSER
Institute of Statistical, Social and Economic Research
LEAP
Livelihood Empowerment against Poverty
MDG
Millennium Development Goal
MESW
Ministry of Employment and Social Welfare
MMDA
Metropolitan, Municipal and District Assembly
MOH
Ministry of Health
NDPC
National Development Planning Commission
NGO
Non-Government Organisation
NHIA
National Health Insurance Authority
NHIC
National Health Insurance Council
NHIF
National Health Insurance Fund
NHIL
National Health Insurance Levy
NHIS
National Health Insurance Scheme
NMIMR
Noguchi Memorial Institute for Medical Research
NSPS
National Social Protection Strategy
OPD
Outpatient Department
OVC
Orphan or Vulnerable Child
PAMSCAD
Program of Action to Mitigate the Social Costs of Adjustment
PCA
Principal Component Analysis
PNDC
Provisional National Defence Council
PWD
Person with extreme disability
RHD
Regional Health Directorate
SAP
Structural Adjustment Programme
SPEC
Social, Political, Economic and Cultural
SSNIT
Social Security and National Insurance Trust
TB
Tuberculosis
UN
United Nations
VAT
Value Added Tax
v
vi
1. INTRODUCTION
The research project puts forward the hypothesis that social exclusion is an important
cause of the limited success of recent health financing reforms. Firstly, social
exclusion can explain barriers to accessing health care. Social exclusion from health
care provision may be due to disrespectful, discriminatory or culturally inappropriate
practices of medical professionals and their organisations, within the context of poor
accessibility and quality of care. Social exclusion from health care services means that
removing financial barriers does not necessarily guarantee equitable access to health
care. Secondly, social exclusion can explain barriers to accessing the health financing
mechanism itself.
The main objectives of the study were as follows: (1) To conduct are view of existing
evidence on social exclusion and inclusion and health in the country/state to be
studied; (2) To adapt the conceptual framework and research tools for the
country/state to be studied; (3) To describe the goals of the health financing system
and to assess the extent to which equity and social inclusion are articulated; (4) To
review evaluations of the health financing system so as to identify existing evidence
of whether it is equitable and socially inclusive;(5) To identify the main mechanisms
for social and financial inclusion and exclusion in the health financing system and (6)
To identify multi-sectoral collaborations between government ministries which
promote social inclusion in health financing.
Research questions:
•
•
•
•
•
•
What are the reasons for the limited success of the health financing
arrangement in providing free or “affordable” access to care to the below
poverty households in Ghana?
What does social exclusion mean or how is it understood in Ghana and what
are the indicators of social exclusion in Ghana?Does social exclusion prevent the development of health care financing for the
informal sector in Ghana and how? Does the National Health Insurance Scheme (NHIS) reduce or increase social
exclusion in Ghana and how?
What is the potential of NHIS for reducing social exclusion in Ghana?
What is the potential of policy makers in health and other sectors for reducing
social exclusion in the NHIS in Ghana?
1
2. BACKGROUND
2.1 Country/State context
Background profile of Ghana
Ghana is a relatively small country in the west coast of Africa with a land size of
238,537 km2with a population density varying from 897 per km2 in Greater Accra
Region to 31 per km2 in the Northern Region. The country is divided into 10
administrative regions and 170 metropolitan, municipal and district assemblies
(MMDAs). Ghana’s population is estimated at 24.2 million with 51.3 percent being
females in 2010 (GSS, 2010). It is estimated that about 41 percent of Ghana’s
population are aged below 15 years while 5 percent are above 65 years (DHS, 2008).
About 51 percent of the population live in urban areas as of 2010 from 36.4 percent in
the 1990 (UNDP, 2010). Ghana’s neighbouring countries include Burkina Faso to the
north, Togo to the east and Cote D’Ivoire to the west. The south is bordered by the
Gulf of Guinea.
Figure 2.1
Economy of Ghana
Ghana is a low middle income country after the rebasing of the national accounts in
late 2010. The Gross Domestic Product (GDP)was estimated at US$43,388 million in
2010 increasing to US$55,300 million in 2011. Ghana’s economic growth in 2011 of
14.4 percent from 7.7 percent in 2010 was mainly due to oil exports, which started in
Ghana in 2011. The major driver to this overall growth of the economy was the robust
2
performance in the non-oil sector and the commencement of oil production in Ghana.
This made the industrial sector the main driver of economic growth.
Ghana’s economy since political independence in 1957 has been dominated by the
agricultural sector in terms of employment creation and contribution to GDP. The
dominance of the sector which is characterised by subsistence agriculture and a major
contribution of cocoa exports has seen a decline since the 1990s. The services sector
is now the largest contributor to GDP contributing to about half of the nation’s GDP
(Table 2.1). The major growth points of the services sector include transport, finance,
insurance, real estate, business services, trade and government services. Ghana’s
major export commodities include cocoa, gold, diamonds, timber and horticulture
while her major imports also include capital equipment, petroleum products and
foodstuffs.
Table 2.1: Macroeconomic Indicators (2007-2011)
Indicator
Growth in GDP at constant
2006 prices
GDP current (million $)
2007
2008
2009
2010
2011
6.5
24,632.9
8.4
28,203.9
4.0
25,773.3
7.7
43,388
14.4
55,300
31.8
19.0
49.2
29.9
18.6
51.4
25.6
25.9
48.5
Distribution of GDP (at basis prices) by economic sector
Agriculture
29.1
31.0
Industry
20.7
20.4
Service
50.2
48.6
Source: GSS, 2012
Human Development Indicators
Human development in Ghana is relatively low with vast disparities across the
country. Ghana ranked 130 on the Human Development Index (HDI) in 2010 with a
value of 0.467. This signifies a low level of human development in the country. The
life expectancy of the population is estimated at 60 years (57years for men and 64
years for women). Though Ghana’s adult literacy rate of 65 percent is relatively high
in Africa, the mean years of schooling is only 7.1 years. Only about 29 percent of the
population have at least secondary education. The low human development is
manifested in widespread poverty and deprivation among the population though the
proportion in extreme poverty has been declining since 1991 (Tables 2.2a and2.2b).
Available data indicates that 18 percent of the population lived in extreme poverty in
2006 with high inequalities between rural and urban areas (25.6 percent vs. 5.7
percent) and between Northern Ghana and Southern Ghana as shown in Table 2b. The
situation is even made worse when poverty is defined to include deprivation and
vulnerability. About 46 percent of the population was estimated to be living in
multidimensional poverty in 2010.
While access to improved water sources is generally good at 80 percent, only 10
percent of the population have access to improved sanitation facilities. The generally
low standard of living among the population is reflected in the country’s high
mortality indicators. Notwithstanding the poor human development indicators, Ghana
has made substantial progress over the past few years in achieving its Millennium
Development Goals (MDGs) giving hope for the future.
3
Table 2.2: Selected Human Development Indicators for Ghana
Indicator
Human Development index (HDI) (value)
Life expectancy at birth, total (years)
2010
0.467
60.0
Adult literacy rate (%)
- Male
- Female
Mean years of schooling (years)
Population with at least secondary education
Population below national poverty line (2006) %
Population below extreme poverty line (2006) %
65
72
59
7.1
28.7
28.5
18.2
Population below $1.25 a day (2006) %
Population in multidimensional poverty (Intensity of deprivation)
Income Gini coefficient (2000-2010)
Access to improved water source
Access to improved sanitation facilities
Adult mortality rate (per 1000 population)
Under-five mortality rate (1000 live births)
Infant mortality rate (1000 live births)
Prevalence of underweight children under 5 years (%)
30.0
46.4
42.8
80
10
332
69
47
14
Sources: World Health Statistics, 2011, World Development Report, 2010, Human Development
Report 2010, World Development Indicators, 2010
Table 2.3: Trends in Poverty Incidence by Region and Location, 1990-2006
REGION
ASHANTI
BRONG AHAFO
CENTRAL
EASTERN
GREATER
ACCRA
NORTHERN
UPPER EAST
UPPER WEST
VOLTA
WESTERN
Urban
Rural
National Total
Proportion below the lower
(extreme) poverty line
1991/92
1998/99
2005/2006
25.0
16.4
11.2
46.0
18.8
14.9
24.0
31.0
9.7
35.0
30.4
6.6
13.0
54.0
53.0
74.0
42.0
42.0
15.1
47.2
36.5
2.4
57.4
88.0
68.3
20.4
14.0
11.6
34.4
26.8
6.2
38.7
60.1
79.0
15.2
7.9
5.7
25.6
18.2
Proportion below the upper poverty
line
1991/92
1998/99
2005/2006
41.0
28.0
20.0
65.0
36.0
29.0
44.0
48.0
20.0
48.0
44.0
15.1
26.0
63.0
67.0
87.9
57.0
60.0
27.7
63.6
51.7
5.2
69.2
88.0
83.9
38.0
27.0
19.4
49.5
39.5
11.8
52.3
70.0
88.0
31.4
18.0
11.0
39.0
28.5
Source: Ghana Statistics Services, 2007
4
Social exclusion in Ghana
Social exclusion can be described as the systematic denial of particular groups of
people from fully enjoying a set of social opportunities, such as the right to
“participate on equal terms in social relationships in economic, social, cultural or
political arenas” (GSDRC, University of Birmingham 2006).Social exclusion theory
builds on the evidence that the causes of poverty and inequality are embedded in the
structures of social systems and relationships − in exclusionary processes − and not in
individual inadequacies (SEKN, 2008). SEKN (2008) defines social exclusion in the
following way:
Exclusion consists of dynamic, multidimensional processes driven by unequal power
relationships interacting across four main dimensions − economic, political, social
and cultural and at different levels including individual, household, group,
community, country and global levels.
Additionally, social exclusion may come about as a result of policies put in place to
deliberately exclude specific groups of people from participating in a shared social
opportunity. A practice which is quite common in African political economies
whereby access to resources and opportunities are restricted to a limited group of
people with the intention of gaining a future advantage in the form of political votes
or professional favours.
Social health protection is a critical component of social protection, underpinned by
principles of solidarity and equity whereby all individuals are guaranteed access to an
adequate package of health care based on needs rather than the ability to pay. In
Ghana, health inequities are seen to be a major form of social exclusion. There is
striking evidence of rural-urban disparities in access to health care services,
inequitable distribution of health workers; striking disparities in access to health
services between rich and poor and gender gaps in access due to poverty, deprivation
and ignorance.
Traditional concepts of social protection, based on the notion of mutual support, are
still strongly rooted in Ghanaian culture, but are eroding under the influence of
modernisation. Recently, attention has been given to the challenge of developing a
broader, more comprehensive social protection system that would address the
vulnerabilities and risks facing the mass of the population, and help to promote
poverty reduction and human development. The drivers of social exclusion are many
and often interrelated and the difficulty in conceptualising it and measuring it is seen
throughout the literature.
SPEC – Ghana Context
Health Inc views social exclusion as a range of dynamic, multidimensional processes
driven by unequal power relationships interacting across four main dimensions social, political, economic and cultural (SPEC) - and at different levels including
individual, household, group, community, country and global levels (SEKN, 2008).
Through literature review, Health Inc explores each of these four dimensions,
resulting in the Health Inc SPEC framework. The SPEC-by-step tool, complementary
5
to the framework, aims at providing a simple yet structured checklist for guidance of
social exclusion analysis in the Health Inc research. Ghana adopted this framework
and adapted it to suit the context of the study. A brief overview of the dimensions as
they relate to the Ghanaian context is given below. A copy of the localised framework
is attached in the Annex Tables 1 and 2.
Social
The social dimension is constituted by proximal relationships of support and
solidarity (such as friendship, kinship, family, neighbourhood, community, social
movements) that generate a sense of belonging within social systems. Social bonds
are strengthened or weakened along this dimension (SKEN, 2008). In the Ghanaian
context we considered four different aspects of this dimension.
Political
The political dimension is constituted by power dynamics in relationships which
generate unequal patterns of formal rights embedded in legislation, constitutions,
policies and practices and the conditions in which rights are exercised, including
access to safe water, sanitation, shelter, transport and power and to services such as
health care, education and social protection. Along this dimension, there is an unequal
distribution of opportunities to participate in public life, to express desires and
interests, to have interests taken into account and to have access to services.
In the context of this study we looked at two main areas, political resources and
political and civic participation. For political resources, we considered amongst others
access to educational opportunities, access to health, access to decent housing dwelling precariousness, access to transport infrastructures and services, access to
administrative services and access to social assistance. In the area of political and
civic participation, we concentrated on civic participation and efficacy focusing on
empowerment issues such as knowledge of democratic rights and duties, awareness
of their obligations and duties, participation in the elective process (national, local) voter enrolment and turnout and participation in the community governance bodies in local government structures.
Economic
The economic dimension is constituted by access to, and distribution of, material
resources necessary to sustain life (such as income, employment, housing, land,
working conditions and livelihoods). Here, we focused on material and economic
resources such as ownership of property/housing, landholdings per acre per
household, savings; ownership of other liquid assets, access to bank accounts and
access to other credit (formal and informal). Another aspect that is considered is
economic participation, specifically issues regarding employment and social welfare.
Cultural
Boundaries between social and cultural dimensions are difficult to draw because
social participation is highly connected to cultural aspects such as values and norms
6
translated into current social practices. Many patterns of relational exclusion have
been found to have cultural and historical origins, where people uphold norms and
values which lead them to set themselves above others based on a variety of
attributes.
2.2 Health systems context
Health care system
Health care in Ghana is delivered through a system consisting of four categories of
service providers. The health system is made up of public facilities, private-for-profit
facilities, private-not-for-profit facilities and traditional medical practitioners. In
terms of ownership of the facilities, the public facilities owned by the government
consisted about 65 percent of the total number in 2008 (Table 3). The private-forprofit facilities represented 26.4 percent while the private-not-for-profit facilities
owned by religious groups represented 6.6 percent, but they have been estimated to
provide about 42 percent of the total health services in the country (MOH, 2009).
Quasi-government facilities mainly operated by the security services and the
universities represented the remaining 2.1 percent.
The organisation and the administration of the health sector is done through a welldefined structure with the Ministry of Health (MOH) at the apex. The MOH is
responsible for national health policy formulation, monitoring and evaluation and
resource mobilisation. It also regulates health services delivery. The Ghana Health
Service (GHS) is also responsible for the implementation of national health policies
and the management of public health facilities but its activities excludes those of the
teaching hospitals and the quasi-government facilities. The teaching hospitals provide
tertiary services and also provide the highest level of medical education and research
in the country.
At the regional level, every region has a Regional Health Directorate (RHD) to
provide supervision and management support to the districts in the region. The region
also has a regional hospital which provides specialised clinical and diagnostic care
and serves as a referral hospital for the region. The District Health Management Team
in each of the districts of the country is also responsible for district health planning,
budgeting, management and supervision of facilities under its jurisdiction. The district
has a district hospital which usually serves between100,000–200,000 people in a
clearly defined geographical area and could have between 50-60 beds. It provides
mainly primary health care services and some secondary care and operates as the first
referral hospital for the district.
At the base of the structure are the Budget Management Committees (BMCs) which
are responsible for service provision at the sub-district and community levels. The
sub-district is served by a health centre which provides primary health care and
outreach services. The communities could also have rural clinics and Communitybased Health Planning Services (CHPS) to provide basic preventive and curative
services for minor ailments at the community level (MOH, 2009).
7
Health sector indicators
The performance of Ghana’s health sector continue to improve over the years though
the situation is still far from impressive for some selected indicators. Outpatient
Department (OPD) attendance per capita has been improving alongside indicators
such at the Tuberculosis (TB) success rate and Antenatal care (ANC) coverage rate.
Immunization coverage rates have also been encouraging (Table 2.4). Coverage for
supervised delivery by skilled personnel is below 50 percent while the institutional
maternal mortality ratio though declining is still high. Family planning coverage is
also far below expectation.
Table 2.4: Health Sector Output Indicators, 2005-2010
Indicator
2005
2006
2007
2008
2009
2010
-
67.6
76.1
84.7
85.3
86.4
88.7
88.4
89.5
97.4
92.1
90.6
46
44.5
35.1
39.5
45.6
48.2
-
3.2
2.6
2.2
2.9
2.0
OPD attendance per capita
-
0.55
0.69
0.77
0.81
0.89
Family planning acceptors
-
-
-
-
31.1
23.5
HIV clients receiving ARV therapy
Institutional Maternal Mortatlity Ratio
(IMMR)
-
-
-
-
33745
47559
-
-
-
-
170
164
Measles Immunization coverage rate
88.6
86.5
89.1
-
Penta 3 Immunization coverage rate
87.8
86.6
89.3
-
87.6
88.1
88.7
-
70.1
76.3
78.6
TB Success rate
Antenatal Care Coverage
Supervised delivery by Skilled personnel
HIV/AIDS Prevalence among pregnant
women
OPV 3 Immunization coverage rate
Tetanus Toxoid Immunization coverage
rate
Source: Ministry of Health, 2011
The Disease Burden
The disease pattern in the country has not changed much over the years. In a recent
study, the health status of the country was described as ‘the onset of a health
transition with a predominance of communicable disease conditions, malnutrition,
high infant mortality, and generally poor reproductive health, with only recently
emerging importance of non-communicable diseases, such as, diabetes and
cardiovascular diseases’ (Gyapong et al. 2007). Table 2.5 presents the top ten causes
of OPD morbidity in Ghana for the period 2002-2009. Malaria continues to be the
number one cause of morbidity accounting for over 40 percent of the OPD cases. This
is followed in the far distance by upper respiratory tract infections, diarrhoeal diseases
and skin diseases. Hypertension has consistently remained the 5th cause of OPD
morbidity constituting about 3 percent of all OPD reported cases. The continuous rise
in hypertension and diabetes cases poses a serious challenge to the health system
which is already constrained with both human and financial resources (de-Graft
Aikins, 2005 and 2007, Seddoh et al, 2011).
8
Table 2.5: Top Ten Causes of Outpatient Morbidity (2002-2009)
Disease
2009
2008
2007
2006
2005
2004
2003
2002
Malaria
Upper respiratory tract
infection
44.55
44.74
41.6
37.83
44.76
44.1
43.9
43.7
8.3
7.84
7.3
6.2
6.85
7.2
6.8
7.4
Diarrhoeal Diseases
3.39
3.81
4.3
3.38
4.15
4.3
4.2
4
Skin Diseases
4.16
4.17
4.3
3.34
4.15
4.1
4.3
4.3
Hypertension
Home/Occupational
Injuries
3.58
3.18
4.0
2.78
2.94
2.7
2.8
2.7
-
1.31
1.5
1.64
2.26
2.3
2.5
2
Acute Eye Infections
Pregnancy and Related
Complications
Rheumatic and Joint
Diseases
1.91
1.83
2.3
1.89
2.24
2.1
2.4
2.6
1.28
1.56
1.5
1.34
2.03
1.9
2
2.5
3.02
2.51
2.1
1.79
1.91
1.9
1.9
2
Anaemia
1.48
1.38
1.5
1.4
1.7
1.7
1.7
2
Others
25.96
27.67
29.6
38.41
27.01
27.7
27.5
26.8
Total
100.0
Source: CHIM/PPME-GHS
100.0
100.0
100.0
100.0
100.0
100.0
100.0
In terms of mortality, malaria is the number one killer. Other major causes of
mortality include HIV/AIDS, anaemia, cerebro vascular accidents, pneumonia,
hypertension, cardiac diseases and diarrhoeal diseases. The contribution of maternal
deaths and road traffic accidents to total mortality in Ghana is also significant.
