towards a client-oriented health insurance system in ghana” some key findings nhis 10th...
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“Towards a client-oriented health insurance system in Ghana”Some key findings
NHIS 10th Anniversary Conference 5th November, 2013
Accra, Ghana
Edward Nketiah-AmponsahStephen Duku Christine FenengaRobert Kaba AlhassanTobias Rinke de Wit, Inge Hutter, Menno Pradhan, Daniel Arhinful
NHIS 10th Anniversary Conference
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Background• Key question of this project derived from NHIS:
2010 enrolment about 64% , active membership 34%
Retention problem => what are the barriers?
• Anecdotal information and growing empirical evidence showing differences in enrolment rate among the population (Asante & Aikins, 2008)
• This RCT project is a joint initiative between NHIA, GHS, CHAG and other health partners and the University of Ghana and 3 Universities in The Netherlands with an initiation workshop in 2011
• Funded by the Global Health Policy and Health Systems Research Fund 2010 of the Dutch Scientific Organization NWO-WOTRO NHIS 10th Anniversary Conference
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Main Objective and Research Question
• Main Objective: – To enhance and sustain health insurance participation
in Ghana through improved client-oriented quality of care
• Main research questions: – What are the main perceived barriers of health care
clients to (re-)enroll in the NHIS?– Which are effective interventions that address these
barriers?
NHIS 10th Anniversary Conference
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Client-Provider-Insurer Tripod Framework
Perspectives of the 3 key stakeholder groups, allowing comparison and triangulation of data
Client-Oriented NHIS System
Client
InsurerProviderNHIS 10th Anniversary Conference
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Set up of research Selected Regions: GAR and WR
Phase 1 Qualitative Phase (3Q 2011)
Phase 2 Baseline Surveys (1-2Q 2012)
Phase 3 Interventions (2Q 2013-1Q 2014)
Phase 4 Follow up Surveys/+ Qual.(2Q 2014)
NHIS 10th Anniversary Conference
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Sampling Strategy
2 Regions (Western and Greater Accra)
8 Districts (Western Region)Purposive Selection
4 Primary Health Care FacilitiesPer District
30 Households Per Catchment Area of Health Care Facility
8 Districts (Greater Accra Region)Purposive Selection
4 Primary Health Care Facilities
Per District
30 Households Per Catchment Area of Health Care Facility
NHIS 10th Anniversary Conference
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Remaining content of this presentation
• Health insurance perspectives by Stephen Duku
• Client perspectives by Christine Fenenga
• Healthcare provider perspectives by Robert K. Alhassan
NHIS 10th Anniversary Conference
Tripod with Focus on the Insurer
Client-Oriented NHIS System
Client
Provider Insurer
8NHIS 10th Anniversary Conference
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Qualitative Research MethodologyLocation: Greater Accra and Western Regions
In-depth Interviews (n=16)• 8 interviews in 4 NHIA districts offices (Dangme West, Ga West, Ahanta West
and Mpohor Wassa), 2 interviews per district• 4 interviews, 2 each at the NHIA Regional offices of the Greater Accra and
Western regions• 4 interview at the NHIA Headquarters in Accra
Interviewees • NHIA District Office – District Scheme Managers and Claims Officers• NHIA Regional Office – Regional Managers and M&E Officers• NHIA Headquarters – Divisional Directors and Senior Officers
Data management• Topic guides for all the interviews• All interviews were recorded and transcribed verbatim• Interviews were Coded, Categorized and conceptualized• Findings were validated in a feedback workshop in each region
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Household Survey MethodologyLocation: Greater Accra and Western Regions
Data collected with a semi-structured questionnaire on:• Socio-demographics• Social capital and Social schemas• Employment status• Health status and healthcare utilization behavior• NHIS enrolment status• Perceived quality of health care services• Perceived quality of NHIS services• Consumption expenditure patterns • Dwelling characteristics
Districts/Health Facilities(Purposive Selection)
Households(Random Selection)
Individuals
168 from each Region
1,920(960 from each Region)
7,097
64 Primary Health Facilities(4 from each District)
30 Households per catchment area of each Health Facility
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Qualitative Research FindingsQuality of NHIS Services to Clients1. Determinants of Quality• Ease of Registration and registration time• Waiting period to acquire NHIS card and the accuracy of information on
cards• Availability of information on benefit package• Attitude of NHIS staff.
