“ “ Towards a client-oriented health insurance system in Ghana” Some key findings NHIS 10th Anniversary Conference 5th November, 2013 Accra, Ghana

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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

http://www.rug.nl/corpora

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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?


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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)


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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


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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


Tripod with Focus on the Insurer


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 EnrolledSector 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 MERegion 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


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


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)


Family , friends ,

neighborsClient Groups and

associations

Authorities i.e. Government, NHIS,

Healthcare providers

Vertical SC

Horizontal SC

Differentiating Social Capital


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)


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)


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***


Survey findings: Trust in the healthcare provider (N=3963) Enrolled Not enrolled P valueAttitude of staffstrongly 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 availabilitystrongly 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 complaintsstrongly agree 877 (32,5) 1023 (25,5) 0.000***agree 820 (30,3) 956 (23,8)


Tripod with Focus on the Provider


Client

InsurerProvider• Quality

healthcare


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


Profile of Health Facilities Surveyed (n=64)Freq. Percentage

OwnershipPrivate 38 60%

Public 26 40%

Total 64 100%

Location Rural 36 56%

Urban 28 44%

Total 64 100%


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


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

scor

es


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


Profile of Health Staff Interviewed (n=324)Freq. Percentage

OwnershipPrivate 185 57%

Public 139 43%

Total 324 100%

LocationRural 182 56%

Urban 142 44%

Total 324 100%


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*


Quality of drugs given to insured clients (n=319)



Information dissemination to clients on the NHIS benefits package (n=313)

Disappointing 29% 21% 50% 0.429


Lead time for reimbursement of health providers (n=272)



Current tariff system of provider payment by the NHIS (n=276)



Perspectives health staff on the effects of NHIS on quality care

Increase

d workl

oad on staff (n

=313)

Reduced

quality of ti

me spen

t per

patien

t (n=3

13)

Patients

no longe

r get q

uality d

rugs (n=3

10)

Deteriorated healt

h facili

ty infra

structu

re (n=3

12)

Increase

d staff

motivati

on (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.


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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

Documents

“ “ Towards a client-oriented health insurance system in Ghana” Some key findings NHIS 10th Anniversary Conference 5th November, 2013 Accra, Ghana