Though most of the diseases afflicting Ghanaians are preventable and could be easily
treated, resource constraints coupled with marked inequalities in the distribution of
the available resources deny many people access to quality health care. It is estimated
that about 37 percent of physicians trained in the Ghana have migrated abroad while
24.1 percent of nurses born in the country have also migrated. The doctor to
population ratio of 1: 11, 929 in 2009 revealed an unacceptable situation with the
regions in northern Ghana having one doctor to over thirty-five thousand people
(Table 2.6). Increased workload has the potential to undermine the provision of
quality health care to the population especially with the improvement in accessibility
to health care.
Table 2.6: Doctor to Population Ratio
2009
Region
ASHANTI
BRONG AHAFO
CENTRAL
EASTERN
GREATER
Number
of Doctors
589
134
84
148
839
Doctor
Population
Ratio
8,288
16,919
22,877
16,132
5,103
Numbe
r of
Doctors
495
103
72
134
827
2008
Doctor
Population
Ratio
9,537
21,475
26,140
17,571
4,959
2007
Number
of
Doctors
428
96
63
128
755
Doctor
Population
Ratio
10,667
22,479
29,260
18,141
5,202
9
ACCRA
NORTHERN
46
UPPER EAST
29
UPPER WEST
14
VOLTA
73
WESTERN
77
TOTAL
2,033
Source: Ghana Health Service, 2009
50,751
35,010
47,932
26,538
33,187
11,929
33
30
15
68
78
1,855
68,817
33,475
43,988
27,959
31,745
12,713
24
30
15
66
71
1,676
92,046
30,111
43,265
28,269
33,794
12,591
The nurse to population ratio is not any better as shown in Table 2.7. The situation in
2009 was better compared to 2008 and 2007. It has been observed elsewhere that ‘this
low medical personnel to population ratio can barely support the optimal running of
the present health system, let alone any scaled-up health system’ (Gyapong et al.,
2007).
Table 2.7: Nurse to Population Ratio
2008
2009
Number
of Nurses
Region
ASHANTI
4,161
BRONG AHAFO
2,283
CENTRAL
2,369
EASTERN
2,871
GREATER CCRA
4,897
NORTHERN
1,708
UPPER EAST
1,262
UPPER WEST
895
VOLTA
2,421
WESTERN
2,107
TOTAL
24,974
Source: Ghana Health Service, 2009
Nurse
Population
Ratio
1,173
993
811
832
874
1,367
805
750
800
1,213
971
Number
of
Nurses
3533
1940
2104
2454
4656
1480
1051
758
2132
1753
21,861
Nurse
Population
Ratio
1,336
1,140
895
959
881
1,534
956
870
892
1,413
1,079
2007
Number
of Nurses
2251
1099
1249
1977
4011
1131
798
537
1474
1197
15724
Nurse
Population
Ratio
2,028
1,964
1,476
1,175
979
1,953
1,132
1,209
1,266
2,004
1,342
Health care financing
According to Gyapong et al., (2007) Ghana has a fragmented history of health care
financing. Health care financing in Ghana has gone through several changes dating
back to the pre-independence era and are often driven by political ideologies. The
main sources of financing over the years have included general taxation, user fees
(out-of-pocket payments), donor support and recently health insurance.
During the colonial period, there was free health care for few civil servants but user
charges were in place in public health facilities for non-civil servants. The situation
however changed soon after independence in 1957. As part of the socialist agenda for
the new government, health services became free to the public in public health
facilities and were financed through general tax and donor support. With dwindling
state funding to the sector resulting from the economic crisis in the early 1970s,
nominal fees were charged at public facilities mainly to discourage frivolous usage of
services (Agyepong et al., 2007).
10
The severe deterioration in economic performance in the country in 1970s continued
to the mid-1980s. Aryeetey and Harrigan (2000) described the period 1973-1982 as a
‘period of unmitigated economic disaster’ as a result of the dramatic economic
decline and the near collapse of economic and social infrastructures in the country.
The country recorded negative real GDP growth (e.g. -6.92 percent in 1982 and -4.56
percent in 1983), decline in per capita income, hyperinflation, large fiscal deficit,
massive unemployment, drought and food shortages coupled with severe external
shocks due to falling export prices (Hutchful 1989, Aryeetey and Harrigan 2000,
Todaro 2000).The introduction of the Economic Recovery Programme (ERP) in 1983
and the Structural Adjustment Programme (SAP) in 1987 to address the economic
crisis led to the introduction of cost recovery policies in the public sector especially in
the health sector.
The Hospital Fees Regulation of 1985 required patients of public health facilities to
pay fully for their drugs. The aim was to recover at least 15 percent of recurrent
operating costs (Gyapong et al., 2007). In 1992 another change in the health care
finance scheme led to what popularly became known as the ‘Cash and Carry’ system
which was a full cost recovery policy for drugs in public health facilities. Patients also
paid partly for consultation, laboratory services and diagnostic procedures, medical,
surgical and dental services medical examinations and hospital accommodation
(Asenso-Okyere et al., 1998, Nyonator and Kutzin, 1999, Atim et al., 2001). The
negative effects of these user fees in Ghana on patients and their households in terms
of access and utilisation of health services and household incomes are well
documented (Waddington and Enyimayew 1989; Nyonator and Kutzin 1999; AsensoOkyere et al., 1998, Coleman, 1997; Seddo et al., 2011). Though there were
exemptions under the health user fees policies for children under five years, pregnant
women attending antenatal care services, the aged and the poor, poor targeting of the
intended beneficiaries and delays in reimbursement of facilities made the
implementation less effective (Atim et al., 2001; Gyapong et al., 2007).
Ghana introduced a National Health Insurance Scheme (NHIS) in 2003 with the aim
of removing previous barriers created by the user fees financing system. The NHIS
benefits package covers over 95 percent of the most common and prevalent disease
conditions in Ghana. This includes general outpatient and inpatient care, generic
medicines, emergency care, comprehensive delivery care, diagnostic tests, oral health
and eye care. However, highly specialised care such as organ transplants, dialysis for
chronic renal failure and drugs such as HIV retroviral drugs that are not on the NHIS
drug list are not covered by the scheme (Ghana National Health Insurance Authority,
2008).
The main focus of this study is to assess the impact of the NHIS on access to health
care with regards to the various levels of socioeconomic groups. The NHIS' stringent
criteria for exemption means only 2.3 percent of all members are classified as
‘indigent’ lower than the 28.5 percent living below poverty line and 18 percent below
extreme poverty line. Accordingly, the main research question is whether the NHIS
offers the conditions necessary for the entire population to access good quality
healthcare.
11
2.3 Social Health Protection
In Ghana, the main objective of social protection strategies is to provide social
assistance or social insurance which will enable the poor and vulnerable in society to
access basic social services. Social protection is also meant to reduce shocks and risks
that may occur by increasing people’s ability to manage such events when they occur.
These have been done through a combination of facilities such as support in kind,
cash transfers and exemptions. Ghana’s conceptualisation of social protection is the
provision of basic social services to vulnerable groups and this is quite evident in the
various social policies implemented over the years. However, whilst the provision of
basic services may in theory reduce social exclusion, there is extensive evidence that
access to these amenities by poor and vulnerable is not assured. Besides financial,
political, social and cultural barriers, the poor implementation and monitoring of these
programmes limit access among poor and vulnerable groups.
Since the attainment of independence, governments have initiated many projects
aimed at improving the wellbeing and standard of living of the Ghanaian society.
Many of these have been stand-alone welfare programs which often encountered
enormous challenges leading to their subsequent discontinuation. Amid the economic
woes of the 1980s, the Provisional National Defence Council (PNDC) government
embarked on the Programme of Action to Mitigate the Social Costs of Adjustment
(PAMSCAD) to reduce poverty by providing training, work and income through
community development projects for vulnerable workers, women and poor
households. However, this programme came under high criticism for failing to carry
out its mission as it rather favoured more men over women (Mensah, et al. 2002).
A key turning point was the United Nations (UN) Social Summit of 1995 which drew
attention to issues regarding social protection and the need for more enabling
legislation to be introduced to strengthen social policy formulation. Since then many
international and local Non-Government Organisations (NGOs) and civil society
organisations have been instrumental in holding governments accountable for
improvements in the livelihood of poor and vulnerable groups. As a result, there has
been a gradual shift from the previously narrow and temporary social welfare
programs to more encompassing social policies which are often embedded in the
overall government developmental plans. Hitherto, there have been a number of
policies that provide essential guidelines for the protection of vulnerable groups.
Ghana produced its first Poverty Reduction Strategy Paper – the Ghana Poverty
Reduction Strategy (GPRS I) in 2003 and entered the Heavily Indebted Poor
Countries (HIPC) initiative. This enabled the country to mobilise more funding for
social development and ensured that previously excluded groups were given more
attention. The successor programme, the Growth and Poverty Reduction Strategy
(GPRS II) for the 2006-2009 period, went further to mainstream social protection
issues in the various sectors of the economy.
The Ghanaian Government’s commitment to social protection is clearly expressed in
the GPRSI and II as well as the National Social Protection Strategy (NSPS) which
followed. These policy documents clearly pay progressively explicit attention to
gender issues and related policy implications. The NSPS represents the Government
of Ghana’s (GoG) current agenda framework for creating an all-inclusive and socially
12
empowered society and is founded upon the principle that “every Ghanaian matters
and is capable of contributing his or her quota to national development” (NSPS; GoG,
2007). It envisages a Rights-Based Approach for the vulnerable and excluded as well
as a Child-Centred and Gender Sensitive Approach to interventions.
Meanwhile, a number of social protection programmes have been rolled out, many
with a specific focus on women and children. The specific types of social protection
measures currently in use in Ghana are detailed in Table 2.8.
Table 2.8: Selected Social Protection Instruments in Ghana
Type of
social
protection
instrument
Social
assistance
Programme example
•
•
•
•
•
Social
insurance
•
•
•
Social equity
•
•
•
•
•
National Youth Employment programme aims at providing
employment for the youth
LEAP cash transfer provides financial assistance to the poor and
vulnerable
The Free School Uniform programme
Capitation grant abolishes school fees by substituting these grants
to schools
School Feeding Programme provides one hot meal a day for
targeted public school children
Free bus rides for schoolchildren
Free Maternal and Infant Healthcare addresses maternal and infant
mortality in the country
National Health Insurance Scheme aims at providing basic
healthcare access
National Programme for the Elimination of Worst Forms of Child
Labour in Cocoa
Elimination of Human Trafficking (Human Trafficking Act 2005)
Domestic Violence Act 2007
Disability Act
The Children’s Act 1998
In addition quite a few policies are in existence that provides essential guidelines for
the protection of vulnerable groups, including:
• National HIV/AIDS Policy, 2002
• Adolescent and Reproductive Health Policy, 2000
• Draft Ageing Policy, 2003
• Gender and Children’s Policy, 2003
• Early Childhood Development Policy, 2004
• National Policy Guidelines on Orphans and Vulnerable Children, 2006
The Livelihood Empowerment against Poverty (LEAP) Program
The Livelihood Empowerment against Poverty (LEAP) Program is a social cash
transfer program which provides cash and health insurance to extremely poor
13
households across Ghana to alleviate short-term poverty and encourage long term
human capital development. LEAP started a trial phase in March 2008 and then
began expanding gradually in 2009 and 2010. LEAP is still a relatively small pilot
programme and, even after its initial five-year implementation period, will reach only
about one-sixth of the extreme poor.
The program is fully funded from general revenues of the GoG, and is the flagship
program of its National Social Protection Strategy. It is implemented by the
Department of Social Welfare (DSW) in the Ministry of Employment and Social
Welfare (MESW). Eligibility is based on poverty and having a household member in
at least one of three demographic categories; single parent with orphan or vulnerable
child (OVC), elderly poor, or person with extreme disability (PWD) unable to work.
Initial selection of households is done through a community based process and is
verified centrally with a proxy means test (NSPS, 2007). Aside from direct cash
payments, beneficiaries are provided free health insurance through the NHIS.
The Draft Policy on Ageing
The process of drafting the policy on ageing started in 1997 by a National Committee
on Ageing was formed by the MESW. The Draft Policy was reviewed by the Centre
for Social Policy Studies (CSPS) of the University of Ghana and submitted to the
Ministry in February 2002. The Ministry has since initiated steps to have the policy
ratified by Parliament. The main goal of the Draft Policy is to promote the social,
economic and cultural re-integration of older persons into mainstream society, to
enable them participate fully and as far as practicable in national development and
social life, while recognizing their fundamental rights.
2.4 National Health Insurance Scheme (NHIS)
Ghana has initiated various health sector reforms over the past decades aimed at
improving the overall health system and increasing access to health care services by
all groups of people. Health care financing in Ghana has gone through many
dynamics recognizing free health care at the eve of independence, introduction of the
nominal fee in the 1970sand the introduction of cost recovery mechanisms through
user fees (traditionally known in Ghana as “cash and carry”). This was initiated in
1985 as part of a broad strategy to reduce government spending on the health sector
and curb the shortages of essential medicines and medical supplies. The financial
aims of the reform were achieved but this resulted in inequities in financial access to
basic primary health care. The “Cash and Carry System” of paying for health care at
the point of service was observed as a key financial barrier to health care access for
the poor.
The NHIS was launched to remove financial barriers to utilization of health care in a
way that was sustainable and did not rely heavily on government machinery and
funds. The National Health Insurance Act (Act 650) was therefore passed into law in
2003, with the main objective of increasing access to healthcare (by making it more
affordable) and thereby improving health outcomes.
14
The structure of the NHIS is outlined in the National Health Insurance Act 2003, Act
650. The Act established a body corporate to be known as the National Health
Insurance Authority (NHIA) with the mandate to secure the implementation of a
national health insurance policy that ensures access to basic healthcare services to all
residents (NHIS Act 2003, Act 650, NHIA, 2009). It is therefore the legal
implementing body to register, license and regulate health insurance schemes;
supervise the operations of health insurance schemes and grant accreditation to
healthcare providers and monitor their performance among other functions.
The NHIA also has a 15 member governing body known as the National Health
Insurance Council (NHIC) with a chairman and a Chief Executive Officer appointed
by the sitting president of the state. The composition of the NHIC is spelt out in
Section 3 of the NHI Act 2003, Act 650. Another important feature of the NHIS is the
establishment of the National Health Insurance Fund (NHIF) by the National Health
Insurance Act. The purpose of the fund as contained in Act 650 is to provide finance
to subsidise the cost of provision of healthcare services to members of district mutual
health insurance schemes (DMHIS)licensed by the authority.
Financing mechanisms of the NHIS
The NHIF has five main sources which accumulate funds to operate the NHIS. The
sources include the National Health Insurance Levy (NHIL), 2.5 percent social
security deductions from formal sector workers managed by the Social Security and
National Insurance Trust (SSNIT), GoG annual budgetary allocations proposed and
approved by parliament to the NHIF, accruals from investments of surplus funds held
in the NHIF by the NHIC and grants, gifts and donations made to the NHIF (Figure
1). In addition to these are the voluntary contributions paid by subscribers to the
various DMHIS. The contributions/premiums vary among the DMHIS. These
contributions are kept at the district level for claims payment and administrative
support at that level.
In terms of the contributions to the NHIF, the NHIL which is a 2.5 percent value
added tax (VAT) levied on selected goods and services accounts for over 60 percent
of the total revenue (Figure 2.2). In 2009, investment income and SSNIT
contributions contributed 17 percent and 15.6 percent respectively to the NHIF.
Sector budget support from GoG was 2.3 percent while insurance premiums, mainly
from informal sector workers was only 3.8 percent.
15
Figure2.2: NHIS Total Inflow as at 31 December, 2009
Insurance
premium, 3.8%
SSNIT
contribution,
15.6%
Sector budget
support, 2.3%
Investment
income, 17.0%
Other income,
0.2%
NHIL, 61%
NHIS Membership registration
Data from the NHIA indicates that 62 percent of the population had registered for the
NHIS by the end of 2009 from a low of 6.31 percent in 2005. This figure had risen to
69.5 percent by the end of 2010. It is estimated that about 50 percent (34 percent from
the National Development Planning Commission data) of the population are active
members with valid membership cards (NHIA 2009, MOH 2011, Seddoh et al.,
2011). NHIS enrolment figures must be interpreted with caution because there is a
possibility of multiple registrations by persons who fail to review their membership
and rather decide to register as new members to escape the penalty payment.
Registration of categories
The National Health Insurance Act 2003, Act 650 exempts certain categories of
persons from paying premium to become members of the NHIS. They also pay for the
registration process. The exempt groups under the act include SSNIT pensioners,
individuals aged 70 years or more, children under 18 years and indigents (i.e. the poor
and destitute). In July 2008, pregnant women were also added to the exempt groups.
The exempt groups constitute over 60 percent of the registrants with children under
18 years forming the bulk.
2.5 Gaps in evidence
Compared with most countries in the region, Ghana has clearly made impressive
progress in developing a comprehensive social protection policy framework and in
implementing operational programmes, some of which have been taken to significant
scale. However, a number of challenges remain. The country faces difficult
macroeconomic and fiscal challenges and is on the path to recovery from the effects
of the global economic crisis. Nonetheless, the government has safeguarded social
protection spending and in the 2009budget, increased expenditure on LEAP and
expanded the School Feeding Programme while also introducing a new programme to
provide free exercise books and school uniforms to 1.6 million poor children.
16
Primarily, weak inter-agency coordination and the lack of robust monitoring and
evaluation systems make it difficult to ensure the effective implementation of
programmes. Despite a range of exemptions, the NHIS still reaches only about half
the total population, and membership is lowest among the poorer quintiles, owing to
the cost of registration and annual premiums (Sarpong et al, 2010; Jehu-Appiah et al.
2011). LEAP is still a relatively small pilot programme and even after its initial fiveyear implementation period will reach only about one-sixth of the extreme poor.
Many of the other social welfare services are small, fragmented and under-funded,
depending mainly on donor funding in most cases.