2. Challenges in Providing High Quality Services• Delays by Registration Agents to submit registration forms to schemes.• Delays by district schemes to submit registration forms to region.• Inadequate staff at the scheme level to enter registration data into the system.• Low registration fees leading to inadequate administrative funds at schemes.• Misunderstanding and misinformation of clients on the NHIS registration
process.• Education, infrastructural and environmental problems posses a huge
challenge in the provision of high quality services.
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Quality of NHIS Services to Health Providers1. Determinants of Quality• Health providers’ accreditation process• Prompt payment of claims• Monitoring of provider service quality to clients
2. Challenges in Providing High Quality Services• Inadequate education of health providers on claims processing
and NHIS in general.• Providers borrowing staff and equipment for accreditation
process.• Lack of right caliber of staff at health facilities for claims
processing.• Inadequate staff at health facilities to process claims quickly.• Lack of ICT support to speed up claims verification and processing
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Quantitative Household Survey FindingsSummary of Descriptive Characteristics of Total Sample
Summary Total Sample Mean (SD)(N=7,097)
Sample of 18+ years Mean (SD)(N=4,214)
Age (Years) 25.8 (19.2) 37.7 (15.8)
Age, <18 years (%) 40.6%
Sex, female (%) 54.3% 56.3%
Married, >18 years (%) 43.8% 46.2%
Christian (%) 89.8% 89.6%
Employed (%) 65.5% 69.6%
Urban (%) 48.6% 51.5%
Annual Income (GH₵) 2,937.30 (5,070.85) 2,952.09 (5,091.03)
Good Health Status (%) 89.7% 87.6%
Basic Education (%) 59.6% 52.3%
Main Occupation (Trader) (%) 31.9% 31.9%
Average Household size 4.9 (2.1) 4.5 (2.1)
Enrolment in Health InsuranceInsurance Enrolment Total Sample Sample of 18+ Years Sample of Households
Heads
Enrolment in any Health Insurance
(N = 6,742) (N =4,213 ) (N = 1,902)
Currently enrolled 40.3% 41.4% 39.6%
Currently not enrolled 59.7% 58.6%% 60.4%
Type of Health Insurance Scheme
(N 2,693) (N =1,547) (N 679)
Enrolled in NHIS 98.4% 92.7% 93.5%
Enrolled in other schemes 1.6% 7.3% 6.5%
Among Currently Not Enrolled (N = 3,916) (N = 2,409) (N = 1,119)
Previously enrolled in NHIS 32.1% 32.5% 31.1%
Never enrolled in NHIS 67.9% 67.5% 68.9%
N = Number of individuals or households14
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Reasons for Never Enrolling in the NHISReason Never Enrolled
of Total Sample(N=2,620)
Never Enrolled Individuals 18+ years (N =1,565 )
Never Enrolled Households
(N = 772)
Cannot afford premium 40.5% 37.5% 35.4%
Never heard of the NHIS 0.4% 0.6% 0.4%
Covered by employer 3.4% 3.3% 3.9%
Mostly healthy do not need NHIS 19.9% 22.5% 23.7%
No scheme in the area 1.0% 0.7% 0.7%
No confidence in the NHIS 19.4% 21.1% 21.1%
Registration point too far 2.5% 2.6% 2.3%
Have private health insurance 0.2% 0.1% 0.1%
Other reasons 12.8% 11.6% 12.4%
N = Number of individuals or households
Age Group, Sex and Locality of Residence per Percentage Enrolled of Sample 18+ Years
Variables Enrolled Not Enrolled
Age Group*** N=4,019)
18 - 39 34.7% 65.3%
40 – 69 42.2% 57.8%
