THE SUSTAINABILITY OF THE NATIONAL HEALTH INSURANCE SCHEME IN THE KINTAMPO MUNICIPALITY: THE ROLE OF SERVICE PROVIDERS AND FIELD AGENTS by SALIFU NUHU (PG3090209) A Thesis submitted to the Institute of Distance Learning, Kwame Nkrumah University of Science and Technology in partial fulfillment of the requirements for the degree of COMMONWEALTH EXECUTIVE MASTERS OF BUSINESS ADMINISTRATION April, 2012 CERTIFICATION I hereby declare that this submission is my own work towards the CEMBA degree and that, to the best of my knowledge, it contains no material previously published by another person nor material which has been accepted for the award of any other degree of the University, except where due acknowledgement has been made in the text Salifu Nuhu (20103969) Student Name & ID …………………… Signature ……………… Date …………………… ………………… Certified by: Cassius Amoako Supervisor’s Name Prof I K Dontwi Dean, IDL Signature …………………… Signature ii Date …………………… Date DEDICATION I dedicate the entire work to Almighty Allah for taking care of my life throughout my education, and to my dear mother, Madam Fatima Abubakari for her advice and support towards my success in education, and finally to my children: Buhari, Khadijah, Abdalla and Aminah iii ACKNOWLEGEMENT My appreciation goes to the Almighty Allah for His wisdom, Knowledge, mercies and direction in the writing of this thesis I would also like to acknowledge my supervisor Mr Cassius Amoako of KNUST – Institute of Distance Learning for his fatherly and excellent manner in which he approached and handled the supervision of the thesis Again, I acknowledge and appreciate other authors whose published materials have been refereed to and cited in this thesis I would like to thank Kwaku Asare for his help in editing of this work I am profoundly grateful to the Kintampo Municipal Director of Health Services and staff, Mr Amoako Adoesom (Scheme Manager of Kintampo Municipal Mutual Health Insurance Scheme) and his staff and my entire staff for their cooperation during the collection of data Additionally, I acknowledge the various facilitators of the Commonwealth Executive Master in Business Administration, Institution of Distance Learning, KNUST Finally, my thanks go to friends and my family who have been of help in diverse ways to bring this thesis to a successful end iv ABSTRACT This study provides an assessment of the role of service providers and field agents in the sustainability of National Health Insurance Scheme taking Kintampo Municipality as the case study It provides an empirical platform for assessing how the health service providers and field agents are helping in the sustainability of the scheme Kintampo Municipality was chosen because it was among the first National Health Insurance Schemes that were inaugurated by the then President John Agyekum Kuffour on 18th March, 2004 Questionnaires, interview and focal group discussion were the data collection instruments employed The data were analyzed using tables, percentages, graphs, charts and diagrams The study revealed that the health service providers and field agents play major roles in the sustainability of the National Health Insurance Scheme in Ghana However, the extent to which health service providers and field agents achieve their roles in the municipality was limited by factors such as untimely release of funds by government, political interferences, limited health facilities to meet the high coverage of the scheme, lack of logistics for field agents, training and motivation The following recommendations were made from the findings: The government should release funds early to the scheme, there should be intensive education of residents on the health insurance concept, the health facilities should be expanded and more health personnel should be trained to cater for the growing population in the municipality v TABLE OF CONTENT CERTIFICATION ii DEDICATION iii ACKNOWLEGEMENT iv ABSTRACT v TABLE OF CONTENT vi LIST OF TABLES x LIST OF FIGURES xi ABBREVIATIONS xii CHAPTER ONE INTRODUCTION 1.1 Background to the Study 1.1.2 The Concepts of Health Insurance in Ghana 1.2 Problem Statement 1.3 Objective 1.3 General Objective 1.3 Specific Objectives 1.4 Research Questions 1.5 Overview of Research Methodology 1.6 Significance of the Study 1.7 Scope and Limitations of the Study 1.8 Organization of the Study CHAPTER TWO REVIEW OF LITERATURE 10 2.1 Overview of Health Insurance 10 2.2 Universal