multivariate analysis to assess the effectiveness of …

MULTIVARIATE ANALYSIS TO ASSESS THE EFFECTIVENESS OF

THE NATIONAL HEALTH INSURANCE SCHEME (NHIS) IN GHANA

BY

FRANK OKWAN

(10513128)

THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA,

LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR

THE AWARD OF THE MPHIL DEGREE IN STATISTICS

SEPTEMBER, 2015

University of Ghana http://ugspace.ug.edu.gh

ii

DECLARATION

Candidate’s Declaration

This is to certify that this thesis is the result of my own research work and that to the best of my

knowledge, no part of it has been presented for the award of any other degree in the university or

elsewhere, except where due acknowledgement has been made in the text.

SIGNATURE:……………………………… DATE:…………………………………..

FRANK OKWAN

(10513128)

Supervisors Declaration

We hereby certify that this thesis was prepared from the candidate’s own work and supervised in

accordance with guidelines on supervision of thesis laid down by the University of Ghana.

SIGNATURE:……………………. DATE:……………………………….

PROF. O.A.Y JACKSON

(Supervisor)

SIGNATURE:……………………… DATE:……………………………..

PROF. J.B. OFOSU

(Co-Supervisor)


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ABSTRACT

This thesis provides an assessment of the effectiveness of the National Health Insurance Scheme

(NHIS) in Ghana implemented by Act 650 and L.I 1809, 2004. This assessment is done by taking

the Akuapem South Mutual Health Insurance Scheme, selected health facilities in the Nsawam-

Adoagyiri Municipality and Akuapem South District that provides health insurance services and

health insurance users as case study. The selected health facilities are the Nsawam Government

Hospital, Pokrom Health Centre, Kom Presby Clinic and New Life Hospital. The purpose of this

study was to try to use statistical tools such as regression and hypothesis to determine whether the

scheme is effective by using both primary and secondary data. The study employed quantitative

and qualitative approach which used secondary and primary data. The study also used descriptive

and inferential statistics to analyse the data. The analysis done on secondary data on enrolment

recorded from 2010 to 2013 on monthly revealed that enrolment has increased over the period.

This is to verify whether there has been an increase in enrolment onto the scheme since its

implementation in the study area. Data collected on a number of claims paid to service providers

by the scheme also showed that health insurance usage has also increased from 2007 to 2013 on

monthly basis. The finding of the study has revealed that 72.9% of respondents who participated

in the study to assess the effectiveness of the Nation Health Insurance Scheme responded that the

health insurance scheme implemented by Act 650 and L.I 1809, 2004, is effective and can be made

more effective if claims payments to service providers are not delayed.


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DEDICATION

I dedicate this thesis to the Almighty God for his faithfulness, mercies and endless favour He

bestowed on me throughout the trials and tribulation years of my days on campus. I also, dedicate

to my dear wife, Abigail Boateng Okwan and my lovely children Isabella Yaa Ehuramah Okwan

and Nana Yaw Boateng Okwan.


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ACKNOWLEDGEMENT

All praise and honour to God for the great thing He has done. The giver of all good and perfect

gifts, really deserve praise adoration and thanksgiving for his protection and guidance and for

granting me wisdom, knowledge and understanding for all these years of my studies and more

especially for the great things He is about to do in my life.

I will like to express my deepest gratitude to my supervisors: Professor O.A. Y Jackson

(Supervisor) and Professor J. B. Ofosu (Co-Supervisor) for their expert advice, encouragement,

support, guidance, stimulating criticism, time and energy in putting this work together. To my

family, I say thank you for your encouragement, support and advice even when all hopes were

lost you kept me going and special thanks to my dear wife Abigail, my two kids and my mother-

in-law for their time and understanding throughout these years of study.

My sincere appreciation goes to the management of Akuapem South Mutual Health Insurance

Scheme, Nsawam, Nsawam Government Hospital, New Life Hospital, Adoagyiri, Pokrom Health

Centre and Kom Presby Clinic, Aburi, Dr. Ezekiel Nii Noi Nortey and Gabby Dagadu of the

Statistics Department, University of Ghana, Legon for their great contribution and support towards

the completion of this work. I would like to acknowledge Mr. Eric Oduro Amparbeng and Mr.

Michael Shika Kposu for editing this work.

Finally, my greatest thanks goes to all lecturers of the Department of Mathematics and Statistics

and my MPhil colleagues who encouraged me anytime I was troubled and also supported me in

many ways.

I say thank you all and God richly bless you.


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TABLE OF CONTENTS

Content

Declaration……………………………………………………………………….. i

Abstract…………………………………………………………………………… ii

Dedication………………………………………………………………………… iii

Acknowledgement………………………………………………………………… iv

Table of Contents………………………………………………………………….. v

List of Tables……………………………………………………………………… viii

List of Figures……………………………………………………………………... x

List of Abbreviations................................................................................................ xi

Chapter One.............................................................................................................. 1

Background of the Study.......................................................................................... 1

1.0 Introduction........................................................................................................ 1

1.1 Functions of the NHIS........................................................................................ 3

1.2 Premiums............................................................................................................ 4

1.3 Types of Health Insurance.................................................................................. 6

1.4 Benefits of Health Insurance........................................................................ 8

1.5 Statement of the Problem.................................................................................. 9


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1.6 Objectives of the Study……………................................................................. 10

1.7 Research Hypothesis ….................................................................................... 10

1.8 Scope and Geographical Background of the study Area.................................... 10

1.9 Significance of the Study.................................................................................... 13

1.10 Organisation of the Study................................................................................. 13

1.11 Limitations of the study.................................................................................... 13

Chapter Two............................................................................................................. 15

Literature Review..................................................................................................... 15

2.0 Concept of National Health Insurance Scheme (NHIS)..................................... 15

2.1 Global Perspective of Social Health Insurance.................................................. 16

2.2The Development of Health Insurance Scheme in Ghana................................... 19

2.3 The Challenges of NHIS in Developing Countries............................................ 21

2.4 The Structure of National Health Insurance Scheme in Ghana.......................... 23

2.5 The Role of Health Insurance in Health Care Delivery...................................... 26

2.6 Financing of Health Insurance in Ghana............................................................ 28

Chapter Three........................................................................................................... 30

Methodology............................................................................................................. 30

3.0 Introduction....................................................................................................... 30


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3.1 Population........................................................................................................... 30

3.2 Sample Size Determination.............................................................................. 30

3.3 Sources of Data................................................................................................... 31

3.4 Sampling Procedure............................................................................................ 32

3.5 Research Design................................................................................................. 32

3.6 Data Collection Methods.................................................................................... 33

3.7 Data Analysis and Presentation.......................................................................... 34

3.8 Kolmogorov-Smirnov Goodness-of-Fit Test………………………………..... 35

3.9 Regression Analysis........................................................................................... 36

3.10 Multiple Linear Regression.............................................................................. 37

Chapter Four………………………………………………………………………. 40

Data Presentation, Analysis and Interpretation…………………………………… 40

4.0 Introduction…………………………………………………………………… 40

4.1 Response to Questionnaire by Health Insurance Users……………………….. 73

4.2 Age of Respondents…………………………………………………………… 75

4.3 Response from Interview Guide………………………………………………. 92

Chapter Five………………………………………………………………………. 95

Summary, Conclusion and Recommendations……………………………………. 95


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5.0 Introduction……………………………………………………………............ 95

5.1 Summary of Findings…………………………………………………………. 95

5.2 Conclusion…………………………………………………………………….. 97

5.3 Recommendations…………………………………………………………….. 98

5.4 Further Studies………………………………………………………………… 100

References…………………………………………………………………………. 101

Appendices ……………………………………………………………………….. 106


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LIST OF TABLES

Table 4.1: Data on Number of Claims Paid From 2007-2013 …………………… 41

Table 4.2: Data on Number Enrolled onto the Scheme from 2010-2013…… 43

Table 4.3: Data on Clinic Attendance on Monthly Basis from 2008 – 2013…...... 45

Table 4.4: Data on Clinic Attendance on Monthly Basis from 2010 – 2013…....... 46

Table 4.5: Data on Clinic Attendance on Monthly Basis from 2010- 2013……… 47

Table 4.6: Data on Clinic Attendance on Monthly Basis from 2008- 2013………. 48

Table 4.7: Test for Difference between Two means……………………………… 49

Table 4.8: One Sample K-S test for Pokrom Health Centre……………………... 52

Table 4.9: One Sample K-S test for Kom Presby Clinic………………………… 54

Table 4.10: One Sample K-S test for Nsawam Government Hospital……………. 56

Table 4.11: General Linear Model Output for Pokrom Health Centre…………… 57

Table 4.12: Goodness of Fit Output for Pokrom Health Centre…………………... 58

Table 4.13: Ominibus Test for Pokrom Health Centre…………………………… 59

Table 4.14: Test for Model Effect for Pokrom Health Centre…………………… 60

Table 4.15: Parameter Estimates for Pokrom Health Centre…………………… 60

Table 4.16: General Linear Model Output for Kom Presby Clinic……………… 61

Table 4.17: Goodness of Fit Output for Kom Presby Clinic …………………… 62


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Table 4.18: Ominibus Test for Kom Presby Clinic ………………………………. 63

Table 4.19: Test for Model Effect for Kom Presby Clinic ……………………….. 64

Table 4.20: Parameter Estimates for Kom Presby Clinic ………………………… 65

Table 4.21: General Linear Model Output for Nsawam Gov’t Hospital …………. 66

Table 4.22: Goodness of Fit Output for Nsawam Gov’t Hospital ……………….. 67

Table 4.23: Ominibus Test for Nsawam Gov’t Hospital …………………………. 68

Table 4.24: Test for Model Effect for Nsawam Gov’t Hospital ………………….. 69

Table 4.25: Parameter Estimates for Nsawam Gov’t Hospital…………………… 70

Table 4.26: Regression Output for Regression of Y on 𝑋1,𝑋2, 𝑋3, 𝑋4….................. 71

Table 4.27: Gender Distribution of Respondents…………………………….. ….. 74

Table 4.28: Age Distribution of Respondents…………………………………….. 75

Table 4.29: Occupation of Respondents………………………………………… 76

Table 4.30: Level of Education of Respondents………………………………….. 77

Table 4.31: Marital Status of Respondents……………………………………….. 78

Table 4.32: How Often Do You Use your NHIS Card to Access Medical Care?.... 78

Table 4.33: Is the Health Insurance Effective…………………………………….. 79

Table 4.34: The NHIS is Effective because It is Affordable……………………… 80

Table 4.35: Health Professionals Pay Attention to NHIS Users………………….. 81


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Table 4.36: User Not Joining Queues……………………………………………... 82

Table 4.37: Process Followed By Health Insurance Users Is Smooth……………. 83

Table 4.38: Most Drugs Are Supplied By Providers……………………………… 84

Table 4.39: Health Professionals do not Pay Attention to NHIS Users…………... 85

Table 4.40: Most of the Drugs Supplied to NHIS Users are Substandard Drugs… 86

Table 4.41: Services Provided By Health Insurance Providers………………… 87

Table 4.42: Rating of Services Provided By Health Insurance Providers………… 88

Table: 4.43: Equal Treatment to Insured and Non-Insured……………………….. 89

Table 4.44: Effectiveness of Scheme……………………………………………... 89


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LIST OF FIGURES

Figure 4.1: A Graph of Number of Claims Paid on Monthly Basis……………… 42

Figure 4.2: A Scatter Diagram of Number of Claims Paid on Monthly Basis…… 42

Figure 4.3 A Graph on NHIS Enrolment on monthly basis……………................ 44

Figure 4.4: A Scatter Diagram Representing NHIS Enrolment………………….. 44

Figure 4.5: Normal Q-Q Plot for Pokrom Health Centre………………………… 51

Figure 4.6: Normal Q-Q Plot for Kom Presby Clinic…………………….……… 53

Figure 4.7: Normal Q-Q Plot for Nsawam Gov’t Hospital……………………… 55

Figure 4.8: Gender of Respondents………………………………………………. 74


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LIST OF ABBREVIATIONS

NHIL National Health Insurance Levy

SSNIT Social Security and National Insurance Trust

NHIS National Health Insurance Scheme

NHIC National Health Insurance Council

DMHS District Mutual Health Insurance Scheme

NHIA National Health Insurance Authority

SHI Social Health Insurance

WHO World Health Organization

NHIF National Health Insurance Fund

IOM Institute of Medicine

CBHI Community-Based Health Insurance

MHOs Mutual Health Organizatio


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CHAPTER ONE

BACKGROUND OF THE STUDY

1.0 INTRODUCTION

National Health Insurance is a form of formal sector social health insurance programme that pools

risk across population and pay part of all ill health-care expenses for defined members from a

premium paid by individual employers, employees, unemployed, non-governmental organizations

and government. It is a social health security system in which health care of an employee is paid

by both the employer and the employee. The National Health Insurance Scheme in Ghana is also

a social health security system which is financed by a National Health Insurance levy (NHIL) of

2.5% tax on selected goods and services. A 2.5% out of the18.5% SSNIT contribution which is

made up of 5.5% of workers’ pay (Social Security Law 1991 (PNDCL 247) and 13 % (Pensions

Act 766) of employees contribution of Social Security and National Insurance Trust (SSNIT)

deductions from the formal sector, premiums from the informal sector and government budget

allocations.

The National Health Insurance is a form of health insurance established by the Government of

Ghana, with a goal to provide equitable access and financial coverage for basic health care services

to all Ghanaian resident and foreign visitors living in Ghana. The idea of Health Insurance Scheme

(NHIS) in Ghana was conceived by the former president, John Agyekum Kuffour, when he was

seeking the mandate of the people of Ghana in the 2000 elections. He promised to abolish the cash

and carry system of health delivery. Under the cash and carry system, the health need of an

individual was only attended to after the initial payment for the services were made. In cases

where patients had been brought into hospital on emergencies, it was required that money was paid


2

at every point of service delivery. When he was elected as president, he pushed through his idea

of getting rid of "cash and carry” and replaced it with an equitable insurance scheme that ensures

treatment is provided first before payment for Ghanaian citizens. In 2003, the scheme was passed

into law (Act 650, 2003). Under the law, the Ghana National Health Insurance Authority was

established to license, monitor and regulate the operations of health insurance in Ghana. Like many

other countries in the world, Ghana’s health insurance was fashioned out to meet specific needs of

all Ghanaian residents and foreign visitors living in Ghana.

There are various reasons for introducing health insurance schemes in developing countries. One

of the often stated reasons is improving health financing given the increasing evidence of a direct

relationship between how a health system is financed and the performance of its functions and

achievement of its goals. Some studies have drawn attention to the weaknesses and impact of

health facility user fees on the poorest people of developing countries as being the main reason.

In an attempt to increase access and improve the quality of basic health care services, the

Government of Ghana passed the National Health Insurance Act 650 (HI Act) in August 2003,

establishing the Ghana National Health Insurance Scheme (NHIS). The primary goal of the act

was to improve access and quality of basic health care services in Ghana through the establishment

of District- Wide Insurance Schemes. The policy objective states:

Within the next five years, every resident of Ghana shall belong to a health insurance scheme that

adequately covers him or her against the need to pay out-of-pocket at the point of service in order


3

to obtain access to a defined package of acceptable and quality health services. (Government of

Ghana Parliament, 2004).

In addition to providing guidance on the structure of the District Insurance Schemes, the Health

Insurance Act 650 provides the legislative framework for the establishment of a regulatory body,

the National Health Insurance Council (NHIC). The role of the NHIC is to register, license, and

regulate Health insurance schemes to accredit and monitor health care providers operating under

the scheme. It plays a key role in guiding implementation efforts and management of the National

Health Insurance Fund. The Health Insurance (HI) Act authorized the NHIC to license any of the

following schemes; District Mutual Health Insurance Schemes (DMHIS), Private Commercial

Health Insurance Schemes, and Private Mutual Health Insurance Schemes.

All public health facilities are automatically accredited to participate in the scheme, while private

health facilities must apply for accreditation to participate in the NHIS. A Legislative Instrument,

outlining the regulations for implementation at the district level, was approved by parliament and

published in January 2005.

1.1 FUNCTIONS OF THE NHIS

The Health Insurance was set up to allow Ghanaian citizens to make contributions into a fund so

that in the event of illness Ghanaian contributors could be supported by the fund to receive

affordable health care. Under the Health Insurance policy, three types of health insurance schemes

were set up. They are: The District-Wide Mutual Health Insurance Scheme, The Private Mutual

Health Insurance Scheme and The Private Commercial Health Insurance Scheme. In order for the


4

Health Insurance system to function well, the Government decided to support the District Wide

Mutual Health Insurance Scheme programme to ensure that:

Opportunity is provided for all Ghanaian citizens to have equal access to functional structures of

health insurance. Ghanaian residents do not move from unaffordable ‘cash and carry ' regime to

another unaffordable health insurance one. A sustainable health insurance option is made available

to all Ghanaian resident and foreign visitors living in Ghana. The quality of health provision

cannot be compromised under health insurance scheme.

1.2 PREMIUMS

Like all insurance schemes, different types of premiums are available under the country’s NHIS.

