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CHAPTER ONE

1.0 EXECUTIVE SUMMARY

The National Health Insurance Scheme (NHIS) was introduced in 2003 by the National Health

Insurance Act, 2003, Act 650 with the view to improving accessibility of Ghanaians, especially

the poor and the vulnerable, to quality basic health care services. Thus, this social policy was

introduced to enable residents in Ghana to obtain, at least, basic healthcare services without

paying money at the point of delivery of the service1.

The NHIS was welcomed in principle by all and sundry since the cash and carry system in place

was not the best of schemes considering the socio-economic status of most Ghanaians. In the

light of this development, members of the Ghanaian community took part in the registration of

the scheme which made the National Health Insurance Authority [NHIA] record a whopping

fifty percent (50%) national coverage which according to the worlds standards is one of the

highest rates of registration in the world2.

From 2008, down the line, in an attempt to increase the patronage of the NHIS, the NHIA

decentralized registration of the NHIS at the district level to make it accessible to all 3. The NHIA

also made sure the scheme covered over ninety-five (95) percent of the disease conditions that

afflict the populace right from the outpatient service through maternity care to emergencies4.

Notwithstanding the decentralization of the NHIS at the district level and coverage of over 95%

1Retrieved July 2010 from http://www.nhis.gov.gh/?CategoryID=216

2Retrieved July 2010 from http://www.ghanaweb.com/GhanaHomePage/features/artikel.php?ID=44014




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disease conditions under the scheme, patronage of the NHIS has been low in Accra Metropolis.

This raised a lot of concern to the management of the NHIA and as such they were asking what

could be done to improve upon the patronage of the NHIS in the Accra Metropolis.

Based on the need to improve upon the patronage of NHIS by management, the research was

therefore undertaken to unearth the underlying causes of the low patronage of the NHIS in the

metropolis.

The population of interest consisted of the general public in Accra Metropolis. Owing to the

homogeneous nature of the target population, simple random sampling technique was used to

obtain the sample size. A sample size of fifty (50) was selected to enable more information to be

gathered on the underlying causes of low patronage of the NHIS which was used to conveniently

answer the management question.

The variables employed in the research study are cost of registering NHIS, education on NHIS,

processing time of NHIS cards, attitude of NHIS staff and patronage. Cost of registration,

processing time of NHIS cards, education and attitude of NHIS staff were the independent

variables whilst patronage was the dependent variable.

Survey questionnaires and personal interviews were used for the collection of primary data. The

research also made use of the internet, journals and previous researches in this field of study for

gathering of secondary information.

The test of hypotheses revealed that cost of registering NHIS, education on NHIS, processing

time of NHIS cards and attitude of NHIS staff contributed significantly to the low patronage of

the NHIS in Accra metropolis.


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Based on the conclusions, the recommendations made included the following.

Cost of registering the NHIS should be further subsidized to enable the populace of Accra

metropolis subscribe to the scheme.

Installmental payment can also be introduced to accommodate the poor who cannot meet

the cost one time.

Management should modify the technology used in processing the NHIS cards. This

modification should be aimed at reducing the processing time to allow subscribers get

their cards as early as possible.

Staff of NHIA should be made to go through relationship management programme to

equip them with the necessary skills so as to serve the public well with minimal

complaints.

Intensified publicity of the scheme should be undertaken in earnest by management

within the Accra Metropolis.

The government should implement a policy that would ensure hospitals and approved

pharmacies are well stocked with drugs to supply to patients under NHIS. This policy

should also put in place structures that will enable prompt payment for the cost of the

drugs to the pharmacies and hospitals.


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CHAPTER TWO

2.0 PROBLEM STATEMENT

Health service delivery in Ghana started right from the attainment of independence. Health care

delivery was virtually free to the general public from the late 1950s to the late 1970s. The

Provisional National Defence Council [PNDC] introduced the cash and carry system in the

early 1980s which was basically payment for health care services at the point of delivery. The

widespread unpopularity of this cash and carry system brought about negative consequences

especially to the poor. This made people go to the hospital only when they were really very sick

and often at the terminal end of their lives. It was pointed out that the cash and carry system

constrained citizens from accessing healthcare except when they were in very dire situations

resulting in needless deaths5.