Financial Protection: Obstacles to Implementation of Insurance Schemes 12 vi 2.3 Characteristics of Health Information System in Ghana 14 2.4 Concept of Sustainability 18 2.4.1 Affordability of Contributions 18 2.4.2 Unit of Enrolment 20 2.4.3 Distance 21 2.4.4 Timing of Collection of Contribution 22 2.4.5 Quality of Health Care 23 2.4.6 Trust 24 2.5 Health Insurance Coverage 26 2.6 Problems in the Health Insurance Market 27 2.7 Health Insurance in Kintampo Municipality 28 CHAPTER THREE METHODOLOGY 30 3.0 Introduction 30 3.1 Study Design and Methods 30 3.2 Scope of the Study 31 3.3 Study Population 31 3.4 Sampling Method and Sampling Size 32 3.5 Data Collection Techniques and Tools 33 3.6 Pretesting of Study Instruments 33 3.7 Ethical Consideration 33 3.8 Data Handling 33 3.9 Data Analysis Technique 34 3.10 Validity and Reliability of the Research 35 3.11 Profile of the Study Area 35 3.11.1 Geographical Location and Size 35 vii 3.11.2 Population Growth and Spatial Distribution 38 3.11.3 Climate and Vegetation 40 3.11.4 Relief and Drainage 41 3.11.5 Major Economic Activities 42 3.11.6 Transportation System 43 3.11.7 Telecommunication 43 3.11.8 Ethnicity and Religion 43 3.11.9 Health Services Delivery 44 3.11.10 Common Diseases in the District 45 3.11.11 Issues of Public Health Importance 47 CHAPTER FOUR DISCUSSIONS OF RESULTS 49 4.0 Introduction 49 4.1 Socio-Demographic Characteristics of the Respondents 49 4.1.1 Age Distribution 49 4.1.2 Gender Composition 50 4.1.3 Educational Background of the Respondents 51 4.1.4 Marital Status 52 4.1.5 Religion 53 4.2 The Role of Service Providers in Ensuring Sustainability of the Scheme 53 4.3 The Role of Field Agents in Ensuring Sustainability of the Scheme 57 4.4 Challenges that can affect the Sustainability of NHIS 60 CHAPTER FIVE SUMMARY, CONCLUSION AND RECOMMENDATIONS 62 5.1 Summary of the Study 62 5.2 Conclusions (Findings) 62 5.2.1 The Role of Service Providers in Ensuring the Sustainability of the Scheme 63 viii 5.2.2 The Role of Field Agents in Ensuring the Sustainability of the Scheme 64 5.2.3 Challenges Identified: 65 5.3 Recommendations 66 REFERENCES 70 APPENDIX 76 ix LIST OF TABLES Table 3.1: Study Population…………………………………………………………… 31 Table 3.2 Sampling Size and Data Collection Techniques………………………………32 Table 3.3: Distribution of Population 39 Table 3.4 Distribution of Health Facilities in the Kintampo Municipality 45 Table 4.1.1 Age of the Respondent 50 Table 4.1.2 Gender Composition of Respondents 51 Table 4.1.3 Educational Background of Respondents 51 Table 4.1.4 Marital Status of the Respondents 52 Table 4.1.5 Religion of the Respondents 53 Table 4.2 The Role of Service Providers 54 Table 4.3: The Role of Field Agents 58 x The field agents are not given requisite logistics in the discharge of their duties The health facilities are not enough to cater for all the people in the municipality which results in a lot of congestions at the facilities level Claims are processed manually There are a lot of complications in the claims that are processed electronically, thus, slowness of the processing and unseen diagnosis that can be checked against drugs after entries have been made There are undue delays in claims payment by scheme to the health facilities It takes at times about six months before claims bills are paid This impede against smooth health care delivery in the district There is delay in receiving reinsurance funds from NHIA The high claims bills payment is attributable partly to high Ghana Diagnostic Related Grouping Tariffs There are excessive workload at both scheme and facilities level Thus, few people are there to cater for the growing population Lack of motivation of health insurance staff, field agents and health facilities staffs resulting in low performance at both scheme and health facilities level 5.3 Recommendations From the study the following recommendations are made based on personal observation and those suggestions by respondents for the sustainability of the scheme 66 More health facilities should be opened in the various communities to reduce the incidence of travelling long distance to access health care as a means of ensuring the sustainability of the scheme Government and perhaps the private sector must as a matter of necessity embark on serious facility planning by making significant investments in the construction of new hospitals while expanding existing ones and providing them with basic equipments