2.6 Research objectives, questions and hypotheses
The literature shows that social exclusion exists in Ghana as highlighted in the Ghana
Human Development Report 2007. This is driven economically by the unbalanced
socio-economic development traced to our political and economic history (NorthSouth Ghana, Rural-Urban). It is therefore not surprising that poverty has been proven
to be a strong driver of social exclusion in Ghana. Majority of Ghanaians are not
active members of NHIS but to what extent can we say that they are socially
excluded? There are opportunities for further research to deepen our understanding of
social exclusion in Ghana.
Research questions specific to Ghana (based on SPEC results)
1. How much is the Government spending on social health protection programs
and how has this impacted on social exclusion?
2. What efforts is the Government engaged in to reach the ‘socially excluded’
from formal social health protection programmes
3. What is the impact of the NHIS on health care utilisation?
4. Is the funding mechanism of the NHIS progressive or regressive for the
different socioeconomic groups?
5. Are there any mechanisms to measure the extent of social exclusion in Ghana?
6. Are there any mechanisms to identify and reach the poor?
7. What proportion of NHIS members are in the exempt group?
8. What have been the pro-poor effects of the NHIS?
9. Are there any administrative deficiencies of the NHIS scheme (institutional
capacity) and how has this affected the socially excluded?
10. Which supply-side constraints in Ghana need to be addressed to improve
social health protection?
17
3. METHODOLOGY
3.1 Selection of study sites
All households in Ghana constituted the study population (24.2 million). A total of
4,050 were interviewed in the five selected districts across the three ecological zones
of Ghana, namely the coastal, forest and savannah (Table 2). The choice of these
districts was informed by their level of development and previous working experience
in these districts by the Institute of Statistical, Social and Economic Research (ISSER)
team. They are all rural districts and relatively underdeveloped. It is expected that a
representative random household survey in these districts would produce a significant
sample of excluded individuals as well as the voluntary excluded populations.
Table 3.1: Districts for the Household Survey
Zone
Region
District
Coastal
Central
Forest (south)
Forest (middle)
Forest
(transitional)
Savannah
Eastern
Ashanti
BrongAhafo
Northern
Total
Abura-AsebuKwamamkese
(AAK)
Kweabebirem
Ejisu-Juabeng
Asutifi
SaveluguNanton
Sampled
households
810
810
810
810
810
4, 050
Background profile of selected districts
Abura-Asebu-Kwamamkese (AAK)
The Abura-Asebu-Kwamamkese was selected in the coastal zone. The district is
bordered by the Cape Coast Municipality in the Central region and has a population
of 90,093. The district remains predominantly rural with the majority involved in the
agricultural sector. The Health Services of the district are organised around a fullfledged District Hospital and 69 community-based outreach clinics and 32 Traditional
Birth Attendant outposts.
Kwaebebirem
Kwaebibrim district was selected in the coastal agro-ecological zone. The district is
located in the South Western part of the Eastern region and has a population of
205,932. It is predominantly an agricultural district with about 77 percent of the
labour force engaged in agriculture. Kwaebibirem has 33 health facilities, comprising
of district hospitals, health centres, clinics and CHPS compounds.
18
Ejisu-Juabeng
Ejisu-Juaben Municipal is one of the 27 administrative and political districts in the
Ashanti Region. The Municipality is located in the central part of the region with a
population of about 144,272. The rural settlements account for about70percent. The
Municipal falls within the forest zone with agriculture being the main stay of its
residents. The Ejisu-Juaben district has 1 district hospital and other health facilities
like clinics, health posts and maternity homes.
Asutifi
In the forest agro-ecological zone, the Asutifi district was selected. It is located in the
southeast of the Brong Ahafo region with a population of 108,993. It is typically rural
with the predominant occupation being subsistence farming. Gold and diamond
mining is undertaken in certain areas of the district. The district has 16 health
facilities serving six-sub districts also comprising one district hospital, health centres,
clinics and CHPS compounds.
Savelugu-Nanton
Savelugu/Nanton shares boundaries with the Tamale metropolis, the capital city of the
Northern region. It is mostly rural with a population of 118,582. The vegetation is
savanna grassland with subsistence farming being the main economic activity in the
district. The district has 13 health facilities with the Savelugu District hospital serving
as the district hospital.
3.2 Mixed methods approach
i.
Stakeholder analysis
Stakeholder analysis was conducted in two parts. The first part consisted of a
‘stakeholder scoping’ exercise that described national and regional stakeholders (their
motives, influence and role), restricting to the NHIS in Ghana.
ii.
Field Research
The initial suggestion was to focus the field research on the categories of population
who are exempted by the NHIS (elders, children, women etc). However, the
feasibility and the relevance of such a “purposive” approach in the Ghanaian context
were considered given the following reasons:
1. The lack of baseline information on the exempted groups, that made their
identification difficult (e.g. the definition of ‘indigents’ is still not clear)
2. Using this approach to explore the voluntary exclusion process may not have
been feasible
3. There was the necessity to carry out a general household survey to have an
impact on the policy dialogue
Hence, the study exclusively included districts or communities that faced strong
exclusionary processes at the meso level (i.e. for the sampling). The research was
carried out in geographical zones that presented high risk of exclusion, e.g. rural poor
19
districts so as to have both a significant sample of excluded individuals, but also still
having the voluntary excluded populations.
3.3 Quantitative method: household survey
3.3.1 Sampling strategy and size
A list of representative Enumeration Areas (EAs) for each district was obtained from
the Ghana Statistical Service (GSS). These EAs are made up of rural and urban
localities and are determined by the GSS for nationally representative surveys. In each
district, 27 EAs were selected by the GSS. All households in each EA were listed by
the ISSER team since a current list of households was not available. After the listing
to obtain the sampling frame, 30 households (with an additional 10 households for
replacement) were systematically sampled for the interviews. Thus, in each district,
810 households (i.e. 30 households x 27 EAs) were interviewed resulting in a total of
4, 050 households with an estimated household population of 16,200.
3.3.2 Design of the questionnaire
For quantitative study, there were 2 questionnaires, the household questionnaire and a
SPEC pull-out. The purpose of the household survey was to describe those that are
socially excluded at each step of the SPEC tool (answering the question: who are
socially excluded). Further, specific hypotheses like intra-household selection of
members for enrolment was investigated in these interviews (who are the household
members enrolled in the NHIS and who are not within the household).
The purpose of the pilot was to pre-test the questionnaire as well as to do a ‘test-run’
of the actual survey. With regard to the pre-test, the questions in the survey were
tested (relevance, wording, order, multiple choices, average time needed per
respondent). The ‘test-run’ tested the research process (e.g. the sampling
frame).Based on the results of the pilot, modifications in the questionnaire and the
research process were made.
3.3.3 Data collection process
For each household, there were questions asked on the SPEC (SPEC pull-out). The
household head responded to the household questionnaire in addition to the SPEC
pull-out. The spouse of the household head or in his/her absence an adult member of
the household was also required to respond to the SPEC pull-out. Thus, two data
collectors visited each household so that the head and spouse (in the absence an adult)
were interviewed at the same time to ensure that they were not influenced by the
other.
All filled questionnaires were edited in the field by the field supervisors assigned to
the interviewers. They were also finally checked by the office editor before data entry
began.
Training and orientation to equip and prepare field staff with relevant skills for the
major research on social exclusion in health financing in Ghana was carried out in
20
April 2012. The training focused on qualitative and quantitative data collection tools
of the study. The research team was thus trained to administer qualitative tools
comprising focus group discussions (FGDs) and key informant semi-structured
interviews as well as a quantitative tool made up of a household survey.
The research team included a team leader, two supervisors and twelve interviewers.
One supervisor and two interviewers were given additional orientation in the use of
the qualitative tools while the remaining majority was responsible for the household
survey.
In general the fieldwork teams were taken through the following key modules to
ensure a standard approach and administration on the field:
•
The principles of research ethics that guide social research such as respect
for respondents, beneficence, and justice.
•
Understanding the detailed English and vernacular guidelines for asking
study questions
•
How to locate the structures and households in the sample
•
How to fill in the Household Questionnaire and check completed
interviews to be sure that all questions are asked and the responses neatly
and legibly recorded
•
Returning to households to interview respondents who could not be
interviewed during the initial visit
To ensure that the research team was very conversant with the field instruments, a
field test was carried out to pilot the tools and practice the field procedures. In
addition to the general instructions to all fieldworkers, the following specific skills
were also emphasized.
3.3.4 Identification of households for study
EA maps obtained from the GSS showed all the households in the selected EA.
3.3.5 Mapping and listing
Households within the selected EA were listed. Team leaders and supervisors were
trained on the procedures for listing and selecting households. Households were
systematically selected from the household list.
3.3.6 Supervision skills
Supervisors were instructed on ability to adhere to survey schedules and instructions
and be capable of guiding interviewers/enumerators and dealing with any unforeseen
problems with the field administration. The desired skills of supervisors to exhibit
high sense of maturity in community orientation with local government officials and
traditional authorities were also emphasized. Supervisors were also given additional
training in checking questionnaires and ensuring quality control.
21
3.3.7 Data entry, processing and analysis
Data entry was done in CSPro. This was followed by editing and cleaning of the data
set. The cleaned data set was then imported into SPSS and STATA for further
processing.
3.3.8 Methodological challenges faced
Delay in getting ethical clearance; lack of baseline data; difficulty in targeting. The
field data collection was done during the rainy season and also because of the
presidential election in December 2012 the data collection was perceived as being
politically motivated.
3.4 Qualitative methods
The initial set of stakeholders was identified by the literature review. These
stakeholders were grouped into broad categories like the GHS, NGOs, Civil Society
Organisations (CSOs), health providers, NHIS managers, etc. and socially excluded
populations as identified by the literature review (the poor, women, elderly, urban
poor etc.). Key informants from each of these broad categories were identified. A
‘map’ (or maps) of stakeholders was drawn describing the links (or the absence of
links) between them as well as their role and influence (or lack of influence) in the
NHIS (Table 3.2).
Table 3.2: Stakeholder Analysis – Part I
Purpose
Methods
Participants
- NHIA
-Ghana Health Service
-NGOs, CSOs,
- to describe national, regional & -Health service providers in study
district stakeholders (their
districts,
motives, influence, role, etc.) on -NHI scheme managers in study
the NHIS in Ghana
districts
Sampling
strategy
Data
collection
process
Data analysis
strategy
-Literature review
- Purposive sampling
- In-depth interviews
- qualitative analysis of KI
interviews
The second part of the stakeholder analysis was carried out after the policy
recommendations had been drafted, at the end of data analysis. At this stage the
purpose of the stakeholder analysis was to validate the policy recommendations
(Table 3.3).
22
Table 3.3: Stakeholder Analysis – Part II
Methods
Purpose
Participants
- NHIA
-Ghana Health Service
-NGOs, CSOs,
-Health service providers in study
districts,
-NHI scheme managers in study
To validate findings and policy districts
recommendations
Participants
Sampling
strategy
Data
collection
process
Data analysis
strategy
As identified above
As identified above
In-depth interviews
Qualitative analysis of indepth interviews
3.4.1 Sampling strategy
Focus Group Discussions (FGDs)
The purpose of FGDs was to know the perceptions and views of the socially excluded
on the performance of the NHIS and to identify the barriers they face at each step of
the SPEC tool. Analysis of the FGDs was to give an indication of the extent to which
social exclusion acts as a barrier at each of the SPEC steps.
A total of 40 FGDs were conducted in the five districts. The participants were
selected after the household survey. Findings from the literature review, stakeholder
analysis and preliminary results from the household survey provided the needed
information for the formation of the groups. Each of the potential target groups was
stratified by sex (male/female). Table 3.4 shows the target groups for the FGDs.
Table 3.4: Potential Target Groups for the Formation of Focused Groups
Targeted population
Type
(Potential targets - who?)
Never insured
• Voluntary exclusion
• Socially excluded (unreached)
Previously insured
• Voluntary exclusion
• Socially excluded
Registered but yet to received ID • Socially excluded
card
• Non claimers (not using available
Currently insured (Valid card
services)
holders)
• Non-users (benefits not
#
2
2
2
2
23
provided/received)
Total per district
Overall total (8 FGDs x 5 districts)
8
40
3.4.2 Design of the topic guides
Key informants included community leaders, an opinion leader, district NHIS
managers, health care providers (public and private) and national stakeholders.
Relevant NGOs whose work is related to the subject matter of social exclusion were
identified and interviewed. A total of 5interviews were conducted per district bringing
the total to 25 in the five districts.
Semi-structured interviews/Key informant interviews
The purpose of semi-structured interviews was to describe the process of social
exclusion at each step of the SPEC tool (answering the question: how and
why).Further, specific hypotheses like intra-household selection of members for
enrolment were investigated in these interviews (why are some household members
enrolled in NHIS while others are not).
Community Questionnaire
Each of the 27 EAs were taken as a community and a community questionnaire was
administered. In total there were 135 (that is, 27x5) community questionnaires. This
questionnaire was administered to the community leader or an opinion leader in the
community such as the chief or the person representing the community at the District
assembly.
3.4.3 Data collection process
For the team of three field staff that implemented the qualitative instruments, attention
was also paid to the following:
i.
Focus group discussions (FGDs)
How to effectively elicit data on the social and cultural norms of a group and in
generating broad overviews of issues of concern to the cultural groups or
subgroups represented.
ii.
In-depth interviews
How to optimally elicit information on individuals’ personal histories,
perspectives, and experiences, particularly when sensitive topics are being
explored during interviews.
iii.
Data management
The qualitative tool implementation team was given refresher orientation on indepth interviewing and FGD techniques as well as note-taking and data
transcription.
24
3.4.4 Data entry, processing and analysis
Qualitative data was transcribed and synthesized for the report.
3.4.5 Methodological challenges faced
There were no methodological challenges in the qualitative survey.
25
4. ETHICAL CONSIDERATIONS
4.1 Ethical clearance
The study was approved by the Noguchi Memorial Institute for Medical Research
Institutional Review Board (NMIMR-IRB)
4.2 Consent forms and permissions
Confidentiality
In the consent form for all three instruments, there are statements describing how
confidentiality of participants will be maintained.
“I would like to assure you that the information you provide would be kept strictly
confidential. There is no way your identity will be revealed to anyone apart from the
members of the research team.”
“You may also ask any question about this study if you so wish at this stage. Are you
please willing to take part in this study based on the information I have provided
you?”
Voluntary Participation and Right to Leave the Research
A statement that the research is voluntary and participants can withdraw without penalty.
“You are free to participate in this study which will take between 15 and 20 minutes
of your time to complete. If you agree to participate in this study, there are questions
you may skip if you are not comfortable with them. You can also discontinue the
interview if need be.”
26
5. RESULTS
5.1 Description and overview of data collected (all methods)
The household survey involved a total of 4050 households in the five districts
recorded 16,178 household members. The Savelugu-Nanton district in the Northern
region accounted for 27.5 percent of the total household members. This is followed by
Asutifi (19.7 percent) while the remaining three districts had a little over 17 percent
each. The majority (53 percent) were urban dwellers compared to 47 percent in rural
communities. About 53 percent of the total household members surveyed were
females. Children under 18 years constituted about 48 percent while the elderly (≥70
years) formed just 3.8 percent. The remaining 48.5 percent were aged between 18-69
years (Table 5.1).
The marital status of household members aged 15 years or more, the majority (56.8
percent) was either married or had partners. The remaining were either divorced (6.2
percent) or widowed (6.6 percent) while 30.5 percent had never married. Close to 65
percent of the household members surveyed reported to be Christians while 33
percent were Muslims. The remaining 2 percent either belonged to other religious
groups or belonged to none. Not surprising, about 56 percent of the surveyed
population were Akans because 4 out of the 5 districts surveyed are dominated by the
Akan ethnic group which is the dominant ethnic group in Ghana. The Mole-Dagbani
who are mostly found in Northern Ghana represented 29.5 percent of the sample. The
remaining belonged to other minority ethnic groups including few non-Ghanaians.
For household members aged 6 years or more, about 77 percent reported to have
attended school. Just a little over half (35 percent) reported to have completed junior
high or middle school (9-10 years). About 19 percent had completed primary school
(6 years) while 35.2 percent had less than the 6 year primary education. Only about 11
percent had secondary or higher education. The mean years of schooling for
household members aged 6 years and above was 7.0years. The AAK district (6.9
years) and the Savelugu-Nonton district (5.5 years) had means below the total sample
mean while Kwaebibirem had 7.2years, Asutifi had 7.3 years with Ejusi-Juabeng
having the highest of 7.7 years.
In terms of households’ socioeconomic status, about 18 percent were in the lowest
wealth quintile while 19.9 percent were in the highest wealth quintile. About 21
percent were in the middle quintile.
Table 5.1: Summary Description of the Sample
Characteristics
Frequency
(n=16,178)
Region
Ashanti
Brong-Ahafo
Central
Eastern
Northern
Residence
2,853
2,882
2,809
3,184
4,450
Percent
(100%)
17.4
19.7
17.6
17.8
27.5
27
Urban
Rural
Sex
Male
Female
Age
Children (under 18 years)
Adult
Elderly (≥70 years)
Marital status (≥15 years)
Never married
Married/in union
Divorced/separated
Widowed
Religion
Christian
Muslim
Traditional
None
Other
Missing
Ethnicity
Akan
Ga/Dangme
Ewe
Guan
Mole-Dagbani
Other
Highest school grade completed (≥6
years)
Pre-school
Primary
Middle/Junior High school
Senior High school
Vocational/Technical sch.
Post secondary or higher
Don’t know
Mean years of schooling (≥6 years)
Wealth quintile1
Lowest
Second
Middle
8,526
7,652
52.7
47.3
7,537
8,641
46.6
53.4
7,716
7,830
608
47.7
48.5
3.8
2,843
5,291
573
614
30.5
56.8
6.2
6.6
10,503
5,341
104
194
15
21
64.9
33.0
0.6
1.2
0.1
0.1
8,976
467
781
77
4,781
1.039
55.5
2.9
4.8
0.5
29.5
6.8
3,202
1,681
3,152
656
130
275
19
35.2
18.5
34.6
7.2
1.4
2.8
0.2
9,725
7.0
2,980
3,218
3,343
18.4
19.9
1The
wealth quintile to categorise households into different socioeconomic status was
constructed using Principal Component Analysis (PCA). Twenty-six items were
included and ranged from households’ housing characteristics (e.g. material of
dwelling of floor, roof, and wall), ownership of durable assets (e.g. car, television,
motorcycle, bicycle, radio, refrigerator, etc), access to basic utilities (e.g. electricity
supply, source of drinking water, toilet facilities) to ownership of livestock,
agricultural lands and building plots.
28
Fourth
Highest
3,414
3,223
20.7
21.1
19.9
A total of 5,292 adults responded to the SPEC pull-out household questionnaire
(Table 5.2). 60 percent were household heads while 31 percent were their spouses.
