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“ “ Towards a client-oriented health insurance system in Ghana” Some key findings NHIS 10th Anniversary Conference 5th November, 2013 Accra, Ghana. Edward Nketiah-Amponsah Stephen Duku Christine Fenenga Robert Kaba Alhassan

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“Towardsa client-oriented health insurance system in Ghana”SomekeyfindingsNHIS 10th Anniversary Conference 5th November, 2013Accra, Ghana

Edward Nketiah-Amponsah

Stephen Duku

Christine Fenenga

Robert Kaba Alhassan

Tobias Rinke de Wit, Inge Hutter, Menno Pradhan, Daniel Arhinful

NHIS 10th Anniversary Conference


Background
Background

  • Key question of this project derived from NHIS:

    2010 enrolment about 64% , active membership 34%

    Retention problem => what are the barriers?

  • Anecdotal information and growing empirical evidence showing differences in enrolment rate among the population (Asante & Aikins, 2008)

  • This RCT project is a joint initiative between NHIA, GHS, CHAG and other health partners and the University of Ghana and 3 Universities in The Netherlands with an initiation workshop in 2011

  • Funded by the Global Health Policy and Health Systems Research Fund 2010 of the Dutch Scientific Organization NWO-WOTRO

NHIS 10th Anniversary Conference


Main objective and research question
Main Objective and Research Question

  • Main Objective:

    • To enhance and sustain health insurance participation in Ghana through improved client-oriented quality of care

  • Main research questions:

    • What are the main perceived barriers of health care clients to (re-)enroll in the NHIS?

    • Which are effective interventions that address these barriers?

NHIS 10th Anniversary Conference


Client-Provider-Insurer Tripod FrameworkPerspectives of the 3 key stakeholder groups, allowing comparison and triangulation of data

Client

Client-Oriented NHIS System

Insurer

Provider

NHIS 10th Anniversary Conference


Set up of research selected regions gar and wr
Set up of research Selected Regions: GAR and WR

NHIS 10th Anniversary Conference


Sampling strategy
Sampling Strategy

NHIS 10th Anniversary Conference


Remaining content of this presentation
Remaining content of this presentation

  • Health insurance perspectives by Stephen Duku

  • Client perspectivesby Christine Fenenga

  • Healthcare provider perspectives by Robert K. Alhassan

NHIS 10th Anniversary Conference


Tripod with focus on the insurer
Tripodwith Focus on the Insurer

Client

Client-Oriented NHIS System

Provider

Insurer

NHIS 10th Anniversary Conference


Qualitative research methodology
Qualitative Research Methodology

Location:Greater Accra and Western Regions

In-depth Interviews (n=16)

  • 8 interviews in 4 NHIA districts offices (Dangme West, Ga West, Ahanta West and MpohorWassa), 2 interviews per district

  • 4 interviews, 2 each at the NHIA Regional offices of the Greater Accra and Western regions

  • 4 interview at the NHIA Headquarters in Accra

    Interviewees

  • NHIA District Office – District Scheme Managers and Claims Officers

  • NHIA Regional Office – Regional Managers and M&E Officers

  • NHIA Headquarters – Divisional Directors and Senior Officers

    Data management

  • Topic guides for all the interviews

  • All interviews were recorded and transcribed verbatim

  • Interviews were Coded, Categorized and conceptualized

  • Findings were validated in a feedback workshop in each region


Household survey methodology
Household Survey Methodology

Location:Greater Accra and Western Regions

Data collected with a semi-structured questionnaire on:

  • Socio-demographics

  • Social capital and Social schemas

  • Employment status

  • Health status and healthcare utilization behavior

  • NHIS enrolment status

  • Perceived quality of health care services

  • Perceived quality of NHIS services

  • Consumption expenditure patterns

  • Dwelling characteristics


Qualitative research findings
Qualitative Research Findings

Quality of NHIS Services to Clients

1. Determinants of Quality

  • Ease of Registration and registration time

  • Waiting period to acquire NHIS card and the accuracy of information on cards

  • Availability of information on benefit package

  • Attitude of NHIS staff.

    2. Challenges in Providing High Quality Services

  • Delays by Registration Agents to submit registration forms to schemes.

  • Delays by district schemes to submit registration forms to region.

  • Inadequate staff at the scheme level to enter registration data into the system.