Regardless of how much Insurance there is, if our hospitals not have the basic equipment to accommodate the increase in numbers, then the core objective for introducing the system is defeated The expiring dates written at the back of the National Health Insurance Cards should be visible enough for the members to see when their cards are expiring Since the inability of the card bearing members to be able to know that their membership cards have expired is affecting the smooth operation of the scheme Again, it is the duty of the service providers to check that members with invalid cards are not attended to on the ticket of health insurance The field agents should be given requisite logistics like motor bikes, bicycles, bags and other relevant materials for the discharge of their duties And appropriate commission should be paid to them on timely basis to motivate them to work extra hard towards the sustainability of the scheme There should be accurate and timely submission of claims by the health care providers Again, for smooth and faster claims processing, all the health facilities in the district should be hooked to the national network and be made to send claims electronically 67 The premium paid by the informal sector should either be increased or government sends enough money to meet the claims pay by the scheme To ensure sustainability of the scheme and the health facilities, funds should be released early enough by the National Health Insurance Authority The NHIA and the various schemes must pay service providers on time for service rendered It must be noted that the Health Insurance is still at the experimental period, and if the scheme cannot pay for services provided now that the coverage is within reasonable levels, then what will be the fate of the schemes when the saturation point is reached The government must through the proposed legislation, require all schemes to pay 50% of claims submitted within one month and all other claims that are not disputed within two months to avoid a backlog of unpaid bills for services rendered If this problem is not resolved, the service providers and the public at large will lose confidence in the scheme and this will affect the viability of the scheme The health insurance clients should not be made to suffer when they attend health facilities with their cards This is because if clients are treated well in the name of health insurance in terms of sickness, then that will encourage them to always renew their membership and others upon hearing that will also join the scheme and by this the schemes sustainability is rest assured Intensive education should be carried out in the municipality about the gatekeeper system and other concepts of health insurance and health care delivery to the people of Kintampo Municipality for the sustainability of the scheme 68 The operations of the scheme should be devoid of political interferences to ensure trust in the system Since unqualified personnel may be employed on political line which in long run may lead to the collapse of the scheme More health personnel should be trained and posted to the district for efficient and effective health service delivery This in the long run will lead to the sustainability of the scheme Regular training should be organized for the field agents to enhance the performance of their duties There is also need to emphasize the role of continuing education and refresher courses for all staff, especially those who have been working for many years in relative isolation in rural health centers and hospitals if acceptable standards of clinical care are to be maintained On the whole, the health care providers and the field agents are doing their best to ensure the sustainability of the scheme in the municipality Therefore, all people in the municipality must have the opportunity to learn more and understand its importance This is the only way they can support the scheme Finally, the people in the municipality must be made to know that they own the health insurance scheme By so doing, they can help formulate policies that will enhance the achievement of the goals of the health insurance system and strive to work towards achieving these goals 69 REFERENCES Adeniyi-Jones, O (1976) Community Involvement: New Approaches WHO Chronicle, vol.30, pp.8-10 Atim, C (1998) Contribution of Mutual Health Organizations to Financing, Delivery, and Access to Health Care Maryland: ABT