Ghanaian contributors are grouped according to their level of income. Based on the group, a

Ghanaian contributor may belong to, there is specific premium that the individual has to pay. This

was done since the socio economic condition of scheme contributors are not the same. The

contribution for Ghanaians was made affordable for all to ensure that no one is forced to remain

in cash and carry system. This means that contributions payable by Ghanaians could vary from

one district to the other, even though the disease burden is also not the same in all the districts. To

ensure that all Ghanaian resident and foreign visitors living in Ghana make some contributions

to the scheme, a 2.5% Health Insurance Levy was selected on goods and services and passed

into law so that money collected could be put into a National Health Insurance Fund to subsidize

fully paid contributions to the District Health Insurance Schemes.


5

One of the key regulations specified in the legislation was the annual premium, set on a sliding

scale at a minimum of GH₵7.20 per adult. In a typical family with three children, entire family

would be covered for GH₵14.40 per year. Children (up to age 18), the elderly (age70 and above),

and the indigent, were to be exempt from payment. The premiums stated above were the premiums

expected to be paid at the initial stages. Currently premiums are determined based on the socio-

economic background of the individual. People who fall in the poor and very poor category pay

GH₵7.20, adults in the middle income category pay GH₵ 18.00 and lastly the rich and very rich

adults pay GH₵ 48.00 yearly as premium.

The NHIC developed the benefit package, which is intended to cover basic health care services,

including outpatient consultations, essential drugs, inpatient care and shared accommodation,

maternity care (normal and caesarean delivery), eye care, dental care, and emergency care. Certain

public health services considered a public good, such as family planning and minimum benefit

package, as it was assumed that these services would continue to be provided for free at public

health facilities. District health schemes were required to adhere to the defined benefit packages.

Some services deemed either unnecessary or too expensive are excluded from the coverage. These

include cosmetic surgery, drugs not listed on the NHIS drugs list (including HIV/AIDS

antiretroviral drugs), assisted reproduction, organ transplantation, and private inpatient

accommodation.

To mobilize additional funds to support the implementation of the District Mutual Health

Insurance Scheme, the government of Ghana instituted a National Insurance Levy of 2.5 % on

Specific goods and services made in or imported to Ghana. In addition, 2.5% of the 18.5 % Social


6

Security (known as SSNIT) contributions paid by formal sector employees are automatically

diverted to support the NHIS. Accordingly, formal sector employees, their dependents, and SSNIT

pensioners are automatically enrolled in their district scheme and are exempted from further

premiums.

For those in the informal sector, it was envisioned that community health insurance committees

categorized residents into social groups based on economic status, and those identified as ‘core

poor’ are exempt from paying premiums (Government of Ghana Parliament Report, 2004).With

the passage of the Health Insurance Act, a primary objective was for all Ghanaians to enroll in one

of the three insurance schemes within five years. To achieve this goal, local district assemblies

were tasked with the responsibility for initiating the District Mutual Insurance Scheme (DMHIS).

Specifically, district assemblies are required to promote the schemes, identify human resources to

provide technical support for the establishment of the scheme and carry out social mobilization.

The DMHIS are mandated to operate exclusively for the benefit of their members. By the end of

2008, Ghana’s National Insurance program covered 61 percent of the population, with DMHIS

operating in all districts (Ghana National Health Insurance Scheme, 2008).

1.3 TYPES OF HEALTH INSURANCE

There are three main categories of health insurance in Ghana:

The first and most popular category is the District Mutual Health Insurance Scheme, which is

operational in every district in Ghana. This is the public non-commercial scheme and anyone

resident in Ghana can register under this scheme. If you register in ‘District A’ and move to


7

‘District B’, you can transfer your insurance policy and still be covered in the new district. The

District Mutual Health Insurance Scheme also covers people considered to be indigent – that is too

poor, without a job and lacking the basic necessities of life to be able to afford insurance premiums.

Apart from the premium paid by members, the District mutual Health Insurance Schemes receive

regular funding from the central government. This central government funding is drawn from the

National Health Insurance Fund. Every Ghanaian worker pays two-and-a-half percent of their

social security contributions into this fund and the VAT rate in Ghana also has a two-and-a-half

percentage component that goes into the fund.

To sign up for the District Mutual Health Insurance Scheme, you need to get to the district

assembly where you reside or look for the offices of the scheme and register. You will fill a form,

offering some basic personal information and you will be asked to present at least two passport-

sized pictures. You will need to fill forms and pay for dependents’above18years as well.

The second category of health insurance comprises the Private Commercial Health Insurance

Schemes, operated by approved companies. You can walk into any of such accredited Health

Insurance office and buy the insurance for yourself and dependants. Commercial health insurance

companies do not receive subsidy from the National Health Insurance Fund and they are required

to pay a security deposit before they start operations.

The third category of health insurance is known as the Private Mutual Health Insurance Scheme.

Under this, any group of people (say members of a church or social group) can come together and


8

start making contributions to cater for their health needs, providing for services approved by the

governing council of the scheme. Private Mutual Health Insurance Schemes are not entitled to

subsidy from the National Health Insurance Fund.

1.4 BENEFITS OF HEALTH INSURANCE

If you register under any of the schemes, you will be given a card which you can use to seek

treatment in any hospital or participating clinic in the country. When you visit a health facility with

the card, you are treated and offered the services you have signed for without you having to pay

for anything – unless you ask for an extra service, like a private ward. Your bills are then sent to

your scheme provider (district, private scheme or mutual scheme) which then pays the money to

the hospital. You can also use your health insurance card to buy prescribed drugs at accredited

pharmacies or licensed chemical shops without paying at the point of delivery – the money will be

reimbursed to the pharmacy by the Health Insurance Scheme. At least, that’s how the system is

supposed to work on paper. But there have been reports of some hospitals and pharmacies turning

patients away, complaining that the public health insurance schemes owe them huge sums of

money. Some of the big hospitals in the country have often been compelled to issue public

statements warning that their operations could grind to a halt if the National Health Insurance

Authority (NHIA) doesn’t speed up the payment of their claims. The NHIA has assured that it is

working on these problems and in due course, they will be resolved.

Whatever form of health insurance you sign up to you are entitled to some minimum services?

These are:


9

Out-patient services – general and specialist consultations reviews, general and specialist

diagnostic testing including, laboratory investigation, X-rays, ultrasound scanning,

medicines on the NHIS Medicines list, surgical operations such as hernia repair and

physiotherapy.

In-patient services – General and specialist in patient care, diagnostic tests, medication-

prescribed medicines on the NHIS medicines list, blood and blood products, surgical

operations, in patient physiotherapy, accommodation in the general ward and feeding

(where available).

Oral health – pain relief (tooth extraction, temporary incision and drainage), dental

restoration (simple amalgam filling, temporary dressing).

Maternity care – antenatal care, deliveries (normal and assisted), Caesarean section,

postnatal care, medical emergencies, surgical emergencies, pediatric emergencies,

obstetric and gynecological emergencies and road traffic accidents.

The establishment of the NHIS in Ghana was to enable service providers to offer quality

and affordable health care to the poor and the needy in society. The research is conducted

to ascertain whether or not the Scheme has been effective in the delivery of health care to

the people of Ghana.

1.5 STATEMENT OF THE PROBLEM

In recent times, politicians, journalists, literates and illiterates in the Ghanaian society are saying

that the National Health Scheme is not effective and as a result some Health Facilities in the

country do not recognize the Scheme and due to that people who have registered with the Scheme


10

are not using it to access medical care. This study is conducted to find out whether the health

scheme is effective or not.

1.6 OBJECTIVES OF THE STUDY

To study the trend of enrollment onto the Scheme on monthly basis to ascertain whether it

has increased or decreased.

To fit a general linear model to the insured attendance and claim payment.

To test hypothesis to find out whether there is a significant difference in the number of

people enrolling onto the Scheme and the number using the Scheme to access medical care.

To find out from service providers when last payment was made and how long did it take

after bill was presented.

To test whether the claims payment data fits a particular distribution.

1.7 RESEARCH HYPOTHESES H0: There is no significant difference between the numbers of people enrolling

onto the Scheme and the number using the Scheme to access medical care.

H1: There is a significant difference between the number enrolling onto the

Scheme and the number using the scheme to access medical care.

1.8 SCOPE AND GEOGRAPHICAL BACKGROUND OF THE STUDY AREA

This study will focus on the Akuapem South Mutual Health Insurance Scheme, accredited

Hospitals, Health Centres and Clinics in Nsawam-Adoagyiri Municipality and Akuapem South

District that provide health insurance services. Clients who are health insurance card users would

be selected from the Nsawam-Adoagyiri Municipality and Akuapem South District by a simple

random sampling method .The period under study is from 2005 to 2013.This period was chosen


11

because it coincides with the start of the Akuapem South Mutual Health Insurance. The Akuapem

South Mutual Health Insurance Scheme covers accredited health facilities in the Nsawam-

Adoagyiri Municipality and Akuapem South District. The samples for this study would be selected

from Nsawam, Adoagyiri, Pokrom and Aburi. These communities fall under Nsawam - Adoagyiri

Municipality and Akuapem South District.

The Nsawam- Adoagyiri Municipal Assembly was established under Legislative Instrument (L.I

2047) 2012 from the previous Akuapem South Municipal Assembly when it was split into two in

the year 2012. The Akuapem South District Assembly, Aburi and Nsawam Adoagyiri Municipal

Assembly. There are 29 electoral areas and three councils comprising of Nsawam Zonal Council,

Adoagyiri Zonal Council and Nkyenekyene Zonal Council.

The Nsawam- Adoagyiri Municipality has land area which spans 503 km². Globally, it is located

between 5.45N and 5.58N and longitude 0.07W. The municipal is about 23km from Accra. It

shares boundary with Ga West, Suhum, Kraboa-Coaltar and West Akim Municipal. It has a

population made up of 42,790 males and 44,617 females per the 2010 population and housing

census. Thirty seven (37) percent of the population are into crop farming. The municipality

produces pineapples and pawpaw of high quality for export. Twenty eight (28) percent of the

population is into the commercial sector, 20% are in the industrial sector and 15% are in the

services sector. The district capital is Nsawam which is a fairly urban community and merging

Adoagyiri, another urban community. There are over 122 communities in the municipality. The

Akuapem South District is one of the newly created districts in the Eastern Region of Ghana under

the Legislative Instrument, LI 2047, dated 6th February, 2012.The district was carved out of the


12

Akuapem South Municipal Assembly. The Akuapem South District consists of 29 electoral areas.

The district has four area councils namely; Aburi Area Council, Obodan Area Council, Dago and

Anamerampong Area Council and Adjenase Area Council. The District is bordered to the west by

the Nsawam-Adoagyiri Municipal Assembly, to the south-east by the Kpone-Katamanso District

Assembly, to the south by the Ga East District Assembly, to the north-east by Akuapem North

Municipal Assembly and to the north by Ayensuano District Assembly. The Akuapem South

District is approximately 20kms from Accra, the capital of Ghana and lies within the South Eastern

part of the Eastern region of Ghana between latitude 5.45N and 5.5N longitude and forms part of

a total land area of about 503 Km².

The Akuapem South Municipality from which the Akuapem South District was carved has a total

population of 129,297 according to the 2010 population and housing census results. It has a

population density of 227 persons per sq. km with an estimated growth rate of 1.7 per annum which

is lower than that of the national at 2.7% but slightly higher than the region’s population growth

rate of 1.4% per annum. Thirty seven percent (37%) of the population are into agriculture, 28%

into the commercial sector, 15% into the industry sector and 15% into the services sector. The

district capital is Aburi, a town that is historically noted for its Botanic Garden. Aburi is again

noted for its cool and serene atmosphere which has attracted and continues to attract foreigners to

the district thereby making cost of land very competitive within the township.


13

1.9 SIGNIFICANCE OF THE STUDY

The purpose of this study is to assist other researchers in this field, to serve as a source of reference

and to contribute to available literature in this area. The study will help the Ghana government and

the managers of the scheme to formulate policies and implement administrative procedures that

would improve service delivery and make the scheme more effective.

1.10 ORGANISATION OF THE STUDY

This study will cover five chapters. Chapter one would comprise of the background of the study,

the statement of the problem, the objectives of the study, the scope of the study, the organization

of the study. Chapter two will cover the review of related literature which would also cover the

following sub headings; concept of health insurance scheme, Global perspective of NHIS, The

structure of NHIS in Ghana, Financing of the NHIS in Ghana, the role of NHIS in Health care

delivery, and the challenges of NHIS in developing countries. Chapter three would be on

methodology, the methodology would cover the methods of data collection and data analysis.

Chapter four would be solely data presentation and interpretation. Chapter five will cover the

summary of the findings, conclusion and recommendations.

1.11 LIMITATIONS OF THE STUDY

The availability of data was one of the bottlenecks of the study. The research should cover period

from 2005 to 2013 but this was not the case because of poor data management in some of the

facilities. Financial constraints was another limitation identified by the researcher since the

researcher has to travel from one facility to other to book appointment with officials of service


14

providers that are to be interviewed and communicate with them to confirm appointment dates and

also money to run scripts. Time allocated for the study was also a challenge and combining job

with the field work was not an easy task. The late response from respondents also delayed the

analysis of the field data and this extended the completion time for the study.


15

CHAPTER TWO

LITERATURE REVIEW

2.0 CONCEPT OF NATIONAL HEALTH INSURANCE SCHEME (NHIS)

Health insurance is a programme that pools risk across populations and pay part of all health-care

expenses for their defined population of members (and possible dependants) from premium

contributed by individual employers, non-governmental organizations or government. The

purpose of NHIS is to secure universal coverage and access to adequate and affordable health care.

In Nigeria, this is achieved by monthly deductions of 5% basic salary paid by the employee’s

employer which is then pooled together and used for all who have enrolled onto the scheme. In

social insurance there is a cross subsidization where the healthy subsidizes for the ill, the young

subsidize for the older and the higher income group subsidizes for the lower income group. Social

health insurance is a social security system that guarantees the provision of a benefit package of

health care services paid from funds created by pooling the contributions of participants. The

health insurance fund in Ghana is mobilized from workers pension contribution to SSNIT and a

valued added tax on all goods and services purchased. This is achieved by a monthly deduction of

2.5% out of the 18.5% SSNIT which comprise of 5.5% of workers’ pension and 13.% (Pensions

Act 766) contribution to SSNIT(Social Security Law 1991(PNDCL 247) and 2.5% of value added

tax on all goods and services purchased are pooled together and used to fund the health insurance

in Ghana.


16

2.1 GLOBAL PERSPECTIVE OF SOCIAL HEALTH INSURANCE

Most low and middle income nations face difficulties in funding health care, while nations declare

admirable goals to provide their citizens with equal access to reasonable quality health care to

prevent health-caused impoverishment. These exalted aims are not backed up with adequate public

funds or a rational financing system. As a result of poor health, impoverishment and disparity are

prevalent. Many nations are now hoping that formally mandated social health insurance (SHI),

involving payroll taxes, will provide the solution.

In order to reduce the out of pocket payment, a wave of Social Health Insurance (SHI) initiatives

has swept across Africa, Asia and Latin America. In May 2005, the World Health Assembly passed

a policy resolution for the World Health Organization (WHO), where it would use the social health

insurance (SHI) as the strategy for mobilizing more resources for health pooling risk by providing

more equitable access to health care for the poor, and delivering better and quality health care (

World Health Organization (WHO), 2005a).

The WHO is using this strategy to encourage member states to move ahead with the social health

insurance and to provide members with technical support to help them develop the social health

insurance. In addition to its capacity to mobilize additional funds for health care, social health

insurance (SHI) is also touted by several international aid agencies, such as the World Bank, the

WHO and the German Agency for Technical Cooperation as a policy instrument that could help

facilitate or stimulate the health sector reforms.


17

According to (World Health Organization (WHO), 2000) health is a state of complete physical,

mental and social well being and not just the absence of disease or infirmity. Looking at the health

state in Ghana and the above definition then one can say that no Ghanaian is said to be a healthy

client for the insurance industry. Every country strives to provide for its citizen’s affordable and

accessible health care. In South Africa, for instance, there is no nationally operated public health

insurance scheme, yet they can boast of better indices than in Ghana. They have a private health

insurance scheme that is affordable, well developed and functioning efficiently (Gana, 2010). A

look at the healthcare system of some countries will educate us more. In the United Kingdom

(UK), there is a National Health Scheme (NHS) which is a publicly funded health care for all

residents of UK. No premiums are collected, costs are not charged at the patient level and costs

are not prepaid from a pool. It is actually not an insurance system but it does achieve the main aim

of an insurance which is to spread financial risk arising from ill health directly through general

taxation. The United States health care on the other hand relies heavily on private health insurance

which is the main source of coverage for most Americans.

In Canada, public and private schemes exist; most health insurance schemes in Canada are

administered at the level of provinces under the Canada Health Act, which requires all people to

have free access to health care. About 65% of Canadians have some form of supplementary private

health insurance; many of them receive it through their employers.

France operates a solidarity system. It has both public and private schemes. The peculiarity of the

French is that; the more ill a person becomes, the less the person pays. This means that for people

with serious or chronic illness, the insurance system reimburses them 100% of their health


18

expenses and waives co-payment charges. Complementary private health insurance is also

available. (Gana, 2010).

In Australia, functional public health insurance exists alongside private schemes. The public health

system (Medicare) ensures free universal access to hospital treatment and subsidized out-of-

hospital medical treatment. The Medicare is funded by 1% levy on all taxpayers, an extra 1% levy

of high income earners as well as general Government revenue. Some private health insurers are

for profit while some non profit health insurance organizations are also operational.