70+ 60.9% 39.1%
Sex*** N=4,019)
Female 42.3% 57.7%
Male 33.6% 66.4%
Locality of Residence***
Urban 37.9% 62.1% Rural 39.1% 60.9%
*=statistically significant at 10% level, **=statistically significant at 5% level ***=statistically significant at 1% level
Sector of Employment and Wealth Quintile per percentage EnrolledVariables Enrolled Not Enrolled
Sector of Employment*** N=2,737
Formal Sector 47.2% 52,8%
Informal Sector 36.0% 64.0%
Wealth Quintile*** N=4,127
Poorest 34.5% 65.5%
Poor 39.8% 60.3
Middle 41.4% 58.6%
Rich 40.6% 59.4%
Richest 47.7% 52.3%
House Hold Size** N=4,213
HH size 0 – 3 39.6% 60.4%
HH size 4 – 6 41.8% 58.3%
HH size 7 – 9 45.5% 54.5%
HH size 10+ 32.6% 67.4%
*=statistically significant at 10% level, **=statistically significant at 5% level ***=statistically significant at 1% level
Health Status & Utilization per Percentage Enrolled Variables Enrolled Not Enrolled
Self-rated Health Status*** N=3,996
Poor Health 61.1% 38.9%
Average Health 45.2% 54.8%
Good Health 37.1% 62.9%
Heath Service Utilization*** N=4,214
UTL 0 34.1& 65.9%
UTL 1-5 52.3% 47.7%
UTL 6-10 67.6% 32.4%
UTL 11-15 80.0% 20.0%
UTL 16+ 36.9% 63.1%
*=statistically significant at 10% level, **=statistically significant at 5% level ***=statistically significant at 1% level
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Perception on Quality of Services at Nearest Accredited Health Facility
Perception Proportion of Household Heads (Agree or Satisfied)N=1,902
Insured (p-value) Uninsured (p-value)
Respectful treatment from Doc/Med. Asst. /Nurses
85.5% (0.000) 78.7% (0.000)
Organized and fair queuing system at health facility
84.7% (0.000) 74.6% (0.000)
Availability of all prescribed drugs at health facility
68.5% (0.000) 57.4% (0.000)
Equal treatment for insured & uninsured patients
62.1% (0.000) 51.0% (0.000)
Satisfaction with waiting time at health facility
70.7% (0.000) 56.7% (0.000)
Source: Cohesions Project Survey, 2012
N = households Pearson Chi-Square (p-value)
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Perception on Quality of NHIS Services
Perception Proportion of Household Heads Agree or SatisfiedN=1,902
Insured (p-value) Uninsured (p-value)
Adequacy of NHIS benefit package 82.2% (0.000) 68.6% (0.000)
Adequacy of 3 months waiting period to receive ID card
23.8% (0.000) 16.1% (0.000)
Convenience of ID card distribution
59.8% (0.000) 39.7% (0.000)
Too high NHIS Premium 49.2% (0.000) 47.1% (0.000)
Satisfaction with registration and renewal processes
71.5% (0.000) 42.1% (0.000)
Satisfaction with distance from home to NHIS office
51.3% (0.000) 35.7% (0.000)
Source: COHEiSION Project Survey, 2012
N = households Pearson Chi-Square (p-value)
Determinants of Enrolment in the NHISWaiting time
(N=1,752)Organized/fair queuing
system (N=1,752)Sufficiently doctor/medical
assistants (N=1,752)
Coeff ME Coeff ME Coeff ME
Quality of Services
Positive Perception 0.468 0.470 0.4712
Negative Perception -0.070 0.442 -0.078 0.441 -0.077 0.4423
Sex
Females 0.518 0.522 0.5241
Males -0.344*** 0.391 -0.337*** 0.397 -0.342*** 0.3971
Age
18 – 39 0.407 0.411 0.414
40 – 69 0.281*** 0.512 0.290*** 0.519 0.280*** 0.5186
70+ 0.693*** 0.663 0.690*** 0.665 0.674** 0.6623
Marital Status
Married 0.480 0.485 0.4871