The remaining 8 percent were other adult household members. The majority (60
percent) were females. The respondents had a mean age of about 42 years. The
majority (59 percent) were married, 10 percent had divorced or separated while 13
percent had never married. With regard to their health insurance status, 54 percent
were active NHIS members while about 28 percent reported to have never registered
with the scheme. About 15 percent were previous members while 3.1 percent had
registered but were yet to receive their membership cards.
Table 5.2: Characteristics of household members who responded to the
SPEC-pull out questionnaire
Characteristics
Active
members
(n=2,860)
Obs
Current health insurance status
Previously
Registered
insured
but yet to
received
cared
(n=810)
(n=164)
Mean
Obs
Mean
Obs
Mean
Never
Insured
(n=1,458)
Obs
Mean
Total
(n=5,292)
Obs
Mean
Status in household
Head
2855
0.59
810
0.57
164
0.60
1455
0.68
5284
0.61
Spouse
2855
0.33
810
0.34
164
0.28
1455
0.24
5284
0.31
Other adult
2855
0.08
810
0.09
164
0.12
1455
0.07
5284
0.08
Male
2860
0.35
810
0.38
164
0.38
1458
0.52
5292
0.40
Female
2860
0.65
810
0.62
164
0.62
1458
0.48
5292
0.60
Age (mean years)
2854
43.5
810
41.5
164
41.3
1457
40.9
5285
42.4
Never married
2857
0.12
810
0.13
164
0.12
1456
0.15
5287
0.13
Married
2857
0.60
810
0.61
164
0.62
1456
0.57
5287
0.59
Union
2857
0.07
810
0.08
164
0.07
1456
0.10
5287
0.08
Divorced/separated
2857
0.09
810
0.10
164
0.09
1456
0.11
5287
0.10
Widowed
2857
0.11
810
0.08
164
0.10
1456
0.07
5287
0.09
Sex
Marital status
5.2 SPEC-by-STEP adopted by Ghana
29
Level 1: According to the National Health Insurance Act (Act 650) of 2003, all persons
resident in Ghana other than the Armed forces of Ghana and the Police service are required to
belong to a health insurance scheme. So the entire population of the country is targeted by the
NHIS. Though membership of the NHIS is expected to be mandatory, implementation has so
far been voluntary due to the difficulty in enforcing the act. Nobody resident in Ghana is
legally restricted from joining the NHIS.
The entire population of Ghana is targeted by the NHIS
Level 2: The entire population of Ghana is reached by the NHIS through the170 District
Mutual Health Insurance Schemes (DMHIS) operating in all the 216 districts of Ghana under
the NHIA. Many communities in rural areas have registration agents of the DMHIS. General
awareness of the NHIS by the population is very high because health insurance has become a
very topical political issue since the 2000 parliamentary and presidential elections in Ghana.
In Ghana’s latest Living Standard Survey of 2008 (GLSS 5), only 14.8% of the respondents
had no knowledge of the NHIS since it had just began in 2005. While awareness of the NHIS
has been observed to be very high, knowledge about specific issues relating to the NHIS such
as the registration fees and period, renewal conditions, exemptions, the benefit package, etc
may be lower than the level of awareness (NDPC, 2009). All the adults (100%) interviewed
in this household survey reported to have heard about the NHIS.
The entire population of Ghana is reached by the NHIS (Awareness of the NHIS)
Level 3: Since its inception in 2005, the NHIS is reported to have a cumulative membership
of 21.3 million by the close of 2011. This 21.3 million is cumulative membership but it is
estimated that about 70% of the population of Ghana has registered with the scheme. The
accuracy of this figure is difficult to determine due to inadequate national data. There is no
national statistics on the proportion of the population which has never registered with the
NHIS.
Never enrolled
Registered/Enrolled in the NHIS
Level 4: For those who have ever registered with the NHIS, a certain proportion has
withdrawn their membership by not renewing their annual membership. This proportion is
however not known as there are not official statistics. Some of the people who have registered
with the NHIS have not received their membership cards. While this number may be in the
minority, there is no official statistics on it. In a nationally representative household survey, it
was reported that 44.4%of the respondents were not registered while 7.7% had registered but
had not received their membership cards. 47.9% had registered and had their valid NHIS
cards (NDPC, 2009).Official statistics show that 34% of the national population are active
NHIS members by the end of 2011 (NDPC, 2012).
Previous
NHIS
members
Registered but
with no valid
ID card
Active membership (Valid NHIS
card holders)
30
Level 5: For the active NHIS members (34% of the population), some may not use the
available services (non-users) due to their belief systems. For instance, many pregnant women
continue to delivery at home without skilled-care attendant though delivery is covered under
the NHIS and pregnant women are exempted from paying premiums. Others may not use the
services because of several barriers such as non-availability of health facilities, health
personnel and transportation difficulties to access needed health care even though the cost of
medicines and supplies have been covered under the NHIS benefit package. No official
statistics exist on this category.
Nonusers
Active members (users of
services)
Level 6: It is possible that not all the NHIA active members who visit the health facility when
ill will get full benefit. This is because their disease conditions may not be covered by the
NHIS benefit package (e.g. cancer patients other than that of the breast and the cervix).
Sometimes the prescribed drugs and medical supplies may not be available at the health
facility and this can deprive them of full services.
Not full
benefit
Active members with full
benefit
5.2.1 Level 1: Targeted population
According to National Health Insurance Act (Act 650) of 2003, all persons resident in
Ghana other than the Armed forces of Ghana and the Police service are required to
belong to a health insurance scheme. So the entire population of the country is
targeted by the NHIS. Though membership of the NHIS is expected to be mandatory,
implementation has so far been voluntary due to the difficulty in enforcing the Act.
Nobody resident in Ghana is legally restricted from joining the NHIS. By the close of
2011, about 21.3 million people were reported to have ever registered with the NHIS
since its inception in 2005 (Table 5.3).
Only about a third of Ghana’s population was however described as active card
holding members of the scheme in 2011. As a percentage of the total population of
the regions, the Upper West had the highest (52 percent) active population followed
by the Upper East region (47 percent) and the Brong-Ahafo region (43 percent) with
the Central region having the lowest coverage of 24 percent of the population. What
was of contrasting interest was the fact that the two poorest regions in Ghana, namely
the Upper East and Upper West, ironically had the highest proportion of active
population. The Northern and Central regions which are the next poorest regions in
Ghana had active populations of 29 percent and 24 percent respectively. Surprisingly,
the Greater Accra and Volta regions which are not comparatively poor also had less
than 30 percent active membership. The premium exempt groups - mainly children
under 18 years, pregnant women, people 70 years and over and indigents accounted
for about 63.3 percent of the active population in 2011.
31
Table 5.3: Total Registered (cumulative) and Active Membership by Region,
2011
Region
Total
Registered
(2005 2011)
Actives (2011 New + 2011
Renewals)
Informal
Exempt
Total
2011
Population
Ashanti
4,610,778
712,963
1,138,022
1,850,985
4,725,046
Actives in
2011
as % of
Total
Population
39
Brong-
2,442,688
333,860
641,710
975,570
2,282,128
43
Central
1,700,591
184,953
313,858
498,811
2,107,209
24
Eastern
2,242,064
344,791
546,488
891,279
2,596,013
34
Gt. Accra
2,626,372
424,776
607,215
1,931,991
3,909,764
26
Northern
2,098,396
215,697
492,928
708,625
2,468,557
29
Upper East
1,098,262
163,736
319,745
483,481
1,031,478
47
844,856
112,520
241,951
354,473
677,763
52
Volta
1,516,310
205,558
244,138
549,696
2,099,876
26
Western
2,093,975
309,845
538,383
848,328
2,325,597
36
National
21,274,392
3,008,700
5,184,437
8,193,137
24,223,431
34
Ahafo
Upper West
Source:
National Health Insurance Authority, Annual Progress Report, 2011 in NDPC 2012
Table 5.4 shows the aggregate NHIS subscribers by the category of members in 2011.
The non-exempt group mainly in the informal sector constituted about 37 percent of
the total registrants. Children under 18 years who only had to pay a registration fee
were almost 50 percent. Formal sector employees who are SSNIT contributors
represented only 4.4 percent of the members. The indigents who are exempted from
paying both the premium and the registration fee were almost 4 percent.
Table 5.4: Aggregate NHIS Subscribers by Category, 2010 and 2011
Category
Number of Registrants as
at Dec. 2011
Percent of Total
Registrants
2011
36.78
4.37
Informal
3,013,436
SSNIT
358,040
Contributors
SSNIT Pensioners
29,495
0.36
Under 18 years
4,073,628
49.72
Pregnant women
Na
Na
70 years and above
398,189
4.86
Indigents
320,352
3.91
Total
8,193,137
Source: National Health Insurance Authority, Annual Progress Report, 2011 in NDPC 2012
32
5.2.2 Level 2: Level of awareness and reach of NHIS
All (100 percent) the adult household members (5,292) interviewed in the household
survey using the SPEC pull-out questionnaire reported to have heard about the NHIS
irrespective of whether they were NHIS members or not. About 82 percent of the
NHIS members and 76 percent of the non-members felt that the information about
NHIS from the media, the NHIA and the government was adequate
5.2.3 Level 3: Enrollment into the NHIS
Though the NHIS has reached a large section of the population, our results show
that 27 percent of the 16,178 household members recorded in the survey had never
registered (never insured) with the NHIS since its inception in 2005. The remaining
73 percent had ever registered with the scheme (Figure 5.1).
Figure 5.1
Table 5.5 shows the profile and the SPEC characteristics of the registered (enrolled)
and never insured members of the households surveyed. The majority (58.0 percent)
of the never insured were rural dwellers compared to 43.4 percent of their registered
counterparts. The never insured household heads were younger (mean age of 43
years) compared to the registered household heads (48.5 years). With respect to the
sex of the household heads, only 24.1 percent of the never insured were females while
37 of the registered members were males. Majority of the never insured household
heads (69.9 percent) and 65 percent of the registered household heads were married or
in unions. About 12 of the never insured heads and 13 percent of the registered heads
were divorced or had separated from their partners. About 14 percent of the registered
household heads were widowed. On social capital, 34.1 percent of never insured adult
household members who responded to the SPEC household questionnaire belonged to
a social organisation compared to a higher of 41.5 percent among the registered
respondents.
33
On education, 61 percent of the never insured adults and 68 percent of the registered
adults reported to have ever attended school. About 39 percent of the never insured
household members had just pre-school education compared to about 34 percent of
the registered household members. The NHIS registered household members seems
better educated as 35 percent of them compared to 33 percent of the never insured
completed junior high/middle school. Again, about 13 percent of the registered
household members had senior high/vocational or higher education compared to 7.5
percent among the never insured. The registered members therefore had a mean of 7.2
years of education compared to 6.6 years for the never insured.
On access to political resources especially with access to educational opportunities,
the result shows that the respondents who had ever registered with the NHIS seemed
to have better educational environment and conditions. The never insured household
members were within longer time distances to the various educational facilities as
shown in Table 5.5. Access to health facilities was similar to that of education for the
never insured household members. A higher proportion of the never insured were
more than 60 minutes away from the nearest regional hospital (63 percent vs. 59
percent), the district hospital (30 percent vs. 20 percent) and even the licensed
chemical store (5 percent vs. 3 percent). The results on access to transport and
administrative infrastructure show that the never insured relatively lived in remote
communities. On the average, the never insured household members spent longer time
in getting to the nearest tarmac road, daily and weekly markets as well as the district
capital. With regard to political participation, about 90 percent of the never insured
adult household members and 91 percent of the NHIS registered members reported to
have voted in the last national elections.
On access to material and economic resources, the results show that about 31 percent
of the never insured compared to only about 14 percent of the ever registered
members were in the lowest wealth quintile. While about 47 percent of those who had
ever registered with the NHIS were in the two topmost wealth quintiles, only about 26
percent of the never insured were in that category. With respect to economic
participation, 67 percent of the never insured adults and 60 percent of the registered
adult NHIS members were self-employed. Only about 7 percent of the never insured
and about 8 percent of the registered were in paid (wage) employment (both public
and private).On their main economic activity in the past 12 months, about 45 percent
of the never insured household members were engaged in agricultural activities
compared to 32 percent among the registered. About 14 percent of the never insured
engaged in manual jobs. A higher proportion of the registered household members
than their never insured counterparts engaged in ‘white collar’ jobs
(professional/managerial/technical/clerical jobs), sales or being students.
For
respondents whose main economic activity in the past 12 months was agriculture, a
higher proportion of the never insured among them were small or large scale food
crop producers compared to the registered members. About 30 percent of the
registered compared to 18 percent of the never insured were cash crop producers.
Culturally, majority of the household members were Christians with no major
difference between the never insured and the registered. About 32 percent of the ever
insured and 33.5 percent of the registered were Muslims.
34
Table 5.5: Characteristics of the never insured and the ever registered members
of the NHIS
Characteristic
Social dimension
Residence
Urban
Rural
Mean age of household heads (in years)
(n=4,031)
Sex of the household head (n=4,036)
Male
Female
Marital status of household head (n=4,036)
Never married
Married/in union
Divorced/separated
Widowed
% of adults who belong to a social organisation
Political Dimension
% of adults (≥18 years) who ever attended
school (n=8,421)
Highest school level completed (≥6 years)
Pre-school
Primary
Middle/Junior High school
Senior High school/ Vocational/Technical
school or higher
Don’t know
Mean years of schooling (≥6 years) (in years)
Access to educational opportunities (Distance
to the nearest educational facilities (mean time
in minutes)
Day care/nursery
Public primary school
Private primary school
Junior high school
Senior high school
Health insurance status
Not registered
Registered
(never insured)
(n=11,795)
(n= 4,383)
42.0
58.0
56.6
43.4
43.0
48.5
75.9
24.1
62.9
37.1
10.5
69.9
11.8
7.8
34.1
8.3
65.0
12.8
13.9
41.5
61.1
68.0
39.1
20.0
33.0
33.9
17.9
35.2
7.5
0.3
6.6
12.7
0.2
7.2
12.8
13.1
32.6
20.1
44.3
10.2
10.4
23.7
14.7
36.5
35
Access to health (% of population who are more
than 60 minutes from the nearest health
facilities)
Regional hospital
District hospital
Private/NGO hospital
Public health centre
Private clinic
Mission/NGO clinic
Private pharmacy
License chemical store
Access to transport and administrative
infrastructure (mean time in minutes)
The nearest tarmac road
The nearest all-seasoned road
Weekly market
Daily market
District capital
The nearest place with daily bus /taxi services
Political participation (n=5,287)
% of adults who voted in any of the recent
elections
Economic Dimension
Wealth quintile (economic resources)
First
Second
Middle
Fourth
Highest
Current employment status (≥15 years)
Self-employed
Paid employment
Student
Apprentice
Retired
Unemployed
Other
Main economic activity in the past 12
months(≥15 years)
Prof/tech/Mgt/Clerical
Sales and services
Manual
Agricultural
Student
Other
Respondents in agriculture (n=3,175)
Small scale food crop producer
Large scale food crop producer
Cash crop producer
Fishing (traditional)
Other
Cultural dimension
62.6
29.7
42.9
5.5
33.4
39.8
28.9
5.0
58.7
19.6
31.0
4.3
24.7
29.9
19.4
2.8
25.7
10.3
33.3
21.8
52.4
12.1
19.3
9.8
24.6
14.8
39.8
10.0
89.7
91.3
30.9
23.1
19.8
16.0
10.2
13.8
18.7
21.0
23.0
23.5
66.7
6.6
13.6
2.0
1.7
7.3
2.1
60.0
8.4
16.3
1.5
3.5
8.4
1.9
2.42
14.5
14.53
44.79
13.66
10.1
5.08
21.83
11.79
32.26
15.72
13.32
52.2
25.5
18.0
2.9
1.5
47.5
20.2
29.7
1.0
1.7
36
Religion
Christian
Muslim
Traditional
other
64.6
31.9
1.0
2.5
65.2
33.5
0.5
0.8
Main reasons for non-membership in the NHIS
Majority of the never insured (48 percent) attributed their non-membership to the fact
that the NHIS premium/registration fees was too expensive for them. More than 50
percent of the respondents in the first three low wealth quintiles compared to only 19
percent in the highest wealth quintile cited this reason as their major reason (Table
5.6).
From the qualitative study, the discussions with the never insured in the communities
suggested that most of them were fully aware of the benefits of enrolling in the
scheme. They were aware that it is an initiative that one has to join in order to receive
“free health care when you go to the hospital”. They were aware that once a member;
“when you fall sick suddenly and you don’t have money you can go and be taken care
of without paying any money” The main thrust of their contributions during focus
group discussions was however to justify why they themselves have never been part
of the scheme. The most frequent reason given by almost all respondents was
financial constraints. They claimed to face lots of hardships and have no one to help
them pay for the registration fee. As clearly stated by one female participant;
“I want to do it but I don’t have money” (Participant, Female FGD, Abura Amoada)
Another added;
“It is due to hardship. We don’t have any work here except the farming work and we
have children in school that is why we haven’t done it (Participant, Female FGD
Akwasipon)
The second major reason according to 23 percent of the never insured was that they
did not need health insurance because they did not fall sick. This reason was cited by
a higher proportion of respondents in the fourth (27.9 percent) and highest (48.1
percent) wealth quintiles. This finding is supported by the result from the qualitative
study.
Some of the never insured claimed that they had not bothered to join because they
“don’t get sick often” and they are able to use herbal remedies to deal with occasional
bouts of illness. Some even described it as painful having an insurance card and
renewing it annually when they are not likely to use them or enjoy its benefits,
suggesting that they are not aware or don’t accept the risk sharing principle
underlying the scheme: To one participant;
37
“I don’t go to the hospital because I don’t get sick often even. [Even] if I am sick I
usually use herbs. It is painful when you don’t use it but have to renew it every year”
” (Participant, Male FGD, Abura Amoada)
About 9 percent of the never insured have not joined the NHIS because they just did
not have the money to register and relatively higher among those in the lower wealth
quintiles. Other reasons cited by a few others included lack of trust in the NHIS (1.8
percent), reports of bad news about the scheme (2.2 percent), long distances to
registration centres (1.6 percent), not wanting to be a member (1.1 percent) among
others (12.8 percent).
Table 5.6: Respondents’ reasons for not been members of the NHIS
Reason
Premium/registration
expensive
Doesn’t fall sick
Doesn’t have money
No trust in NHIS
Heard bad news about
NHIS
Doesn’t want to be a
member
Registration centre is
far from community
Ignorant about NHIS
Other
Total
Wealth quintile
First Second Middle Fourth
Highest Total
57.6
14.2
10.7
2.0
52.1
20.5
10.6
2.6
50.5
23.1
8.5
0.2
38.2
27.9
7.2
2.3
19.0
48.1
3.1
1.4
48.0
23.0
8.9
1.8
2.1
1.0
2.4
2.4
4.7
2.2
1.2
1.2
1.2
1.1
0.7
1.1
1.5
0.5
10.4
100
0.7
0.2
11.1
100
1.2
1.1
11.8
100
3.9
0.6
16.4
100
1.0
1.4
20.6
100
1.6
0.6
12.8
100
The following are some quotes from the qualitative study to support the quantitative
results;
For me I have not done because when you go to the hospital they will not give
you medicine; they will ask you to go and buy so it is not important for me to
do it”(Participant, Male FGD, Abura Amoada)
Another reason was a perception that people without NHIS cards receive better care
than those who are insured.