The Sickness fund of Germany is a health insurance scheme paid by employers and employees

and managed by not for profit organizations. It is characterized by private provider base, efficient

management, adequate investment and effective control of provider and purchaser behaviour. In

Chile, public and private scheme exist, but like in most countries of Latin America, patients are

migrating from public to private schemes (Korte, 1992).

There is dearth of literature on the effect of various health financing options for low and middle

income countries (Ekman, 2007). Moreover enrolment in insurance has been found to result in

altered behavior, such as utilizing unnecessary medical care, a concept known as ‘moral hazard’

(Sulzback et al, 2005).

Furthermore, evidences from countries that have institutionalized national health insurance

programme indicate positive impact on the health care system (Sanusi and Awe, 2009; Collins, et

al, 2007). In a study in Baltimore, USA, health insurance was to lead an increase in non urgent


19

utilization of health facilities (Speck et al, 2003). Similarly in Taiwan, the utilization of most

prenatal and intrapartum care services increased after commencement of NHIS (Li-Mei et al,

2001). Also in a related study about public insurance in North Carolina, USA, it was reported that

publicly insured children were most likely to have emergency department visit than un-insured

children (Luo et al, 2003). The same trend was also noticed in Minnesota, USA (Kane et al, 2002).

Also in Jordan, insurance was found to have a positive effect on utilization of curative care and

significantly increased the number of visits per illness episode. (Sanusi et al, 2009). Generally,

insurance is found to increase the intensity of utilization and reduce out of pocket spending

(Ekman, 2007). However in Nigeria since the NHIS was established, not much has been carried

out to investigate utilization and access to quality health care as a result of the introduction of the

Scheme (Ibiwoye et al, 2008).

2.2 THE DEVELOPMENT OF HEALTH INSURANCE IN GHANA

The search for an alternative means of financing and the provision of sustainable health care

service for Ghanaians has been the priorities of many successive governments since independence.

During the First republic (1960-1966) a nation-wide passive health insurance from the tax revenue

was introduced in the country. A free health care service was made available from all the country’s

healthcare facilities. In 1970, during the Second Republic, the government instituted a committee

to make a proposal for the introduction of a health insurance scheme and this was headed by Dr.

Konotey Ahulu. This led to the enactment of the hospital free Act 387 of 1971 which replaced the

free health services scheme initiated by the first Republic, but the subsequent military government

of 1972 did not continue with the process. The preparation of the Legislative Instrument to


20

operationalized Act 387 was stated by the third republic government but this was distorted by the

military regime of 1981 (Agyepong, et al, 2008).

In July 1983, when the country’s economy was on the verge of collapse, the government

introduced what was called partial cost sharing of health service through the enactment degree of

"The Hospital Fee Regulation which was updated by L.I 1313 of 1985. In 1985 the government

initiated studies into alternative means of financing health care by entering into a bilateral technical

assistance contract with a German firm that has studied the feasibility of creating a national health

insurance scheme Programme. The German contract did not materialize and a local consultant was

also engaged to carry out studies on the health insurance and the outcome was not followed up.

In 1997 the MOH set up its first Directorate for the National Health Insurance and a forum on

health insurance was conveyed. Social Security and National Insurance Trust (SSNIT) also set up

the Ghana Healthcare company with the intention of providing other sources of health financing.

The MOH also initiated a pilot scheme in Koforidua, Eastern Region, with the intention of

registering a National Health Company and appointed Board of Directors to manage the scheme,

but this also could not materialize. Aside the schemes initiated by the MOH and SSNIT, some

health insurance schemes were set up in urban areas of the country at that time. These insurance

schemes were initiated by some private for profit insurance companies such as the Vanguard

Assurance Company. Vanguard Assurance Company initiated the scheme with the Association of

Private Medical Practitioners as the service providers. The Metropolitan Insurance Company also

formed the Metcare Health Insurance Scheme, Provident Insurance and the Medex Health

Insurance Scheme. All these private insurance schemes failed until September 5th ,2005 when the


21

then parliament passed the National Health Insurance Act 650, which sought to secure the

promotion of basic healthcare service to persons resident in Ghana through a mutual and private

health insurance scheme which is mandated to put in place a body to register, license and regulate

health insurance schemes, to accredit and monitor health care providers operating under the

scheme, to establish a National Mutual Insurance Fund that will provide subsidy to licensed

District Mutual Health Scheme, to impose a health levy and to provide funds for purposes

connected with the establishment of the scheme in Ghana.

2.3 THE CHALLENGES OF NHIS IN DEVELOPING COUNTRIES

After independence in 1957, Ghana adopted a socialist centralist development approach where the

state took absolute control of all services, including health and education. In line with the policy,

all user charges were abolished by government in 1957 though certain services attracted nominal

charges affordable to most, if not all of the population. Free provision of health care was

accompanied by increasing usage, abuse of facilities and commodities, increasing cost and

inefficiency leading eventually to a reduced quality of health care delivery.

In order to reverse this trend, the hospital Fees Decree (1969, later amended into Hospital Fees

Act (1971) and Hospital Regulation 1985 (L.I 1313), introduced forms of payment for health care

delivery. The Act specified fees to be charged for consultation, laboratory and other diagnostic

procedures, medical, surgical and dental services, medical examination and hospital

accommodation in Ghana.


22

L.I 1313 was specifically introduced to enable hospitals to totally recover all costs (except staff

wages) involved in their operations and was hugely successful in ensuring availability of medicines

and medical supplies. However, it lacked a human face and led to a huge reduction uptake of

services, as well as refusal of health professional to treat patients, including those requiring

emergency care, without upfront payment.

The exemptions scheme which was introduced alongside the cost recovery scheme to care for the

poor and vulnerable failed woefully and was subject to abuse, misinterpretation and arbitrary

implementation. The human capacity for managing the complex exemption scheme for the poor

and vulnerable was simply not available and or was not developed in some cases.

The absence of clear guidelines, lack of monitoring and supervision, transparency, ownership and

knowledge of these schemes by heads of institutions all contributed to the failure of this system.

Many studies have concluded that access to health care was generally reduced, especially during

the initial stages of implementation of the out of pocket payment. The absence of governing

structures of the mutual health insurance as mandated by law to ensure transparency and

accountability was also seen as one of challenges confronting health insurance in Ghana. The

absence of these governing structures caused suspicion in the community members about how the

funds were being disbursed by the officials’ appointees of the scheme. This was compounded by

attempt to politicize by leading political figures in the district. As a result, the confidence of the

communities in the scheme began to erode, leading to decline in membership and correspondingly

also led to the reduction of the pool fund to the scheme which is the most valuable in every health

insurance scheme.


23

Access to medicine is an essential ingredient in any health care policy. As a result, any health care

that does not guarantee access to medicine is bound to fail. The supply of drugs to service providers

has become one of the major challenges facing the health insurance scheme since a number of

service providers are in arrears for non-payment of claims submitted to the NHIS. There are many

health care facilities whose reputation among suppliers of pharmaceuticals have been seriously

undermined by non-payment of claims submitted by these providers. In response to these

challenges, governments are in the process of implementing or considering reforms in this sector.

2.4 THE STRUCTURE OF NATIONAL HEALTH INSURANCE SCHEME IN GHANA

The legislative Instrument, Act 650, 2003 and L .I 1809, 2004 are the legal framework guiding the

implementation of the health insurance scheme in Ghana. The Governance of the health insurance

scheme is made up of a fifteen member National Health Insurance Council established to manage

a National Health Insurance Fund, to provide subsidies to District wide Mutual Health Insurance

Schemes, regulate the insurance market and license and monitor service providers under the

scheme. A National Health Insurance Secretariat will provide administrative support to the

National Health Council in the implementation of the Scheme.

The District Mutual Health Schemes, established by sponsors, identified by the District

Assemblies or established by the Council as corporate bodies for the implementation of the scheme

at the district. Private sector schemes may be established but do not receive subsidies from

government. These private schemes operate as insurance schemes based on a premium, contract

and policy.


24

A Health Complaint Committee of the NHIC with decentralized and established in every district

office of the Council. Membership enrollment and membership in a District Mutual Health

Insurance Scheme is mandatory for all residents of Ghana, those working with the Ghana Armed

Forces, the Ghana Police Service or those who have proof of holding a health insurance policy.

Persons eligible to membership are expected to pay a contribution of GHȼ7.2 per year (equivalent

of US$7.74 at the time of passage of the Act. A period of six months may lapse between payment

and issuance of membership cards for accessing service. The scheme provides for persons to be

exempted from paying membership fees. These are;

Contributors to the national Social Security and National Insurance Trust (SSNIT) or

drawing pension benefit on SSNIT.

Persons under the age of 18 with at least one paying membership fees or covered by

exemption clause.

Persons above age 70 years.

Persons classified as indigents according to the criteria set by the Act and LI.

The Legislative Instrument defines a benefit and exclusion package for which a member of the

scheme may have access. Any service provider wishing to provide services to members of the

scheme have to apply to the NHIC for accreditation and licensing to provide specified set of

services from the benefit package according to their assessed competency.

There are five main sources of funds that accrue from a National Health Insurance Fund used

primarily to finance service provided and cover administrative overhead of the NHIC.

Appropriation of 2.5% of all funds mobilized from worker pension contribution to SSNIT


25

Ad valorem tax of 2.5% levied specifically for health insurance over all goods and services

purchased or provided that are eligible for Value Added Tax.

Government annual budgetary allocations proposed and approved by parliament to the

National Health Insurance Fund (NHIF).

Accruals from investment of surplus funds held in the NHIF by the NHIC.

Gifts and donations made by benevolent individuals or organizations to the NHIF

and Services of NHIS.

The NHIS package has certain health care services that are not covered in the Scheme. These

exclusion are either total or partial. When you request for any of these excluded services, you may

need to pay more and they are;

Appliance and prostheses including optical aids, heart aids, orthopaedicaid, dentures, etc

Custometics surgeries and aesthetic treatment.

Anti-retroviral drugs for HIV.

Assisted Reproduction (e.g artificial insemination) and gynecological hormone

replacement therapy.

Echocardiography.

Photography.

Angiography.

Dialysis for chronic renal (kidney) failure.

Organ transplants.

All drugs that are not listed on NHIS list.

Heart and Brain Surgery other than those resulting from accidents.


26

Cancer treatment other than breast and cervical.

Mortuary Services.

Diagnosis and treatment abroad.

Medical examinations for purpose other than treatment in accident health facilities (eg.

Visa application, Education, Institutional, Driving licensing etc.)

VIP ward (accommodation).

2.5 THE ROLE OF HEALTH INSURANCE IN HEALTH CARE DELIVERY

The World Health Organization defines health as complete physical, mental and social

well-being, not merely the absence of disease and injury (Parekh, 2003). Accordingly, a

country’s health system comprises of all the organizations, institutions and resources

devoted to produce health services.

Health care has always been a problem area in India, a nation with a large population and

substantial portion of people living below the poverty line. Consequently, health care

access and equity have become important issues and health insurance has been developed

to its immense potential in the world’s fifth largest economy. An estimated 1.3 billion

people worldwide lack access to effective and affordable health care, whiles more than 150

million people in 44 million households worldwide every year face financial ruins as a

direct result of large medical bills. The goal of providing universal access to health care

based upon the universal declaration of Human Right is a laudable one. In nearly all African

countries, “Demand from international donors for increased efficiency and competition are


27

leading governments to play a smaller role in providing health care” (Panos Report, 1994,

Pg.1).

Health Insurance has played a major role in facilitating access to health care services and

has also helped to protect one against high cost of catastrophic illness. Insurance has also

led to an increased use of health services in developing countries. Evidence from countries

that have institutionalized health insurance programmes indicates positive impact on the

health system. A study in North Carolina, USA, shows that publicly insured children are

more likely to have emergency visits than un-insured children. It is also found that

insurance has increased the intensity of utilization and reduced out of pocket spending.

In America, the insured are likely to obtain recommended screening and care for chronic

condition and are less likely to suffer from undiagnosed chronic condition or to receive

substandard medical care. Apart from health insurance, increasing access to health care, it

has also reduce rate of death. Numerous investigations have showed an association between

uninsured and death. The Institute of Medicine (IOM) estimated that 18,314 Americans

aged between 25 and 64 years die annually because of lack of health insurance. Studies

have also showed that poor health prevails in many developing countries due to lack of

health insurance.

The average infant mortality rate in many African countries still exceed 100 per 1000 live

births compared with 4 per 1000 live births in advance economies. Asian nations usually

do better but results are still high. China has an infant mortality rate of 30 per 1000 live

births and figures stand at 31 per 1000 live births in Indonesia and 62 per 1000 live births


28

in India (World Bank, 2005). The implementation of Social Health Insurance (SHI) is to

minimize the mortality rate in developing countries. The extension of Health Insurance to

a large number of poor household through both indigent programmes and IPP has to greater

access to health care delivery and financial protection for the poorer segments of society.

2.6 FINANCING OF HEALTH INSURANCE IN GHANA

Since independence in 1957, health care financing in Ghana has gone through a number of

significant transformations. At independence, the new Government committed itself to a

welfare state system that include a “free health care for all’’ policy. User fees for health

services were relatively low and were not aimed at cost recovery.

In 1982, user fees were introduced in government-run health facilities, in order to

supplement limited health financing resources (aiming to recover 15 percent of health

sector operating cost) and also to discourage unnecessary use of services (World Bank

Report, 2007). Whiles meeting both of these goals the payment known as “ Cash and

Carry” led to dramatic decline in health care utilization, with outpatient visits to hospital

dropping from 4.6 million to 1.6 million in 1985,when charges were first increased

substantially.

In 1989, Community – Based Health Insurance (CBHI) schemes, also known as mutual

health organizations (MHOs), were introduced in certain districts throughout the country.

Coverage rates were highly variable by districts ranging from 2 to 25 percent. By 2003,

such community schemes covered only a small portion (1 percent) of the country’s 19


29

million population, leaving many Ghanaians vulnerable in the event of a catastrophic

illness. A critical observation of the various related literature reveals that the health

insurance instituted by countries all over the world including Ghana was implemented with

the intention of making health care accessible, affordable and also to reduce deaths related

to sickness covered by the Health Insurance. The essence of this study is to review existing

literature in this area and also add to those that have not been captured by previous

researches to enable researchers who have the interest to research in this area make

reference to and review accordingly.


30

CHAPTER THREE

METHODOLOGY

3.0 INTRODUCTION

This chapter will focus on methods that would be used to collect and analyze data gathered

from the field for the study. These would include population, sample size determination,

sources of data, sampling procedures, research design, data collection methods, research

instrument and data analysis methods. The data to be analyzed from the field would be

both primary and secondary.

3.1 POPULATION

The population or universe is any clearly defined set of objects about which we want to

obtain information. The objects may be persons, farms or households or business firms.

The populations for this study are health insurance card users and accredited providers of

health insurance services in Nsawam-Adoagyiri Municipality and Akuapem South District.

3.2 SAMPLE SIZE DETERMINATION

For this study, the population would be health insurance card users and accredited

providers of health insurance services in Akuapem South District and Nsawam-Adoagyiri

Municipality. According to the 2010 population and Housing census, the total population

of Akuapem South District and Nsawam-Adoagyiri Municipality is 129 297. However,

since it is not feasible to reach the entire population of 129 297, a sample must be

determined.


31

The minimum sample size for this study would be determined by using the following

formula (Arayoe, 2004)

Sample Size (SS) =𝑍2 𝑝(1−𝑝)

𝐷2 …………………………………………………..(3.2.1)

where SS= minimum sample size required

Z =standard normal deviation set at 1.96

Studies done in South Africa show that about 21% rate of health insurance usage

and another study done in Nigeria on health insurance also recorded 15% rate of

usage. Since the prevalence rate (%) vary from country to country and there is no

constant rate of usage, a 25% prevalence rate was chosen for this study.

P= estimated expected prevalence rate (%), i.e. rate of health insurance usage

D= degree of accuracy desired set at 0.05

From Equation 3.2.1, using an expected health insurance usage rate of 25%

Minimum sample size=1.96²×0.25×0.75

0.05² = 288.12 ∽ 288

3.3 SOURCES OF DATA

Data would be collected from both primary and secondary sources. The primary source

would be obtained from the responses of respondents through a questionnaire and interview

guide. The secondary data would be obtained from published articles, journals, Nsawam

Government Hospital, New Life Hospital, Pokrom Health Centre and Kom Presby Clinic

attendance records, claims and enrollment data of the Akuapem South Mutual Health

Insurance scheme.


32

3.4 SAMPLING PROCEDURE

Accredited service providers, Health Insurance card users in Akuapem South Municipality

would constitute the population. Though the population is finite our focus is on all

Hospitals, Health Centres and Clinics in Nsawam-Adoagyiri Municipality and Akuapem

South District that provide health insurance services and health insurance card users. To

have a true reflection of the population a simple random sampling and purposive sampling

method would be used to select the samples for this study. The sample frame for this study

is a list of all accredited hospitals, Health Centres and clinics in the Nsawam-Adoagyiri

Municipality and Akuapem South District that provide Health Insurance services. A

Simple Random sampling method was found to be appropriate since all the accredited

clinics and Hospitals in Nsawam-Adoagyiri Municipality and Akuapem South District that

provide health insurance service have equal chance of being selected. With this method,

all the clinics, Health Centres and Hospitals in the sampling frame would be numbered and

a lottery system would be used to select the clinics and hospitals for the study.