Never Married -0.073 0.453 -0.051 0.465 -0.071 0.4604
Divorced -0.162 0.420 -0.165 0.423 -0.159 0.4279
Living Together -0.107 0.440 -0.120 0.440 -0.135 0.4366
Religion
Christians 0.466 0.471 0.4741
Muslims -0.003 0.465 0.002 0.472 -0.011 0.4699
Traditional -0.090 0.432 -0.114 0.429 -0.105 0.4347
No Religion -0.373 0.331 -0.397* 0.328 -0.546** 0.2811
Determinants of Enrolment in the NHIS Continued
Satisfied with Waiting time
Organized/fair queuing system
Sufficiently good doctor/medical assistants
Coeff ME Coeff ME Coeff ME
Educational Level
Basic 0.440 0.445 0.4483
Secondary 0.299** 0.552 0.305** 0.560 0.294** 0.5585
Tertiary 0.184 0.509 0.180 0.513 0.176 0.5142
Post-Tertiary 0.445 0.606 0.427 0.605 0.436 0.6104
No Education -0.108 0.400 -0.115 0.403 -0.135 0.3986
Sector of Employment
Informal Sector 0.439 0.445 0.4469
Formal Sector 0.335** 0.566 0.324** 0.567 0.316** 0.5659
Household size
HH size 0 – 3 0.448 0.456 0.459
HH size 4 – 6 0.087 0.480 0.080 0.486 0.072 0.4859
HH size 7 – 9 -0.038 0.434 -0.062 0.433 -0.077 0.4305
HH size 10+ 0.006 0.450 -0.013 0.451 -0.031 0.4476
Locality of residence
Rural 0.471 0.480 0.4818
Urban -0.049 0.453 -0.068 0.455 -0.068 0.4562
Determinants of Enrolment in the NHIS Continued
Satisfied with Waiting time
Organized/fair queuing system
Sufficiently good doctor/medical assistants
Coeff ME Coeff ME Coeff ME
Region of Residence
Western 0.396 0.400 0.4001
Greater Accra 0.373*** 0.536 0.382*** 0.544 0.388*** 0.5459
Health Status
Poor health 0.647 0.649 0.6597
Average health -0.338 0.523 -0.342 0.524 -0.378 0.5217
Good health -0.538** 0.447 -0.531** 0.453 -0.558** 0.4539
Wealth Quintile
Poorest 0.413 0.420 0.4186
Poorer 0.225* 0.497 0.228* 0.505 0.236* 0.5067
Middle0.182 0.480 0.187 0.490 0.195 0.4913
Richer 0.065 0.437 0.045 0.437 0.066 0.443
Richest 0.199 0.487 0.186 0.490 0.183 0.487*=statistically significant at 10% level, **=statistically significant at 5% level ***=statistically significant at 1% level
Tripod with Focus on the Clients
Client-Oriented NHIS System
Provider Insurer24NHIS 10th Anniversary Conference
Client Trust-Socio cultural schemas-Social capital
HHS
20 IHH
20 FGD
Abbreviations: IM= Initiation meetingSDM =Stakeholder Design Meeting IHH =Individual Health HistoriesKII =Key Informant InterviewsFGD =Focus Group DiscussionsRVM =Regional Validation MeetingSM =Stakeholder MeetingHHS =Household SurveyIMC =Intervention MyCare
6 KII
Stakeholders Qualitative Quantitative Participatory Action Approach Methods
NHIA
All
Clients
All
Clients
All
SDM
SM
SM
IMC
IM
RVM
NHIS 10th Anniversary Conference
All= clients, healthcare providers and insurance
26NHIS 10th Anniversary Conference FGD Western Region 2011
27NHIS 10th Anniversary ConferenceRVM Greater Accra 2011
28NHIS 10th Anniversary ConferenceStakeholder meeting 2012
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Social Capital(Bourdieu 1986, Coleman 1988, Putnam 1993,Fukuyama 2000, Grootaert 2001)
• social connections or social networks that catalyzes cooperation, coordination and reciprocity;
• reduces incomplete or asymmetric information • reduces transaction costs in the absence of formal,
enforced contracts. • can achieve improved social and economic outcomes.