When it was initiated, a group of people were involved in an accident. Those
who had health insurance were not properly taken care of. Meanwhile, those
who didn’t have health insurance were treated better. That’s why I have no
interest in it.(Participant, Male FGD, Savelgu)
Another reason was based on the concern that it takes unusually too long to be issued
a card after registration.
38
When you register and go for your health insurance card, they tell you to come
for the card in 3 months time. If you happen to fall sick within that time the
insurance won’t cover it. That’s why I haven’t done it. (Participant, Male
FGD, Savelgu)
39
5.2.4 Level 4: NHIS card holders, no card holders and previous members
Of the 11,741 (72.6 percent) household members who had ever registered with the
NHIS, 20.1 percent (2,362) reported to have withdrawn their membership by not
renewing their cards. About 6 percent (663) had not received their cards while 74.2
percent were active NHIS members because they were valid card holders. The active
NHIS members were more urban (57.7 percent) while those with no cards were more
rural (57.5 percent). There was a higher proportion of children among those registered
but with no cards (60.6 percent) while the previous members had more adults (53.6
percent). Though only 4.4 percent of the ever registered were aged 70 years and
above, the proportion was a little higher (4.9 percent) among the active NHIS
members (Table 5.7). Among the household heads who had ever registered with the
NHIS, the proportion that was married was higher among those with no cards (68.6
percent) and among the previous members (65.8 percent). About 15 percent of the
household heads among the active NHIS members were widowed. About 43 percent
of the previous adult members as well as those adults without cards reported to belong
to social organisations compared to 41 percent of the active members.
On the political dimension, 70 percent of the active NHIS members reported to have
obtained some formal education. The proportion was lower among the previous NHIS
members (63.8 percent) and those without cards (52.5 percent). Only 21.5 percent of
those without cards had completed primary education compared to 36 percent among
the active members and 35.4 percent among the previous members. About 14 percent
of the active members had completed senior higher school or a higher level but the
proportion was about 8 percent among the previous members and those without cards.
The results further show that the active members had 7.3 years as the mean years of
education and were followed by the previous members (6.9 years) and those without
cards (5.7 years).
Generally, the active NHIS members had easy physical access to various educational
facilities as they were within shorter time distances educational facilities (Table 5.7).
With regard to access to health facilities, the results were mixed though a little better
for the previous members. Relatively, the previous members had better access to the
nearest district hospital, private clinic, mission/NGO clinic and private pharmacy.
Those without cards were also closer to the nearest regional hospital and the public
health centre. The results further show that the active NHIS members and the
previous members had better access to the selected transport and administrative
infrastructure. For instance, they were closer (about 19 minutes) to the nearest tarmac
road, weekly markets (24 minutes) and the district capital (about 40 minutes)
compared to those without cards. Political participation was generally high for all the
three groups. About 92 percent of the active members and 93 percent of those without
cards participated in the recent national elections.
The results on access to material and economic resources show that the active NHIS
members were better off than the other two groups. For instance, while only 12
percent of the active members were in the lowest wealth quintile, it was almost 28
percent for those without cards. About 50 percent of the active members were in the
fourth and highest wealth quintiles compared to only 28.1 percent for those without
cards.
40
For economic participation, majority of the household members aged 15 years and
above were self-employed. About 9 percent of the active NHIS members were in paid
(wage) employment compared to 5.3 percent among those without cards. About 18
percent of the previous members were students with almost the same proportion of
students (15 percent) among the active members and those without cards. Nearly 4
percent of the active members were retired while 8.7 percent were unemployed. On
the specific economic activity they engaged in the past 12 months, a higher proportion
of those without card (46.3 percent) engaged in agricultural activities. About 23
percent of the active members engaged in sales and services compared to only 13
percent among those without card. The proportion of professionals among the
respondents was generally low but the proportion was higher (5.8 percent) among the
active members. For respondents who engaged in agricultural activities, the majority
were into small scale food crops production with a higher proportion among the
previous members (58.2 percent) and those without card (51.2 percent). More than 30
percent of the active members were cash crop producers.
For cultural participation, the religious affiliations of the household members were
considered. Nearly 68 percent of the active members and 59.4 percent of the previous
members reported to be Christians. The proportion of Muslims was higher among
those without card (46.7 percent) and the previous members (39.1 percent).
Table 5.7: Characteristics of the ever registered members by current insurance
status
Current health insurance status
Active
members
(n=8,716)
Previously
insured
(n=2,362)
Registered but
no ID card
(n=663)
57.7
42.3
56.0
44.0
42.5
57.5
48.2
46.8
4.9
0.2
43.8
53.1
3.1
0.0
60.6
37.3
1.8
0.3
61.0
39.0
68.2
31.8
68.6
31.4
8.3
64.5
12.5
14.7
8.2
65.8
14.5
11.5
9.3
68.6
10.2
11.9
40.9
43.6
43.3
70.0
63.8
52.5
Social dimension
Residence
Urban
Rural
Age
Children (≤18 years)
Adult
Elderly (≥70 years)
Missing
Sex of household head(n=2,752)
Male
Female
Marital of household head (n=2,750)
Never married
Married/in union
Divorced/separated
Widowed
% of adults who belong to a social
organization (n=3,834)
Political dimension
% of adults (≥18 years) who ever attended
school (n=6,079)
41
Highest school level completed (≥6 years)
Pre-school
Primary
Middle/Junior High school
Senior High school/ Voc./Technical
school or higher
Don’t know
Mean years of schooling (≥6 years) (in
years)
Access to educational opportunities
(Distance to the nearest educational
facilities (mean time in minutes)
Day care/nursery
Public primary school
Private primary school
Junior high school
Senior high school
Access to health (% of population who are
more than 60 minutes from the nearest
health facilities)
Regional hospital
District hospital
Private/NGO hospital
Public health centre
Private clinic
Mission/NGO clinic
Private pharmacy
License chemical store
Access to transport and administrative
infrastructure (mean time in minutes)
The nearest tarmac road
The nearest all-seasoned road
Weekly market
Daily market
District capital
The nearest place with daily bus /taxi
services
Political participation (n=3,833)
32.2
17.3
36.0
35.8
21.0
35.4
54.6
16.2
21.5
14.3
0.2
7.8
0.0
7.7
0.0
7.3
6.9
5.7
9.8
10.3
22.5
13.8
35.8
11.7
11.1
25.4
16.3
37.0
10.3
8.6
33.6
20.4
44.1
59.6
20.0
30.9
4.7
25.7
30.4
19.6
3.2
56.8
16.7
30.4
3.5
20.9
26.9
16.9
1.7
54.1
25.9
34.9
1.4
24.8
34.2
26.9
1.4
19.3
9.9
24.4
14.1
39.2
18.9
8.7
24.4
16.8
40.9
23.0
14.8
28.4
17.2
44.9
9.6
10.9
12.9
% of adults who voted in any of the
recent elections
91.8
89.3
93.3
Economic dimension
Wealth quintile (economic resources)
First
Second
Middle
Fourth
Highest
Current employment status (≥15 years)
Self-employed
Paid employment
Student
Apprentice
Retired
Unemployed
12.2
17.6
19.9
23.1
27.2
59.4
9.1
15.8
1.3
3.9
8.7
1.8
15.8
21.6
25.2
23.6
13.8
60.9
6.6
18.1
2.1
2.4
7.6
2.3
27.8
23.4
20.8
17.8
10.3
67.0
5.3
15.1
2.1
2.1
6.7
1.7
42
Other
Main economic activity in the past 12
months(≥15 years)
Prof/tech/Mgt/Clerical
Sales and services
Manual
Agricultural
Student
Other
Respondents in agriculture (n=2,056)
Small scale food crop producer
Large scale food crop producer
Cash crop producer
Fishing (traditional)
Other
5.8
22.7
12.0
30.3
15.3
14.0
3.1
20.9
10.3
36.4
17.6
11.7
3.2
12.8
14.2
46.3
14.2
9.3
43.2
23.2
31.4
0.7
1.5
58.2
11.1
27.6
0.8
2.3
51.2
23.2
19.2
4.8
1.6
67.8
31.0
0.3
0.8
59.4
39.1
0.7
0.9
50.6
46.7
2.6
0.2
Cultural dimension
Religion
Christian
Muslim
Traditional
Other
Main reasons for non-renewal of membership
About 83 percent of previous NHIS members explained why they had not renewed
their NHIS membership. Of this number (1,966), 44.3 percent complained that the
premium and the registration fees were expensive for them. This complaint was made
by all respondents irrespective of their wealth status though higher among those in the
lowest wealth quintiles (Table 5.8). Surprisingly, this complaint was higher among
the urban dwellers (46.8 percent) compared to the rural dwellers (40.9 percent).
The second reason for non-renewal of membership cited by 14.8 percent was the fact
that they were healthy and therefore did not need any health insurance. In one FGD,
one participant who rarely falls sick stated that;
Mine has expired for a long time now and it is not because of financial
difficulties that is why I have not renewed it. I have not been sick for a long
time. That is why I have not renewed my health insurance. (Participant,
male FGD, Senchiam)
Another 12.5 percent also complained that they just had no money to renew their
membership (Table 5.8).During the FGDs in the communities, the general opinion of
the previous members was that the NHIS is good because it provides free access to
healthcare at the point of use for the insured. As one of them put it:
43
It helps them (the insured) a lot, because whenever you have health insurance
and you go to the hospital, they will treat you free of charge. And even if they
don’t have drugs to give you, they will explain to you and treat you, and give
you prescription so that you can go to the drugstore and buy drugs.
(Participant, Male FGD, Tampion)
But the frequently cited reason was financial. An FGD participant typified it as
follows:
No money. … I have not renewed because I don’t have money. …recently I
went to renew but because I had not renewed for a long time I had to pay the
registration fee again. I couldn’t do it” (Participant, male FGD, Abenase)
The complaints about financial difficulties were however not only in reference to
individuals. Some people had financial difficulty renewing their premiums due to
large family size, as one woman explained:
I have seven children and the man has run away so I have done it for some of
the children but not all of them. … That is why when I heard that you have
come I came so that you will help me do it for them. Some are grown ups and
in the secondary school, theirs are expensive unlike the children. the older
ones pay 150 and they are three so I want you to help me do it for them so
that when they are sick they can go to the hospital so I will not have any
problem (Participant, female FGD,- Nkwantang)
.
About 9 percent of them also did not know that their cards had expired. Other reasons
mentioned included lack of trust in the NHIS, no benefit from previous membership,
long distances to registration centres, poor services to NHIS members or bad
experiences with staff of health facilities, piloting of the capitation payment system in
the Ashanti region among others.
Table 5.8: Reasons for non-renewal of membership by wealth quintile
Reason
Lowest
Wealth quintile
Second Middle Fourth Highest
Total
Premium/registration is
expensive
Does not fall sick
Does not have money
Does not know it had
expired
Never benefited from it
in the past
Registration centre far
from community
Other
Total
47.8
10.9
14.0
57.6
9.9
12.3
39.3
11.0
18.0
46.0
17.9
11.3
25.9
28.4
3.2
44.3
14.8
12.5
4.4
6.1
8.3
10.0
17.3
8.9
1.2
4.7
2.7
1.7
2.5
2.6
1.9
19.9
100.0
0.5
9.0
100.0
3.3
17.4
100.0
0.0
13.1
100.0
1.8
20.9
100.0
1.5
15.5
100.0
44
In the Ashanti region where capitation was being piloted at the time the data
collection was carried out, members of the scheme were required to register with a
facility and could only access health care from where they registered. Some of the
non-renewal participants indicated that they did not renew their membership of the
scheme because of their inability to access health care in any hospital of their choice
except where they registered. One FGD participant explained that;
Formerly, you could take the health insurance card to any hospital but now
because of the capitation you have to go to only one hospital. I am not happy with
that so I decided not to renew my membership so I can go to any hospital of my
choice when I need help ( Participant, Male FGD, Abenase)
Again, some also did not renew their membership on the basis of the notion that those
without insurance receive better care than those who had.
The reason why I have not renewed mine is that, I fell sick and went to the
hospital and was told that if I want to be treated, then I have to put the insurance
away. And at that time, I saw that they were separating those with the insurance
from those without the insurance and they were serving them before us so I
changed my mind (Participant, Male FGD, Abakrampa)
A handful of participants also claimed that they renewed their membership but never
received their cards. As a result they gave up after some time.
I have renewed mine for three times but the card never came. I have renewed it
for my child for three times and when she takes the picture, it doesn’t show, what
can I do about it? I just gave up (Participant, Female FGD- Dinkyin)
Possible reasons for non-receipt of registration/membership cards
While it is difficult to offer reasons for not having their membership cards, it was
possible that they were in the required waiting time as stipulated by the health
insurance act. On the average, they had been waiting for 6.7 months though about 10
percent of them had been waiting for more than 12 months.
Perhaps, the place of registration could be a factor for not receiving the cards. For
instance, they were less likely to get registered at the NHIS district office (42
percent). A quarter (25 percent) of them got registered by NHIS agents in the
communities, 23 percent got registered during mass registration campaigns, about 5
percent registered at the community health facility while the rest registered in other
places different from their current place of residence. About 17 percent described the
registration process as difficult or worse. They paid 7.7 Ghana cedis (SD=4.8 Ghana
cedis) for the registration.
But from the qualitative study, the respondents who had registered but had not
received their cards affirmed that it was taking too long for the insurance scheme to
issue cards to clients after registration. According to one FGD participant ‘it had
taken more than 3 months and the schemes were still giving varied excuses for the
delays’. According to some, the district schemes had explained that their names and
other information they provided had been sent to Accra for the cards to be prepared
45
and that accounted for the delays. This was a great source of concern to this group of
men and women. They concluded that this situation of the insurance scheme is unfair
since they had duly paid for what was due them. The delay was stressful to them but
their greatest pain in the circumstances is that they are made to pay for health care at
the point of use during the three month waiting period. Two FGD participants
captured this concern so well in two separate group discussions as follows:
We registered but the cards are not in. When I was sick yesterday I had to
pay. There are even cases where when the card comes you are given an
expired card. When you follow them they will tell you that it has been sent to
Accra. Some people tend to think it is the fault of the agent. It affects the
image of the health insurance agent as people always think that they have
spent their monies but if you go to Savelugu yourself, they will tell you the
same thing that the card is in Accra ( Male FGD participant- Langa)
We have done it but still have not received our cards anytime you ask him
[the agent] he says it is not ready so when you go you have to pay. That is a
problem for us (Participant, \Female FGD, .Denkyira)
Another important point raised by some of these respondents is the issue of multiple
registrations. They explained that this comes about because having failed to provide
them with a card after the first registration; another group also comes demanding for
them to pay to be registered again. To them it looks as though some fraudulent agents
are taking undue advantage of clients and absconding with their moneys as one
participant explained.
I have paid several times but the agent spent my money and ran away and
another agent came for the same thing and now I have paid but still have not
received the card (Participant Male FGD Denkyira)
Some were of the view that they expected to be given provisional cards during the
waiting period but that never happens.
Since the days of former President Kuffuor, I registered to join in Kumasi but I
waited for three months before receiving the card. They also didn’t give any
provisional card. I have registered several times and in all these instances they
didn’t inform me of any provisional card (Participant, Female FGD. Fumesua)
5.2.5 Level 5: Users and non-users of health care services (Utilization)
46
Assessment of the users and non-users of health care services was based on the
subsample of the study population who reported ill/injured in the past two weeks
preceding the survey. In all, only 8.9 percent (1,434) of the household members
reported an illness or /injury during the two weeks reference period. The proportion
reporting an illness or injury was higher among the active NHIS members (10.3
percent) followed by the previous members (9.3 percent), those without cards (8.9
percent) and the never insured (5.8 percent). Because the sample size was small, the
analysis was not restricted to only the NHIS valid card holders as expected under this
section (Level 5).
About 92 percent of those who reported ill/injured indicated that they sought health
care for the illness/injury. The characteristics of the users and non-users of health care
services during the recent reported illness/injury are presented in Table 5.9. Males
constituted about 40 percent of the users and 43 percent of the non-users. More than
half (53.3 percent) of the users were urban dwellers while about 56 percent of the
non-users lived in rural communities. The proportion of active NHIS members among
the users was higher (63.7 percent) compared to those among the non-users. There
was also a relatively higher proportion (26.6 percent) of the never insured among the
non-users.
Majority (73 percent) of the adult non-users reported to have been to school. There
was no difference in the number of years of education for both groups as each had a
mean of 7.1 years. With respect to access to health facilities, the results show that
about 63 percent of the non-users were more than 60 minutes away from the nearest
regional hospital. A higher proportion of the no-users were 60 minutes away from the
nearest district hospital (29.9 percent), private hospital (33.7 percent), the public
health centre (7.9 percent) and the private clinic (28.7 percent). The non-users also
had to travel longer time to get access to the nearest transport and administrative
infrastructure as shown in Table 5.9.
Economically, nearly 24 percent of the non-users compared to 17.2 percent of the
users were in the lowest wealth quintile. The proportion of the users and the non-users
in the highest wealth quintile were similar. Generally, there was no statistical
difference between the users and the non-users in terms of the wealth quintiles
(૏2=5.0372; p=0.283). In the past 12 months, 69 percent of the users and about 65
percent of the non-users were self-employed. About 8 percent of the users were in
paid (wage) employment. About 9 percent of the non-users were retired while the
proportions of the unemployed in both groups were about the same.
On the cultural dimension, 73 percent of the users and about 83 percent of the nonusers reported to be Christians. A quarter of the users were Muslims. Few others
among the users (1.1 percent) and non-users (3.5 percent) reported to have not
religion.