3.5 RESEARCH DESIGN

Descriptive method of research would be used for this study. A descriptive method of

research is defined by Creswell (1994) as a method of gathering information about present

existing condition. The emphasis is on describing rather than judging or interpreting. The

descriptive approach is found to be quick and practical. Moreover, this method allows for

a flexible approach. Thus when important issues and questions arise during the duration of

a study, a further investigation may be conducted. Descriptive research on the other hand,

is a type of research that is mainly concerned with describing the nature, condition and

degree in detail of the present situation.


33

In this study, a descriptive method would be employed so as to identify the role and

significance of using questionnaire in assessing the effectiveness of the Health Insurance

Scheme in Akuapem South District and Nsawam- Adoagyiri Municipality. The researcher

has seen the descriptive method as advantageous due to its flexibility. This method can be

used for both quantitative and qualitative data and it has greater option when it comes to

selecting instrument for data gathering.

The researcher would use senior officers of the service providers and clients of service

providers (patients) as respondents to gather relevant data. The descriptive method is found

to be appropriate as it allows for identification and similarities of respondents response.

3.6 DATA COLLECTION METHOD

For this research two types of data would be gathered. This will comprise both primary and

secondary data. The primary data would be derived from the responses given by the

respondents on whether the health insurance scheme is effective or not, during the survey.

The secondary data on the other hand would be obtained from the Akuapem South Mutual

health claims and enrollment register. Data would be gathered from the attendance records

of the selected accredited Hospitals, Health Centres and Clinics that provide health

insurance services and users of health insurance in Nsawam-Adoagyiri Municipality and

Akuapem South District. By employing this combined approach, the researcher would be

able to obtain the advantages of qualitative and quantitative research approach and

overcome their limitations.


34

Qualitative approach of research generates verbal information rather than numerical values

(Polgar &Thomas, 1995). Instead of using statistical analysis, the qualitative approach

utilizes content or holistic analysis to explain and comprehend the research findings. The

main purpose of qualitative research method is that, measurements valid, reliable and can

be generalized with clear anticipation of cause and effect (Cassell & Symon, 1994).The

researcher would integrate qualitative research approach into the study due to its significant

advantages. The use of qualitative data gathering method is advantageous since it’s more

open to changes and refinement of research ideas as the study progresses. This implies that

qualitative data gathering tools are highly flexible. One of the notable strengths of

qualitative instrument is that it evokes a more realistic feeling of the research setting which

cannot be obtained from statistical analysis and numerical data utilised through quantitative

means. These data collection methods allow flexibility in data gathering, research analysis

and interpretation of information gathered.

3.7 DATA ANALYSIS AND PRESENTATION

The data gathered from the field would be analyzed electronically by using statistical tools

such as hypothesis testing and Regression Analysis. The analysis would be done by the use

of Statistical Packages for Social Science (SPSS) and Microsoft Excel. A two sample test,

Q-Q normal plot test, a chi-square test and a non-parametric test such as Kolmogorov-

Smirnov test, would be used to analyze some of the data collected from the field. Charts

such as scatter diagrams and linear graphs would be used to present data gathered from the

field. Simple statistical analysis such as frequency distribution, and other descriptive

analysis would be used in this study.


35

3.8 KOLMOGOROV-SMIRNOV GOODNESS-OF-FIT TEST

The Kolmogorov-Smirnov (K-S) goodness of fit test is a nonparametric test used to assess whether

a sample comes from a population with a specified distribution. A hypothesis test involves

calculation of a test statistic from the data and the probability of obtaining a value at least as large

as a tail area if the correct distribution is chosen. The K-S test is based on the empirical cumulative

distribution function (ECDF), it measures the Supremun distance between the cumulative

distribution function of the theoretical distribution and the empirical distribution function, over all

the sample points. The K-S test is distribution free since its critical values do not depend on the

specific distribution being tested. The K-S test is relatively insensitive to differences in the tails

but more sensitive to points near the median of the distribution.

Definition 1

Let 1 2 3, , , ... , nX X X X be a random sample. The empirical distribution function ( )S x is a

function of X , which equals the fraction of 'iX s that are less than or equal to X for each iX ,

,iX

1

1( ) , 3.4

i

n

x xi

S x In

where

( )ix x

I x

is an indicator function and

0, if

( ) 3.51, if i

i

x x

i

x xI x

x x


36

*( ) ( ) 3.6sup i i

i

D F x S x

For testing the hypotheses,

*

0

*

1

: ( ) ( ), for all -

: ( ) ( ), for at least one value of ,

H F x F x x

H F x F x x

3.9 REGRESSION ANALYSIS

Regression is used to find the probable form of the relationship between two or more

variables and predict or estimate the value of one variable corresponding to given values

of other variables. The concepts of regression were first discussed by the English Scientist

Sir Francis Galton (1822-1911) in reports of his research on heredity (Galton 1899, 1908).

Regression Analysis seeks to find the regression model or mathematical equation that best

describes the relationship that exists between two or more variables. Regression may be

linear or non-linear and simple or multiple. Regression analysis is a conceptually a method

of investigating functional relationship among variables. The relationship is expressed in

the form of an equation or a model connecting the response or dependent variable and one

or more explanatory variables. Regression is one of the most widely used statistical tools

because it provides a simple method for establishing a functional relationship among

variables. It has extensive application in many areas such as Agricultural Science,

Industrial and Labour relations, History, Governments, Environmental Sciences, Health,

etc. A simple and multiple regression method would be used to analyze data gathered from

the field. Regression analysis would be used since one of the objectives of the study is to


37

determine the trend and also determine the trend line equation. Though statistical software

would be used to determine the trend and the equation of the model, it would be appropriate

to discuss some theories of regression analysis in this study.

3.10 MULTIPLE LINEAR REGRESSION

The multiple regression model will be of the form

Y = 𝛽0+𝛽1𝜒1+𝛽2𝜒2+…+ 𝛽𝑘𝜒𝑘+ 𝜀,……………………………………….. (3.10.1)

where 𝛽𝜊,𝛽1, 𝛽2…,𝛽𝑘 are regression coefficients which can be estimated from the sample

data and 𝜀 is the random disturbance or error.

The response variable (Y) for the multiple regression generated from the field data would

be the total number of claims paid by the Akuapem South Mutual Health Scheme and the

predictor variables (𝜒1 ,𝜒2,… ,𝜒𝑘) are the number of claims paid to the selected service

providers in Nsawam-Adoagyiri and Akuapem South District Assemblies.

In the case of two independent variables (i.e. k=2) in such situation, the least squares

estimate 𝑏𝜊,𝑏1 𝑎𝑛𝑑 𝑏2 of 𝛽𝜊, 𝛽1 𝑎𝑛𝑑 𝛽2 respectively are obtained from simultaneous

solution of the normal equations:

𝑏𝑜n +𝑏1 ∑ 𝑥𝑛𝑖=1 𝑖1

+ 𝑏2 ∑ 𝑥𝑖2𝑛𝑖=1 =∑ 𝑦𝑛

𝑖=1 𝑖

𝑏0 ∑ 𝑥𝑛𝑖=1 𝑖1

+ 𝑏1 ∑ 𝑥²𝑖1𝑛𝑖=1 + 𝑏2 ∑ 𝑥𝑖1

𝑛𝑖=1 𝑥𝑖2=∑ 𝑥𝑖1𝑦𝑖

𝑛𝑖=1 …......... 3.10.2

𝑏0 ∑ 𝑥𝑖2𝑛𝑖=1 + 𝑏1 ∑ 𝑥𝑖1

𝑛𝑖=1 𝑥𝑖2 +𝑏2 ∑ 𝑥²𝑖2

𝑛𝑖=1 =∑ 𝑥𝑖2𝑦𝑖

𝑛𝑖=1

𝑇ℎ𝑒 𝑎𝑏𝑜𝑣𝑒 𝑛𝑜𝑟𝑚𝑎𝑙 𝑒𝑞𝑢𝑎𝑡𝑖𝑜𝑛𝑠 𝑤𝑜𝑢𝑙𝑑 𝑏𝑒 𝑜𝑏𝑡𝑎𝑖𝑛𝑒𝑑 𝑏𝑦 𝑚𝑖𝑛𝑖𝑚𝑖𝑧𝑖𝑛𝑔 𝑡ℎ𝑒 𝑒𝑞𝑢𝑎𝑡𝑖𝑜𝑛 𝑏𝑒𝑙𝑜𝑤

Q (𝛽0,𝛽1,…,𝛽𝐾)=∑ 𝜀²𝑛1= = ∑ (𝑦𝑖−

𝑛𝑖=1 𝛽0-𝛽1𝜒𝑖1− … , 𝛽𝜌𝜒𝑖𝜌) ² ………………….. (3.10.3)


38

Since the parameters would be obtained after regressing Y on 𝜒1 ,𝜒2,… ,𝜒𝑘 using Microsoft

Excel, we would not go through the calculus method for determining the normal equations.

The parameters of the regression coefficient would be tested by using the following

hypothesis and test statistic

𝐻𝑂: 𝛽𝑗 = 0

𝐻1: 𝛽𝑗≠ 0 (or 𝛽𝑗>0 or 𝛽𝑗<0) for at least one j, j= 0, 1…, p,

where the 𝛽𝑗′s are the regression coefficients to be tested. It also represents the

contribution 𝑜𝑓 𝑋𝑖’s (the total number of claims paid to the service providers) and

the response variable (Y), in this case is the total number of claims paid by the

Akuapem South Mutual Health Scheme.


39

The test statistic is

t =�̂�𝑗

𝑠.𝑒(𝛽𝑗)̂ ,…………………………………………………………… (3.10.4)

where t has the t-distribution with n-p-1 degrees of freedom when 𝐻𝑂 is true.

Decision: reject 𝐻0 at significance level α if t< −𝑡½𝛼,𝑛−𝑝−1 𝑜𝑟 t > 𝑡½𝛼,𝑛−𝑝−1otherwise

fail to reject 𝐻𝑂.


40

CHAPTER FOUR

DATA PRESENTATION, ANALYSIS AND INTERPRETATION

4.0 INTRODUCTION

This chapter presents a classification of data gathered from the field during the study by using

statistical tools such as regression analysis, test of hypothesis and non-parametric test such as chi-

square test, Kolmogorov-Smirnov test, Q-Q Normal Plot Test will be used in the analysis. Data

collected will be analyzed critically to ascertain whether the Health Insurance Scheme is Effective.

The researcher gathered both secondary and primary data. The secondary data is gathered from the

clinic attendance register of the selected health insurance service providers in Akuapem South

District and Nsawam Adoagyiri Municipal Assemblies. The researcher also designed a

questionnaire and an interview guide which was used to obtain the primary data from health

insurance users and Providers of Health insurance services in Akuapem South District and

Nsawam Adoagyiri Municipal Assemblies. The researcher also obtained secondary data on claims

payment and health insurance enrolment from the Akuapem South Mutual Health Scheme. The

questionnaire and interview guide were designed based on the objectives of the study and the

literature review of the study. In all, three hundred (300) questionnaires were administered to

health insurance users and eight senior staff were interviewed from the four (4) selected health

insurance service providers. Two Hundred and Eighty Eight questionnaires were received and

analyzed representing a response rate of 96%. The data gathered from the field were organized

and subjected to statistical analysis.


41

TABLE 4.1 DATA ON NUMBER OF CLAIMS PAID FROM 2007 - 2013

N 77

Mean 14 400

Std. Deviation 4 645

Minimum 2 551

Maximum 2 4639

Sum 1 110 070

Source: Akuapem South Mutual Health Insurance Scheme, (2013)

Table 4.1 shows the number of claims paid by the Akuapem South Mutual Health Insurance

Scheme from September, 2007 to December, 2013 to Health Insurance Service Providers in

Akuapem South District and Nsawam Adoagyiri Municipal Assembly. The summary table above

shows that the Akuapem South Mutual Heath Insurance Scheme paid a total number of claims of

1 110 070 to accredited service providers in its catchment area which includes Nsawam

Government Hospital, Pokrom Health Centre, Kom Presby Clinic and Newlife Hospital. The

Mutual Health Scheme on the average paid 14 400 claims to the accredited health insurance

providers in the Municipality. The total number of claims paid by the Akuapem South Mutual

Health Insurance Scheme ranged between a minimum number of 2 551 and maximum number of

24 639 to its service providers.


42

Figure 4.1: A GRAPH OF NUMBER OF CLAIMS PAID ON MONTHLY BASIS

Figure 4.1 above is a line graph presenting the number of claims paid by the Akuapem South

Mutual Health Scheme on monthly basis from September, 2007 to December, 2013.

FIGURE 4.2: A SCATTER DIAGRAM OF NUMBER OF CLAIMS PAID ON MONTHLY BASIS

y = 178.34x + 7461.2

0

5,000

10,000

15,000

20,000

25,000

30,000

0 10 20 30 40 50 60 70 80 90

NU

MB

ER O

F C

LAIM

S

MONTH

NUMBER OF CLAIMS PAID ON MONTHLY BASIS FROM 2007-2013

0

5,000

10,000

15,000

20,000

25,000

30,000

1 3 5 7 9 11131517192123252729313335373941434547495153555759616365676971737577

NU

MB

ER O

F C

LAIM

S

MONTH

NUMBER OF CLAIMS PAID ON MONTHLY BASIS FROM 2007-2013


43

Figure 4.2 above is a pictorial presentation of the number of claims paid by the Akuapem South

Mutual Health Scheme on monthly basis from September, 2007 to December, 2013.The trend line

above shows that the number of claims paid increased from month to month during the period.

The trend line equation y = 74 61.2 + 178.34Χ from figure 4.2 confirms a positive linear

relationship between the months and the number of claims paid by the Mutual Health to the health

insurance service providers.

TABLE 4.2 DATA ON NUMBER ENROLLED UNTO THE SCHEME FROM 2010 - 2013

N 48

Mean 59 500

Std. Deviation 20 980

Minimum 29 619

Maximum 91 657

Sum 2 854 255

Source: Akuapem South Mutual Health Insurance Scheme, (2013)

Table 4.2 above shows the number of people that were enrolled onto the scheme on monthly basis

from January, 2010 to December, 2013. Information from the table shows that a total of 2 854

255 people were enrolled onto the Akuapem South Mutual Health Insurance Scheme. It is observed

from the table that on the average 59 500 people enrolled onto the scheme between January, 2010

and December 2013.The total enrolment onto the Akuapem South Mutual Heath Scheme ranged

between a minimum of 29 619 people and a maximum of 91 657 people during the period.


44

FIGURE 4.3 A GRAPH ON NHIS ENROLLMENT ON MONTHLY BASIS

Figure 4.3 is a line graph representing the number of people enrolling onto the Akuapem South

Mutual Health Scheme on monthly basis from January 2010 to December, 2013.

FIGURE 4.4: A SCATTER DIAGRAM REPRESENTING NHIS ENROLLMENT

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47

TOTA

L EN

RO

LLM

ENT

MONTH

A GRAPH REPRESENTING NHIS ENROLLMENT ON MONTHLY BASIS FROM

2010 - 2013

y = 1367.2x + 25967

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

0 10 20 30 40 50 60

TOTA

L EN

RO

LLM

ENT

MONTH

A SCATTER DIAGRAM REPRESENTING NHIS ENROLLMENT ON MONTHLY BASIS FROM

2010-2013


45

Figure 4.4 is a scatter diagram representing the number of people enrolling onto the Akuapem

South Mutual Health Scheme on monthly basis from January 2010 to December, 2013. From the

scatter graph above it is observed that the number of people enrolling onto the scheme increased

on monthly basis from January 2010 to December 2013.The line of best fit above confirms a

positive linear relationship between the number of people enrolling onto the scheme and the month.

TABLE 4.3 DATA ON CLINIC ATTENDANCE ON MONTHLY BASIS FROM 2008 - 2013

Insured Non insured

N 72 72

Mean 7 449.94 1 309.40

Variance 4 324 000 332 200

Range 13 899 3 135

Minimum 3 191 241

Maximum 17 090 3376

Sum 536 396 94 277

Source: Nsawam Government Hospital (2013)

Table 4.3 above, represents the number of insured and non-insured patients that assessed medical

care at Nsawam Government Hospital from January, 2008 to December, 2013. From the summary

table it is observed that a total of 630 673 patients visited the hospital and this comprises of 536

396 insured patients and 94 277 non-insured patients. The insured patients represent 85.05% of

the total patients that visited the Hospital and that of the non –insured patients represent 14.95%

of total number of patients that visited the Nsawam Government Hospital on monthly basis from

2008 to 2013.An average of 74 450 patients that visited the hospital were health insurance users.


46

The number of health insurance users that visited Nsawam Government Hospital ranged between

a minimum of 3 191 patient and a maximum of 17 090 patients. On the average 1 309 non - insured

patients visited the Nsawam Government Hospital. The number non-insured patients that used the

facility ranged between a minimum of 241 patients and a maximum of 3 376 patient on monthly

basis from 2008 to 2013.


Insured Non insured

N 40 40

Mean 234.80 110.02

Variance 5 488 1 687.512

Range 287 172

Minimum 120 44

Maximum 407 216

Sum 9 392 4 401

Source: New Life Hospital (2013)

Table 4.4 above shows the number of insured and non-insured patients that visited the New life

Hospital from September, 2010 to December, 2013. From the summary table it is observed that a

total of 13 793 patients visited the hospital and this comprises 9 392 insured patients and 4 401

non-insured patients. The insured patients represent 68.09% of the total patients that visited the

Hospital and that of the non –insured patients represent 31.91% of total number of patients that

visited the New Life Hospital on monthly basis from 2010 to 2013.An average of 235 patients that

visited the hospital were health insurance users. The number of health insurance users that visited

New Life Hospital ranges between a minimum of 120 patient and a maximum of 407 patients. On


47

the average 110 non - insured patients visited New Life Hospital. The number of non-insured

patients that visited the facility ranged between a minimum of 44 patients and a maximum of 216

patients on monthly basis from 2010 to 2013.