• Trust is seen as important determinant of SC.
• SC at the community level can positively and significantly impact households’ decision in take up of health insurance (Donfouet et al 2011; Zangh et al 2006)
NHIS 10th Anniversary Conference
Family , friends ,
neighborsClient Groups and
associations
Authorities i.e. Government, NHIS,
Healthcare providers
Vertical SC
Horizontal SC
Differentiating Social Capital
NHIS 10th Anniversary Conference
Clients’ views on social networks and support structures
‘Why I realized that ‘health’ is not good is because most of my siblings and even my friends that I know have insurance, look disappointed when they go for treatment and come back’ (FGD female GAR)
If ‘you walk alone’ and keep things to yourself, nobody knows what is worrying you or what is in your heart but if you are part of a group, you can share what is bothering you. Someone who is knowledgeable about it will give you advice and help you. So the group is good’ (IHH female, Insured Western Region)
What motivated me to join the NHIS is that I may not have money when I fall ill and that would make the illness worse. I have already paid and keep my card so when I fall ill without having any money I can access health care. (Female insured IHH GAR)
‘Now the world has become difficult, family members are no more supporting anybody, (interjection by a participant: 'Everyone for himself, God for us all' that is the motto we have in this family’ (FGD Male/Female Western Region)
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Social capital: membership of groups (n=3963)
insured not insured P value
membership of a groupYes 487 (30,7) 556 (22,4) 0.000***No 1098 (69,3) 1922 (77,6)Total 1585 (100) 2478 (100,0)
membership size of groupSmall 33 (7,2) 39 (7,1) 0,919.Medium 269 (58,4) 329 (59,6)Large 159 (34,5) 184 (33,3)Total 461 (100,0) 552 (100,0)
group links outside community
yes occasionally 356 (75,9) 415 (74,5) 0.832.yes frequently 40 (8,5) 53 (9,5)no 73 (15,6) 89 (16,0)Total 469 (100,0) 557 (100,0)
most dominant groupreligious group 856 (60,4) 1230 (55,1) 0.003**Youth association 81 (5,7) 94 (4,2)Others 279 (19,7) 519 (23,3)
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Social capital: Social cohesion and inclusion (n=3963)
insured not insured P value
I feel excluded because of my financial situation
89 (13,1) 208 (18,2) 0.019**.
Because of my social status I get preferential treatment
95 (14,0) 183 (15,9) 0.137.
I feel excluded because of my ethnic background
47 (6,9) 106 (9,2) 0.224.
Because of my religious background I receive more benefits than others
52 (7,7) 120 (10,4) 0.136.
Because of political alliance one gets preferential treatment
65 (9,6) 127 (11,1) 0.612.
I am happy with my future prospect 604 (89,0) 978 (85,1) 0.035**.
I am able to make important decisions that can change the course of my life
647 (95,6) 1063 (92,7) 0.005**.
* Significant at the 10% level
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Social capital :Trust and solidarity (n-3963)
(Read column)
insured not insured P value
I trust most people in this community 326 (47,9) 528 (46,0) ,489.
I trust my Traditional Chief 303 (44,5) 466 (40,6) ,08.
I trust local politicians 177 (26,0) 309 (26,9) ,825.
I trust national politicians 167 (24,6) 294 (25,6) ,873.