The search for an alternative to the cash and carry system as a means of healthcare financing in

Ghana began in earnest in the second term of the National Democratic Congress (NDC)

administration under former President J. J. Rawlings. This could not materialize for

implementation though the foundation was laid with some pilot projects in the Dangbe

West District in the Greater Accra Region and Nkoranza District of the Brong Ahafo Region

as a means of laying a firm foundation for what eventually became the National Health

Insurance Scheme(NHIS)6.

5Retrieved September 2010 from

http://www.nhis.gov.gh/?categoryid=158&articleid=82&searchparam=search

6 Ibid
http://www.nhis.gov.gh/?categoryid=158&articleid=82&searchparam=searchhttp://www.nhis.gov.gh/?categoryid=158&articleid=82&searchparam=search


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The New Patriotic Party (NPP) Government under the leadership of the then president, J.A.

Kuffour finally implemented the NHIS through a statutory enactment, the National Health

Insurance Act, 2003, Act 650. The Scheme became operational in 2004 with the view to

improving financial accessibility of Ghanaians, especially the poor and the vulnerable, to quality

basic health care services. This social policy was introduced to enable residents in Ghana to

obtain, at least, basic healthcare services without paying money at the point of delivery of the

service7.

In the light of this development, Ghanaians openheartedly received the scheme and went ahead

to register which made the National Health Insurance Authority [NHIA] record a whopping fifty

percent (50%) national coverage which according to the worlds standards is one of the highest

rates of registration in the world.

However, statistics have shown that the greater Accra region despite being the second most

populated region in Ghana recorded 24.1% NHIS registration of its total population8. This

percentage is indeed quite staggering comparing it with the percentages of the other nine regions.

Whether this is intentional or unintentional, the profile of the metropolis will either support or

reject this.

Accra City Profile

Accra lies within the coastal-savanna zone with low annual rainfall averaging 810 mm

distributed over less than 80 days. The rainfall pattern of the town is bimodal with the major

season falling between the months of March and June, and a minor rainy season around October.


8George Frempong, An evaluation of the National Health Insurance Program in Ghana,2009, pp 27


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The mean annual rainfall is about 730 mm. Mean temperatures vary from 24 C in August to 27

C in March.

There are two major categories of agriculture in Accra which takes place in and around homes

(About 50-70hectares distributed over 80,000 tiny backyards), and open-space farming. In

Accra, about 680 hectares are under maize, 47 hectares under vegetables (rain-fed) and 251

hectares under mixed cereal- vegetable systems. Irrigated vegetable production takes place on a

100 hectares land area in the dry season. Other components of agriculture in Accra are livestock,

poultry, floriculture and mushroom.

Fig.1 Map of Accra Metropolis

Accra is the capital city of Ghana and covers an area of about 170 km. It has an estimated

population of about 1.66 million9. The population growth rate is estimated at 3.4 % per annum in

9Ghana Statistical Services, 2002


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the city itself but up to 10% in its peri-urban districts10

. Accra has a very youthful population

with 56% of the population being under the age of 24 years11.

Accra is the most urbanized city in Ghana. The urbanization has been mainly due to development

factors. Paramount to these factors has been the urban-biased development strategies adopted by

policy makers since the colonial era. Thus, the concentration of industry, manufacturing,

commerce, business, culture, education, political and administrative functions in the conurbation

(Accra-Tema conurbation) since independence till date continue to attract migrants, not only

from all over the country but also from neighboring countries. This has contributed a great deal

to urbanization of Accra. As a metropolitan area and coastal city, the predominant primary

economic activity is marine fishing and urban agriculture. The Odaw River is the main river that

flows through Accra. Accras main water supply is from the Weija Dam on Densu stream with

some water being pumped from the Akosombo dam in the Volta River.

According to statistics available, urban centres in the country are rapidly growing, especially the

Accra metropolis. This rapid growth had led to the neglect of some of the old indigenous

settlements, whilst efforts are being made to provide the newly developing suburban areas with

services and infrastructure to cater for the needs of the middle-income earners mostly found

there12.

10Ghana Statistical Services, 2002; Drechsel et al., 2004

11Ghana Statistical Services, 2002

12en. wikipedia.Org /wiki/Accra


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The result is that the older indigenous areas of Accra like Ga Mashie among others which are the

historical and cultural repository of the Nation are experiencing decay. This calls for proactive

measures at inner city revitalisation to address this issue.