Insured Non insured

N 48 48

Mean 572.10 24

Variance 47 610 19.06

Range 852 392.273

Minimum 188 0

Maximum 1 040 70

Sum 27 461 915

Source: Pokrom Health Center (2013)

Table 4.5, above, shows the number of insured and non-insured patients that visited the Pokrom

Health Centre from January 2010 to December, 2013. From the summary table it is observed that

a total of 28 376 patients visited the Health Centre and this comprises of 27 461 insured patients

and 915 non-insured patients. The insured patients represent 96.78% of the total patients that

visited the Health Centre and that of the non –insured patients represent 3.22% of total number of

patients that visited Pokrom Health Centre on monthly basis from 2010 to 2013. An average of

572 patients that visited the Health Centre were health insurance users. The number of health

insurance users that visited Pokrom Health Centre ranges between a minimum of 188 patients and

a maximum of 1 040 patients. On the average 19 non - insured patients visited Pokrom Health

Centre Hospital. The number of non-insured patients that visited the facility ranges between a


48

minimum of zero patients and a maximum of 70 patients on monthly basis from 2010 to 2013.The

above analysis shows that majority of patients that visited Pokrom Health Centre are health

insurance users


Insured Non insured

N 72 72

Mean 797.19 108.51

Variance 55 500 3 766.169

Range 975 294

Minimum 460 43

Maximum 1 435 337

Sum 57 398 7 813

Source: Kom Presby Clinic, (2013)

Table 4.6 above shows the number of insured and non-insured patients that visited Kom Presby

Clinic from January 2008 to December, 2013.From the summary table it can observed that a total

of 67 211 patients visited Kom Presby Clinic and this comprises 57 398 insured patients and 7

813 non-insured patients. The insured patients represent 88.38% of the total number of patients

that visited the Clinic and that of the non –insured patients represent 11.62 % of the total number

of patient that visited Kom Presby Clinic on monthly basis from 2008 to 2013. An average of 797

patients that visited Kom Presby Clinic were health insurance users. The number of health

insurance users that visited Kom Presby Clinic ranged between a minimum of 460 patients and a

maximum of 1 435 patients. On the average 109 non - insured patients visited Kom Presby Clinic.

The number of non-insured patients that visited the facility ranged between a minimum of 43 and


49

maximum of 337 patients on monthly basis from 2008 to 2013. The above analysis shows that

majority of patients that visited Kom Presby Clinic are health insurance users.

TABLE 4.7: TEST FOR DIFFERENCE BETWEEN TWO MEANS

z-Test: Two Sample Means

Variable 1 Variable 2

Mean 59463.64583 16704.14583

Known Variance 439956161.9 15239841.11

Observations 48 48

Z 13.88526002

z Critical one-tail 1.644853627

z Critical two-tail 1.959963985

Table 4.7 is z-test for the difference between two means. One of the objectives of the study is to

determine whether there is any significant difference between the mean number of people enrolling

onto the health insurance scheme and the mean number of people using the health insurance

scheme to access medical care in Nsawam Adoagyiri Municipality and Akuapem South District

Assemblies.

The hypothesis and test statistics below would be used to test for difference in the above means.

𝐻0: 𝜇1 = 𝜇2 𝐻1: 𝜇1 ≠ 𝜇2

Z = 𝑋1−𝑋2−𝑑𝑜

√𝑆²1𝑛1

⁄ + 𝑆²2

𝑛2⁄

, Z is N (0 ,1) when 𝐻0 is true.


50

From the above analysis comparing the computed z value of 13.885 to 𝑍0.975 = 1.96 we reject 𝐻0

at 5% significance level since 13.885 is greater than 1.96 and conclude that there is significance

difference between the number of people enrolling onto the national insurance scheme and those

using the health insurance to access medical care in Nsawam-Adoagyiri Municipality and

Akuapem South District. Though analyzing the trend data, it shows that enrolment is on the

increase but the test for the difference between means also shows that not all those who have

enrolled onto the scheme use the scheme to assess medical care. The statistical analysis above to

some extent confirms that enrolment is increasing but the patronization of health insurance services

does not correspond to the enrolment.


51

FIGURE 4.5: NORMAL Q-Q PLOT FOR POKROM HEALTH CENTRE

One of the objectives of the study is to fit the claim payment data to a distribution and test whether

the data fit that particular distribution. Figure 4.5 is a Q-Q Normal Plot for claim payment to

Pokrom Health Centre. The Plot shows that the claim payment data for Pokrom Health Centre

follow a Log- Normal Distribution.


52

Table 4.8: One-Sample Kolmogorov-Smirnov Test for Pokrom Health Centre

Pokrom Claim

N 66

Normal Parametersa,b

Mean 8.2161

Std. Deviation .58996

Most Extreme Differences

Absolute .058

Positive .058

Negative -.042

Kolmogorov-Smirnov Z .469

Asymp. Sig. (2-tailed) .980

Monte Carlo Sig. (2-tailed)

Significance .970c

99% Confidence

Interval

Lower Bound .966

Upper Bound .975

a. Test distribution is Normal.

b. Calculated from data.

c. Based on 10000 sampled tables with starting seed 2000000.

Table 4.8 is a one-sample K-S test which shows that the data on claim payment for Pokrom Health

Centre follows a Log-Normal Distribution. The significance value of 0.970 and the 2-tail

asymptotic significance value of 0.980 which are all greater than 0.01 shows that the data follows

a Log-Normal Distribution. The Monte Carlo Significance (2-tailed test) and 99% confidence

interval also shows that the claim payment to Pokrom Fit Log- Normal Distribution.


53

FIGURE 4.6: NORMAL Q-Q PLOT FOR KOM PRESBY CLINIC

One of the objectives of the study is to fit the claim payment data to a distribution and test whether

the data fit that particular distribution. Figure 4.6 is a Q-Q Normal Plot for claim payment to Kom

Presby Clinic. The Normal Q-Q Plot shows that the claim payment data for Kom Presby Clinic

follows a Log- Normal Distribution.


54

Table 4.9 One-Sample Kolmogorov-Smirnov Test for Kom Presby Clinic

Kom_Claim

N 72


Mean 8.9256



Absolute .107

Positive .080

Negative -.107

Kolmogorov-Smirnov Z .912



Significance .353c

99% Confidence Interval

Lower Bound .341

Upper Bound .366




Table 4.9 is a one-sample K-S test which shows that the data on claim payment to Kom Presby

Clinic follows a Log-Normal Distribution. The significance value of 0.353 and the 2-tail

asymptotic significance value of 0.376 which are greater than 0.01 shows that the data follows a

Log-Normal Distribution. The Monte Carlo Significance (2-tailed test) and 99% confidence

interval also shows that the claim payment to Kom Presby Clinic Fits a Log- Normal Distribution.


55

FIGURE 4.7: NORMAL Q-Q PLOT FOR NSAWAM GOV’ HOSPITAL

Figure 4.6 is a Q-Q Normal Plot for claim payment to Nsawam Government Hospital. The Plot

shows that the claim payment data for Kom Presby Clinic fits a Log- Normal Distribution. One of

the objectives of the study is to fit the data on claim payment for the selected service providers to

a particular distribution.


56

Table 4.10 One-Sample Kolmogorov-Smirnov Test for Nsawam Gov’t Hospital

Nsawam_Claim

N 70


Mean 11.9432



Absolute .123

Positive .091

Negative -.123

Kolmogorov-Smirnov Z 1.031



Significance .224c

99% Confidence Interval

Lower Bound .213

Upper Bound .235




Table 4.10 is a one-sample K-S test which shows that the data on claim payment for Nsawam

Government Hospital fits a Log-Normal Distribution. The significance value of 0.224 and the 2-

tailed asymptotic significance value of 0.239 which are all greater than 0.01 shows that the data

follows a Log-Normal Distribution. The Monte Carlo Significance (2-tailed test) and 99%

confidence interval also shows that the claim payment to Nsawam Government Hospital fits a Log-

Normal Distribution.


57

Table: 4.11 General Linear Output for Pokrom Health Centre

Model Information

Dependent Variable prok

Probability Distribution Normal

Link Function Identity

Continuous Variable Information

N Minimum Maximum Mean Std. Deviation

Dependent Variable prok 66 7.00 9.92 8.2161 .58996

Covariate adpok 66 174.00 2542.00 629.5303 308.57739

The model information table show that dependent variable being the claim payment for Pokrom is

normally distributed. The variable information recorded a mean value of 8.2161 and standard

deviation of 0.58996. The claim payment difference is between a minimum value of 7 and

maximum value of 10. Pokrom health Centre recorded a minimum claim payment covariance of

174.00 and a maximum of 629.5303. The average claim payment covariance is 629.5303 and a

standard deviation of 308.57739.


58

Table: 4.12 Goodness of Fit Output For Pokrom Health Centre

Goodness of Fita

Value df Value/df

Deviance 8.437 64 .132

Scaled Deviance 66.000 64

Pearson Chi-Square 8.437 64 .132

Scaled Pearson Chi-Square 66.000 64

Log Likelihoodb -25.768

Akaike's Information

Criterion (AIC) 57.537

Finite Sample Corrected

AIC (AICC) 57.924

Bayesian Information

Criterion (BIC) 64.106

Consistent AIC (CAIC) 67.106

Dependent Variable: prok

Model: (Intercept), adpok

a. Information criteria are in small-is-better form.

b. The full log likelihood function is displayed and used in computing

information criteria.

The goodness of fit output table recorded a deviance test statistic value of 01.32 and Pearson test

statistic value of 01.32, which is the deviance value divided by its degrees of freedom (df).The

goodness of fit output recorded a deviance scale value of 66 and a scale Pearson chi-square value

of 66. Comparing the AIC 57.537 and the BIC value of 57.924 to the deviance scaled value of 66.


59

It can be concluded that the General Linear model fit the difference in attendance and claim

payment for Pokrom Health Centre.

Table 4.13: Ominibus Test for Pokrom Health Centre

Table 4.13 is an Ominibus test for Pokrom Centre. It’s a test that compares the fitted model against

its intercept. Since the Likelihood Ratio Chi-significance value of 0.00 is less than

the p- value of 0.01, we conclude that the linear model fits the data and can be used to

predict claims payment for Pokrom Health Centre.

Omnibus Testa

Likelihood Ratio

Chi-Square

df Sig.

65.098 1 .000

Dependent Variable: prokrom

Model: (Intercept), adpokrom

a. Compares the fitted model against the intercept-only model.


60

Table 4.14: Test for Model Effect for Pokrom Health Centre

Table 4.14 is a model effect test for Pokrom Health Centre. This test also compares the intercept

and dependent variable of the linear model. From the output table the Wald Chi-square value for

the intercept is significant at 0.01 significance level. The Wald Chi-square value is also significant

at 0.01 significance level. The output of the test of the model effect shows that the general linear

model fit the data on claims payment and insured attendance for Pokrom Health Centre.

Table 4.15: Parameter Estimates for Pokrom Health Centre

Parameter Estimates

Parameter B Std. Error 95% Wald Confidence Interval Hypothesis Test

Lower Upper Wald Chi-

Square

df Sig.

(Intercept) 7.263 .2281 6.816 7.710 1013.599 1 .000

adpok .002 .0004 .001 .002 15.793 1 .000

(Scale) .128a .0223 .091 .180



Tests of Model Effects

Source Type III

Wald Chi-Square df Sig.

(Intercept) 1013.599 1 .000

adpok 15.793 1 .000




61

a. Maximum likelihood estimate.

From the parameter estimates table the beta value of 7.263 for the intercept is significant at 0.01

significance level and 95% Wald Confidence interval also show that it is significant. The beta

value of 0.002 is also significant since its significant value of 0.00 is less than the p-value of 0.01.

The 95% Wald confidence interval also confirms that beta value for the insured attendance is also

significant since it falls with the interval.

The analysis above concludes that the general linear model for Pokrom Health Centre fit the data.

Table: 4.16 General Linear Output for Kom Presby Clinic

Model Information

Dependent Variable Kom_Claim





Dependent Variable Kom_Claim 72 7.46 10.20 8.9256 .42134

Covariate adkom 72 365.00 2536.00 940.4167 285.79682

The model information table show that dependent variable being the insured claim payment data

for Kom Presby Clinic is normally distributed. The variable information recorded a mean value of

8.9256 and standard deviation of 0.58996.The claim payment difference is between a minimum

value of 7 and maximum value of 10. Kom Presby Clinic recorded a minimum claim payment


62

covariance of 365.00 and a maximum of 2536.00. The average claim payment covariance is

940.4167 and a standard deviation of 285.79682.

Table: 4.17 Goodness of Fit Output for Kom Presby Clinic

Goodness of Fita

Value df Value/df

Deviance 6.309 70 .090








AIC (AICC) 35.382




Dependent Variable: Kom_Claim

Model: (Intercept), adkom







63


of 72. Comparing the AIC value of 35.382 and the BIC value of 41.859 to the deviance scaled

value of 72. It can be concluded that the General Linear model fit the data difference in attendance

and claim payment for Kom Presby Clinic.

Table 4.18: Ominibus Test for Kom Presby Clinic

Omnibus Testa

Likelihood

Ratio Chi-

Square

df Sig.

49.829 1 .000



a. Compares the fitted model against the intercept-only

model.

Table 4.18 is an Ominibus test for Kom Presby Clinic. It’s a test that compares the fitted model

against its intercept. Since the Likelihood Ratio Chi-significance value of 0.00 is less than

the p- value of 0.01, we conclude that the linear model fits the data and can be used to

predict claims payment for Kom Presby Clinic.


64

Table 4.19: Test for Model Effect for Kom Presby Clinic


Source Type III


(Intercept) 2066.561 1 .000

Attendance

kom 37.877 1 .000



Table 4.19 is a model effect test for Kom Presby Clinic. The test for the model effect also compares

the intercept and dependent variable of the linear model. From the Model effect output table, the

Wald Chi-square value of 2066.561 for the intercept is significant at 0.01 significance level. The

Wald Chi-square value of 37.877 for the intercept is also significant at 0.01 significance level. The

output of the test of the model effect shows that the general linear model fit the data on claims

payment and insured attendance for Kom Presby Clinic.


65

Table 4.20: Parameter Estimates for Kom Presby Clinic

Parameter Estimates



Square

df Sig.

(Intercept) 7.946 .1748 7.603 8.288 2066.561 1 .000

Attendance

Kom .001 .0002 .001 .001 37.877 1 .000

(Scale) .088a .0146 .063 .121




Table 4.20 is maximum likelihood estimates for the insured attendance and its intercept for Kom

Presby Clinic. From the parameter estimates table the beta value of 7.946 for the intercept is

significant at 0.01 significance level and 95% Wald Confidence interval also show that it is

significant. The beta value of 0.002 for the insured attendance for Kom Presby Clinic is also

significant since its significant value of 0.00 is less than the p-value of 0.01. The 95% Wald

confidence interval also confirms that beta value for the insured attendance is also significant since

it falls within the interval. The analysis above concludes that the general linear model for Kom

Presby Clinic fit the data.


66

Table: 4.21 General Linear Output for Nsawam Gov’t Hospital

Model Information

Dependent Variable Nsawam_Claim





Dependent Variable Nsawam_Claim 70 9.85 12.81 11.9432 .64513

Covariate Nsawam 70 2767.00 11422.00 7263.6857 2099.30243

The model information table show that dependent variable being the insured claim payment data

for Nsawam Government Hospital is normally distributed. The variable information recorded a

mean value of 11.9432 and standard deviation of 0.64513. The claim payment difference is

between a minimum value of 9.85 and maximum value of 12.81.The Nsawam Government

Hospital recorded a minimum claim payment covariance of 2767.00 and a maximum of 11422.00.

The average claim payment covariance is 7263.6857 and a standard deviation of 2099.30243.


67

Table: 4.22 Goodness of Fit Output for Nsawam Gov’t Hospital

Goodness of Fita

Value df Value/df

Deviance 5.618 68 .083








AIC (AICC) 28.443




Dependent Variable: Nsawam_Claim

Model: (Intercept), adNsawam







of 70. Comparing the AIC value of 28.079 and the BIC value of 34.824 to the deviance scaled


68

value of 70. It can be concluded that the General Linear model fit the data on insured attendance

and claim payment for Nsawam Government Hospital.

Table 4.23: Ominibus Test for Nsawam Gov’t Hospital

Omnibus Testa

Likelihood Ratio Chi-

Square

df Sig.

114.203 1 .000


Model: (Intercept), adnsawam

a. Compares the fitted model against the intercept-only

model.

Table 4.23 is an Ominibus test for Nsawam Government Hospital. It’s a test that compares the

fitted model against its intercept. Since the Likelihood Ratio Chi-significance value of 0.00 is less

than the p- value of 0.01, we conclude that the linear model fits the data.The Ominibus test have

confirmed that there is a linear relationship between the insured attendance submitted by the

facility and the claim amount disbursed by the scheme to the facility.