Total 5.9: Characteristics of users and non-users of health care services with
reference to the recent reported illness/injury
Characteristics
Status
Total
47
Users Non-users
Social dimension
Sex
Male
Female
Residence
Urban
Rural
Age
Children (≤18 years)
Adult
Elderly (≥70 years)
Insurance status
Active members
Previous members
No card
Never insured
39.9
60.1
42.7
57.3
40.1
59.9
53.3
46.7
44.4
55.6
52.6
47.4
44.9
47.1
8.1
35.3
54.3
10.3
44.1
47.7
8.2
63.7
15.1
4.0
17.2
50.43
17.9
5.1
26.6
62.6
15.3
4.1
17.9
65.1
73.0
65.8
7.1
7.1
7.1
60.8
19.7
32.0
3.3
23.4
29.4
17.2
2.3
62.6
29.9
33.7
7.9
28.7
28.7
19.8
1.7
61.0
20.5
32.1
3.6
23.7
29.3
17.5
2.5
19.0
7.5
25.3
15.5
42.0
9.5
27.3
11.1
28.8
21.3
51.6
10.0
19.7
7.8
25.5
16.0
42.8
9.6
17.2
21.9
21.3
21.0
18.5
23.9
17.1
23.9
17.1
18.0
64.9
5.2
5.2
1.3
9.1
17.8
21.6
21.6
20.7
18.4
68.6
7.5
6.0
1.1
6.4
Political dimension
% of adults (≥18 years) who ever attended school
(n=796)
Mean years of schooling (≥6 years) (in years)
Access to health (% of population who are more than
60 minutes from the nearest health facilities)
Regional hospital
District hospital
Private/NGO hospital
Public health centre
Private clinic
Mission/NGO clinic
Private pharmacy
License chemical store
Access to transport and administrative
infrastructure (mean time in minutes)
The nearest tarmac road
The nearest all-seasoned road
Weekly market
Daily market
District capital
The nearest place with daily bus /taxi services
Economic dimension
Wealth quintile (economic resources)
First
Second
Middle
Fourth
Highest
Current employment status (≥15 years)
Self-employed
Paid employment
Student
Apprentice
69.0
7.7
6.1
1.1
48
Retired
Unemployed
Other
Cultural dimension
Religion
Christian
Muslim
Traditional
Other
6.1
7.6
2.4
7.8
6.5
7.6
2.8
73.0
25.0
0.9
1.1
82.8
12.9
0.9
3.5
73.8
24.0
0.9
1.2
Reasons why health care was not sought for the recent reported illness/injury
About 76 percent (89) of the household members who reported an illness or injury
during the two weeks period but did not seek health care gave reasons for their action.
Table 5.10 presents the reported reasons by the health insurance status of the
respondents. The main reason cited by majority (46.1 percent) of the respondents was
that the illness/injury was not considered as a serious condition. This was cited by
63.4 percent of the active NHIS members who did not seek care. All the 5 non-card
holders and 54.2 percent of the never insured considered the cost of seeking health
care as high to them. About 21 percent of the previous members indicated that they
preferred to try traditional medicine while another 15.8 percent thought the illness
was spiritual. About 15 percent of the active members also did not seek health care
because they wanted to self medicate.
Table 5.10: Reasons for not seeking health care for the recent reported illness by
insurance status
Insurance status
Reason
Illness not considered serious
High cost of seeking health care
Preferred to try traditional
medicine
Preferred to try self-medication
Illness was considered spiritual
Other
Total
Active
members
(n=41)
63.4
4.9
Previous
members
(n=19)
42.1
15.8
No card
(n=5)
0.0
100.0
Never
insured
(n=24)
29.2
54.2
Total
(n=89)
46.1
25.8
9.8
14.6
0.0
7.3
21.1
0.0
15.8
5.3
0.0
0.0
0.0
0.0
4.2
8.3
0.0
4.2
10.1
9.0
3.4
5.6
100
100
100
100
100
5.2.6 Level 6: Receivers of full benefit package and those who did not
49
Table 5.11 shows the facilities from where the sick first sought health care during the
recent reported illness/injury. About a third (34.2 percent) of the active NHIS
members (valid card holders) visited the public health centre which was followed by
the district hospital (21.6 percent) and the pharmacy/drug store (11.2 percent). As
many as 42.9 percent of the previous members and about 19 percent sought health
care from the pharmacy/drug store and the public health centre respectively. For those
without cards, the majority (37.7 percent) visited the public followed by the drug store
(22.6 percent). About 38 percent of the never insured visited the pharmacy/drug store
while 22.6 percent sought care from the public health centre. About 7.5 percent of
them also resorted to self medication with modern medicines.
Table 5.11: First source of health care for the last reported illness/injury
Facility
Regional hospital
District hospital
Private hospital/clinic
Public health centre
Mission/NGO hospital/clinic
Pharmacy or drug store
Traditional/spiritual healer
Home treatment with
traditional remedies
Home treatment with orthodox
medicine
Self medication with traditional
medicine
Self medication with modern
medicine
Total
Insurance status
Active
Previous
members members No card
(n=837) (n=198)
(n=53)
4.9
3.5
15.1
21.6
9.6
15.1
13.9
7.1
3.8
34.2
18.7
37.7
9.6
2.5
0.0
11.2
42.9
22.6
0.2
0.0
0.0
Never
insured
(n=226)
3.1
9.3
8.0
22.6
3.1
37.6
1.8
Total
(n=1,315)
4.8
17.4
11.4
30.0
7.0
21.0
0.5
1.0
3.5
0.0
2.2
1.5
0.6
6.1
0.0
1.3
1.5
0.7
2.5
1.9
3.5
1.5
2.2
100
3.5
100
3.8
100
7.5
100
3.4
100
From all these sources, it was difficult to assess whether valid NHIS card holders
received the full benefits as stipulated by the NHIS benefit package. This is because
the reported illness/injury may not be covered by the NHIS benefit package or the
facility of treatment may not be an NHIS accredited facility. The respondents may
also be ignorant of the full benefit package for the reported health problem. The
available did not permit the analysis of the level 6 of the adopted SPEC framework
which is restricted to valid NHIS card holders who visited NHIS accredited health
facilities when ill/injured but did not receive the benefits as stipulated by the NHIS
benefit package.
However, respondents who sought health care from NHIS accredited public health
facilities during the recent illness/injury were asked to indicate whether they thought
they received the expected care. Generally, about 87 percent of the respondents were
satisfied with the services they received with the proportion being higher among the
previous members (90.3 percent) and the never insured (88.6 percent) (Table 5.12). A
50
few other respondents were not at all satisfied with the care they received irrespective
of their insurance status.
Table 5.12: Level of satisfaction of the health care received from service
providers by respondents
Level of satisfaction
To a large extent
To some extent
Not at all
Total
Insurance status
Active
Previous
Never
members members No card insured
(n=501)
(n=62)
(n=35)
(n=79)
87.2
90.3
82.9
88.6
9.2
4.8
8.6
8.9
3.6
4.8
8.6
2.5
100
100
100
100
Total
(n=677)
87.4
8.7
3.8
100
For the few respondents (12.5 percent) who were dissatisfied with the health care
services they received from their service providers, the main complaint (69 percent)
was that they did not get well after the visit. Others felt the reception given by the
service providers was not the best (7.8 percent) while some (7.8 percent) complained
that they did not get all their prescribed medicines at the facility. The remaining
complaints (15.4 percent) related to high cost of treatment, delays at the health
facility, referral to other facility and the fact that they were still recuperating at the
time of the survey.
5.3.1 Perception of the NHIS by Respondents
Generally, the never insured household members who responded to the SPEC pull-out
questionnaire had negative perceptions about the NHIS (Table 5.13). For instance,
20.3 percent of the 1,453 never insured adults who expressed their views on the NHIS
felt that spending money on health insurance was not a priority for them. According
to 35 percent of them, health insurance is something meant only for the poor in
society while about 15 percent agreed that if one was not sick often they should not
get insured with the NHIS. About 51 percent also felt the office of the NHIS for
registration and renewal was not convenient.
From the qualitative study, the active NHIS members described the NHIS as a social
support system that provides benefit for the rich and the poor as well as the weak and
strong. One FGD participant vividly explained it as follows:
I said that since the government brought this, my wife, children and I have
done it so many times. We do it to protect ourselves from any unforeseen
sickness. When you are unwell, you can just take your insurance card and go to
hospital. By God’s grace, we are strong. … You have to renew it because even
if you, your child or wife doesn’t fall sick, your family member can fall sick and
they can use your contribution to help. That is why whenever it expires, we
have to renew ( Participant, Male FGD, Mehame)
Another participant stressed the risk sharing principle as follows:
51
There is nothing wrong with me and I usually don’t fall ill. If I have a
headache I buy Para (paracetamol) 20 pesewas and chew and am free. If am
dizzy I drink a bottle of malt [non alcoholic drin]. But my children take theirs
(their cards) to the hospital (Participant, female FGD, Abura Adukrom)
In effect some of the insured participants retained their membership in the NHIS to
fulfill the hitherto requirement in the scheme that coupled the exemption of the
payment of premium of children under eighteen to the membership status of their
parents as a condition for the children enjoying the benefits of the scheme.
Much as the insured were very positive about the scheme, they also had some
reservations about it. One source of reservation was related to the situation of being
given a prescription to purchase drugs from outside sometimes when they attend a
health facility.
The essence of [joining the NHIS] is to insure oneself now for a future date,
when you fall ill. This implies that any treatment is supposed to be free, but
this is not always the case. …Sometimes the drugs are not given out instead
you would be given the prescription to buy it yourself. That is a problem –
participant, male FGD Bonwire
Some of the insured also had complaints about quality of care and suggested that
people with insurance sometimes receive poor quality of care compared to those who
pay cash at the point of use.
When my child got sick and I took him to the hospital they gave him medicines
but he was not getting well. When I took him again but didn’t use his
insurance card they gave him quality medicines and he became well; because
I paid – Participant, Male FGD Abura Adukrom
52
Table 5.13: Perception of the NHIS by Respondents to the SPEC Pull-Out Questionnaire
Current health insurance status
% who strongly agree or agree
We are always able to cover health care costs in this household
Active
member
Previously
insured
(n=2852)
(n=810)
Registered
Never
but yet to insured
receive
card
(n=164)
(n=1453)
63.6
15.7
30.8
51.6
17.9
40.5
62.2
14.1
36.6
46.1
20.3
34.7
90.6
100
89.9
100
89.6
100
80.9
100
81.9
97.2
15.3
90.2
79.4
32.2
74.1
96.8
11.5
86.5
65.6
37.2
76.6
96.8
10.1
84.8
57.3
27.9
75.6
89.7
15.2
72.9
48.7
29.1
Only those who fall sick should register with NHIS
26.6
6.7
32.1
6.4
21.5
3.8
25.1
7.1
NHIS members still have to pay for drugs and treatment when they visit a
health facility
29.2
28.1
25.3
23.6
Spending money on health insurance is not a priority for me
Health insurance is something for the poor
Having health insurance is good as my contribution can also help other
people when they fall sick
Have you heard of the NHIS in Ghana?
The information about NHIS from the media, the NHIA and the government
is adequate
It is good to be a member of the NHIS even if I don’t fall sick
If one is not sick often they should not get insured with the NHIS
NHIS helps people save money on hospital bills
The office of NHIS for registration and renewal is convenient
The insured members of NHIS are given poor quality drugs
The insured members of NHIS are treated worse than people not insured
by NHIS when they seek care at a health facility
53
5.3.2 Perception on Access to Health Care
According to the adult household members who responded to the SPEC
questionnaire, two-thirds (3,494) reported to have accessed formal health care
services at least once in the last five years. The proportion was much higher among
the currently insured (76 percent), the previously insured (69 percent), those
registered but yet to receive their cards (57 percent) and the never insured (46
percent).Table 5.13 shows respondents’ perception on the health care services
received during the last visit. About 88 percent of the currently insured and 87 percent
of the never insured reported to take the decision to visit a modern health care facility
when sick on their own. Not much differences were recorded between the currently
insured and the never insured on whether it mattered if they were seen by a male or a
female doctor/nurse at a health facility, whether they were seen by a younger or older
doctor or nurse and whether they were treated differently than other patients when
they sought care at a health facility.
Compared to the others, more than half of the currently insured strongly agreed that
they were treated with respect when they sought health care at a health facility. While
about 54 percent of the currently insured strongly agreed that their concerns and
questions were taken seriously by the medical staff at the health facility, the
proportion was lower for the other categories of respondents. A similar observation
was made on how the respondents felt about how their feelings and views were
listened to by medical staff and whether doctors and nurses provided them with
sufficient information about their medical situations. About 63 percent of the
currently insured compared to 52.6 percent of the never insured strongly agreed that
their health facilities provided adequate privacy during physical examinations. About
47 percent of all the respondents strongly agreed that they understood the vocabulary
used by medical staff when they talked to them. The proportion was lower for those
who were yet to receive their NHIS registration cards (44.7 percent) and the never
insured (45.6 percent).
Table 5.14: Perception on access to health care by health insurance status
Current health insurance status
54
Active
member
Perception
In general, when you are sick, who
decides if you need to go to modern
health care facility?-those who
decide by themselves (%)
Does it matter if you’re seen by a
male or a female doctor/nurse?-No, it
doesn’t matter (%)
Does it matter if you’re seen by a
young or an older doctor or nurse?No, it doesn’t matter (%)
Do you feel you are treated
differently than other patients when
you seek care at a health facility?
% NO
Do you feel you are treated with
respect when you seek care at health
facilities? (%)
Strongly agree
Agree
Do you feel that your concerns and
questions are taken seriously by
medical staff? (%)
Strongly agree
Agree
Do you feel that your feelings and
views are carefully listened to by
medical staff? (%)
Strongly agree
Agree
Do you feel you receive services that
fully cover your needs? (%)
Strongly agree
Agree (%)
Do you feel that doctors or nurses
provide you with sufficient
information about your medical
situation? (%)
Strongly agree
Agree
Do you feel that health facilities
provide adequate privacy during
examinations? (%)
Strongly agree
Agree
Do you understand the vocabulary
used by medical staff when they talk
to you? (%)
Strongly agree
Agree
Total (N)
Previously
insured
Registered
but yet to
receive
card
Never
insured
Total
88.2
81.2
76.6
86.8
86.5
83.5
80.1
85.1
79.0
82.2
80.3
78.7
82.9
78.1
79.7
92.5
91.6
94.7
94.1
92.3
53.1
37.2
41.7
49.2
39.4
46.8
41.5
47.4
48.7
41.3
54.5
38.7
45.3
47.1
42.6
45.7
45.3
46.9
50.9
41.8
55.8
37.1
45.3
47.4
40.4
48.9
45.6
46.6
51.8
40.9
55.5
38.3
46.2
47.3
43.6
50.0
46.9
45.4
52.0
41.4
43.7
35.0
40.1
53.3
38.3
40.4
38.5
42.3
42.0
37.9
62.6
34.4
54.2
43.7
58.5
39.4
52.6
43.8
59.2
37.8
47.2
31.2
50.6
39.4
563
44.7
39.4
94
45.6
42.3
667
47.4
34.9
3,494
2,170
5.3.3 Views on accessibility to health from the qualitative study
55
In the Ashanti region, some participants in the FGDs complained about the
restrictions imposed by the implementation of the capitation policy which made it
impossible for them to use the NHIS card in another facility rather than where they
registered.
I registered at Juaben hospital. At first you can take it everywhere. Now they
say capitation so everybody should register with one hospital so we asked
them in case you are sick and at a different place can you use it but they said
they have started in this district and after some time you can take it
everywhere. Participant. Male FGD, Juaben
Participants also described various ways that they were experiencing exclusion from
the scheme apart from the exclusion arising from not having their insurance cards.
One other form of exclusion they described was that the scheme did not cover all
medicines and as a result one sometimes has to find the money to purchase some
drugs.
Whether you have money or not, whether you are poor or not, once you do the
health insurance you can access healthcare…but sometimes even if you have
the health insurance card they will ask you to buy medicine and if you don’t
have money you can’t buy some of the drugs you need… then it becomes a
problem- Participant, Female FGD, Denkyira.
They also mentioned insurance status discrimination as another form of exclusion and
explained that NHIS clients are discriminated against when it comes to health care
provision. As a result, they are not keen to obtain their cards. One participant
captured it in the following excerpts during a group discussion:
Female FGD participant: There was a time my child got very sick in the night
so I have to rush her to the clinic early in the morning. When I got there, the
woman said because it is too early in the morning she won’t attend to us. And
this was because I was using the insurance.
Moderator: Did she tell you, it’s because of the insurance?
Female FGD participant:: That is what I made out of it because as a nurse
you have to attend to every sick person at any given time. I believe if I was
paying cash, she would have attended to us. So I left there to the private clinic
where I paid cash” Excerpts from FGD, Nkasiem
Non-portability of the scheme, which refers to the inability of clients to access
healthcare wherever they find themselves was also considered a source of exclusion
for some clients:
Recently, we heard the government said everybody should choose the hospital
he wants so that when he is sick he can go there. That means if you don’t
choose a clinic they will not accept your card there. So you either have to pay
or go to the place you chose… it is the policy of the new government that has
resulted in this situation.
It’s a problem because you know we have travelers in Ghana, so if somebody
travel from Fumesua and get sick in the north, then the person has to pay his
56
bills over there or must be carried back to Fumesua. Then what is the benefit
of the NHIS. Participant Male FGD-Fumesua
6. DISCUSSION
6.1 Discussion of Results
Ghana’s NHIS as part of the national social protection strategy is expected to cover
every Ghanaian, especially the vulnerable in society. However, for almost a decade
after the establishment of the NHIS, only 34 percent of Ghana’s 24.2 million people
were active members in 2011in spite of the comprehensive exemption package of the
NHIS (NDPC, 2011). This study had a main aim of assessing the characteristics of
individuals covered by the NHIS as well as those who were not members and the
extent to which social exclusion and inclusion in health can be used to explain the
phenomenon.
The results of our household survey show that nearly 73 percent of the household
members had ever registered with the NHIS since its inception in 2005. This
suggested that awareness of the NHIS was high among the populace. About 54
percent of the household members were active NHIS members (currently insured)
during the survey. The results showed that the currently insured had a high proportion
of females, the married and urban dwellers even though the five districts studied were
generally rural. They were also relatively better educated and in higher wealth
quintiles. In terms of education and wealth, those who had withdrawn their
membership from the NHIS were the next best group. A high proportion of the never
insured were males, in rural communities, in their productive ages (18-69 years) and
relatively less educated (41 percent had completed Junior High or more compared to
50 percent of the currently insured and 43 percent of the previous NHIS members).
About 54 percent of the never insured and 51 percent of those who were yet to receive
their registration cards were in the two bottom wealth quintiles compared to 29.8
percent of the currently insured and 37.4 percent of the previous members. This raised
serious equity and exclusion concerns in the NHIS enrolment even in the face of the
exemption package.
Since the NHIS is aimed at removing the financial barrier to health care for the
population, especially those with low socioeconomic status, the decision to enrol to a
large extent will depend on people’s perceived health status since membership is not
compulsory. For instance, while 89.5 percent of the currently insured perceived their
current health status as good or better, the proportion was higher among the previous
members (91 percent), those waiting for their registration cards (92 percent) and the
never insured (96 percent).