I trust my health care provider. 600 (87,8) 884 (76,6) ,000***
I trust the NHIS 358 (52,5) 503 (43,9) ,000***
NHIS 10th Anniversary Conference
Survey findings: Trust in the healthcare provider (N=3963) Enrolled Not enrolled P value
Attitude of staff
strongly agree 1186 (43,9) 1448 (36,1) 0.000***agree 1162 (43,0) 1808 (45,1)Staff availability
strongly agree 996 (37,0) 1169 (29,3) 0.000***agree 1101 (40,9) 1723 (43,2)Drugs availability
strongly agree 882 (32,7) 1134 (28,4) 0.000***agree 945 (35,0) 1274 (31,8)Queue system
strongly agree 1083 (40,1) 1364 (34,0) 0.000***agree 1216 (45,0) 1753 (43,7)Information prov.
strongly agree 862 (32,2) 927 (23,2) 0.000***agree 1314 (49,0) 1907 (47,7)Lodging complaints
strongly agree 877 (32,5) 1023 (25,5) 0.000***agree 820 (30,3) 956 (23,8)
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Tripod with Focus on the Provider
Client-Oriented NHIS System
Client
InsurerProvider• Quality
healthcare
36NHIS 10th Anniversary Conference
Methodology (Qualitative & quantitative)• Qualitative
– Individual in-depth interviews (IDIs) in private and public facilities in WR & GAR– Cadre of health providers
• Managers at national, regional, district levels (n=4)• Clinical staff at service delivery point (n=18)
– Grounded theory=>qualitative findings informed structuring of quantitative tool– Total sample size=22 IDIs
• Quantitative• Medical technical quality assessment• Tools (Essentials, and SA+)• Total of 41 questions grouped into 5 major components
– Staff perceptions data• Structured questionnaires on the ff:
– Socio-demographic features of staff– Perspectives on client-centered quality care– Perspectives on the NHIS and QHC– Perceptions on workplace incentives and constraints
NHIS 10th Anniversary Conference
Profile of Health Facilities Surveyed (n=64)
Freq. Percentage
Ownership
Private 38 60%
Public 26 40%
Total 64 100%
Location
Rural 36 56%
Urban 28 44%
Total 64 100%
NHIS 10th Anniversary Conference
Quality care and patient safety situation in clinics and health centresMean percentage scores in NHIA core standard areas (n=64)
Source: Analyzed NHIA Accreditation Data on selected 64 clinics and health centres (2009/2010)
Range of services Staffing Organization and management
Safety and quality management
Service delivery0%
10%
20%
30%
40%
50%
60%
70%
80%
68%63%
68%
53%
62%
NHIA Core Standard Areas
Mea
n Pe
rcen
tage
Sco
res
NHIS 10th Anniversary Conference
Mean percentage scores on Essentials Risk Areas (n=64)
0%
10%
20%
30%
40%
50%
60%
28%
42%
36%
48%
22%
Five major risk areas
Mea
n pe
rcen
tage
sco
res
NHIS 10th Anniversary Conference
4050
6070
80O
vera
ll N
HIA
Sco
res
20 30 40 50 60Overall Essentials Scores
95% confidence interval Linear fitObservations
Figure 3: Relationship between NHIA and Essentials scores
NHIS 10th Anniversary Conference
Profile of Health Staff Interviewed (n=324)
Freq. Percentage
Ownership
Private 185 57%
Public 139 43%
Total 324 100%
Location
Rural 182 56%
Urban 142 44%
Total 324 100%
NHIS 10th Anniversary Conference
Percentage of staff satisfied with working conditions in NHIA accredited facilities (n=64)
*p<0.05
Private Public p-value
Satis. Satis.