69

Table 4.24: Test for Model Effect for Nsawam Gov’t Hospital


Source Type III


(Intercept) 3055.049 1 .000

adnsaw 166.560 1 .000


Model: (Intercept), adnsawam

Table 4.24 is a model effect test for Nsawam Government Hospital. This test also compares the

intercept and dependent variable of the linear model. From the output table the Wald Chi-square

value for the intercept is significant at 0.01 significance level. The Wald Chi-square value is also

significant at 0.01 significance level. The output of the test of the model effect shows that the

general linear model fit the data on claims payment and insured attendance for Nsawam

Government Hospital.


70

Table 4.25: Parameter Estimates for Nsawam Gov’t Hospital

Parameter Estimates



Square

df Sig.

(Intercept) 9.941 .1799 9.589 10.294 3055.049 1 .000

Attend nsaw .000 2.1356E-005 .000 .000 166.560 1 .000

(Scale) .080a .0136 .058 .112


Model: (Intercept), adnsaw


Table 4.25 is the parameter estimates output for Nsawam Government Hospital. From the

parameter estimates table the β value of 9.941 for the intercept is significant at 0.01 significance

level and 95% Wald Confidence interval also show that it is significant. The β value of 0.000 for

the insured attendance for Nsawam Government Hospital is also significant since its significant

value of 0.00 is less than the p-value of 0.01.

The 95% confidence interval also confirms that β value of 0.000 for the insured attendance is also

significant since it falls within the interval. The analysis above concludes that the general linear

model for Nsawam Government Hospital fit the data.

The analysis from the general linear model output have shown that the insured attendance and

claim amount payment has a linear relationship. This means that there is a linear relationship


71

between the number of insured attendance submitted to the scheme by the facility and the claim

amount disbursed by the scheme to the service provider.

TABLE 4.26: REGRESSION OUTPUT FOR REGRESSION OF Y on 𝑿𝟏,𝑿𝟐, 𝑿𝟑, 𝑿𝟒

SUMMARY OUTPUT

Regression Statistics

Multiple R 0.8994571

R Square 0.8090232 Adjusted R Square 0.7871972

Standard Error 1783.917

Observations 40

ANOVA

df SS

MS F Significance F

Regression 4 471843068.1 117960767 37.06707228 3.96097E-12

Residual 35 111382599 3182359.97

Total 39 583225667.1

Coefficients Standard Error

t Stat P-value Lower 95% Upper 95%

Intercept 8191.0163 1749.133936 4.682898286 4.165E-05 4640.08564 11741.94698

X Variable 1 0.0848273 0.195826045

0.433177028 0.667544154 -0.312720662 0.48237535

X Variable 2 5.8546184 1.577025404 3.712443921 0.000710944 2.653086599 9.05615015

X Variable 3 8.9573311 2.097859569 4.269747704 0.000142088 4.698449734 13.21621242

X Variable 4 -8.191913 3.970386439 -

2.063253256 0.046567538 -16.25222574

-0.131599758

The multiple regression above is to assist in the prediction of claims payment for Akuapem South

Mutual Health Scheme. The 𝑅2 value of 0.809 indicates that a linear relationship exists between

the response variable and the predictor variables 𝑋1,𝑋2, 𝑋3, 𝑋4.The 𝑅2 value of 0.899 means that

80.9% of variability in the response variable is being accounted for by the predictor variables. This

indicates that the multiple regression equation below can be used for prediction.


72

�̌� = 8191.0163 + 0.0848𝑿𝟏+5.8546𝑿𝟐 +8.957𝑿𝟑 -8.1919𝑿𝟒. ……………………………4.26.1

The above regression equation is from the output summary of regression Y on 𝑋1,𝑋2, 𝑋3, 𝑋4 and

can be interpreted as follows. A change in the predictor variable (𝑋1) by one unit will increase the

response variable(Y) by 0.0848 units when the predictor variable 𝑋2, 𝑋3, 𝑋4 and the value

8 191.0163 are held constant. Adjusting the variable ( 𝑋2) by one unit will also increase the

response variable by 5.8546 units when the predictor variables ( 𝑋1, 𝑋3, 𝑋4) and the value

8191.0163 are all held constant. The coefficient 𝑋3 means that each unit of 𝑋3 adds 8.957 to Y

when the variables 𝑋1, 𝑋2, 𝑋4 and the value 8 191.0163 are all held constant. An increase in the

predictor variable 𝑋4 by one unit will reduce the response variable (Y) by 8.1919 units when the

variables 𝑋1,𝑋2, 𝑋3 and the value 8 191.163 are all held constant.

From Table 4.26, it is seen that the regression coefficients are statistically significant except that

of 𝑋1,which has a test statistics of 0.4333 and a p- value of 0.6675 which is greater than the p-value

of 0.05. It means that 𝑋1,the total number of claims paid to Nsawam Government Hospital (total

number of patients that used health insurance to access medical care in the facility) is not

statistically significant and can be dropped from the model. It also means that 𝑋1, is not important

and deleting it will not have any effect on the model.

This study seeks to test for the significance of the regression coefficients and this will be done by

using the hypothesis and test statistic below.

𝐻0: 𝛽𝑗= 0 against 𝐻0: 𝛽𝑗≠0 ∀ j=0, 1,2,3,4.

The test statistic is given as


73

t =�̂�𝑗

𝑠.𝑒(𝛽𝑗)̂ ,∽ 𝑡𝑛−𝑝−1

From figure 4.26, it is observed that the regression coefficients are all significant except that of 𝑋1.

The test statistics and the p-value for the regression coefficients confirms the results above. The

multiple regression model for the study was developed to assist in the prediction of claims payment

by the Akuapem South Mutual Health Scheme.

The analysis above has shown that the number of claims paid to Nsawam Government Hospital is

not statistically significant even though the facility recorded high attendance for insured patients

over the period.

4.1 RESPONSE TO QUESTIONNAIRE BY HEALTH INSURANCE USERS IN

NSAWAM ADOAGYIRI MUNICIPALITY AND AKUAPEM SOUTH DISTRICT

The tables below and their interpretations are based on the information that the health insurance

users in Nsawam- Adoagyiri Municipality and Akuapem South district gave when the researcher

administered the questionnaires to them. The questionnaire administered included three sections

with questions on the socio-demographic characteristics of the respondents, health insurance

utilization and services provided. The respondents for the study are users who have been card

bearers for at least six months. Fourteen (14) of the respondents had used their card for less than a

year. One hundred and sixty seven (167) of the respondents had also used their cards between one

(1) year and five (5) years. Eighty seven (87) of the respondents had used their cards between six

(6) years and ten (10) years. Twenty (20) of the respondents for the study have been card users for

over ten (10) years.


74

TABLE 4.27: GENDER DISTRIBUTION OF RESPONDENTS

Frequency Percent Valid Percent Cumulative Percent

Male 151 52.4 52.4 52.4

Female 137 47.6 47.6 100.0

Total 288 100.0 100.0

Source: Field Data, (2014)

Table 4.27 above shows the number of respondents who responded to the questions. This shows

the total number of male and female who responded to the questionnaire administered.

FIGURE 4.8: GENDER OF RESPONDENTS


Table 4.27 and Figure 4.8 shows the total number of respondents used for the study. Out of the

total respondents who answered the questions, one hundred and fifty one (151), representing

52.4%, were males and the remaining one hundred and thirty seven (137) representing 47.57%,


75

were females. The above analysis shows that males who participated in the survey are slightly

more than females.

4.2 AGE OF RESPONDENTS

The age distribution of respondents shows how the ages of the respondents are distributed.


Table 4.28 above shows how the ages of respondents are distributed. Information from the table

shows that majority of respondents, one hundred and thirty (132) are between the ages of 18years

and 25years which stands at 45.8%. Fifty Three (53) of the respondents are between age 26years.

TABLE 4.28: AGE DISTRIBUTION OF RESPONDENTS

Frequency Percent Valid Percent Cumulative

Percent

18yrs-25ys 132 45.8 45.8 45.8

26yrs-30yrs 53 18.4 18.4 64.2

31yrs-35yrs 39 13.5 13.5 77.8

36yrs-40yrs 23 8.0 8.0 85.8

41yrs-45yrs 19 6.6 6.6 92.4

46yrs-50yrs 9 3.1 3.1 95.5

51yrs-60yrs 8 2.8 2.8 98.3

>60yrs 5 1.7 1.7 100.0

Total 288 100.0 100.0


76

TABLE 4.29: OCCUPATION OF RESPONDENTS


public servant 70 24.3 24.3 24.3

private sector employee 79 27.1 27.4 51.7

private sector employer 19 6.6 6,6 58.3

self employed 50 17.4 17.4 75.7

unemployed 41 14.2 14.2 89.9

others 29 10.1 10.1 100.0

total 288 100.0 100.0


Table 4.29, above, shows that majority of the respondents are private sector employees and they

form about 27.4% of the total respondents selected for the study. Seventy (70) of the respondents

are public servants. They represent about 24.4% of the total respondents for the study. Forty one

(14) of the respondents were unemployed. The table above shows that the occupation of the

respondents for the study are well distributed.


77

Source: Field Data, 2014

Table 4.30 shows the level of education of respondents. It’s observed that the educational level of

respondents ranges from no formal education to tertiary. One Hundred and Eight (108) of the total

respondents have attained tertiary qualification. One Hundred and thirty four (134) of the

participants representing 46.5% have secondary and post-secondary qualifications. The analysis

above shows that majority of the participants have secondary, technical and vocational

qualifications. The above table shows that only few of the participants do not have formal

education. The number of participants who have no formal education is only 4.2% of the total

respondents for the study.

TABLE 4.30: LEVEL OF EDUCATION OF RESPONDENTS

Frequency Percent Valid Percent

Cumulative

Percent

tertiary 108 37.5 37.5 37.5

secondary/tech/vocational 134 46.5 46.5 84.0

basic 34 11.8 11.8 95.8

no formal education 12 4.2 4.2 100.0

Total 288 100.0 100.0


78

TABLE 4.31: MARITAL STATUS OF RESPONENTS


married 92 31.9 31.9 31.9

single 184 63.9 63.9 95.8

divorced 5 1.7 1.7 97.6

widow/widower 7 2.4 2.4 100.0

Total 288 100.0 100.0


Table 4.31 above shows that majority of the respondents are single. The total number of

participants who are single stands at 63.9%. Ninety Two (92) out of the two hundred and eighty

eight (288) respondents selected for the study are married and they represent 31.9% of the total

respondents.

TABLE 4.32: HOW OFTEN DO YOU USE YOUR NHIS CARD TO ACCESS MEDICAL CARE?


once a week 5 1.7 1.7 1.7

once every two weeks 3 1.0 1.0 2.8

once a month 22 7.6 7.6 10.4

very often 35 12.2 12.2 22.6

once a while 223 77.4 77.4 100.0

Total 288 100.0 100.0



79

Table 4.32 above shows how often respondents use their health insurance card to access medical

care at health facilities that have been accredited to provide health insurance services. It is observed

from the table that two hundred and twenty three (223) of the respondents use their health insurance

card to access medical care once a while and this represents 77.4% of the total respondents. Thirty

five (35) of the respondents use their health insurance card very often and twenty two (22), which

stands at 7.6%, use their card once every month to access medical care. The analysis above shows

that majority of the respondents use their health insurance card once a while to access medical care

at the accredited health facilities in Nsawam Adoagyiri Municipality and Akuapem South District.

TABLE4.33: IS THE HEALTH INSURANCE EFFECTIVE


yes 210 72.9 72.9 72.9

no 60 20.8 20.8 93.8

uncertain 18 6.2 6.2 100.0

Total 288 100.0 100.0


Table 4.33 above clearly shows that majority of the respondents representing 72.9%, of the total

respondents responded that the health insurance is effective. Sixty (60) out of the Two Hundred

and eighty Eight (288) respondents responded that the health insurance scheme is not effective.

From table 4.33 it is observed that majority of the respondents answered that the health insurance

scheme is effective. Only Eighteen (18) of the respondents are uncertain, they were not able to

confirm whether the scheme is effective or not. They represent only 6.2% of the total respondents

for the study.


80

TABLE 4.34: THE NHIS IS EFFECTIVE BECAUSE IT IS AFFORDABLE


strongly agree 62 29.5 29.5 29.5

agree 132 62.9 62.9 92.4

disagree 13 6.2 6.2

98.6

strongly disagree 3 1.4 1.4 100.0

Total 210 100.0 100.0


From Table 4.34, sixty two (62) of the respondents strongly agree that the health insurance scheme

is effective because it’s affordable. The number of respondents who strongly agree that the scheme

is effective because of its affordability stands at 29.5%. One hundred and thirty two (132) out of

the two hundred and ten (210) respondents who said the health insurance scheme is effective agree

that it is effective because it’s affordable. Only thirteen (13) of the respondent disagree that the

health insurance is effective because it is affordable. They are of the view that, if it is affordable,

it does not make it effective. The above analysis shows that majority of the respondents agree that

the health insurance is effective because it’s affordable.


81

TABLE 4.35: HEALTH PROFESSIONALS PAY ATTENTION TO NHIS USERS



agree 91 43.3 43.3 56.2

disagree 71 33.8 33.8 90.0


Total 210 100.0 100.0


From table 4.39 it is seen that ninety one (91) out of the two hundred and ten (210) respondents

who answered that the health insurance scheme is effective agrees that the health insurance is

effective because health professionals pay attention to health insurance clients and they stand at

43.3%.They are of the view that whiles the health professionals have time for them when they can

visit the facility as health insurance users, then they can boldly say that the scheme is effective.

Twenty seven (27) of the respondents, representing 12.9% of the total respondents selected for the

study strongly agree that health professionals do pay attention to health insurance card users.

Seventy one (71) of the respondents, representing 33.8%, disagree with the statement that health

professionals pay attention to health insurance users even though they answered that the health

insurance scheme is effective. The remaining twenty one (21) which represent 10% of the total

respondents for the study strongly disagree that health professionals pay attention to health

insurance card users who visit health facilities that provide health insurance services. Table 4.35

shows that majority of the respondents who said the health insurance is effective agree that health

professionals pay attention to health insurance users.


82

TABLE 4.36: USER NOT JOINING QUEUES



agree 32 15.2 15.2 21.4

disagree 115 54.8 54.8 76.2


Total 210 100.0 100.00


Table 4.36 shows that majority of the clients who responded that the health insurance scheme is

effective disagree that it is effective because clients do not join long queues when they visit

accredited health insurance facilities to access medical care. The one hundred and fifteen (115)

representing 54.8% are not in agreement that health insurance users do not join long queues. Fifty

(50) out of the two hundred and ten (210) respondents who responded that the health insurance

scheme is effective strongly disagree that health insurance users do not join queues when they visit

health facilities accredited to provide health insurance services to access medical care. Some of

the respondents for the study agree that the health insurance scheme is effective because card

users do not join queues to access medical at accredited facilities that provide health insurance

services, they represent about 15.2% of the total respondent who answered that the health

insurance scheme is effective. Only thirteen of the respondents strongly agree that health insurance

is effective because users do not join long queues. Thirteen (13) of the respondents representing

6.2% of the total respondents who answered that the health insurance scheme is effective strongly

agree to the statement that health insurance card users do not join long queues The analysis above

concludes that though the health insurance is effective, but users will always join queues when


83

accessing medical care and this will always happen since some of the analysis for the study

confirms high patronage for health insurance services among the study population.

TABLE 4.37: PROCESS FOLLOWED BY HEALTH INSURANCE USERS IS SMOOTH.



agree 108 51.4 51.4 60.0

disagree 74 35.2 35.2 95.2


Total 288 100.0 100.0


Table 4.37 above shows that majority of the respondents agree that the health insurance scheme is

effective because processes followed by health insurance users who visit health facilities that

provide health insurance services to access medical care is smooth. Respondents who responded

that medical processes followed by health insurance users is smooth stand at 51.4%. About 35.2%

of the respondents also disagree that medical processes followed by health insurance users is very

smooth. They are of the view that the health insurance is effective but the process followed by

clients are not smooth but rather longer than that of non-insured clients. Ten (10) of the respondents

representing about 4.8% of the respondents who responded that the health insurance scheme is

effective strongly disagree that the medical processes followed by health insurance users is

smooth.


84

Data, (2014) Source: Field

Table 4.38 gives reasons why respondents say that the health insurance scheme is effective. From

the table it is observed that 50.5% of the respondents agree that the health insurance scheme is

effective because most of the drugs that the health insurance covers are supplied to health insurance

users by the accredited health insurance service providers. Ninety two (92) of the respondents

representing 43.8% out of the total respondent who answered that the health insurance scheme is

effective disagree that most of the drugs are provided to health insurance users. They disagree

because when they use their health insurance to access medical care, they are made to pay for most

of the drugs supplied. Twelve (12) of the respondents representing 5.7% responded that the health

insurance is effective but they strongly disagree to the statement that health insurance providers

supply most of the drugs.

TABLE 4.38: MOST DRUGS ARE SUPPLIED BY PROVIDERS



agree 90 42.9 42.9 50.5

disagree 92 43.8 43.8 94.7


Total 210 100.0 100.0


85

TABLE:4.39 : HEALTH PROFESSIONALS DO NOT PAY ATTENTION TO NHIS USERS



agree 27 45.0 45.0 76.7

disagree 12 20.0 20.0 96.7


Total 60 100.0 100.0


The analysis from table 4.34, 4.35, 4.36, 4.37 and 4.38 confirm that majority of the

respondents agree and strongly agree that the health insurance is effective because it is

affordable, most of the drugs are supplied by service providers, health insurance users do

not join long queues, process followed by health insurance users are very smooth and

health professionals pay attention to health insurance users.