The peripheral residential development is usually haphazard, with barely sufficient infrastructure

to support it. There are also large numbers of uncompleted houses inter-dispersed with pockets

of undeveloped land which are often subject of litigation or the inability of organisations and

individuals who own it to complete or develop due to lack of funds.

Housing in the metropolis can be grouped into 3 broad categories: the low income, middle

income and high income areas. The low income housing zones may be divided into indigenous

and non-indigenous (dominantly migrant) areas. The low-income indigenous housing areas

comprise Osu, Jamestown, Adedenkpo, Chorkor, La, Teshie and Nungua.

The low-income non-indigenous housing areas include: Sukura, Kwashieman, Odorkor,

Bubiashie, Abeka, Nima, Maamobi and Chorkor. Altogether these areas accommodate about

58% of Accras population. Most of the informal businesses are located in low-income areas and

they are the first place of abode for any new job-seeking migrant

The economically active population of Accra Metropolitan Assembly (AMA) is estimated to be

823,327. However, the daily influx of people from dormitory towns makes the figure higher than

estimated. It is worthwhile to state that the estimated figure of all the economically active

population who dwell within the Metropolis excludes the workers of both formal and informal

sectors who commute daily to engage in various economic activities.


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The sectors of AMA economy consist of Primary Sector (farming, fishing, mining and

quarrying), Secondary Sector (manufacturing, electricity, gas, water, construction) and Tertiary

Sector (Wholesale trade, retail trade, hotel, restaurant, transportation, storage, communication,

financial intermediation, real estate service, public administration, education, health and other

social services). As an urban economy the service sector is the largest, employing about 531,670

people. The second largest, secondary sector employs 22.34% of the labor force (that is 183,934

people). Accra has 114,198 of its labour unemployed, making an unemployment rate of 12.2%. 13

The primary sector is the smallest economic sector of Accra which employs 91,556. The

predominant primary economic activities are fishing and urban agriculture, with fishing

accounting for 77.8% of production labour.14

With the buoyant economic structure in the Accra metropolis, one would have thought that

poverty was not a major problem to the inhabitants of Accra. But the housing conditions in the

metropolis clearly disprove this case because the earlier statistic that 58% of Accras total

population is the low income groups also known as the pro-poor group. And with the low income

groups being the majority, there is no denial of the fact that many inhabitants are poor. Chapters

four and five would reveal as to whether poverty in the metropolis contributes significantly to the

poor patronage of the national health insurance scheme.

The NHIA decentralised the scheme to the district level with Accra having over fourteen [14]

district mutual health insurance centers15. This became necessary because of the low turnout for

13Retrieved 2010-08-05;A repository of all districts in the republic of Ghana". Ghana Districts.

http://ghanadistricts.com/districts/?r=1&_=3&sa=5724.

14en. wikipedia.Org /wiki/Accra
http://ghanadistricts.com/districts/?r=1&_=3&sa=5724http://ghanadistricts.com/districts/?r=1&_=3&sa=5724http://ghanadistricts.com/districts/?r=1&_=3&sa=5724http://ghanadistricts.com/districts/?r=1&_=3&sa=5724


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registration of NHIS in the metropolis. The NHIA also made sure the national health insurance

scheme covered over ninety-five [95%] percent disease conditions afflicted by the inhabitants of

the metropolis16

. All these were done to improve upon the patronage of the scheme but

unfortunately did not work out. It is therefore against this backdrop that management was asking

what could be done to increase the number of subscribers to an appreciable level in the Accra

metropolis.

To answer the management question, the following research questions were asked:

i. Will a downward adjustment of cost of registering NHIS encourage more patronage?

ii. Will education on the scheme increase its patronage?

iii. Will a reduction of processing time of NHIS cards improve patronage?

iv. Can attitude of NHIS staff towards subscribers encourage more patronage?

2.1 RESEARCH OBJECTIVES

The research was aimed at improving upon the patronage of the National Health Insurance

Scheme [NHIS] in Accra Metropolis.

To achieve the said objective, the following specific questions were investigated:

i. What is the average fee for registration of NHIS?

ii. How many times is the public educated on the benefits and operation of the NHIS in a

month?