Work conditions (%) (%)
Physical work environment(n=323) 50% 27% 0.000
Availability of modern equipment(n=322) 45% 17% 0.000
Availability of consumables and logistics(n=323) 52% 31% 0.000
Water supply(n=323) 43% 5% 0.000
Electricity supply(n=322) 44% 28% 0.001
Workload(n=322) 43% 27% 0.046
Availability of drugs for patients(n=322) 49% 30% 0.000
Payment of financial incentives(n=316) 17% 5% 0.000
Accommodation for staff(n=323) 21% 11% 0.193
Possibility for promotion(n=310) 27% 25% 0.025
Experiences and overall perceptions of health workers on the NHIS (n=324) (*p<0.05)
Region
GAR WR
(%) (%) Total p-value
Adequacy of illness covered by the NHIS benefits package (n=317)
Disappointing 25% 17% 42% 0.468
Satisfactory 30% 28% 58%
Adequacy of drugs covered by the NHIS benefits package (n=320)
Disappointing 28% 20% 48% 0.025*
Satisfactory 27% 25% 52%
Quality of drugs given to insured clients (n=319)
Disappointing 20% 10% 30% 0.001*
Satisfactory 34% 36% 70%
Information dissemination to clients on the NHIS benefits package (n=313)
Disappointing 29% 21% 50% 0.429
Satisfactory 25% 25% 50%
Lead time for reimbursement of health providers (n=272)
Disappointing 43% 28% 71% 0.001*
Satisfactory 11% 18% 29%
Current tariff system of provider payment by the NHIS (n=276)
Disappointing 36% 25% 61% 0.003*
Satisfactory 15% 24% 39%
Perspectives health staff on the effects of NHIS on quality care
Increas
ed w
orkload
on staff
(n=3
13)
Reduce
d quality
of time s
pent p
er pati
ent (
n=313)
Patien
ts no lo
nger g
et quali
ty dru
gs (n
=310)
Deterio
rated hea
lth fa
cility
infrastr
ucture
(n=3
12)
Increas
ed st
aff m
otivation (n
=313)0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
12%
81%86% 88%
72%
88%
19%14% 12%
29%
Little extentGreat extent
Perc
enta
ge o
f sta
ff
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Quality of care
Attitude of staff
Availability of drugs
Transparent information
Fair queuing system
Facility to file complaints
Availability of staff
Rational use of drugs
Adequate equipment
Sufficient trained staff
Qualitative
Quantitative
Clients:Relational aspects quality are poor
HC Providers:Quality is good but need for more staff, equipment & logistics
NHIA and ESS: low quality standards
HH survey:Quality is good except for Facility to file complaints
(80% dissatisfied) and queuing time (40% diss. )
Comparing and triangulating Client and Provider Perspectives on Quality Care
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Concluding remarks (1):We found a positive association between enrolment in the NHIS and existing social capital in the target population (social trust and social participation).
There is positive association between enrolment in the NHIS (formal institution) and trust factors such as information provision, reliable delivery of benefit package and client perceived quality of services and facility to file suggestions or complaints (significant)
There is also a positive association between enrolment in the NHIS and socio-economic attributes such as health status, educational level, sector of employment and wealth status.
Clients’ views of HC quality is largely based on inter-relational factors. This contrasts with providers views, which relates quality to medical technical aspects, creating a gap between perceptions of clients and providers. Our qualitative findings of client perceptions on quality of services generally show a more negative trend than survey findings. We argue that a mixed methods lead to more reliable, precise and valid data. NHIS 10th Anniversary Conference
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Essentials tool results positively correlate with the NHIA accreditation scores suggesting the former could be a complementary assessment tool for quicker assessment over shorter time by the NHIA.
Overall quality situation per Essentials*and NHIA accreditation data in sampled facilities is generally low even though all these facilities are accredited. Regular post accreditation monitoring is therefore imperative to ensure quality care standards are maintained after facilities are given accreditation.
Providers perceive medical technical quality indicators as benchmarks for quality service delivery; client-centered indicators not emphasized. Client-centered care modules should therefore be integrated into the training curricula of health training institutions in Ghana.
Interventions to reduce barriers and enhance enrolment should focus on improving interpersonal relations and information sharing at the health facilities (community level).
Concluding remarks (2):
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Thank you
NHIS 10th Anniversary onference