  • Low registration fees leading to inadequate administrative funds at schemes.

  • Misunderstanding and misinformation of clients on the NHIS registration process.

  • Education, infrastructural and environmental problems posses a huge challenge in the provision of high quality services.


Quality of NHIS Services to Health Providers

1. Determinants of Quality

  • Health providers’ accreditation process

  • Prompt payment of claims

  • Monitoring of provider service quality to clients

    2. Challenges in Providing High Quality Services

  • Inadequate education of health providers on claims processing and NHIS in general.

  • Providers borrowing staff and equipment for accreditation process.

  • Lack of right caliber of staff at health facilities for claims processing.

  • Inadequate staff at health facilities to process claims quickly.

  • Lack of ICT support to speed up claims verification and processing


Quantitative household survey findings
Quantitative Household Survey Findings

Summary of Descriptive Characteristics of Total Sample












Tripod with focus on the clients
Tripod Health Facilitywith Focus on the Clients

Client

Trust

-Socio cultural schemas

-Social capital

Client-Oriented NHIS System

Insurer

Provider

NHIS 10th Anniversary Conference


Methods Health Facility

Stakeholders Qualitative Quantitative Participatory Action Approach

NHIA

All

Clients

All

Clients

All

IM

All= clients, healthcare providers and insurance

SDM

20 IHH

Abbreviations:

IM= Initiation meeting

SDM =Stakeholder Design Meeting IHH =Individual Health Histories

KII =Key Informant Interviews

FGD =Focus Group Discussions

RVM =Regional Validation Meeting

SM =Stakeholder Meeting

HHS =Household Survey

IMC =Intervention MyCare

6 KII

20 FGD

RVM

SM

HHS

SM

IMC

NHIS 10th Anniversary Conference


NHIS 10 Health Facilityth Anniversary Conference

FGD Western Region 2011


NHIS 10 Health Facilityth Anniversary Conference

RVM Greater Accra 2011


NHIS 10 Health Facilityth Anniversary Conference

Stakeholder meeting 2012


Social capital bourdieu 1986 coleman 1988 putnam 1993 fukuyama 2000 grootaert 2001
Social Capital Health Facility(Bourdieu 1986, Coleman 1988, Putnam 1993,Fukuyama 2000, Grootaert 2001)

  • social connections or social networks that catalyzes cooperation, coordination and reciprocity;

  • reduces incomplete or asymmetric information

  • reduces transaction costs in the absence of formal, enforced contracts.

  • can achieve improved social and economic outcomes.

  • Trust is seen as important determinant of SC.

  • SC at the community level can positively and significantly impact households’ decision in take up of health insurance (Donfouet et al 2011; Zangh et al 2006)

NHIS 10th Anniversary Conference


Differentiating Social Capital Health Facility

Authorities i.e. Government, NHIS, Healthcare providers

Vertical SC

Client

Family , friends , neighbors

Groups and associations

Horizontal SC

NHIS 10th Anniversary Conference


Clients views on social networks and support structures
Clients’ views on social networks and support structures Health Facility

If ‘you walk alone’ and keep things to yourself, nobody knows what is worrying you or what is in your heart but if you are part of a group, you can share what is bothering you. Someone who is knowledgeable about it will give you advice and help you. So the group is good’ (IHH female, Insured Western Region)

‘Why I realized that ‘health’ is not good is because most of my siblings and even my friends that I know have insurance, look disappointed when they go for treatment and come back’ (FGD female GAR)

‘Now the world has become difficult, family members are no more supporting anybody, (interjection by a participant: 'Everyone for himself, God for us all' that is the motto we have in this family’ (FGD Male/Female Western Region)

What motivated me to join the NHIS is that I may not have money when I fall ill and that would make the illness worse. I have already paid and keep my card so when I fall ill without having any money I can access health care. (Female insured IHH GAR)


Social capital membership of groups n 3963
Social capital: membership of groups Health Facility (n=3963)

NHIS 10th Anniversary Conference


Social capital social cohesion and inclusion n 3963
Social capital: Social cohesion and inclusion Health Facility(n=3963)

NHIS 10th Anniversary Conference


Social capital trust and solidarity n 3963
Social capital :Trust and solidarity Health Facility(n-3963)

NHIS 10th Anniversary Conference


Survey findings trust in the healthcare provider n 3963
Survey findings: Trust in the healthcare provider Health Facility(N=3963)

