“
“Towards a client-oriented health insurance
system in Ghana”
Some key findings
NHIS 10th Anniversary Conference
5th November, 2013
Accra, Ghana
Edward Nketiah-Amponsah
Stephen Duku
Christine Fenenga
Robert Kaba Alhassan
Tobias 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
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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?
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Client-Provider-Insurer Tripod Framework
Perspectives of the 3 key stakeholder groups,
allowing comparison and triangulation of data
Client
Client-Oriented
NHIS System
Insurer
Provider
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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)
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Sampling Strategy
2 Regions
(Western and Greater Accra)
8 Districts (Western Region)
8 Districts (Greater Accra Region)
Purposive Selection
Purposive Selection
4 Primary Health Care Facilities
4 Primary Health Care
Facilities
Per District
Per District
30 Households Per Catchment
Area of Health Care Facility
30 Households Per Catchment
Area of Health Care Facility
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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
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Tripod with Focus on the Insurer
Client
Client-Oriented
NHIS System
Provider
Insurer
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Qualitative Research Methodology
Location: Greater Accra and Western Regions
In-depth Interviews (n=16)
•
8 interviews in 4 NHIA districts offices (Dangme West, Ga West, Ahanta West
and 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 Methodology
Location:
Greater Accra and Western Regions
Districts/Health Facilities
(Purposive Selection)
Households
(Random Selection)
16
1,920
8 from each Region
(960 from each Region)
64 Primary Health Facilities
(4 from each District)
Individuals
7,097
30 Households per catchment
area of each Health Facility
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
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Qualitative Research Findings
Quality of NHIS Services to Clients
1. Determinants of Quality
•
Ease of Registration and registration time
•
Waiting period to acquire NHIS card and the accuracy of information on
cards
•
Availability of information on benefit package
•
Attitude of NHIS staff.
2. Challenges in Providing High Quality Services
• Delays by Registration Agents to submit registration forms to schemes.
• Delays by district schemes to submit registration forms to region.
• Inadequate staff at the scheme level to enter registration data into the
system.
• Low registration fees leading to inadequate administrative funds at
schemes.
• Misunderstanding and misinformation of clients on the NHIS registration
process.
• Education, infrastructural and environmental problems posses a huge
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challenge in the provision of high quality services.
Quality of NHIS Services to Health Providers
1. Determinants of Quality
•
•
•
Health providers’ accreditation process
Prompt payment of claims
Monitoring of provider service quality to clients
2. Challenges in Providing High Quality Services
• Inadequate education of health providers on claims processing
and NHIS in general.
• Providers borrowing staff and equipment for accreditation
process.
• Lack of right caliber of staff at health facilities for claims
processing.
• Inadequate staff at health facilities to process claims quickly.
• Lack of ICT support to speed up claims verification and processing
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Quantitative Household Survey Findings
Summary 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)
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Enrolment in Health Insurance
Insurance Enrolment
Total Sample
Sample of 18+ Years
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%
(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%
Among Currently Not Enrolled
N = Number of individuals or households
Sample of Households
Heads
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Reasons for Never Enrolling in the NHIS
Reason
Never Enrolled
of Total Sample
(N=2,620)
Never Enrolled
Individuals 18+
years (N =1,565 )
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
Never Enrolled
Households
(N = 772)
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Age Group, Sex and Locality of Residence per Percentage
Enrolled of Sample 18+ Years
Variables
Enrolled
Age Group***
Not Enrolled
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%
Urban
37.9%
62.1%
Rural
39.1%
60.9%
Locality of Residence***
*=statistically significant at 10% level, **=statistically significant at 5% level ***=statistically
significant at 1% level
Sector of Employment and Wealth Quintile per percentage Enrolled
Variables
Enrolled
Sector of Employment***
Not Enrolled
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
