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The Impact of Community Outreach Intervention on National Health Insurance Enrolment, Knowledge and Health Services Utilisation: Evidence from Two Districts in Ghana

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The Impact of Community Outreach Intervention on National Health Insurance Enrolment, Knowledge and Health Services Utilisation: Evidence from Two Districts in Ghana J Glob Health Sci. 2020 Jun;2(1):e8 https://doi.org/10.35500/jghs.2020.2.e8 pISSN 2671-6925·eISSN 2671-6933 Original Article The impact of community outreach intervention on national health insurance enrolment, knowledge and health services utilisation: evidence from two districts in Ghana Eric Nsiah-Boateng ,1,2 Mariam Musah,1 Hyejin Jung ,3 Collins Danso Akuamoah,1 Donghoon Yang ,3 Yanghee Kim ,4 Bounggui Kim,3 Chi-wan Kim,4 Francis Asenso-Boadi ,1 Woun-hum Kim,4 Lydia Dsane-Selby ,1 Francis-Xavier Andoh-Adjei 1 1National Health Insurance Authority, Accra, Ghana 2University of Ghana, College of Health Sciences, School of Public Health, Accra, Ghana Received: Feb 13, 2020 3Korea Foundation for International Healthcare, Seoul, Korea Accepted: May 15, 2020 4National Health Insurance Service, Wonju, Korea Correspondence to Eric Nsiah-Boateng National Health Insurance Authority and ABSTRACT University of Ghana, College of Health Sciences, School of Public Health, P. O. Box LG 25, Legon, Accra, Ghana. Background: Several low- and middle-income countries implementing health insurance E-mail: [email protected] programmes are challenged with increasing coverage of the poor and the informal sector workers, resulting in low population coverage and weak risk-pool. In this evaluation study of © 2020 Korean Society of Global Health. the National Health Insurance Scheme (NHIS) in Ghana, we examined effects of combined This is an Open Access article distributed under the terms of the Creative Commons information, education and communication (IEC) and community outreach registration Attribution Non-Commercial License (https:// intervention on enrolment, health insurance knowledge, and healthcare utilisation. creativecommons.org/licenses/by-nc/4.0/) Methods: We employed a quasi-experimental design to assign study participants into which permits unrestricted non-commercial treatment and control groups in two districts (Kadjebi and North Tongu) of the Volta region use, distribution, and reproduction in any of Ghana after a baseline study in 2015. Participants in the treatment group received the IEC medium, provided the original work is properly and on-site registration intervention for a period of nine months (April–December 2018). A cited. follow-up survey using interviewer-administered questionnaire was conducted in January ORCID iDs 2019 to collect data in the intervention and control districts. A total of 1,199 individuals Eric Nsiah-Boateng participated in the pre- and post-intervention survey. We examined the data using descriptive https://orcid.org/0000-0001-5217-9805 statistics and difference-in-differences analysis. Hyejin Jung https://orcid.org/0000-0001-5312-8698 Results: The IEC-Community outreach registration intervention significantly increased Donghoon Yang enrolment in the intervention group by 15.8 percentage points, compared to the control https://orcid.org/0000-0003-1248-0438 group. It also increased healthcare utilisation in the intervention group by 18.5 percentage Yanghee Kim points, relative to the control group. The intervention, however, had no significant effect on https://orcid.org/0000-0002-1259-0955 participants' knowledge of the NHIS. Bounggui Kim Conclusion: https://orcid.org/0000-0001-9156-9697 The study demonstrates that integrated IEC and community outreach Francis Asenso-Boadi registration improves enrolment of people in remote areas, as well as utilisation of health https://orcid.org/0000-0002-9862-0552 services. Policy makers need to consider these findings in their decisions to accelerate Lydia Dsane-Selby progress towards realization of universal health coverage. https://orcid.org/0000-0003-1788-9961 Francis-Xavier Andoh-Adjei Keywords: Health knowledge; Health insurance enrolment; Health care utilisation; https://orcid.org/0000-0002-0874-3111 Universal health insurance; Ghana https://e-jghs.org 1/12 Health insurance enrolment, knowledge and health services utilisation Funding INTRODUCTION This study received funding from the Korea Foundation for International Many low- and middle-income countries (LMICs) are experimenting with various health Healthcare (KOFIH), grant number: KOFIH- AL-20141201-865. financing mechanisms such as social health insurance (SHI) schemes to accelerate efforts towards universal health coverage (UHC).1-3 Countries such as Germany, Japan, Austria, South Conflict of Interest Korea, Belgium, and Israel are on record to have achieved UHC through SHI.2 Whilst coverage Nsiah-Boateng E, Musah M, Danso Akuamoah expansion took several decades in some countries, other countries such