NHIS 10th Anniversary Conference


Tripod with focus on the provider
Tripod Health Facilitywith Focus on the Provider

Client

Client-Oriented NHIS System

  • Provider

    • Quality healthcare

Insurer

NHIS 10th Anniversary Conference


Methodology qualitative quantitative
Methodology (Qualitative & quantitative) Health Facility

  • Qualitative

    • Individual in-depth interviews (IDIs) in private and public facilities in WR & GAR

    • Cadre of health providers

      • Managers at national, regional, district levels (n=4)

      • Clinical staff at service delivery point (n=18)

    • Grounded theory=>qualitative findings informed structuring of quantitative tool

    • Total sample size=22 IDIs

  • Quantitative

    • Medical technical quality assessment

    • Tools (Essentials, and SA+)

    • Total of 41 questions grouped into 5 major components

  • Staff perceptions data

    • Structured questionnaires on the ff:

      • Socio-demographic features of staff

      • Perspectives on client-centered quality care

      • Perspectives on the NHIS and QHC

      • Perceptions on workplace incentives and constraints

NHIS 10th Anniversary Conference


Profile of Health Facilities Surveyed (n=64) Health Facility

NHIS 10th Anniversary Conference


Quality care and patient safety situation in clinics and health centresMean percentage scores in NHIA core standard areas (n=64)

Source: Analyzed NHIA Accreditation Data on selected 64 clinics and health centres (2009/2010)

NHIS 10th Anniversary Conference


Mean percentage scores on essentials risk areas n 64
Mean percentage scores on Essentials Risk Areas (n=64) health

NHIS 10th Anniversary Conference


NHIS 10 health th Anniversary Conference


Profile of Health Staff Interviewed (n=324) health

NHIS 10th Anniversary Conference


Percentage of staff satisfied with working conditions in nhia accredited facilities n 64
Percentage of staff satisfied with working conditions in NHIA accredited facilities (n=64)

*p<0.05




Comparing and triangulating client and provider perspectives on quality care
Comparing and triangulating Client and Provider Perspectives on Quality Care

HC Providers:

Quality is good but need for more staff, equipment & logistics

Clients:

Relational aspects quality are poor

Facility to file complaints

Qualitative

Attitude of staff

Rational use of drugs

Availability of drugs

Quality of care

Quantitative

Fair queuing system

Sufficient trained staff

Transparent information

Adequate equipment

Availability of staff

HH survey:

Quality is good except for

Facility to file complaints (80% dissatisfied) and queuing time (40% diss. )

NHIA and ESS:

low quality standards

NHIS 10th Anniversary Conference


Concluding remarks 1

Concluding remarks (1): on Quality Care

We found a positive association between enrolment in the NHIS and existing social capital in the target population (social trust and social participation).

There is positive association between enrolment in the NHIS (formal institution) and trust factors such as information provision, reliable delivery of benefit package and client perceived quality of services and facility to file suggestions or complaints (significant)

There is also a positive association between enrolment in the NHIS and socio-economic attributes such as health status, educational level, sector of employment and wealth status.

Clients’ views of HC quality is largely based on inter-relational factors. This contrasts with providers views, which relates quality to medical technical aspects, creating a gap between perceptions of clients and providers.

Our qualitative findings of client perceptions on quality of services generally show a more negative trend than survey findings. We argue that a mixed methods lead to more reliable, precise and valid data.

NHIS 10th Anniversary Conference


Concluding remarks (2): on Quality Care

  • Essentials tool results positively correlate with the NHIA accreditation scores suggesting the former could be a complementary assessment tool for quicker assessment over shorter time by the NHIA.

  • Overall quality situation per Essentials*and NHIA accreditation data in sampled facilities is generally low even though all these facilities are accredited. Regular post accreditation monitoring is therefore imperative to ensure quality care standards are maintained after facilities are given accreditation.

  • Providers perceive medical technical quality indicators as benchmarks for quality service delivery; client-centered indicators not emphasized. Client-centered care modules should therefore be integrated into the training curricula of health training institutions in Ghana.

  • Interventions to reduce barriers and enhance enrolment should focus on improving interpersonal relations and information sharing at the health facilities (community level).

NHIS 10th Anniversary Conference


Thank you

Thank you on Quality Care

NHIS 10th Anniversary onference


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