86

TABLE 4.40: MOST OF THE DRUGS SUPPLIED TO NHIS USERS ARE SUBSTANDARD DRUGS



agree 25 41.7 41.7 66.7

disagree 13 21.7 21.7 88.4


Total 60 100.0 100.0


Tables 4.39 and 4.40 represent reasons given by respondents who responded that the health

insurance scheme is not effective. From table 4.39, twenty seven (27) out of the sixty respondents

who responded that the health insurance is not effective agrees that health professionals do not pay

attention to health insurance users and these represents 45% of the total respondents who answered

that the health insurance scheme is not effective. Nineteen (19) of the respondent strongly agree

to the statement that health professional do not pay attention to health insurance users. Twelve (12)

of the respondent disagree to the statement and the remaining seven respondents representing

11.6% also strongly disagree to the statement that professional do not pay attention to health

insurance users even though they are of the view that the health insurance is not effective.

From table 4.40, twenty five (25) of the respondents who answered that the health insurance

scheme is not effective agree to the statements that most of the drugs supplied to health insurance

users by service provider are substandard drugs. They represent 41.1% of the total respondents

who answered that the health insurance scheme is not effective. Fifteen (15) of the respondents

strongly agrees that most of the drugs supplied by health facilities that provides health insurance


87

services to health insurance users are substandard drugs. They strongly agree that most people do

not patronize the health insurance services because of the substandard drugs provided by health

insurance service providers. Some of the respondents representing about 13.7% disagree to the

statement that drugs provided by scheme providers are substandard drugs, even though they

answered that the health insurance scheme is not effective. Seven of the respondent also strongly

disagree that most of the drugs supplied by services providers to health insurance users who access

medical care are substandard drugs. The analysis above shows that majority of the respondent

agrees to the statement that most of the drugs supplied are sub-standard drugs and health

professionals also do not pay attention to health insurance users. The above factors has contributed

to the ineffectiveness of the health insurance scheme.

TABLE 4.41 : SERVICES PROVIDED BY HEALTH INSURACE PROVIDERS



agree 127 44.1 44.1 55.2

disagree 110 38.2 38.2 93.4


Total 288 100.0 100.0


Table 4.41 aims to find out if the premium paid merit the services provided by the accredited health

insurance service providers. From the above table it can be observed that majority of the

respondents agree that the services provided to health insurance users do not merit the premium

paid. One hundred and ten (110) of the respondents representing 38.2% of the total respondents of


88

the study disagree to the statement that the services provided to health insurance do not merit the

premium paid. They disagree because they are of the view that the services provided is more than

the premium paid if the services are quantified in monetary terms.

TABLE 4.42: RATING OF SERVICES PROVIDED BY HEALTH INSURANCE PROVIDERS


very good 33 11.5 11.5 11.5

good 116 40.3 40.3 51.7

average 108 37.5 37.5 89.2

poor 31 10.8 10.8 100.0

Total 288 100.0 100.0


Table 4.42 shows the rating of the services provided by health insurance providers by the

respondents selected for the study. Thirty three (33) of the respondents rated the services provided

by the health insurance providers to be very good. They represent about 11.5% of the total

respondents who participated in the study. The table also shows that majority of the respondents

rated the services provided by the health insurance users to be very good. Only thirty one (31) of

the respondents representing 10.8% responded that services provided to health insurance users by

accredited health insurance service providers is poor. The analysis above seem to confirm that the

health insurance is effective since most of the users are comfortable with services provided to them

by the health insurance service providers.


89

TABLE: 4.43: EQUAL TREATMENT TO INSURED AND NON-INSURED

Frequency Percent Valid Percent Operative Percent

no 200 69.4 69.6 69.4

yes 88 30.6 30.6 100.0

Total 288 100.00 100.00


Table 4.43 shows that most of the respondents answered that health insurance providers do not

give equal treatment to both the insured and the non-insured. From the above table it is observed

that two hundred of the respondents representing 69.4% out of the total respondents who

participated in the study answered that health insurance service providers do not give equal

treatment to both the insured and the non- insured. Eighty eight (88) of the respondents responded

to the statement that health insurance providers give equal treatment to both the insured and the

non-insured.


90

TABLE 4.44: EFFECTIVENESS OF SCHEME

Chi-Square Test

Table 4.44 above is an analysis to determine whether there is any statistical difference between the

number of respondents who responded ‘ yes’ to the statement health insurance scheme is effective

and the number that answered ‘no’ to the same statement. From the chi square test above it is

observed that there is significance difference between the number of respondents who responded

that health insurance scheme is effective and the number who also responded that the health

insurance scheme is not effective. The asymptotic value of 0.000 (significance level) confirms that

there is significance difference between all who responded ‘yes’ the scheme is effective and those

who answered ‘no’ to the statement. The p-value of 0.05 which is greater than the asymptotic value

of 0.000 shows that the statistical difference between the total number of respondents who ‘yes’

Observed N Expected N Residual

yes 210 96.0 114.0

no 60 96.0 -36.0

Total 270

Test Statistics

effectiveness of scheme

Chi-Square 212.250a

df 1

Asymptotic. Significance .000


91

to the statement the health insurance is effective and the number of respondents who also answered

‘no’ to the statement, the health insurance scheme is effective

The study also aims to find out how card users are treated by providers when claims payment are

delayed by the scheme. About 90% of the respondents said they are made to pay cash before

treatment commences when payment to providers delay. This is what is termed as the ‘cash and

carry’. The respondents also said that when claims payments delay some facilities stop taking the

health insurance card and they resort to charging full medical bills. When such situation occurs,

some card users decide not to use their card to access medical care. The respondents said that some

even go home with their sickness since they cannot afford paying for the full medical bill.

The researcher wanted the respondents for the study to suggest measures that can be put in place

to make the health insurance scheme more effective. Most of the respondents suggested that the

health insurance scheme would be more effective if claims are paid on time to service providers.

They also suggest that the health insurance service provision should be made more competitive.

The quota for the private scheme should be increased and procedures for private license acquisition

should be made more flexible. The drugs provided must be more effective. They also suggested

full government participation in the monitoring and management of the scheme. They also said

the budget allocation for the health insurance scheme should be increased to make the scheme

more effective. The facilities accredited to provide health insurance services should be increased.

Some suggested that all Government health facilities should be equipped to provide health

insurance services especially those in the rural communities. The respondents for the study also

said that to make the health insurance more effective the procedure for registration onto the scheme


92

and renewal must be made more flexible. They also suggested that the biometric machines should

be made available at all health facilities that have been accredited to provide health insurance

services for easy accessibility. They are also of the view that the health insurance scheme would

be more effective if the procedure for claims payment is reviewed and decentralized to make

claims payment prompt.

4.3: RESPONSE FROM INTERVIEW GUIDE

The purpose of this study is find out whether the health insurance scheme is effective or not. To

determine the effectiveness of the health insurance scheme, the researcher interviewed senior

officers from the selected health insurance service providers who work on the scheme to seek their

views as to whether the health insurance scheme is effective or not. The officials’ interviewed are

Hospital Administrators, Internal Auditors, Physician Assistants, Management Information

System (MIS) Managers and Midwifes in Charge.

The researcher wanted to find out from the official how long their facility has been a health

insurance service provider. Some have been service providers for minimum of four (4) and a

maximum of eight (8) years. The time for receiving claims payment from the scheme by the

service providers vary. Some said they receive claims payment every six months. Most of them

answered that the time for receiving claims is between three (3) and six (6) months.

All the eight (8)senior officers from the four selected health facilities that provide health insurance

services responded that the services they provides to clients do not commensurate the claims paid


93

by the scheme. They responded that the services rendered are more expensive than the claims paid

by the scheme. They said the cost of treatment given to clients and the time claims are paid even

makes the treatment more expensive than the claim paid by the scheme.

Most of them submitted their last claim in January 2015 and have not received claims payment as

at May 2015. The study also wanted to find out when the last claim payment was made to the

service providers by the scheme. Majority of the service providers said they received payment for

the August 2014 claims submitted to the scheme in April 2015.The providers said about 80 to 95

percent of the claims submitted to the scheme is paid. This shows that the scheme pays majority

of the claims submitted by the providers, but the only challenge is the time of payment. Most of

the senior officers interviewed said about 60 to 98 percent of their attendance cost goes into health

insurance services. This shows that most of the facilities operational cost goes into health

insurances services. The study also aims to find out the effect of the claims delay on these service

providers. The service providers said when the claims are delayed, it distorts their plans and it

makes their daily operation very difficult. Some of the service providers said when the claims

payment delay they are not able to pay suppliers on time and this brings about shortage of vital

medicines sometimes. The delay in claim payment also interact quality health service delivery.

Six (6) out of the eight (8) senior officers interviewed said the health insurance is not effective.

Their reason for saying that the scheme is not effective is because the scheme delays claims

payment and also the drugs tariffs are low, facilities are always challenged financially because

they have to credit drugs and other medical equipment to provide quality services to clients.


94

Two (2) of the senior officers interviewed said the health insurance is effective because it is

affordable. People living in rural communities are able to access quality health services because

of the health insurance. They said the only challenge is the delay in claims payment and they are

of the view that the scheme would be more effective if the procedure for claims payment is

streamlined and claims paid on time for quick supply of drugs for treatment.

The senior officers from the selected service providers for the study who said the scheme is not

effective are of the view that the health insurance can be made more effective if claims are paid on

time. They also suggested that operational cost of the scheme must be reduced and channelled into

claims payment. They also said to make the scheme more effective the health insurance levy of

2.5% should be paid into a separate account and disbursed directly to the service providers. They

also said the health insurance can be made more effective if realistic tariffs for drugs are quoted


95

CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

5.0 INTRODUCTION

This chapter covers three sections. The first section is devoted to the summary of the findings of

the study. The conclusion drawn from the study will be in the second section whiles the third

section deals with recommendations to address issues raised in the study.

5.1 SUMMARY OF FINDINGS

The findings have shown that claim payments to Service Providers by the Akuapem South

Mutual Health Insurance Scheme has increased on a monthly basis. The line graph in figure

4.1 and the scatter graph in figures 4.2 show the increasing trend. The analysis has shown

that more people enroll onto the scheme on monthly basis.

The study also shows that health insurance enrolment onto the scheme has increased on

monthly basis. The line graph in figure 4.3 and scatter graph in figure 4.4 show the

increasing trend. The analysis also revealed that there is high patronage of health insurance

services in Nsawam Adoagyiri Municipality and Akuapem South District.

The research has revealed that there is a linear mathematical relationship between the total

insured attendance and the claim payment for selected service providers. The general linear

model fitted to the insured attendance and claim payment data collected from the selected

service providers confirmed the linear relationship


96

The hypothesis testing for the difference between two means has also shown that there is

significance difference between the total enrolment and the total claims paid by the

Akuapem South Mutual Health Insurance Scheme.

The study revealed that over 60% of the service providers operational cost goes into health

insurance services. The analysis showed that the selected health facilities render most of

their service to health insurance clients.

The study has also revealed that service providers resort to cash and carry when claim

payment delays. The finding also showed that clients fail to use their health insurance card

to access medical care when claim payment to service providers are delayed by the scheme.

According to the policy guiding claims payment, claims are to be paid three (3) months

after submission. Finding also showed that claims submitted to the Scheme in August, 2014

by the service providers were paid in April, 2015: eight (8) months instead of three (3).

The finding of study has revealed that 72.9% of the total respondents who participated in

the study to assess the effectiveness of the National Health Insurance Scheme responded

that the health insurance scheme implemented by Act 650 and L.I 1809, 2004 is effective.

Their reason for saying that the health insurance scheme is effective is that, it’s affordable.

It has made it easier for people living in rural communities to access quality health care,

health insurance clients are provided with most of the drugs need for their treatment, health

professionals pay more attention to health insurance clients. The process followed by health


97

insurance card users in accessing medical care is very smooth and they do not join long

queues when they visit facilities accredited to provide health insurance services to access

medical care.

The findings of the study have revealed that most of service providers selected for the study

responded that the health insurance to them is not effective in the sense that claims

payments are delayed and this distorts their daily planning, it distracts from quality health

care delivery and they are challenged financially to purchase drugs and other equipment

needed for treatment.

The study has identified that the number of respondents who said that the health insurance

scheme is effective and those who responded that the health insurance scheme is not

effective have rated the services provided by health facilities accredited to provide health

insurance services to be good.


98

5.2 CONCLUSION

The findings from the study have shown that the health insurance scheme is effective. The

statistical analysis conducted on data collected on enrolment and claims, the clinic attendance

on health insurance usage in the four (4) selected service providers and the response from

questionnaire administered to health insurance users in Nsawam-Adoagyiri Municipality and

Akuapem South District show that the National Health Insurance Scheme implemented by Act

650, 2003 and L.I 1809, 2004 is effective. Also for 72.9% of the total respondents for the study

to respond that the scheme is effective, then we can conclude that the health insurance is

effective but can be made more effective if claim payment to service providers are not delayed.

5.3 RECOMMENDATIONS

The following recommendations are drawn from the study based on personal observations and

suggestions made by the respondents for the National Health Insurance Scheme (NHIS) to be more

effective.

The management of the Scheme (NHIA Authority) and the service providers (health

institutions) should collaborate and review the procedure for claims processing and

disbursement.

The government budget allocation in addition to the 2.5% of employees SSNIT

contribution and the 2.5% on all goods and services should be increased to enable the

Scheme have enough funds to pay claims on time.


99

The monitoring teams should be made up of qualified staff who have in-depth

knowledge in social health insurance and health management to scrutinize the claims

processing procedure and come out with measures that will address some of the

bottlenecks in the processing and disbursement of claims.

The managers of the scheme should make the scheme more competitive and overhaul

the accreditation process to increase private participation.

The government should improve facilities of health institutions in rural communities to

enable them acquire accreditation to provide health insurance services since majority of

health insurance users are in these rural communities.

The biometric registration machine should be made available to all health institutions

that have been accredited to provide health insurance services to increase the enrolment

and make the renewal easier.

The payment of claims should be decentralized and computerized for prompt payment.

The government should go into agreement with selected banks to pay the claims directly

to the service providers and the funds later disbursed to them by the government. This

will make the claims payment to providers very prompt.

The managers of the scheme should organize half yearly refresher training for officers

from accredited facilities who have been assigned to work on claims report. The delay


100

in submission of claims report by service providers has been seen as one of the

contributing factors for the delay in claim payment.

The drugs tariff for the scheme must be renewed quarterly instead of the yearly review

to meet current drug price list to enable service providers purchase effective and

standard drugs from suppliers.

The medicine list should be reviewed half yearly and other expensive drugs should be

included in the medicine list.

5.4 FURTHER STUDIES

Findings of the study have revealed that there is high insured attendance in health facilities situated

in rural communities. Further studies can be done to find out factors contributing to high health

insurance usages in rural communities. Further studies can also be done to find out from service

providers other factors that could make the health insurance scheme ineffective apart from the

delay in claims payment by the scheme.


101

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106

APPENDIX (A)

The Researcher is a Master of Philosophy Degree in Statistics student from the Methodist

University College Ghana who is undertaking a research on the topic; Statistical Analysis to Assess

the Effectiveness of the National Health Insurance Scheme in Ghana.

The research is for Academic purpose. All information furnished will be treated with strict

confidentiality.

Please read through the following questions and answer all questions as you can.

Tick [ ] where appropriate and supply the needed information where applicable.

SECTION A

Socio Demographic Characteristics

1. Age:

(a) 18-25 [ ]

(b) 26-30 [ ]

(c) 31-25 [ ]

(d) 36-40 [ ]

(e) 41-45 [ ]

(f) 46-50 [ ]

(g) 51-60 [ ]

(h) Above 60yrs [ ]

2. Gender

(a) Male [ ]

(b) Female [ ]

3. Occupation

(a) Public Servant [ ]

(b) Private sector employee [ ]

(c) Private sector employer [ ]

(d) Self employed [ ]

(e) Unemployed [ ]

(f) Others specify…………………..

4. What is your level of education?

(a) Tertiary [ ]

(b) Secondary/Tech/Vocational [ ]

(c) Basic [ ]


107

(d) No formal education [ ]

5. Marital status

(a) Married [ ]

(b) Single [ ]

(c) Divorced [ ]

(d) Widow/Widower [ ]

6. Religion

(a) Christianity [ ]

(b) Islamic [ ]

(c) Traditional [ ]

(d) Others specify:………………….

SECTION B

Health Insurance Utilization

7. For how long have you been an NHIS card user? …………………………….

8. How often you use your health insurance card to assess medical care?

(a) Once a week [ ]

(b) Once every two week [ ]

(c) Once a month [ ]

(d) Very often [ ]

(e) Once a while [ ]

(f) Others specify……………………

9. Is the health insurance scheme effective?

If yes go to question 10,if no go to question 11

(a) YES [ ]

(b) NO [ ]

(c) Uncertain [ ]

10. The health insurance is effective because of the reasons below, please tick the options below.

A.The health insurance is effective because it is affordable.

i. I strongly agree [ ] ii. I agree [ ] iii I disagree [ ] iv. I strongly disagree [ ]


108

b. Health professionals pay more attention to NHIS users


c. Health insurance chard users do not join long queues.


d. Medical processes followed by health insurance card users is very smooth.


e. Most drugs are supplied by the service provider.