Self-rated Health Status***
Not Enrolled
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
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 Satisfied
N=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, N = households
2012
Pearson Chi-Square (p20
value)
Determinants of Enrolment in the NHIS
Waiting time
Organized/fair queuing
Sufficiently doctor/medical
(N=1,752)
system (N=1,752)
assistants (N=1,752)
Coeff
Coeff
Coeff
ME
ME
ME
Quality of Services
Positive Perception
Negative Perception
0.468
-0.070
0.442
0.470
-0.078
0.441
0.4712
-0.077
0.4423
Sex
Females
Males
0.518
-0.344***
0.391
0.522
-0.337***
0.397
0.5241
-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
Muslims
0.466
-0.003
0.465
0.471
0.002
0.472
0.4741
-0.011
0.4699
Determinants of Enrolment in the NHIS Continued
Satisfied with Waiting
Organized/fair queuing
Sufficiently good
time
system
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
Formal Sector
0.439
0.335**
0.566
0.445
0.324**
0.567
0.4469
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
Determinants of Enrolment in the NHIS Continued
Satisfied with Waiting
Organized/fair queuing
Sufficiently good
time
system
doctor/medical assistants
Coeff
ME
Coeff
ME
Coeff
ME
Region of Residence
Western
Greater Accra
0.396
0.373***
0.536
0.400
0.382***
0.544
0.4001
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
Middle
0.182
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
Trust
-Socio cultural schemas
-Social capital
Client-Oriented
NHIS System
Insurer
Provider
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Methods
Stakeholders
Qualitative Quantitative Participatory Action Approach
IM
NHIA
All= clients, healthcare
providers and insurance
SDM
All
20 IHH
Clients
6 KII
20 FGD
RVM
SM
All
Clients
HHS
SM
All
IMC
NHIS 10th Anniversary Conference
Abbreviations:
IM= Initiation meeting
SDM =Stakeholder Design Meeting
IHH =Individual Health Histories
KII =Key Informant Interviews
FGD =Focus Group Discussions
RVM =Regional Validation Meeting
SM =Stakeholder Meeting
HHS =Household Survey
IMC =Intervention MyCare
FGD Western Region 2011
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RVM Greater Accra 2011
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Stakeholder 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)
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Differentiating Social Capital
Authorities i.e.
Government, NHIS,
Healthcare providers
Vertical SC
Family ,
friends ,
neighbors
Client
Horizontal SC
NHIS 10th Anniversary Conference
Groups and
associations
Clients’ views on social networks and support structures
If ‘you walk alone’ and keep things to yourself, nobody
knows what is worrying you or what is in your heart but if
you are part of a group, you can share what is bothering
you. Someone who is knowledgeable about it will give you
advice and help you. So the group is good’ (IHH female, Insured
Western Region)
‘Why I realized that ‘health’ is not good is because most of
my siblings and even my friends that I know have insurance,
look disappointed when they go for treatment and come
back’ (FGD female GAR)
‘Now the world has become difficult, family members are
no more supporting anybody, (interjection by a participant:
'Everyone for himself, God for us all' that is the motto we
have in this family’ (FGD Male/Female Western Region)
What motivated me to join the NHIS is that I may not have
money when I fall ill and that would make the illness worse.
I have already paid and keep my card so when I fall ill
without having any money I can access health care. (Female
insured IHH GAR)
Social capital: membership of groups
(n=3963)
insured
not insured
P value
membership of a group
Yes
No
Total
487 (30,7)
1098 (69,3)
1585 (100)
556 (22,4)
1922 (77,6)
2478 (100,0)
0.000***
membership size of group
Small
Medium
Large
Total
33 (7,2)
269 (58,4)
159 (34,5)
461 (100,0)
39 (7,1)
329 (59,6)
184 (33,3)
552 (100,0)
0,919.
356 (75,9)
40 (8,5)
73 (15,6)
469 (100,0)
415 (74,5)
53 (9,5)
89 (16,0)
557 (100,0)
0.832.
856 (60,4)
81 (5,7)
279 (19,7)
1230 (55,1)
94 (4,2)
519 (23,3)
0.003**
group links outside community
yes occasionally
yes frequently
no
Total
most dominant group
religious group
Youth association
Others
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Social capital: Social cohesion and inclusion
(n=3963)
I feel excluded because of my financial
situation
Because of my social status I get preferential
treatment
I feel excluded because of my ethnic
background
Because of my religious background I receive
more benefits than others
Because of political alliance one gets
preferential treatment
I am happy with my future prospect
I am able to make important decisions that can
change the course of my life
insured
not insured
P value
89 (13,1)
208 (18,2)
0.019**.
95 (14,0)
183 (15,9)
0.137.
47 (6,9)
106 (9,2)
0.224.
52 (7,7)
120 (10,4)
0.136.
65 (9,6)
127 (11,1)
0.612.
604 (89,0)
978 (85,1)
0.035**.
647 (95,6)
1063 (92,7)
0.005**.