In discussing the reasons behind people’s decision to enrol or not with the NHIS in
the context of social exclusion, it is important to understand the dimensions of social
exclusion in Ghana as outlined in the adopted SPEC framework (Annex1). The
combination of the social, political, economic and cultural (SPEC) dimensions of
social exclusion shape the structures and systems in the wider society which could
negatively affect people’s access to the available health financing mechanism and
57
their ability to access health care when in need. Analysis of the reasons why some
people have never insured with the NHIS or why some of them have withdrawn their
membership seemed to suggest that economic factors were the major determinants of
enrolment. The results showed that active membership was higher in the wellendowed districts like Kwaebibirem and Asutifi and lowest in Savelugu-Nanton and
Abura-Asebu-Kwamankese which are in regions of higher poverty levels. Active
membership was also higher among households in the higher wealth quintiles. Forty
eight percent of the never insured and 44 percent of the previous members attributed
their non-membership to NHIS premium/registration fees which they perceived to be
expensive. Again, 9 percent of the never insured and 12 percent of the previous
members reported that they did not have the money to pay the premium/registration
fees. It is important to note that about 52 percent of the never insured engaged in
agriculture compared to 44 percent of the currently insured who were small scale food
crop producers. This group happened to be one of the poorest in Ghana.
Another important reason cited by 23 percent of the never insured was that they did
not need health insurance because they never got sick. This reason was also given by
15 percent of those who had withdrawn their membership. While awareness of the
NHIS was quite high, perhaps because of the intense politics surrounding it, it seemed
many people did not understand the principle of health insurance. As observed by the
NDPC (NDPC, 2009) the level of knowledge of respondents to a large extent
informed the decision to enrol with the NHIS or not. The results showed that the
never insured generally had a negative perception of the NHIS. They generally felt
that health insurance was meant for the poor and the sick. This suggested that the
never insured had limited social capital. For instance, 41 percent of the adult
household members who responded to the SPEC questionnaire reported to belong to a
social organisation compared to 34 percent of the never insured. The level of social
participation for the never insured also seemed to be low. The proportion attending
social ceremonies and religious functions were observed to be low (Annex 1). It is
important for the never insured to appreciate the importance of community solidarity
to help them understand that having health insurance is good and serves as their
contribution to help other people when they fall sick.
Perhaps one of the major barriers to health care in Ghana is physical inaccessibility to
health facilities for a large proportion of the population. The Ghana Human
Development Report of 2007,"Towards a more inclusive society" (UNDP, 2007)
identifies spatial polarisation as a major driver of social exclusion which falls under
the political dimension of social exclusion. There is unequal access to social services
such as health care, education, water, sanitation, etc generally between rural and
urban areas. This can affect the decision to enrol with the NHIS. Rationally, nobody
would want to pay for a service that is not available or very difficult to access. The
results showed that the never insured had longer distances in reaching the nearest
educational, health and transport infrastructure and services. It was therefore not
surprising that some of the respondents complained of the long distances to NHIS
registration centres. As stated in the introduction of this study, social exclusion from
health care provision may be due to disrespectful, discriminatory or culturally
inappropriate practices of medical professionals and their organisations, within the
context of poor accessibility and quality of care. This brings to the fore the issue of
power relations and trust between medical professionals and their patients.
Unfavourable power relations and lack of trust can discourage people from accessing
58
health care from health facilities and therefore a low desire to enrol with the NHIS.
Though both the currently insured and the never insured respondents were not very
different in their perception on whether the age and sex of a doctor or a nurse
mattered to them, a lower proportion of the never insured strongly agreed that they
were treated with respect at the health facility. A higher proportion of the never
insured also felt their concerns, questions and feelings were not taken seriously by
medical staff. A few individuals had withdrawn their membership from the NHIS or
had decided not to enrol with the NHIS because of lack of trust for the scheme and
bad experiences with health professionals in the past.
7.
CONCLUSION
The findings of the country case study, based on five representative districts across
the three ecological zones of Ghana, revealed significant insights into the impact of
the NHIS on the access to health care with regards to the various levels of
socioeconomic groups. It is the intention of this report that the findings will be used
by all health stakeholders to reduce social exclusion in the NHIS and by so doing
improve its implementation as part of the national social protection strategy.
Though membership of the NHIS is expected to be mandatory, implementation has so
far been voluntary due to the difficulty in enforcing the Act (Act 650). The health
insurance status of the 16,178 household members surveyed showed that 54 percent
were categorised as active NHIS members because they had valid NHIS memberships
at the time of the survey. 27 percent of the sample had never registered with the NHIS
since its inception. While 15 percent were identified as previous members because
they had not reviewed their membership as at the time of the survey, 4 percent were
reported to have registered with the NHIS but were yet to receive their membership
cards.
The results showed that the currently insured had a high proportion of females, the
married and urban dwellers even though the five districts studied were generally rural.
They were relatively better educated with 50 percent having completed Junior High.
Those who had withdrawn their membership from the NHIS were the next best group
in terms of education with 43 percent having completed Junior High. A high
proportion of the never insured were males, in rural communities, in their productive
ages (18-69 years) and were relatively less educated with only 41 percent having
completed Junior High. The currently insured were also in higher wealth quintiles
with only 29.8 percent falling in the two bottom wealth quintiles. 37.4 percent of the
previous members were in the two bottom wealth quintiles compared to about 54
percent of the never insured and 51 percent of those who were yet to receive their
registration cards.
Within the SPEC framework, the results suggested that economic factors were the
major determinant of enrolment.Active membership was higher in the well-endowed
districts like Kwaebibirem and Asutifi and lowest in Savelugu-Nanton and AburaAsebu-Kwamankese which are in regions of higher poverty levels. Active
membership was also higher among households in the higher wealth quintiles.48
percent of the never insured and 44 percent of the previous members attributed their
non-membership to NHIS premium/registration fees which they perceived to be
59
expensive. Again, 9 percent of the never insured and 12 percent of the previous
members reported that they could not afford the premium/registration fees. This
raised serious equity and exclusion concerns in the NHIS enrolment even in the face
of the exemption package.
Awareness of the NHIS was clearly high among the populace as 73 percent of the
household members in the survey had registered with the NHIS since its inception in
2003. However, it seemed many people did not understand the principle of health
insurance. The level of knowledge of respondents to a large extent informed the
decision of whether or not to enrol with the NHIS. The results showed that the never
insured generally had a negative perception of the NHIS. They generally felt that
health insurance was meant for the poor and the sick. This suggested that the never
insured had limited social capital with 41 percent of the adult household members
reporting to belong to a social organisation compared to 34 percent of the never
insured.
Physical inaccessibility to health facilities remains a major barrier to health care in
Ghana. There is generally unequal access to social services such as health care,
education, water, and sanitation between rural and urban areas. This can affect the
decision to enrol with the NHIS. Indeed some of the never insured complained of the
long distances to the nearest NHIS registration centres.
8.
RECOMMENDATIONS
Although the NHIS has attained noteworthy achievements in providing health care to
Ghanaians, especially the poor and vulnerable groups, there is still the major
challenge of extending coverage to various population segments which are currently
excluded. Therefore based on the findings, the following recommendations are made:
1. There is the need to undertake extensive educational and public awareness
programmes to improve the perception of the NHIS, thereby forging a more
receptive public opinion towards the scheme. This can be done through the use
of promotional materials via mass media so as to disseminate information
about the scheme.
2. Informal sector workers should be further encouraged to participate in the
NHIS. This will not only ensure a higher coverage rate, but also improve the
financial viability of the scheme. To do this, it is required that the
administrative capacity of the NHIA be strengthened so as to improve the
procedural mechanism of registering and issuing membership cards to targeted
groups.
3. The benefit packages must be revised and updated according to the demand
for health care, as well as affordability of the participants and the NHIS fund.
Considering specific benefits to accommodate different needs of different
members (e.g., children, elderly people and the extremely poor) will ensure
effective uses of limited resources.
60
REFERENCES
Agyepong I.A., Arhinful D., Oppong-Peprah C., Attuah Ntow A. & Baltussen R.
2007 Research agenda to support national health insurance policy and program
development in Ghana, February, Accra: MoH.
Aryeetey, G. & Harrigan, J. (2000). Macroeconomic & sectoral development since
1970. In E. Aryeetey, J. Harrigan, & M. Nissanke (Eds.), Economic Reforms in
Ghana: The Miracle and the Mirage (pp. 344-365). Oxford: James Currey.
Asante F., and Aikins M., (2008), Does the NHIS cover the poor? Danida Health
Sector Support Office paper
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:
181–188.
Atim, C., Grey, S., Apoya, P., Anie, S., Aikens M. (2001). A Survey of Health
Financing Schemes in Ghana. Patners for Health Reformplus, Abt Associates Inc.
Bethesda
Coleman, N.A. (1997) "The Uneven Implementation of user Fee Policy in Ghana"
Reseach Paper No. 138 Boston: Harvard School of Public Health.
de-Graft Aikins, A. 2005. “Healer-shopping in Africa: new evidence from a ruralurban qualitative study of Ghanaian diabetes experiences”. British Medical Journal;
331, 737.
-------- 2007. “Ghana’s neglected chronic disease epidemic: a developmental
challenge”. Ghana Medical Journal, 41:154-159.
Ghana National Health Insurance Authority (2008), National Health Insurance
Authority Status Report: Operations, Accra, Ghana National Health Insurance
Authority.
Ghana Statistical Service (2009); Ghana Demographic and Health Survey 2008.
Accra, Ghana.
Ghana Statistical Service. (2008). Ghana Living Standards Survey: Report on the
Fifth Round, Accra.
Government of Ghana, Ghana Health Service. 2007. 'Ghana Health Service: Annual
Report'. Accra: Government of Ghana.
61
Gyapong, J., Garshong, B., Akazili, J., Aikins, M., Agyepong, I. and Nyonator, F.
2007. 'Critical Analysis of Ghana's Health System with a focus on equity challenges
and the National Health Insurance'. SHIELD Workpackage 1 Report.
Hutchful, E. (1989). From "revolution" to monetarism: The economics and politics of
the adjustment programme in Ghana. In B. Campbell & J. Loxley (Eds.), Structural
Adjustment in Africa (pp. 122-123). London: Macmillan.
Jehu-appiah, C., Aryeetey, G., Spaan, E., Hoop, T. De, Agyepong, I., & Baltussen, R.
(2011). Equity aspects of the National Health Insurance Scheme in Ghana : Who is
enrolling , who is not and why ? Social Science & Medicine, 72(2), 157–165.
doi:10.1016/j.socscimed.2010.10.025
Jehu-Appiah C., et al. (2011); Household perceptions and their implications for
enrolment in the National Health Insurance Scheme in Ghana. Health Policy and
Planning 2011;1–12.
Mensah, J., Oppong, J.R., and Schmidt, C.M. (2010). “Ghana’s National Health
Insurance Scheme in the Context of the Health MDGs: an Empirical Evaluation Using
Propensity Score Matching”. Health Economics. 19: 95-106.
Ministry of Health. (2011). The Health Sector Medium-term Development Plan 20102013. Accra: Ministry of Health of Ghana.
National Health Insurance Authority. Annual Report, 2009. National Health Insurance
Authority, Accra. 2009.
NDPC (2009), 2008 Citizens Assessment of the National Health Insurance Scheme.
Accra, Ghana.
Nyonator F & Kutzin J (1999) Health for some? The effects of user fees in the Volta
Region of Ghana. Health Policy and Planning 14, 329–341.
Sarpong, N., Loag, W., Fobil, J., Meyer, C. G., May, J., & Schwarz, N. G. (2010).
National health insurance coverage and socio-economic status in a rural district of
Ghana. Tropical medicine & international health : TM & IH, 15(2), 191–197.
doi:10.1111/j.1365-3156.2009.02439.x
Seddoh, A., Adjei, S., and Nazzar, A. (2011), Ghana’s National Health Insurance
Scheme, New York; Rockefeller Foundation.
SEKN (2008). Understanding and tackling social exclusion. Final report to the WHO
Commission on Social Determinants of Health from the Social Exclusion Knowledge
Network. Geneva, World Health Organization
(http://www.who.int/social_determinants/knowledge_networks/
final_reports/sekn_final%20report_042008.pdf, accessed 23 December 2012).
UNDP Ghana office (2007), The Ghana Human Development Report 2007; towards a
more inclusive society. Accra, Ghana.
62
Waddington CJE & Enyimayew KA (1989) A price to pay: the impact of user charges
in Ashanti-Akim district Ghana. The International Journal of Health Planning and
Management 4, 17–47.
World Health Organisation, 2010, Health Systems Financing. The path to universal
coverage, World Health Report
63
ANNEX
1. SPEC FRAMEWORK: DIMENSIONS, DOMAINS, VARIABLESAND INDICATORS
Domains
Variables
Indicators
Remarks
1. Social Dimension
"The social dimension is constituted by proximal relationships of support and solidarity (e.g. friendship, kinship, family, clan, neighbourhood,
community, social movements) that generate a sense of belonging within social systems. Along this dimension social bonds are strengthened or
weakened."
Variable
1:
1.
Urban
/
Rural
split:
Levels of crime and violence:
Social
Rates of homicides, of criminal activities. Some
• Share of urban/rural dwellers - % URBAN
discrimination Territorial
discrimination
and deprivation
2.
3.
4.
Variable 2: Social
markers /
drivers of social
exclusion
5.
• Currently insured =57.6; Previously insured = 54.8; Registered
but yet to get card = 43.3; Never insured= 42.0
• Rural exodus trends
Northern/Southern Ghana split
• North-south exodus
Informal settlement / formal settlement/illegalsettlements/illegal
miners
• % population living in slums
Environmental insecurity
• Self assessed feeling of insecurity related to environmental causes.
E.g. Residents in drought and flood prone communitiescommunities in the volta basin
Gender:
•
•
•
•
Gender Development Index (GDI)
Gender Empowerment Measure (GEM)
Incidence of gender based violence
Gender roles
information can be obtained for the national level or
regional crime/violence rates though this will be
difficult to do.
5. Gender unemployment rates in the country
In Ghana the GDI is a composite index of adult literacy,
gross enrolmentrate and estimated earned income
rates by gender (gender dimensions of development).
This is used in the Ghana Hunan Development Report
of 2007
The GEM measures gender inequalities in
64
•
Variable 3:
Social capital
Stigmas related to gender, especially in regard to access to health
care
6. Aging:
• Age structures :Mean age (All HH members) in years
• Currently insured =24.9; Previously insured = 25.7; Registered
but yet to get card =19.6; Never insured=23.9
• Stigma related to aging, especially in regard to access to health
care
7. Prevalence of specific health conditions:
• Prevalence rates for chronicle diseases (Diabetes, hypertension:
All HH members)
• Currently insured =4.9; Previously insured = 3.5; Registered but
yet to get card =1.5; Never insured=1.7
• Prevalence rate for "shameful" diseases (HIV/AIDS, Contagious
diseases such as Cholera)
8. Stigmas related to specific health conditions:
9. Physical impairs:
• Disability rates
• Perceptions on disability (discrimination - stigma - segregation
practices...)
10. Mental health:
• Prevalence of mental sicknesses
• Perceptions on mental disorders (discrimination - stigma segregation practices...)
11. Social network analysis:
•
empowerment
economic participation,political participation,
decision-makingand power over economic resources
(Secondary national data e.g. census data, DHS data,
GLSS data)
6. Enrolment figure of the aged in the NHIS can be
explored to identified the characteristics of the
exclude
7. Health facility based data will help identified these
indicators to supplement data from t he household
survey
Number of social organizations persons belong to
Mapping of social ties and interactions (personal social network -
65
group social bounds) - % belonging to a social organization-SPEC
• Currently insured =41; Previously insured =44; Registered but
yet to get card =43; Never insured=34
Variable 4: Social
participation
12. Participation in common social activities:
• Attendance to social ceremonies and functions - % that could not
attend a social event they had wanted to participate in the
community-SPEC
Currently insured =28.2; Previously insured =27.5; Registered
but yet to get card =30.5; Never insured=26.4
% unable to attend due to lack of money
Currently insured =33; Previously insured =47; Registered but
yet to get card =46; Never insured=52
• Attendance to religious functions - % attending once a week-SPEC
• Currently insured =29.1; Previously insured =30.1; Registered
but yet to get card =26.4; Never insured=26.9
• Attendance to community celebrations (e.g. funerals, outdoorings)
13. Social roles:
• Percentage of people who played a social role in the previous year
(if any is offered) as group leader, religious leader, social
organizer…
• Mean number of time spent for social or community work last year
(voluntarism)
14. Social support:
• Participation in preexisting solidarity mechanisms and systems (if
any - e.g. funerals, wedding)
Reliance on networks' support
• Percentage of household expenditure on social transfers, gift…
Assess through the household survey. A composite
index can be developed
66
15. Sense of solidarity:
Community reactivity to social events (burials, sickness episode)
Perceptions on levels of solidarity
Political dimension
"The political dimension is constituted by power dynamics in relationships which generate unequal patterns for both formal rights embedded in legislation, constitution, policies
and practices and the conditions in which rights are exercised - including access to safe water, sanitation, shelter, transport, power and services such as health care, education and
social protection. Along this dimension, there is an unequal distribution of opportunities to participate in public life, to express desires and interests, to have interests taken into
account and to have access to services."
Political
resources
Variable 5:
Access to
educational
opportunities
16. Access to formal education
• Adult literacy rate
• % of people over 15 years of age who have not completed primary
school by district/region/residence
• mean years of schooling
• Net primary education enrolment rate (by
gender/region/district/wealth)
• % of over 15 years of age who and read and write
• Early school drop-out rates (drop out among respondents and
dependents before completion of primary / secondary education)
• Causes for drop out
• State expenditure per student in public education system compared to
upper middle income family expenditure per student
17. Educational environment and conditions
• Presence of qualified sibling in the environment (%)
• Distance in time to the closest school for each person in schooling age
(minutes)
• Day care/nursery: Currently insured =9.8; Previously insured =11.7;
Registered but yet to get card =10.3; Never insured=12.7
• Public primary school: Currently insured =10.3; Previously insured
=11.1; Registered but yet to get card =8.6; Never insured=13.0
• Private primary school: Currently insured =22.5; Previously insured
=25.4; Registered but yet to get card =33.6; Never insured=32.4
• Junior high school: Currently insured =13.8; Previously insured =16.3;
Registered but yet to get card =20.5; Never insured=20.0
16. National indicators for measuring access to
education and literacy exist for tracking progress
in achieving the MDG 2 of achieving universal
primary education
- Net primary enrolment ratio (%)
- Gross primary enrolment ratio (%)
- Net attendance ratio in primary school (DHS)
- Literacy rate of 15-24-year-olds (youth
literacy rate)
- The Gender Parity Index: Ratio of girls to
boys in primary school; Ratio of girls toboys
in secondary school
Both secondary data and primary data from the
household surveys can gather enough data on
education.
