Knowledge, experiences and perceptions of the Ghana National Health Insurance Scheme in three districts

Background Ghana’s National Health Insurance Scheme is a demand side programme where the governing authority registers clients and purchases health care services for them from public and private providers. Access of services is high across a broad Benefits Package with no parallel enrolment necessary for any type of service at the point of access. Nonetheless, there is evidence of difficulty in acquiring and use of the NHIS card to access health care services. Objective While studies had been conducted into general awareness, there was no linkage between awareness, uptake and experiences with registration and use of the card. This study fills this gap. Methods This is a descriptive study. A mix of qualitative (39 Focus Group Discussions) and quantitative (625 household interviews) methods were used to collect the data. Qualitative data was analysed manually using a thematic approach while a frequency analysis was done for the quantitative data. Results Knowledge about the Scheme was near universal. Enrolment was lower among FGD discussants, 38.7% had valid cards, than for household respondents, 62.9% valid cards. While mixed experiences with the registration process was observed among FGD discussants, 74% of the households’ ranked attitudes of Scheme staff as positive. The study found the NHIS card facilitates access to facility based health care. Satisfaction levels with use of the card were mixed and contextual among discussants. However, 90% of households reported their cards were readily accepted at health facilities. Expired card (51.4%) and health facility had stopped accepting NHIS cards (14.3%) were mentioned as reasons for non-acceptance. Conclusion People’s experience during registration and use of the NHIS card to access health care has lasting effect on their perceptions of the Scheme. This can be harnessed to manage the high expectations, grow membership, discourage frivolous use and address artificial barriers of access.

and private providers. Access of services is high across a broad Benefits Package with no 23 parallel enrolment necessary for any type of service at the point of access. Nonetheless, 24 there is evidence of difficulty in acquiring and use of the NHIS card to access health care 25 services. 26 Objective 27 While studies had been conducted into general awareness, there was no linkage between 28 awareness, uptake and experiences with registration and use of the card. This study fills this 29 gap. 30 Methods 31 This is a descriptive study. A mix of qualitative (39 Focus Group Discussions) and quantitative 32 (625 household interviews) methods were used to collect the data. Qualitative data was 33 analysed manually using a thematic approach while a frequency analysis was done for the 34 quantitative data. 35

36
Knowledge about the Scheme was near universal. Enrolment was lower among FGD 37 discussants, 38.7% had valid cards, than for household respondents, 62.9% valid cards. While 38 mixed experiences with the registration process was observed among FGD discussants, 74% Introduction 50 From 1957, health care in Ghana was free until 1969 when the Hospital Fees Decree (NLCD 51 360) was passed, and subsequently amended as Hospital Fees Act 387 of 1970, to introduce 52 user fee for consultation [1][2][3][4]. In the ensuing years, laboratory, and diagnostic services, 53 invasive procedures and a select group of drugs were added to the chargeable list. Later, 54 fixed fee charges for designated services and a 15% charge of the actual cost for general 55 services was introduced with the enactment of The Hospitals Fees Legislative Instrument, LI 56 1313, in 1985 [3,4]. A list of exemptible services and conditions were specified in the 57 legislation [1,3,4]. As the country sunk deeper into economic crisis, government funding for 58 the health sector was reduced substantially, full cost recovery or what in Ghanaian parlance 59 is referred to as 'cash and carry' came into effect in 1992 [4][5][6][7][8]. 60 User fees persisted until 2005 when the National Health Insurance Scheme (NHIS) was fully 61 rolled-out nationwide [9][10][11][12][13]. Building up to this roll-out was the passage in 2003 of Act 650 -62 the legal backing -which has since been replaced by Act 852 of 2012. The NHIS was a direct 63 social response to the adverse effects of financial inaccessibility to health care services [5, 13] for the over sixty-eight percent of the population at the time [14][15]. Act 650 established 65 the National Health Insurance Authority (NHIA) -which has 10 regional offices and 159 66 District Mutual Health Insurance Schemes (DMHISs) -as the implementer of the NHIS. The 67 DMHISs act as agency offices and are responsible for registration, card processing, revenue 68 generation through premium collection, reimbursement of service providers and community 69 engagement [9,16,17]. The Scheme is now widely recognised as a good pro-poor Social 70 Health Insurance scheme [14,18]. 71 About thirty-six percent (10,576,542 members) of the population is actively enrolled [19]. 72 Designed as a demand-side programme, the NHIS run all year-round registration systems for 73 clients and participating service providers [3]. Membership is compulsory for all persons 74 living in Ghana based on an annual renewable system. This is however currently not being 75 enforced [6,17,20,21]. At the point of registration, potential enrolees provide biometric 76 information, which then serves as their identification within the system [16]. Enrolees are 77 either premium-exempted or premium-paying. The premiums are set by the DMHISs, usually 78 higher for urban and lower for rural populations, but within a range determined by the NHIA 79 [6,17,20,21]. An inclusion list of inpatient, outpatient and emergency services is covered at 80 full cost by the curatively-inclined NHIS Benefits Package with no prior authorization before 81 member access [3,22,23]. 82 The NHIS has impacted positively on utilisation of outpatient (increased by more than forty-83 fold) and inpatient (increased by more than thirty-fold) services from the pre-NHIS era 84 [24,25] Table 4.
[Insert] Reasons for the respondents ranking of NHIS staff attitudes are presented in Table 6. 371 Overall, 90.8% of respondents expressed a willingness to renew their cards. Reasons for 372 renewal and non-renewal are shown in Table 7.

Frequency (%)
Assurance that government will pay for the service 20 Confident that I don't need to pay out of pocket to use services 25.3 As an NHIS card holder I was given preferential treatment 13.7 Staff attitude towards me (an NHIS card holder) was very friendly 15.3 Quality medication was made available to me (NHIS card holder) 12.7 Laboratory services were offered to me (NHIS card holder) freely 6.2 Other, specify 5.4

Reasons for non-renewal (N=44)
Waiting time to see the doctor was too long 11.7 Processing procedures for card holders too long 14.9 Long queues at the OPD 8.5 Poor attitude of the health workers 6.4 Doctor not present in the consulting room 6.4 No medicines available in the pharmacy 4.3 Laboratory services not working 2.1 Preference given to those who pay out of pocket 11.7 Staff attitude towards NHIS card holders is unfriendly 7.4 NHIS card holders are issued prescriptions to buy their own drugs 8.5 Card holders are asked to co-pay for health services 14.9 Others, specify 3.2 655