* Significant at the 10% level
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Social capital :Trust and solidarity
(n-3963)
insured
not insured
P value
(Read column)
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***
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Survey findings: Trust in the healthcare provider
(N=3963)
Attitude of staff
strongly agree
agree
Staff availability
strongly agree
agree
Drugs availability
strongly agree
agree
Queue system
strongly agree
agree
Information prov.
strongly agree
agree
Lodging complaints
strongly agree
agree
Enrolled
Not enrolled
1186 (43,9)
1162 (43,0)
1448 (36,1)
1808 (45,1)
0.000***
996 (37,0)
1101 (40,9)
1169 (29,3)
1723 (43,2)
0.000***
882 (32,7)
945 (35,0)
1134 (28,4)
1274 (31,8)
0.000***
1083 (40,1)
1216 (45,0)
1364 (34,0)
1753 (43,7)
0.000***
862 (32,2)
1314 (49,0)
927 (23,2)
1907 (47,7)
0.000***
877 (32,5)
820 (30,3)
1023 (25,5)
956 (23,8)
0.000***
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P value
35
Tripod with Focus on the Provider
Client
Client-Oriented
NHIS System
Provider
Insurer
•Quality
healthcare
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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
Private
38
60%
Public
26
40%
Total
64
100%
Rural
36
56%
Urban
28
44%
Total
64
100%
Ownership
Location
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Quality care and patient safety situation in clinics and health centres
Mean percentage scores in NHIA core standard areas (n=64)
80%
70%
68%
68%
63%
62%
Mean Percentage Scores
60%
53%
50%
40%
30%
20%
10%
0%
Range of services
Staffing
Organization and
management
Safety and quality
management
Service delivery
NHIA Core Standard Areas
Source: Analyzed NHIA Accreditation Data on selected 64 clinics and health centres (2009/2010)
NHIS 10th Anniversary Conference
Mean percentage scores on Essentials Risk Areas (n=64)
60%
48%
Mean percentage scores
50%
42%
40%
30%
36%
28%
22%
20%
10%
0%
Leadership process and Competent and capable Safe environment for
accountability
workforce
staff and patients
Five major risk areas
NHIS 10th Anniversary Conference
Clinical care of patients Improvement of quality
and safety
40
50
60
70
80
Figure 3: Relationship between NHIA and Essentials scores
20
30
40
Overall Essentials Scores
95% confidence interval
Observations
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Linear fit
60
Profile of Health Staff Interviewed (n=324)
Freq.
Percentage
Private
185
57%
Public
139
43%
Total
324
100%
Rural
182
56%
Urban
142
44%
Total
324
100%
Ownership
Location
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Percentage of staff satisfied with working conditions in NHIA
accredited facilities (n=64)
Private
Public
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
*p<0.05
p-value
Experiences and overall perceptions of health workers on the NHIS (n=324) (*p<0.05)
Region
GAR
WR
(%)
(%)
Total
p-value
Disappointing
25%
17%
42%
0.468
Satisfactory
30%
28%
58%
Disappointing
28%
20%
48%
Satisfactory
27%
25%
52%
Disappointing
20%
10%
30%
Satisfactory
34%
36%
70%
Disappointing
29%
21%
50%
Satisfactory
25%
25%
50%
Disappointing
43%
28%
71%
Satisfactory
11%
18%
29%
Disappointing
36%
25%
61%
Satisfactory
15%
24%
39%
Adequacy of illness covered by the NHIS benefits package (n=317)
Adequacy of drugs covered by the NHIS benefits package (n=320)
0.025*
Quality of drugs given to insured clients (n=319)
0.001*
Information dissemination to clients on the NHIS benefits package (n=313)
0.429
Lead time for reimbursement of health providers (n=272)
0.001*
Current tariff system of provider payment by the NHIS (n=276)
0.003*
Perspectives health staff on the effects of NHIS on quality care
100%
Percentage of staff
90%
86%
88%
88%
81%
Little extent
80%
72%
70%
60%
50%
40%
29%
30%
20%
19%
12%
14%
12%
10%
0%
Increased workload
on staff (n=313)
Reduced quality of Patients no longer get Deteriorated health
Increased staff
time spent per
quality drugs (n=310) facility infrastructure motivation (n=313)
patient (n=313)
(n=312)
Great extent
Comparing and triangulating Client and Provider Perspectives
HC Providers:
on Quality Care
Clients:
Quality is good but
Relational aspects
quality are poor
need for more staff,
equipment &
logistics
Facility to file complaints
Qualitative
Attitude of staff
Rational use of drugs
Availability of drugs
Quality of care
Quantitative
Fair queuing system
Sufficient trained staff
Transparent
Adequate equipment
HH survey:
Quality is good except for
Facility to file complaints
(80% dissatisfied) and
queuing time (40% diss. )
information
Availability of staff
NHIA and ESS:
low quality
standards
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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.
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Concluding remarks (2):
 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. Clientcentered 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).
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Thank you
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