67
•
Senior high school: Currently insured =35.8; Previously insured =36.9;
Registered but yet to get card =44.1; Never insured=44.1
•
Lighting opportunity for homework-% that finds it very difficult or
difficult
• Currently insured =24.4; Previously insured =28.3; Registered but
yet to get card =35.8; Never insured=35.1
18. Access to other capacity and life long learning opportunities
• % of enrolment in adult literacy programs
• % of enrolment in other empowerment programs
Variable 6:
Access to health
Objective indicators
19. Outcomes
• Life expectancy, If available probability at birth to exceed 40 years
old, ventilated by risk factors: gender, income quintiles…
• Maternal mortality rate
• Infant mortality rate
Under 5 mortality rate
BMI measurement
20. Access
• Share of children under 1 year of age who have been immunized
against the three most relevant diseases in each site
• Institutional delivery rate (delivery attended by specialized health
care personnel)
• Distance to primary health care (essential package)
•
Disaggregate by residence/region/district where
applicable.
Secondary data from the Ministry of Health/Ghana
Health Service-facts and Figures will address these
indicators
% of population who are more than 60 minutes for the nearest
health facilities
• Regional hospital: Currently insured =60; Previously insured =57;
Registered but yet to get card =54; Never insured=63
• District hospital: Currently insured =20; Previously insured =17;
Registered but yet to get card =26; Never insured=29
68
•
•
•
•
•
•
Variable 7:
Access to decent
housing dwelling
precariousness
• Public health centre: Currently insured =5; Previously insured =4;
Registered but yet to get card =1.4; Never insured=6
• Licensed chemical store: Currently insured =3.3; Previously
insured =1.8; Registered but yet to get card =1.4; Never insured=4.9
Distance to complementary package of care (e.g. district/regional
hospitals
% of population in households which agree that the public health care facility
closest to the household is easy to reach
• Currently insured =76.3; Previously insured =74.1; Registered but
yet to get card =72.4; Never insured=60.7
Medical personnel-population ration by district/region
Quality of health care available
% of population in households which agree that the quality of services
delivered at public health facility closest to the household is good
• Currently insured =72; Previously insured =71; Registered but yet to
get card =74; Never insured=59
Cost of recent illness, household expenditure on health for a period
21. Subjective indicators:
• % in poorest quintile who self reported bad health (/ good health) /
• % in the richest fifth that reported bad health (/ good health)
• Perception of the health services (satisfaction and quality,
accessibility (psychological and physical),...)
• Underlying values of health staff professionals (central role of money)
22. Dwelling precariousness
• Average space per individual in the HH
• Number of rooms per person (mean)
• Fully insured HH = 0.7; Partially insured HH= 0.4; Uninsured
National data (DHS, GLSS, MICS, CWIQ)
disaggregated by rural/urban, districts, region
Primary data from household surveys
HH=0.6
•
% of makeshift dwelling (roofing, building materials…)
69
•
•
•
% of dwelling with access to electricity / power
Main source of lighting for dwelling: % electricity
• Fully insured HH = 78.4; Partially insured HH=67.2; Uninsured
HH=60.1
Main source for cooking: % Electric/LPG/Biogas
• Fully insured HH = 12.5; Partially insured HH=6.3; Uninsured
HH=3.3
•
23. Sustainable access to safe water supply
• % of the population with access to improved sources of water
• Fully insured HH = 96.5; Partially insured HH=93.2; Uninsured
HH=91.2
•
% of the population with access to at least 20 liters of water per day
per capita within a 30 min walk distance
• Time spent per day to fetch water
• Cost of water per household per month
• Number of months in the year without access the regular source of
water
24. Access to decent standards of sanitation
• % of the population with access to improved toilet facilities
• Fully insured HH =56.7; Partially insured HH=47.1; Uninsured
HH=44.8
Variable 8:
Access ot
transport
infrastructures
and services
• % of people with access to latrines within a reasonable distance
• Incidence of water borne disease in the target areas
25. Access ot transport infrastructures and services
• Distance to the closest tarmac road (in minutes)
• Currently insured =19; Previously insured =19; Registered but yet to
get card =23; Never insured=26
•
Distance to the nearest all-seasoned road (in minutes)
• Currently insured =10; Previously insured =9; Registered but yet to
get card =15; Never insured=10
70
•
Distance to the nearest place with daily bus /taxi
services (in minutes)
• Currently insured =10; Previously insured =11; Registered but yet to
get card =13; Never insured=12
• % of population in households which finds it very difficult or difficult to get
a reliable means of transport to the district capital
• Currently insured =26; Previously insured =28; Registered but yet to
get card =44; Never insured=44
Variable 9:
Access to
administrative
services
Variable 10:
Numerical
fracture
• Traffic accident incidence/mortality rates (regional/national level)
•
26. Access to administrative services
• Distance to the local headquarters - to district capital (in minutes)
• Currently insured =39; Previously insured =41; Registered but yet to
get card =45; Never insured=52
• Index of corruption (subjective and objective levels of corruption)
• Perception of availability and accessibility of public servants (including
corruption)
• Perception of the performance of district level political/administrative
structures
• % that is extremely or very satisfied with:
• Local government: Currently insured =48.5; Previously insured
=46.5; Registered but yet to get card =53.9; Never insured=49.3
• National government: Currently insured =49.8; Previously insured
=50.4; Registered but yet to get card =52.2; Never insured=55.9
27. Numerical fracture
•
•
Quality of phone and internet network coverage
Number of working mobile phones in the household currently (mean)
• Currently insured =1.6; Previously insured =1.4; Registered but yet
to get card =1.3; Never insured=1.3
•
% of people owning a cellphone in household
71
•
•
Variable 11:
Access to social
assistance /
social protection
Political and civic
participation
Variable 12: Civic
participation and
efficacy
Variable 13:
democratic
participation
% of children using computers at school
% of children accessing internet at school
28. Access to social assistance / social protection
• Policy analysis - framing process and identification of the underlying
SPEC during the policy design process
• Enrolment rates among eligible (registration)
• Leakage in enrolment (false positive)
• Administrative effectiveness
• Actual access to services / Access to benefits: utilization of health
services
• Identification of other social assistance programs that can influence
enrolment and outcomes of social protection in health
• Social representation attached to enrolment in social assistance
programs
29. Civic participation and efficacy
• Empowerment - knowledge of democratic rights and duties
• People' perception of their fellow citizens' awareness of their
obligations and duties
• Administrative registration rate: birth certificate
• Enrollment in Trade unions, associations, groups, NGOs, faith based
groups…
• Role of groups, NGOs.. into the political framing process (lobbying,
advocacy)
30. democratic participation
• Empowerment - knowledge of democratic rights and duties
• Participation in the elective process (national, local) - voter enrolment
and turnout
• Participation in the community governance bodies - in local
government structures
• Gastill democracy index based on political rights and civic liberties
- Assess the criteria for inclusion into the Livelihood
Empowerment Against Poverty (LEAP) programme
- Coverage of the School capitation grant
- Coverage of the school feeding programme
- NHIS exemption categories
Assess this indicator in January 2012 can be
sensitive due the impending general elections.
72
•
Preference of democracy over other political systems
31. Social justice and Civil liberties
A composite index can be developed based on the
indicators in the master SPEC table.
Economic Dimension
"The economic dimension is constituted by access to and distribution of material resources necessary to sustain life (e.g. income, employment, housing, land, working
conditions, livelihoods, etc)."
Material and
Variable 14:
32. Income poverty
Poverty measures in the MDGs:
Income poverty
economic
- Prevalence of underweight children under 5 years by
• Income (consumption) ($)
resources
• Poverty headcount ratio at $1.25 a day (PPP), national, rural and
region/district
urban poverty lines (% of population)
- % population in overall poverty
• Poverty gap at $1.25 a day (PPP), national, rural and urban poverty - % population in extreme poverty
lines (%)
• Persistent at risk of poverty rate
Variable 15:
HH can be categories based on wealth quintiles
• Physical and financial assets:
Physical and
• Ownership of property/Housing
through factor analysis. Analysis on
financial assets
• If HH owns at least one of radio, TV, telephone, bike, or motorbike
gender/residence/district can be performed.
• Landholdings per acre per household
• Savings; ownership of other liquid assets
• If individual/HH has a bank account
• Access to other credit (formal and informal)
• Level of debt
Variable 16:
33. Income inequality
Income
• Poverty gap squared
inequality
• Proportion of income/consumption in poorest quintile
• Gender inequality gap
• Gini coefficient
Variable 17:
34: Hunger
MDGs; Multidimensional poverty index
Hunger
• Prevalence of underweight children under-five years of age
• Proportion of population below minimum level of dietary energy
consumption
73
Economic
participation
Variable 18:
Social welfare
Variable 19:
Employment
34. Social welfare
• % labour force claiming unemployment benefits
• % of labour force claiming disability benefits
35. Employment
• Long term unemployment rate
• % unemployed
• % of people employed in informal sector
• Proportion of people employed in informal sector living below
$1.25 (PPP) per day
• Share of school children and working age adults living in a jobless
household
• Children in harmful jobs
• Subjective measurement of satisfaction of carers/stay-at-home
parents
• Employment gap of immigrants
• % of people employed earning below minimum wage
This will be difficult to measure in Ghana due to
inadequate data on unemployment.
Cultural dimension
"The cultural dimension is constituted by the extent to which diverse values, norms and ways of living are accepted and respected. At one extreme along this dimension
diversity is accepted in all its richness and at the other there are extreme situations of stigma and discrimination"
Human
Variable 20:
36. Values
behaviour
Values
• Disapproval/approval of single mother
• Rating of priority government should give to reducing poverty
• Rating on if governments should provide benefits for unemployed,
disabled
• Rating of how important family, friends, religion, work, politics are
in life.
• Ranking of importance of attributes (e.g. hard work, tolerance,
respect etc.
74
Cultural
participation
Variable 21:
Beliefs
37. Beliefs
• Rating of whether violence against women is acceptable
• Rating of agreement with statement: when jobs are scarce, men
should have more right to a job than women?
• Rating of agreement with statement: when jobs are scarce,
employees should hire (own nationality) before immigrants?
• Rating of beliefs on why people are poor
• Rating of whether people should be able to practice religion freely.
Variable 22:
Norms
38. Norms
• Rating of whether premarital sex is acceptable for women; Rating
of whether premarital sex is acceptable for men
• Rating of whether women should dress conservatively
• Rating of whether homosexual relationships should be (i)legal
• Rating of whether premarital sex is acceptable for women; Rating
of whether premarital sex is acceptable for men
• Rating of whether homosexual relationships should be legal
Variable 23:
Traditional
Practices
39. Harmful traditional practices
• Age of marriage
• Widowhood rites performances
• Child betrothal
• Forced marriages
• Female genital mutilation (FGM)
• Traditional practice of ritual bondage of virgins
• Rating on treatment/handling of perceived witches (e.g. witches
camps in northern region of Ghana).
40. ???
Variable 24:
Language
DHS 2008 has issues on domestic violence. From the
ratings composite indexes of could be developed.
Asking questions about domestic violence however
have ethnic consideration also require special training
as noted in DHS 2008.
% of women and men experiencing domestic violence
during a period
% of children experiencing domestic/physical
violence during a period
% of women and children experiencing of sexual
violence
Issues relating to local languages may not be a major
issue of exclusion though ethnicity can be a cause.
75
Variable 24:
Cultural
activities
Variable 25:
Media visibility
41. Cultural activities
• The percentage of the population within 20 mins travelling time
(urban - walking, rural - car) of a sports facility, cinema or art
gallery.
• Number of hours spent in cultural groups
• Value placed on relationship between arts and culture and
personal and community development
• Number of cultural heritage sites
42. Media visibility
• The number of hours of mainstream TV or radio programmes that
are dedicated to minority group programming
• Number of radio stations accessible to members of household (mean)
• Currently insured =2.5; Previously insured =2.1; Registered but
yet to get card =2.2; Never insured=1.6
• Number of radio stations accessible to members of household (mean)
• Currently insured =2.5; Previously insured =4.0; Registered but
yet to get card =3.5; Never insured=3.6
•
The importance of some of these indicators will be
difficult to assess. People’s main concerns in some of
these areas are butter and bread issues. High level of
ignorance/illiteracy may make it difficult for people to
appreciate the importance of cultural participation.
People may identify themselves with festivals in the
localities/districts.
Multiplicity of TV stations but coverage is limited to
specific locations. More than 200 fm radio stations
across the country with localised programmes.
76
2. SPEC Step-by-Step: Ghana
Step 1:
Targeted
population
All persons resident in Ghana other than the Armed forces of Ghana and the Police service are required to belong to a health insurance scheme [VOLUNTARY
MEMBERSHIP]
TYPE
Step 2:
Never
insured
Voluntary exclusion
[decided not to be
members]
Socially excluded
(unreached)
WHO?
•
•
How??
• Ability to pay
cash at private
facilities
• Workplace
schemes
• Lack of trust
• Lack of
attractiveness to
NHIS
• Less risk averse
1. Economic
Rigid payment
system
a. Rural agric producersmigrant farm labourers &
• Premium is
settlers, food crop
inflexible
producers, traditional
• Inconvenient
fishermen
timing of
b. Seasonal labourers/workers premium
c. Underemployed &
payment-during
unemployed persons
lean season
d. The youth without
• Location of
employable skills
registration
e. Groups negatively affected
centres-distance
by the ERP/SAP in the 1980s places
/90
• Not
f. Ignorant and less educated
understanding
about the scheme
the insurance
2. Gender & culture
principle of risk
WHY? [SPEC]
Social
Political
Economic
Cultural
• Weak social welfare
system
• Lack of participation
and dialogue among
social groups
• Disintegration of the
extended family
system
• Unequal gender
relations
• Lowlevels of education
• Lack of trust in
governance structures
• Perceived corruption
• High levels of deprivation/
inequalities: Rural/urban of
Ghana, Northern/Southern
Ghana (poor educational,
health, transport
infrastructural facilities, limited
access to information,
inadequate health
professionals, etc.)
• Colonial development policiesschools, railways, roads to
mining centres, cocoa
producing areas, etc
• Unequal distribution of
national resources due to
limited political participation of
certain groups
• Resource
degradation/ limited
access to productive
resources e.g. land,
irrigation facilities,
storage facilities,
etc.
• Long term
unemployment
• Low incomes/wages
• High levels of
vulnerability/
poverty(more than
60% of social
exclusion in Ghana
is due to poverty,
UNDP 2007)
• Lack of social
capital
• Weak social
support
system/low level
of solidarity
• Cultural norms of
discrimination/
ethnocentrism/
nepotism
• Harmful
Young and old adults
Self perceived healthy
adults
• Rich
• Formal sector employees
with other alternatives
traditional
practices
• Uncertain
reprocity
77
a. Chn. In difficult
circumstances-e.g. street
chn/child migrants, sch.
drop-outs, OVCs, orphans,
Victims of abuse-women
&chn.
b.Victims of harmful
traditional practiceswidows, witches camp
inmates, ‘trokosi victims’
c. Disadvantaged womenteenage mothers, poor
single mothers, family
head potters & their chn,
d.Elderlybelow 70 years
without support
e. Female headed
households
f. Ex-convicts
g. ‘Indigents’
3.People with poor health
a. People with certain
chronic diseases-PLWAs,
TB, leprosy, mental health
b. People with disabilities
with no employable skills
4. Spatial disparities
a. rural dwellers
b.Urban slum dwellers
c. People in displaced
communities / areas of
decline economic activities
d.People in difficult
environmental conditionsdrought, floods, poor soil
fertility
e. People who are
sharing
• Lack of trust
• Ignorance of the
scheme-lack of
relevant and
timely
information on
benefits and
exemptions
packages of NHIS
• Exclusion of
certain diseases
considered to be
too expensive
• Low government spending in
Ghana on social programmes
for poverty reduction
• Unreliable data on poverty and
vulnerability
• Lack of monitoring, evaluation
and learning mechanisms to
track progress
•
• Low productivity
levels
• Unfavourable trade
agreements
(e.g.cotton farmers,
local rice farmers)
78
geographically isolated‘overseas’ areas of
northern Ghana,
Onchocerciasis areas, etc.
Step 3:
Voluntary exclusion
Previously
insured (but
has not
renewed
registration,
withdrawal
from the
scheme)
Socially excluded
Step 4:
Socially excluded???
Registered
but yet to
•
•
•
•
Healthy
Rich
Youth
Males in general
• Lack of trust
• Not satisfied with
previous service
• NHIS not
addressing needs
• Non use of
services during
previous
registration
•
•
•
•
• High
renewal fees
• High penalty
payments
• Lack of trust
• Poor staff
attitude
•
•
•
•
•
•
•
•
•
Poor
Rural dwellers
Urban slum dwellers
Street chn/chn out of
school
Less educated/illiterates
Unsupported widows
Poor single mothers
Poor informal workers
Chn from large households
Unemployed
Illiterate/less educated
Rural dwellers
Low income groups
• Long distances to
card collection
centres (difficulty
in accessing
services)
SAME AS ABOVE
•
Systemic factors affecting the
scheme-technological
challenges,administrativeprobl
ems / operational challenges–
over concentration of activities
79
received ID
card
Step 5:
Currently
insured
(Valid card
holders)
But..
Non claimers
(not using available
services)
• Chronic illnesses not
covered
• Remote dwellers
• Pregnant women
preferring home delivery
• Patients preferring
traditional/spiritual care
• Ignorance
Non-users
• Poor
(benefits
notprovided/received) • Women
• Rural dwellers
• Fraud on the part
of agents of NHIS
(e.g. failure to
register clients
after collecting
their monies)
• Long waiting time
for cards
• Lost cards
• Partial
registration
• Long distances to
access care
• Limited
knowledge on
the operations of
NHIS
• Other indirect
cost of care
• longer waiting
times at facilities
• Perceived quality
of care
• Unfriendly
hospital
environment
• Shortage of
approved
drugs/supplies at
facility
• Servicesrequired
not available at
level of facility,
especially at
in Accra
• Gender relations e.g.
the need to seek
approval/obtain
consent?? from
one’shusband before
seeking care from a
facility in certain
societies
• Illiteracy/ignorance
among scheme
members
• Strike actions by health care
workers???
• Inadequate health
facilities/personnel
• Unfriendly attitude of service
providers
• Politicisation of NHIS
operations
• supply-side constraints i.e.
quality of health personnel
training and management,
including responsiveness to
health facility users
•
•
• Poverty
• High indirect cost of
care
• Cultural beliefs
(i.e. the perception
among certain
groups that only
unfaithful and
weak women
delivery in
hospitals)
• Power influence of
spiritual leaders on
their followers
Undue delays in
reimbursement of claims to
facilities which tends to
affect service provision
Complains about low tariffs
paid to service providers by
the NHIA
80
primary level of
care
• Weak referrals
system
81
`