# Household perceptions and their implications for enrolment in the National Health Insurance Scheme in Ghana

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4 4 HEALTH POLICY AND PLANNING Third, we calculated the percentages of the maximum attainable scores for each item of the factors that resulted from the factor analysis, in order to rank them according to their relative importance (see Table 5). The percentages of the maximum attainable scores were calculated in the following way: in a scale of 1 to 5, from strongly disagree to strongly agree, we multiplied the responses for each grade in the scale by their corresponding grades (1, 2, 3, 4 and 5) to get the scores. Then we multiplied the sum of the responses by the maximum grade (5) to get the maximum score. We then divided the sum of the score by the maximum score to get the percentage of the maximum attainable score. Finally, we ran a multinomial logistic regression to determine the association of identified perception factors with household decisions to enrol and remain in the NHIS. We controlled for socio-demographic and economic characteristics with recourse to relevant knowledge and past health insurance demand studies (Kirigia et al. 2005; Liu et al. 2009). The dependent variable was the household s insurance status: insured, previously insured and uninsured. Results Descriptive summary characteristics The sample population of individuals is young; the average age is 25 years with children under 18 representing 49% of the sample (Table 1). The mean household size is 5.6, 52% are female and 67% of all individuals are in some form of employment. Education measured by total years of schooling is low at a mean of 7 years. The mean monthly individual income is GH (US\$29). The average annual cost of premiums per individual is GH (US\$9.00) and registration fees GH 3.00 (US\$2.00). Thus the estimated cost of individual enrolment would account for 3% of annual individual income. Socio-demographic characteristics of household heads reveal an average age of 46 years, 35% are female headed, 64% are married, 26% have no education, 90% are employed and most perceived themselves to be relatively healthy (74%). The mean monthly household income and expenditure is GH (US\$121.00) and GH (US\$141.00), respectively. Inaffordability of premiums was cited as the most common reason for not enrolling (72%) and not renewing membership (61%). Table 1 Descriptive characteristics at individual and household level Summary means Mean (SD) Individual Age (years) 24.5 (19.6) Total number years of schooling 7.0 (3.9) Sex, female (%) 52.2 Age <18 years (%) 49.2 Married (%) 29.2 Employed (%) 67.0 Urban (%) 40.6 Monthly income a 43.7 (115.3) Household b Sex, female (%) 35.0 Age of household head (years) 46.0 (15.5) Household size 5.6 (2.5) Urban (%) 40.6 Married (%) 64.0 Good health status (%) c 74.0 Education (%) None 25.7 Primary 22.0 Secondary 43.0 Tertiary 9.4 Home ownership (%) Inherited/rent free 42.0 Rented 28.0 Owned 30.0 Employment (%) Farmer/fisherman 37.0 Casual worker 5.7 Self/govt employed 47.0 Unemployed/students 10.0 Monthly income a 182 (211.62) Monthly expenditure a 212 (212.58) a Ghana cedis (US\$1 ¼ 1.5 GH ). b Total of 3301 households interviewed. c Self-perceived health status. Understanding of NHIS and reasons for enrolling, not enrolling and not renewing membership All respondents had an equal understanding of NHIS, irrespective of their insurance status. Whereas the majority (58 62%) regards insurance as prepayment for health care, a somewhat smaller proportion considers it as free health delivery by the government. This is not surprising given the political nature and campaign slogans under which insurance was introduced in Ghana (Table 2). Accordingly, financial protection against illness was cited as the main reason they enrolled in the first place (Table 3). There is a 16% drop out rate from the NHIS and the main reason for not renewing membership was being unable to afford renewal payments (67%). Six per cent were not satisfied Table 2 Understanding of NHIS Understanding of NHIS Insured % Previously insured % Prepayment for health care Like regular insurance Paying tax to government Free health delivery by government Source: Household survey Pearson chi-square (0.02). Uninsured %

7 PERCEPTIONS OF THE NHIS IN GHANA 7 Table 7 Score ranking Ranking scores All SD Insured Uninsured Difference (n ¼ 3295) (n ¼ 1461) (n ¼ 1834) Technical quality of care Treatment is effective for recovery and cure The quality of drugs is good The provider makes a good diagnosis The doctors do a good clinical examination I can get immediate care if I need it Total Service delivery adequacy There are sufficient good doctors The doctors for women are adequate The medical equipment is adequate The rooms are adequate Total Benefits of NHIS Will save money from paying hospital bills Will not need to borrow money to pay for hospital care Joining the scheme will benefit me Total Convenience of NHIS The district scheme office location is convenient The district scheme office opening hours are convenient The collection of insurance cards is convenient Total Price of NHIS The premium for the package is too high The registration fee is too high Total Provider attitude Attitude of health staff should be improved Availability of drugs should be improved Total Peer pressure Opinion leaders in my community affect my decision to enrol Experience of others with health insurance affects my decision to enrol Total Community health beliefs & attitudes Health is a matter of fate (in the hands of God) and insurance cannot help me deal with its consequences Buying insurance may bring bad luck and illness Total efforts to improve enrolment and retention should focus on these factors. Our findings are in contrast to previous qualitative research that cites quality of care as most important (Criel and Waelkens 2003; Dong et al. 2009). It may be that these differences are related to differences in quality of care and/or client expectations or both in these different study settings. At the same time, households hold both positive and negative perceptions relating to providers and community attributes, and these also merit attention to improve overall satisfaction with health care service delivery and the NHIS. Below, we proceed to further interpret these findings in detail for each of the three main stakeholders: schemes, providers and communities.

9 PERCEPTIONS OF THE NHIS IN GHANA 9 Table 8 Effects of identified perception factors on NHIS enrolment Predictor variables Insured Previously insured B (SE) 95% CI for Odds Ratio B (SE) 95% CI for Odds Ratio Lower Odds Ratio Upper Lower Odds Ratio Upper Constant 5.07*** 3.25*** Household characteristics Education Primary Junior secondary 0.59*** ** Senior secondary 0.95*** *** Technical 0.13*** *** Tertiary 1.79*** *** Religion Christian 1.00*** *** Muslim 0.94*** Traditional Socio-demographics Sex (female) 0.59*** *** Marriage (married) Age 0.04*** *** <5 years years 0.73*** >70 years 1.01*** Urban residence 0.59*** *** Household size 0.05*** Expenditure (log) 0.28*** Health status (self perceived) Good health Poor health Employment Farmer Fisherman Artisan Trader Clerical *** Managerial 1.07*** Professional Perception factors Quality of care Facility adequacy Benefits of NHIS 0.60*** *** Convenience of NHIS 0.18*** ** Price of NHIS 0.18*** Provider attitude Peer pressure 0.10*** *** Community beliefs Likelihood ratio test 786*** Reference category Uninsured Pseudo R 2 (Cox & Snell) Pseudo R 2 (Nagelkerke) Notes: ***P < 0.05; **P < 0.0. Dependent variable (1 ¼ Insured, 2 ¼ Previously insured, 3 ¼ Uninsured).

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