as South Korea, C, Asenso-Boadi F, Andoh-Adjei FX, Dsane- 4 Selby L are employees of the National Health achieved UHC in a relatively short time. Insurance Authority; however, their affiliations did not influence findings of the study in Ghana's quest to achieve UHC started in the 1990s with implementation of community- anyway. Yang DH, Jung H, Kim Y, Kim BG, Kim based health insurance (CBHI) schemes in few districts of the country. These CBHI schemes C, Kim W declare that they have no potential were spearheaded by non-governmental organisations (NGOs) with support from the conflicts of interest. international communities.5,6 Evidence shows that the CBHI schemes covered less than one Author Contributions percent of the population and limited benefits package, mainly inpatient services.6 Thus, Conceptualisation: Nsiah-Boateng E, Musah majority of the population were paying out-of-pocket (OOP) for healthcare services, popularly M, Yang DH, Jung H, Kim Y, Kim BG, Kim C, referred to as “cash and carry” system. This situation created gap in financial access to Asenso-Boadi F, Kim W, Andoh-Adjei FX, healthcare services, resulting in inequity and worsened health outcomes, and in some cases Selby LB. Formal analysis: Nsiah-Boateng E. 7-9 Methodology: Nsiah-Boateng E, Musah M, avoidable deaths. Recognising these challenges, the country introduced the National Health Asenso-Boadi F, Andoh-Adjei FX, Yang DH, Insurance Scheme (NHIS) in 2003 through the passage of the National Health Insurance Act Kim BG. Software: Nsiah-Boateng E. Writing (Act 650 of 2003) and Legislative Instrument (LI) 1809.10 The policy objective of the scheme is - original draft: Nsiah-Boateng E, Musah M. to offer financial risk protection to all Ghanaians and legally resident non-Ghanaians against Writing - review & editing: Nsiah-Boateng, the need to pay OOP at the point of service use.9 Andoh-Adjei FX, Asenso-Boadi F, Jung H, Danso Akuamoah C, Selby LB. Since its establishment, the NHIS has been providing financial access to healthcare services for members of the scheme and contributing to the financial resource of healthcare providers. Nonetheless, the overwhelming initial popularity of the NHIS has not translated into high enrolment and regular renewal of membership in recent years. Enrolment peaked during the early years of implementation and stagnated around 40% of the population between 2011 and 2015.11 Although every health insurance system, much so a practically voluntary system such as the NHIS, is subject to the natural attrition of its members, high drop-out rates are a huge concern especially for realising the overarching goal of UHC. In respect of the above-mentioned challenge, a community outreach registration intervention was piloted in the Kadjebi, Ketu North, and North Tongu districts of the Volta region, from October 2016 to December 2018 in two phases, in collaboration with the Korea Foundation for International Healthcare (KOFIH). Prior to the intervention study, a baseline study was conducted in 2015 in the region, which revealed that distance to the NHIS district office and lack of knowledge of the scheme were major barriers to enrolment.11 These findings informed the design of the community outreach intervention, which comprised expansion of unit- based registration centres and information, education and communication (IEC) to address the identified enrolment challenges and boost enrolment in the NHIS. Phase one of the intervention occurred from October 2016 to July 2017 and the findings showed significant improvement in enrolment in the Kadjebi district, where the expansion of the unit base registration centres took place. The IEC had little effect on enrolment in the Ketu North district, which was one of the intervention districts. In view of these findings, the pilot project was scaled up (phase II) only in the Kadjebi district from April to December 2018 with the hope to achieve more significant improvements in enrolment. In this paper, we investigated the effect of the intervention on NHIS enrolment and knowledge. We https://e-jghs.org https://doi.org/10.35500/jghs.2020.2.e8 2/12 Health insurance enrolment, knowledge and health services utilisation hypothesized that bringing the registration closer to the communities would increase enrolment in the NHIS and participants' knowledge of the scheme. We also investigated the effect of the intervention on utilisation of healthcare services 12 months prior to the follow-up survey. A few intervention studies have been conducted in Ghana12,13 and other LMICs.14-16 These studies employed similar interventions (subsidies, on-site enrolment/convenience sign-up, and education/information) and found short-term (12 months) positive and significant effects on health insurance enrolment. However, there are conflicting effects of the interventions on participants' knowledge of health insurance and utilisation of healthcare services. Whilst some of the studies found positive
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