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iii. How long does it take to process the form of NHIS subscriber before the card is

obtained?

iv. Does attitude of the NHIS staff towards the subscribers influence its patronage?

The hypotheses to the minor objectives are as follows:

Test 1

HO: GH 20; average cost of registering the NHIS is moderate. (Claim)

HA: > GH 20; average cost of registering the NHIS is high.

Test 2

HO: 5; average number of times the public is educated in a month is enough. (Claim)

HA: 2 weeks; average time it takes to process NHIS card of a subscriber is too long.

Test 4

Ho: =0; attitude of the NHIS staff does not influence its patronage. (Claim)

HA: >0; attitude of the NHIS staff does influence its patronage.


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2.2 SIGNIFICANCE OF THE STUDY

NHIS from the start of its implementation had series of debates from both politicians and doctors

as to its flourishing in Ghana. Politicians from the National Patriotic Party (NPP) have always

used and are still using this NHIS implemented as one of their main campaign messages to the

populace by informing them of the programmes flamboyant success and having remarkable

patronage.

Doctors of hospitals under the NHIS on the other hand are also complaining bitterly of its failure

especially those in the Accra metropolis which has led to its very poor patronage. The failure of

the NHIS according to them is attributed to numerous reasons. Reasons such as non-payment of

medical bills by government, high cost of registration, delay in delivery of NHIS cards and a lot

others.

The issues raised from both sides have created a divide among the misinformed and people

cannot really tell where the truth lies. This, therefore necessitated a research to be undertaken on

NHIS to ascertain whether it is really a success with a remarkable patronage or otherwise.

Researchers in this study area could use the findings of this research presented to further work on

subsequent researches.


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2.3.0 LITERATURE REVIEW

2.3.1 OVERVIEW OF NHIS

The National Health Insurance Scheme (NHIS) was introduced in 2003 by the National Health

Insurance Act, 2003, Act 650 with the view to improving financial access of Ghanaians,

especially the poor and the vulnerable, to quality basic health care services.

Under the NHIS, the rich subsidizes the poor, the healthy subsidizes the sick and the

economically active pays for children, the aged and the indigenous people.

It is a social policy, a kind of social re-engineering that caters for the most vulnerable in the

society through the principle of equity, solidarity, risk sharing, cross-subsidization, re-insurance,

subscriber/ community ownership, value for money, good governance and transparency in the

health care delivery.

The Vision of government in instituting the NHIS is to assure equitable and universal access for

all residents of Ghana to an acceptable quality of a package of essential health care services

without out of pocket payment being required at the point of service.

This way, everyone would be protected from the problems that are associated with having to find

money at the time of illness before needed services can be accessed.

The NHIS replaces out of pocket payment at the time of service delivery by providing a specified

minimum healthcare benefit package to members. Over 95% of disease conditions that afflict


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most Ghanaians are covered under the NHIS.17

The NHIS covers almost all the types of health

care services which are listed below.18

Out Patient Services

In Patient Service

Specific Services (Oral Health)

Maternity Care

Emergencies

2.3.2 TYPES OF HEALTH INSURANCE

There are three main categories of health insurance in Ghana.

The first and most popular category is the district mutual health insurance scheme, which is

operational in every district in Ghana. This is the public/non-commercial scheme and anyone

resident in Ghana can register under this scheme. If one registers in District A and move to

District B, one can transfer his/herinsurance policy and still be covered in the new district. The

district mutual health insurance scheme also covers people considered to be indigent that is too

poor, without a job and lacking the basic necessities of life to be able to afford insurance

premiums.

Apart from the premium paid by members, the district mutual health insurance schemes receive

regular funding from central government. This central government funding is drawn from the

national health insurance fund. Every Ghanaian worker pays two-and-a-half percent of his/her

17Retrieved July 2010 from http://www.nhis.gov.gh

18Ibid


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social security contributions into this fund and the VAT rate in Ghana also has a two-and-a-half

percentage component that goes into the fund.

To sign on to the district mutual health insurance scheme, one needs to get to the district

assembly where one resides or look for the offices of the scheme and register. One would fill a

form, offering some basic personal information and he/she would be asked to present at least two

passport pictures. The person signing on to the scheme would need to fill forms for dependants

below 18 years as well.