11. The health insurance scheme is not effective because of the reasons below, please tick the

options below

a. Drugs given to health insurance users are substandard drugs.


b. Health professionals do not pay much attention to NHIS holders anymore?


12. What other procedure do providers use when claims delay?

a. ………………………………………………………………….

13. What do health insurance card users do when claims paid to providers delay?

a. ………………………………………………………………………….

b. Services provided to health insurance card users do not merit the premium paid

ii. I strongly agree [ ] ii. I agree [ ] iii I disagree [ ] iv. I strongly disagree [ ]


109

c. When claims delay providers charge full medical bill from health insurance card users.


SECTION C

Services provided

14. How would you rate the services provided by Service providers to health insurance card

users?

(a) Very good [ ]

(b) Good [ ]

(c) Average [ ]

(d) Poor [ ]

‘;

15. Does the facility give equal give equal treatment to both the insured and the non-insured?

i. YES [ ] ii. NO [ ]

16. In your opinion what do suggest can be done to make the NHIS more effective?

a. …………………………………………………………………………………

b. ………………………………………………………………………………….

c. …………………………………………………………………………………


110

APPENDIX(B)

The Researcher is a Master of Philosophy Degree in Statistics student from the Methodist

University College Ghana who is undertaking a research on the topic; Statistical Analysis to Assess

the Effectiveness of the Health Insurance Scheme in Ghana.

The research is for Academic purpose. All information furnished will be treated with strict

confidentiality.

INTERVIEW GUIDE

NAME OF SERVICE PROVIDER:……………………………….

POSITION:………………………………………………………………

1. For how long has your facility been a service provider?

………………………………………………………………………………………….

2. How often does your facility receive claims from the scheme?

………………………………………………………………………………………………………

3. Is the amount paid by Scheme commensurate with the services provided?

………………………………………………………………………………………………………

4. How long does it take you to receive your claim after you have submitted it to the Scheme?

…………………………………………………………………………………………………

5. When was the last claim submitted to the scheme?

………………………………………………………………………………………………………

6. When was the last payment made to facility by the scheme?

…………………………………………………………………………………………..

7. What percentage of claim is paid to your scheme out of the claims submitted to the scheme?


111

………………………………………………………………………………………………………

8. What effect does the delay in claims have on your facility?

………………………………………………………………………………………………………

9. How do you treat health insurance users when claims delay?

………………………………………………………………………………………………………

10. What percentage of your attendance cost goes into NHIS?

………………………………………………………………………………………………………

11. For how long has the scheme owed your facility since?

………………………………………………………………………………………………………

12. Is the health insurance effective?

………………………………………………………………………………………….

a. if yes, why do you think is effective?

………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

………………………………………………………………………………………………………

b. if no, why do you think it is not effective?

………………………………………………………………………………………………………

……………………………………………………………………………………………………..

………………………………………………………………………………………………………

………………………………………………………………………………………………………

13. In your own opinion what do you suggest could be done to make the NHIS more effective?

………………………………………………………………………………………………………

………………………………………………………………………………………………………


112

AKUAPEM SOUTH MUTUAL HEALTH INSURANCE SCHEME ENROLLMENT FROM JANUARY 2010 TO DECEMBER 2013 Month No Enrolled Month No Enrolled

1 49,536 25 52,183

2 38,788 26 59,906

3 37,131 27 62,319

4 34,967 28 62,309

5 29,619 29 65,738

6 31,831 30 67,672

7 36,229 31 71,256

8 38,724 32 75,745

9 38,396 33 79,416

10 39,929 34 84,685

11 42,925 35 89,505

12 44,799 36 91,657

13 50,620 37 91,385

14 42,409 38 85,040

15 41,134 39 84,027

16 41,026 40 83,474

17 32,120 41 83,709

18 36,814 42 88,883

19 43,609 43 86,757

20 42,851 44 84,769

21 41,887 45 84,260

22 42,990 46 84,301

23 46,617 47 81,494

24 48,199 48 80,615


113

NSAWAM GOVERNMENT HOSPITAL

CLINIC ATTENDANCE FROM JANUARY 2008- DECEMBER 2013 total total total total total total

month insured non insured attendance month insured non

insured attendance

1 3191 1965 5156 37 7752 241 7993

2 3488 3376 6864 38 6691 633 7324

3 3452 2821 6273 39 6158 1034 7192

4 4509 1875 6384 40 7276 1426 8702

5 4998 2026 7024 41 7595 1702 9297

6 5109 1736 6845 42 9858 1927 11785

7 4511 1487 5998 43 8623 1727 10350

8 6581 1156 7737 44 8891 1508 10399

9 4979 2669 7648 45 8071 1409 9480

10 5828 2383 8211 46 7725 1158 8883

11 5600 589 6189 47 7963 1494 9457

12 5570 1493 7063 48 7648 1363 9011

13 6091 1244 7335 49 8239 1352 9591 14 5809 1516 7325 50 8159 1273 9432

15 5676 1036 6712 51 7525 1318 8843

16 5249 1185 6434 52 7500 1532 9032

17 6286 550 6836 53 8860 1356 10216

18 8481 1091 9572 54 9369 1376 10745

19 6998 1371 8369 55 9960 1498 11458

20 8134 1124 9258 56 9236 1483 10719

21 5738 2589 8327 57 7367 1396 8763

22 6542 1096 7638 58 9166 1088 10254

23 6455 1294 7749 59 9335 1131 10466

24 6037 751 6788 60 17090 2296 19386

25 5978 1134 7112 61 9489 1163 10652

26 6815 331 7146 62 8728 1012 9740

27 6065 1386 7451 63 8209 1093 9302

28 5770 1273 7043 64 7912 1062 8974

29 7180 333 7513 65 8914 1121 10035

30 9046 518 9564 66 9536 1233 10769

31 7617 603 8220 67 10619 1243 11862

32 6850 1059 7909 68 8706 1049 9755

33 5873 1367 7240 69 9022 989 10011

34 7334 605 7939 70 10655 1085 11740

35 7906 788 8694 71 10142 1173 11315

36 7286 275 7561 72 9375 1238 10613


114

NSAWAM GOVERNMENT HOSPITAL

CLAIMS PAYMENT FROM AUGUST 2007 TO DECEMBER 2013

Months

Number of Months Number of

claims paid claims paid

1 3,246 40 12,946

2 2,551 41 4,298

3 3,963 42 13,133

4 8,498 43 12,988

5 7,960 44 14,494

6 11,080 45 13,478

7 11,371 46 14,842

8 9,269 47 18,404

9 12,259 48 16,438

10 12,617 49 16,656

11 11,851 50 14,614

12 10,354 51 15,116

13 10,510 52 16,479

14 10,815 53 15,977

15 13,771 54 16,567

16 10,849 55 16,963

17 10,615 56 16,290

18 11,734 57 16,381

19 11,380 58 19,007

20 10,225 59 20,109

21 10,101 60 22,651

22 12,928 61 20,304

23 15,873 62 16,668

24 13,191 63 21,784

25 13,216 64 21,784

26 13,293 65 17,586

27 12,567 66 20,572

28 11,025 67 18,656

29 11,159 68 16,763

30 12,765 69 16,867

31 11,809 70 19,322

32 12,137 71 21,424

33 12,382 72 23,920

34 13,678 73 21,986

35 17,079 74 19,285

36 12,538 75 24,639

37 13,785 76 21,679

38 11,972 77 19,059

39 13,525


115

POKROM HEALTH CENTRE

CLINIC ATTENDANCE FROM JANURY 2010- DECEMBER 2013 total total total total total total

month insured non insured attendance month insured non

insured attendance

1 334 51 385 25 569 5 574

2 432 43 475 26 611 11 622

3 403 49 452 27 516 10 526

4 220 70 290 28 630 5 635

5 347 50 397 29 731 8 739

6 440 65 505 30 741 13 754

7 370 62 432 31 1009 8 1017

8 412 60 472 32 930 8 938

9 318 42 360 33 645 5 650

10 345 20 365 34 859 7 866

11 264 36 300 35 1040 12 1052

12 278 30 308 36 680 7 687

13 432 44 476 37 787 7 794

14 188 23 211 38 619 6 625

15 279 9 288 39 577 1 578

16 346 5 351 40 506 9 515

17 394 0 394 41 650 6 656

18 654 5 659 42 833 13 846

19 649 3 652 43 827 11 838

20 569 4 573 44 832 5 837

21 478 6 484 45 594 2 596

22 452 8 460 46 725 6 731

23 590 6 596 47 807 18 825

24 568 10 578 48 981 31 1012


116

NEW LIFE HOSPITAL

CLINIC ATTENDANCE FROM SEPTEMBER 2010 TO DECEMBER 2013

Month total total total

Month total total total

insured non insured attendance insured non insured attendance

1 353 216 569 21 132 66 198

2 373 197 570 22 242 75 317

3 321 133 454 23 185 78 263

4 407 153 560 24 267 85 352

5 221 101 322 25 220 44 264

6 191 75 266 26 208 61 269

7 312 50 362 27 291 95 386

8 235 161 396 28 239 97 336

9 258 156 414 29 352 121 473

10 246 148 394 30 294 86 380

11 206 157 363 31 273 147 420

12 171 149 320 32 123 97 220

13 120 72 192 33 214 85 299

14 218 94 312 34 164 96 260

15 184 102 286 35 159 95 254

16 204 97 301 36 308 139 447

17 169 78 247 37 257 118 375

18 137 71 208 38 243 137 380

19 124 93 217 39 351 120 471

20 164 67 231 40 256 189 445


117

KOM PRESBY CLINIC

CLINIC ATTENDANCE FROM JANUARY 2008 TO DECEMBER 2013

Months

total total total

Months

total total total

insured non insured attendance insured non

insured attendance

1 634 136 770 37 603 58 661

2 481 156 637 38 597 93 690

3 539 132 671 39 594 141 735

4 923 117 1040 40 494 89 583

5 560 257 817 41 517 88 605

6 906 218 1124 42 544 112 656

7 773 223 996 43 834 119 953

8 796 78 874 44 466 87 553

9 932 125 1057 45 518 85 603

10 651 188 839 46 460 54 514

11 692 80 772 47 584 95 679

12 481 337 818 48 502 73 575

13 556 113 669 49 839 55 894

14 621 96 717 50 942 47 989

15 568 232 800 51 825 71 896

16 647 183 830 52 741 45 786

17 972 213 1185 53 973 44 1017

18 1124 324 1448 54 901 56 957

19 693 148 841 55 989 60 1049

20 613 64 677 56 914 44 958

21 612 109 721 57 678 43 721

22 806 53 859 58 1004 96 1100

23 666 75 741 59 1154 135 1289

24 672 74 746 60 892 76 968

25 836 68 904 61 1057 81 1138

26 898 83 981 62 1015 115 1130

27 1014 92 1106 63 718 110 828

28 805 87 892 64 912 75 987

29 786 77 863 65 1091 69 1160

30 1033 109 1142 66 1192 129 1321

31 834 119 953 67 1302 131 1433

32 777 79 856 68 1188 69 1257

33 574 73 647 69 1101 50 1151

34 643 60 703 70 1435 87 1522

35 626 192 818 71 1333 87 1420 36

559 82 641 72 1186 92 1278


118

CLAIM PAYMENT FOR NSAWAM GOV'T HOSPITAL FROM 2008-2013TOTAL TOTAL GH¢ MONTH TOTAL TOTAL GH¢

ATTENDANCE ATTENDANCE

1 2,882 18,959.94 36 7,167 159,206.56

2 4,172 30,798.58 37 8,416 184,802.63

3 4,241 39,707.65 38 7,785 176,962.66

4 5,466 41,395.79 39 8,060 177,965.62

5 4,939 43,124.78 40 9,458 222,322.97

6 4,391 39,379.38 41 8,666 241,844.57

7 5,557 52,793.82 42 8,830 234,823.54

8 5,274 71,241.41 43 8,149 213,091.61

9 4,851 86,244.77 44 7,563 179,678.46

10 2,767 55,043.18 45 8,175 222,372.84

11 4,566 88,797.21 46 8,244 229,927.30

12 4,827 90,600.88 47 8,254 229,065.27

13 5,945 110,335.42 48 8,301 220,846.26

14 4,761 100,045.61 49 8,113 207,577.82

15 4,713 98,941.02 50 8,130 225,559.06

16 5,470 115,882.62 51 9,112 254,358.46

17 5,214 99,851.78 52 9,391 251,979.89

18 4,733 102,415.48 53 10,516 269,248.04

19 4,533 109,652.42 54 9,443 251,349.09

20 7,560 161,488.74 55 9,757 267,633.76

21 6,429 149,079.81 56 9,757 267,633.76

22 6,429 149,079.81 57 9,707 244,347.31

23 6,493 139,287.68 58 8,404 247,226.80

24 6,220 133,889.01 59 9,528 289,893.90

25 6,055 129,407.08 60 8,937 281,524.35

26 5,412 135,141.19 61 8,707 284,275.74

27 5,465 132,091.07 62 8,223 279,604.46

28 5,876 143,165.49 63 9,068 301,479.60

29 6,114 141,788.99 64 9,797 310,151.88

30 6,246 137,221.33 65 10,983 359,163.51

31 5,828 132,249.32 66 10,051 329,986.93

32 6,142 137,628.55 67 8,925 289,954.43

33 8,398 177,532.08 68 11,422 364,118.45

34 6,524 166,338.02 69 10,767 340,613.90

35 7,515 179,936.93 70 10,644 329,518.32

MONTH


119

CLAIM PAYMENT FOR POKROM HEALTH CENTRE FROM 2007-2013

TOTAL TOTAL


1 554 2,454.01 34 684 2,939.86

2 474 1,990.63 35 271 1,666.06

3 573 3,219.27 36 346 2,849.83

4 727 3,364.24 37 391 3,221.14

5 497 3,055.60 38 2,542 20,766.72

6 734 4,101.10 39 672 5,202.98

7 786 3,473.65 40 586 4,808.76

8 923 4,137.35 41 745 4,949.23

9 400 1,963.54 42 543 4,614.43

10 427 2,567.14 43 542 4,392.39

11 586 3,015.65 44 569 4,680.04

12 660 2,356.67 45 654 5,495.20

13 426 1,651.99 46 661 5,599.62

14 493 2,292.26 47 810 6,147.64

15 412 1,346.82 48 608 5,524.42

16 405 1,874.44 49 630 5,481.02

17 323 1,289.55 50 827 6,999.02

18 344 1,531.17 51 876 7,132.54

19 481 2,400.28 52 1,124 10,093.82

20 649 3,715.69 53 930 7,932.49

21 495 2,925.67 54 645 4,967.23

22 537 3,125.22 55 859 6,961.25

23 498 3,079.52 56 1,048 8,307.05

24 174 1,095.24 57 680 5,348.02

25 416 2,486.71 58 853 6,862.50

26 433 2,729.65 59 717 6,768.69

27 499 3,366.25 60 577 5,299.60

28 521 3,437.84 61 578 5,075.08

29 507 2,328.05 62 709 6,380.74

30 304 1,200.54 63 781 7,441.29

31 370 1,598.44 64 915 9,583.47

32 576 2,885.34 65 594 3,584.57

33 410 2,500.48 66 968 11,701.72

TOTAL GH¢MONTH TOTAL GH¢ MONTH


120

CLAIM PAYMENT FOR KOM PRESBY CLINIC FROM 2007-2013TOTAL TOTAL


1 365 1,741.20 37 924 6,817.68

2 579 3,254.20 38 924 6,403.79

3 472 2,498.90 39 891 5,983.07

4 470 2,927.40 40 684 5,320.94

5 634 3,997.20 41 852 5,994.76

6 649 4,319.70 42 1,031 6,952.22

7 539 4,298.90 43 707 5,243.33

8 782 5,967.59 44 692 4,916.45

9 833 5,781.32 45 792 6,022.58

10 923 6,309.03 46 686 5,188.21

11 906 5,650.75 47 933 8,013.94

12 796 5,504.73 48 751 5,841.24

13 823 5,546.85 49 839 6,233.03

14 932 6,090.57 50 942 6,769.70

15 1,046 8,134.81 51 825 5,884.76

16 708 5,028.48 52 741 5,254.56

17 937 6,493.02 53 973 6,737.18

18 851 5,696.27 54 901 6,463.99

19 898 7,177.52 55 989 7,948.19

20 844 6,076.98 56 914 6,327.59

21 972 6,947.59 57 678 3,951.30

22 1,350 9,641.69 58 1,004 7,711.96

23 968 7,251.23 59 1,154 8,833.11

24 891 6,544.23 60 892 6,892.23

25 911 7,160.24 61 1,057 7,905.57

26 975 7,384.14 62 1,015 8,924.24

27 960 7,888.41 63 718 6,985.72

28 931 7,302.22 64 912 8,823.67

29 1,108 8,631.17 65 1,091 9,731.35

30 1,183 7,475.28 66 1,192 11,624.10

31 1,283 9,647.51 67 1,302 12,819.97

32 1,093 7,608.96 68 1,188 13,218.94

33 1,105 7,222.99 69 1,101 12,160.77

34 1,369 9,651.86 70 1,435 14,847.46

35 1,145 8,005.10 71 2,536 27,008.23

36 1,027 6,766.50 72 1,186 12,466.19

MONTH MONTHTOTAL GH¢ TOTAL GH¢


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