Associates, Partnerships for health reform, Technical Report No.18 Atim, C (1999) Social Movements and Health Insurance: A critical evaluation of voluntary, non-profit insurance schemes with case studies from Ghana and Cameroon Social Science and Medicine, vol.48 Baeza, C Montenegro, F and Nuñez, M (2002) Extending Social Protection in Health Through Community Based Health Organizations Evidence and challenges (Geneva: International Labour Organization) Bärnighausen, T & Sauerborn R (2002) One Hundred and Eighteen Years of the German Health Insurance System: are there any lessons for middle- and low-income countries Social Science and Medicine, vol.54 Bennett, S Creese A and Monasch R (1998) Health Insurance Schemes for People Outside Formal Sector Employment Geneva: World Health Organization, WHO/ARA/CC/98.1 Burgess, R and Stern, N (1991) Social Security in Developing Countries Ch of Ahmad E., Drèze J., Hills J and Sen A (eds.) Social Security in Developing Countries Oxford: Clarendon Press 70 Creese, A &; Bennet S (1997): “Rural Risks Sharing Strategies” In: G (Ed) Criel,B (1998): “District Based Health Insurance in Sub Saharan Africa” Part 1: Case studies in health services organization and policy 10, Antwerp Crier (1999): “The Potential for Social Mobilization in Bangladesh and Functioning of Two Health Insurance Schemes” Social Science and Medicine Volume 48, pp 925-938 Carrin Guy (2003): “The Impact of National Health Insurance Scheme on People’s Health Status in Taiwan”, China Medical University (Taiwan), Health Care Administration, 91 Hsueh Shih Road, Taichung 71 Dror, D.M (2001) Reinsurance of Health Insurance for the Informal Sector Bulletin of the World Health Organization, vol.79 Dror, D.M (2002) Health Insurance and Reinsurance at the Community Level Chapter of Dror D.M and A.S.Preker (eds.) (2002) Social Re Insurance A new approach to Sustainable Community Health Financing (Washington: ILO and World Bank) Ghana Health Service (2008): “Annual Report.2008”.KARA print, Accra Jancloes, M., Seck B., Van De Velden L & Ndiaye B (1985) Financing Urban Primary Health Services Tropical Doctor April 1985 Jütting, J (2001) The Impact of Health Insurance on the Access to Health Care and Financial Protection in Rural Developing Countries The Example of Senegal HNP Discussion Paper (Washington: World Bank) Jütting, J (2000) Social Security Systems in Low-Income Countries: Concepts, constraints and the need for cooperation International Social Security Review, vol.53, Kelly and Quijada (2001): “An Evaluation of National Health Insurance Program in Ghana”, Presented at the Global Development NetWork (GDN) Dissemination Workshop at Pretoria, South Africa Kintampo Municipal Health Directorate (2010): “Annual Review Report 2010” Unpublished Kintampo Municipal Mutual Health Insurance Scheme (2010): “The Profile of the Scheme 2010” Unpublished 72 Ministry of Health (2007): “Legal and Policy Frame Work for Health Information and Health Data Reporting” Draft MPCU (2010): Profile of Kintampo Municipality Government of the Republic of Ghana, Ministry of Local Government and Rural Development, Kintampo Municipal Assembly Musau, S (1999): “Community-Based Health Insurance; Experiences and Lessons Learned East Africa” Technical report no 34 Partnership for health reforms project, Abt Associates Inc Bethesda, MD National Health Insurance Authority (2009): Annual Report, Unpublished Perrot, J and Adams O (2000) Applying the Contractual Approach to Health Service Delivery in Developing Countries Geneva: WHO, Department of the Organisation of Health Services Delivery, discussion paper 73 Preker, A.S., Carrin G., Dror D., Jakab M., Hsiao W & Arhin-Tenkorang D (2002) Effectiveness of Community Health Financing in Meeting the Cost of Illness Bulletin of the World Health Organization, vol.80 Ranson, M.K (2002) Reduction of Catastrophic Health Care Expenditures by a Community Based Health Insurance Scheme in Gujarat, India Bulletin of the World Health Organization, vol 80 Ray, D (1998) Development Economics Princeton: Princeton University Press Ron, A (1999) NGOs in Community Health Insurance Schemes: Examples from Guatemala and the Philippines Social Science and Medicine, vol.48, no.7 Sanguan Nitayarumphong (1998) Universal Coverage of Health Care: Challenges for the Developing Countries Ch.1 of Sanguan Nityarumphong and Anne Mills (eds.), Achieving Universal Coverage of Health Care Nontaburi, Thailand: Office of Health Care Reform, Ministry of Public Health Sauerborn, R., Adams A., Hien M (1996) Household strategies to cope with the economic costs of illness Social Science and Medicine, vol 43 Schneider, P., Diop F and Bucyana S (2000) Development and Implementation of Prepayment Schemes in Rwanda Partners for Health Reform Technical paper nr 45 (Bethesda, Maryland: ABT Associates) Shneider, Diop, F (2001): “Impact of Prepayment Pilot on Health Care Utilization and Financing in Rwanda” Findings from Household’s Survey for Health Reform/Plus Technical Paper, Bethesda, Maryland: Abt Associates 74 WHO (2000) Health Systems: Improving Performance The World Health Report 2000 Geneva: WHO WHO (2003) Minimum Health Spending: Feasibility of Set of Essential Health Interventions WHO/FAR, unpublished Wiesmann, D and Jütting J (2001): Determinants of Viable Health Insurance Schemes in Rural Sub-Saharan Africa Quarterly Journal of International Agriculture, vol.40 75 APPENDIX THE SUSTAINABILITY OF THE NATIONAL HEALTH INSURANCE SCHEME IN THE KINTAMPO MUNICIPALITY: THE ROLE OF SERVICE PROVIDERS AND FIELD AGENTS The researcher is a Master of Business Administration student of the Kwame Nkrumah University of Science And Technology, Kumasi who is undertaking a research into “The Sustainability of the National Health Insurance Scheme in the Kintampo Municipality: The Role of Service Providers and Field Agents” for purely academic purposes All information furnished will therefore be treated with strict confidentiality Kindly answer or tick [ ] one of the options to each 5- Strongly Agree 4- Agree 3- Uncertain 2– Disagree – Strongly Disagree Section A: Socio-Demographic Characteristics Age: (a) Below 20 years [] (b) 20 – 29 years [] (c) 30 – 39 years [] (d) 40 – 49 years [] (e) 50 and above years [] 76 Gender: (b) Male [] (b) Female [] What is your educational background? (a) Tertiary [] (b) Technical/Commercial /SHS/ ‘O’ Level [] (c) Middle/JHS [] (d) Primary school /Informal [] Marital Status (a) Married [] (b) Single [] (c) Divorce/Widow/Widower [] Religion (a) Islamic [] (b) Christianity [] (c) Traditional [] (d) Others Specify [] Section B: The Role of Service Providers Service providers are to authenticate the membership of the scheme before service delivery 77 Health service providers are to provide quality health care to NHIS clients Accurate and genuine claims submission Ensure the enforcement of gatekeeper system 10 Are there any other roles that the health service providers are to play to ensure the sustainability of the scheme? (a) Yes [] (b) No [] (11) If yes to question 10, kindly state them a)……………… ………………………………………b)……………………………… c)…………………………………………………………d)……………………………… e)…………………………………………………………f)……………………………… 12) What suggestion(s) you have for the scheme management, health service providers and policy makers to ensure the sustainability of the scheme? a) b) c) d) -d) e) - 78 Section C: The Role of Field Agents 13 The field agents are to register members into the scheme 14 Field Agents are to educate the general public on the NHIS 15 Field agents are the play the role of mediation between the scheme and the general public 16 The field agents are to make prompt payment of all monies collected into the scheme’s accounts 17 Are there any other roles that the field agents are to play to ensure the sustainability of the scheme? (a) Yes [] (c) No [] 18 If yes to question 17, kindly state them a)……………… ………………………………………b)……………………………… c)…………………………………………………………d)……………………………… e)…………………………………………………………f)……………………………… 79 19 What suggestion(s) you have for the scheme management and the government on the role of field agents to ensure the sustainability of the scheme? a) b) c) d) -d) e) - 20 Suggest how best to improve the efficient and effective of the operations of the scheme a) b) c) d) -d) e) - 80 ... ABBREVIATIONS BAR - Brong Ahafo Region CDI - Centre de deveppement integre CHI - Community-Base Health Insurance CHPS - Community-Based Health Planning Services FGD - Focus Group Discussion GDRG - Ghana... Grouping GHS - Ghana Health Service GK - Gonosasthya Kendra ILO - International Labour Organisation JHS - Junior High School KMHD - Kintampo Municipal Health Directorate KMMHIS - Kintampo Municipal... Scheme LI - Legislative Instrument MHMT - Municipal Health Management Teams MOH - Ministry of Health MPCU - Municipal Planning Coordinating Unit NHI - National Health Insurance NHIA - National