The second category of health insurance comprises the private commercial health insurance

schemes, operated by approved companies. One can just walk into any of such companies and

buy the insurance just as one would insure a car. Commercial health insurance companies do

not receive subsidy from the National Health Insurance Fund and they are required to pay a

security deposit before they start operations.

The third category of health insurance is known as the private mutual health insurance scheme.

Under this, any group of people (say members of a church or social group) can come together

and start making contributions to cater for their health needs, providing for services approved by

the governing council of the scheme. Private mutual health insurance schemes are not entitled to

subsidy from the National Health Insurance Fund.

Looking at the three types of the health insurance schemes offered, the District Mutual Health

Insurance Scheme would be the best type of scheme for the metropolis considering the fact that

58% of the population of the metropolis are within the low income group.


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There could be a high possibility that the type of health insurance offered significantly affected

the poor patronage in Accra i.e. the second or third categories of the health insurance schemes

were the ones offered in the metropolis.

2.3.3 BENEFITS OF HEALTH INSURANCE

If a person registers under any of the schemes, he/she will be given a card which can be used to

seek treatment in any hospital in the country. When one visits a health facility with the card,

he/she is treated and offered the services signed for without having to pay for anything unless

he/she asks for an extra service, like a private ward. The bills are then sent to the scheme

provider (district, private scheme or mutual scheme) who then pays the money to the hospital.

The card can also be used to buy prescribed drugs at accredited pharmacies or licensed chemical

shops without paying at the point of delivery the pharmacy will contact the service provider to

take its money.

At least, this is how the system is supposed to work on paper. But there have been reports of

some hospitals and pharmacies turning patients away, complaining that the public health

insurance schemes owes them huge amounts of money. Some of the big hospitals in the country

have often been compelled to issue public statements warning that their operations could grind to

a halt if the Health Insurance Authority (NHIA) did not speed up the payment of their claims.


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2.3.4 GHANAS ECONOMY AND THE NHIS

At independence (in 1957), Ghana was a prosperous country with the highest per capita income

in West Africa. Agriculture, based on cocoa production, accounted for about half of the nations

GDP19. Cocoa exports enabled the economy to grow at 4.1% annually from 1950 to 1960, and

Ghana became the leading destination of migrant labor from across West Africa20

. With cocoa

prices falling after 1960, Ghanas post-independence economic strategy emphasized

industrialization by state-owned enterprises (SOEs). However, poor performance of the SOEs led

to further economic decline, and annual inflation jumped from about 6% during 1965-73 to 50%

during the following decade. By 1982, per capita income had fallen by 30% in real terms, export

earnings were halved, and import volumes had fallen to one third of their 1970 levels21

. With the

nations external debt standing at 105.7% of GDP, the government of Flight Lt. Jerry Rawlings

and his military Provisional National Defence Council (PNDC) embraced a remarkably harsh

Structural Adjustment Program (SAP)22

. While those engaged in the export of timber, gold and

other raw materials prospered, for most Ghanaians, particularly rural dwellers that depended on

subsistence farming, survival became more difficult. For example, between 1983 and 1994 the

number of farmers living below the poverty line in the Northern region increased 4.5 times 23.

Additionally, health conditions deteriorated dramatically throughout the country, as hunger and

malnutrition increased, and the sick, unable to afford payments, delayed seeking health care with

19

Bequele, 1983

20Mensah, 2006a and 2006b

21World Bank, 1985

22Saris and Shames, 1991

23Saris and Shams, 1991


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often grave consequences24

. Considering the fluctuated performance of the economy over the

years and how it affected the living standards of Ghanaians which resulted in the subsequent

introduction of the NHIS to ameliorate the health conditions of Ghanaians, one would have

thought Ghanaians would accept the scheme with open arms. However, the situation on the

ground is the opposite. Ghanaians are yet to take advantage of this wonderful and unique social

intervention and this would have the tendency of increasing the patronage of the scheme

nationwide especially in the Accra Metropolis.

2.3.5 HEALTHCARE AFTER NHIS IMPLEMENTATION

According to Hassan Wahab (2008), many of his respondents were happy with the idea of the

NHIS even though there were mixed feelings. Sixty percent [60%] of the respondents were

frustrated about the time it took them to obtain their ID cards after they paid their registration

and enrollment fees. The Public Agenda Newspapers report tends to support this claim.

According to the newspaper, the executive secretary of the National Health Insurance Council

[NHIC] reacted to public criticisms of the NHIC regarding the delay in the issuance of ID cards

that the NHIC could not be blamed alone for the delay.

In assessing the Scheme by cost, Hassan Wahab (2008) also stated that Sixty percent of his

interviewees observed that they had had to purchase prescription drugs on several occasions

because the hospital or clinic at which they consulted their doctors did not have all the prescribed

medications. It is important to mention that prescription drugs that are purchased outside the list

of allowable pharmacies are not refundable. In a Ghana News Agency story, some districts were

24Oppong, 2001; Shaw and Griffin, 1995


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discouraged from enrolling in the Scheme because of the cost of medications. With regards to

quality of service, all the interviewees said the quality of healthcare service so far has been good.

Dr. Felix Asante

25

and Dr. Moses Aikins

26

in their research write up, Does NHIS cover the poor

stated that the most important barrier to registration with NHIS was that the premium was too

expensive. This was reported as a reason for not registering with NHIS by 91.7% of the non-

registered respondents. According to the two scholars, a surprisingly high proportion of the total

respondents [24%] especially the poorer population has not even heard of NHIS. They finally

concluded that individuals belonging to the poorest socio-economic quintile are registering to a

significantly lower extent as compared with the other quintiles. It was therefore stated in their

write up that equitability of the scheme should be looked into since the response from the field

did not tally with the vision statement of the NHIS. This implies that there is the need for an

intensive publicity to be made to the public especially those in the hinterlands.

25Institute of Statistical Social & Economic Research (ISSER), University of Ghana, Legon, Accra

26School of Public Health, University of Ghana, Legon, Accra.


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CHAPTER THREE

3.0METHODOLOGY

3.1 INTRODUCTION

This chapter looks at the methodology that was used for this research. It entails the research

design, the sampling design used, data collection procedures, as well as the problems

encountered in the collection of data.

3.2 RESEARCH DESIGN

Correlational design was used for the research study. This design was selected because the

research sought to discover the relationship between the dependent and independent variables.

Cost of registration, level of education, Processing time and attitude were the independent

variables while patronage was the dependent variable. Considering the cost involved in a

research of this nature, sample was drawn from the target population at one given time period

hence the cross-sectional design was adopted. In order to collect data on the variables,

respondents were contacted for their opinions hence a field survey was conducted.

3.3 SAMPLING DESIGN

The population of interest consisted of the general public within Accra Metropolis. There are

different forms of Sample determination from the population of interest thus the rule-of-thumb

and other statistical means. Considering the alternatives; the population characteristics technique

for selection of the sample size was used. This made the target population to be homogenous and

as a result the simple random sampling method was used. Information gathered from the Ghana

Statistical Service on the households in Accra metropolis enabled the metropolis to be stratified

into five (5) zones and 10 households picked from each zone. This is to enable the sample


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selected to be a good representation of the target population. Simple random sampling was used

to select the 10 households from each zone. The expected response rate ( err) of the target

population is sixty percent (60%) based on previous research in this area. In order to come out

with accurate sample size for the target population, the research factored into the sample size the

non-response bias element of the target population (i.e. n/0.60=50/0.60=83 respondents

approximately). The questionnaires were then distributed to 83 respondents; however, 50

respondents returned theirs. This sampling was done at 95% confidence interval (i.e. at an error

level of 5% (=0.05))

3.4 DATA COLLECTION PROCEDURE

The variables on which data was collected are Cost of registration, level of education, Processing

time, attitude and patronage. Cost of registration, level of education, Processing time, and

attitude are the independent variables while patronage is the dependent variable. The variables

are operationally defined as follows:

Cost of registrationmeans the NHIS registration and renewal fee. It is a quantitative variable

which was measured on a ratio scale.

Education means the number of times information about the importance of NHIS is

disseminated to the public. It is a quantitative variable which was measured on a ratio scale.

Processing time means how long it takes to process the subscription of an NHIS subscriber

before the NHIS ID card is delivered to him/her. It is a quantitative variable which was measured

on ratio scale.


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Attitude means the behavior of NHIS staff towards subscribers. It is a qualitative variable which

was measured on an ordinal scale. It was categorized into very satisfactory, satisfactory, and

unsatisfactory and operationally defined as:

Very Satisfactory- less than three (3) persons made complaints about the attitude of

NHIS staff to the Authority in every quarter of the year.

Satisfactory- between three (3) to six (6) persons made complaints about the attitude of

NHIS staff to the Authority in every quarter of the year.

Unsatisfactory- more than six (6) persons made complaints about the attitude of NHIS

staff to the Authority in every quarter of the year.

Patronage means the number of people subscribing for the NHIS in a month. It was transformed

into a qualitative variable and measured on the ordinal scale. It was categorized into high,

moderate and low:

High- 60% and above of the inhabitants of the Accra Metropolis subscribed for the NHIS.

Moderate- 35-59% of the populace of the Accra Metropolis subscribed for the NHIS

Low- 34% and below of the populace of the Accra Metropolis subscribed for the NHIS

Survey questionnaires and personal interviews were found to be the most appropriate tools to be

used for the collection of the primary data since the research sought the opinion of the

respondents on the above variables. The Questionnaires consisted of both structured (closed-

ended) and unstructured (open-ended) questions.

Previous researches in this field of study and journals were used for the secondary information.


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3.5 RESEARCH LIMITATIONS

Although the research was properly conducted, there were some few problems that were

encountered. Below are some of the said problems.

Due to the heavy rains at the time of the research, certain areas could not be

reached easily and this delayed the whole research process.

Interviewing the respondents was difficult because many expected a token to be

given to them before the commencement of the interview and this therefore

limited the number and type of respondents who were willing to be interviewed.

Respondent-fatigue due to lack of implementation of outcomes of such researches

which had been conducted in the past was also expressed by respondents during

questionnaire administration. This made respondents not willing to give out vital

information regarding NHIS.


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CHAPTER FOUR

4.0 RESULTS

4.1 Introduction

This chapter deals with data analysis and presentation. The hypotheses derived from the

investigative questions were also tested.

4.2.0 Raw data for the cost of registration of NHIS (GH)

25 15 22 29 37 40 39 50 30 13

11 20 21 28 38 32 49 16 12 14

22 25 29 32 35 43 47 37 31 22

11 13 9 18 22 27 8 17 18 21

22 26 34 35 41 28 33 26 22 14

Source: Field Survey, 2011

X(i=8,9,10,n=50) where i=8, 9, 10, n=50 means the amount paid as registration fee by

subscribers.


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5040302010

Median

Mean

3028262422

1st Quartile 17.750

Median 25.500

3rd Quartile 34.250

Maximum 50.000

23.109 29.251

22.000 29.328

9.028 13.468

A -S quared 0.32

P-V alue 0.528

Mean 26.180

StDev 10.808

Variance 116.804

Skewness 0.332764

Kurtosis -0.596731

N 50

M inimum 8.000

Anderson-Darling Normality Test

95% C onfidence Interval for Mean

95% C onfidence Interv al for Median

95% C onfidence Interval for StDev95 % Confidence Intervals

Summary for Cost of Registration of NHIS

4.2.1 Test of Hypothesis I

It was claimed by the Director of NHIS in an interview that the average cost of GH20 paid by

subscribers is moderate. The test of hypothesis I tested this claim against the general belief that

the average cost of registration is high. The parameter of interest is the mean cost of registration

in Ghana Cedis.


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HO: GH 20; average cost of registering the NHIS is moderate.

HA: > GH 20; average cost of registering the NHIS is high.

Since the skewness of 0.332764 is between -1 and +1 i.e. [-1


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4.2.4 Confidence Interval Estimate

The confidence interval estimate for the population mean was between 23.109 and 29.251. This

clearly shows that the population mean of GH20 is outside the interval range thus confirming

the average cost of registration being high.

4.3.0 Raw data for Education on NHIS

3 2 0 5 2 1 4 1 1 3

1 2 1 1 4 2 2 2 0 2

2 5 2 2 1 2 2 0 2 2

1 3 3 5 3 4 3 4 3 0

3 3 1 4 2 3 5 3 0 2


X(i=1, 2, 3n=5)where i=1, 2, 3 n=5 means the number of times the pubic is educated on the

benefits and operations of NHIS in a month.


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543210

Median

Mean

3.02.82.62.42.22.0

1st Quartile 1.0000

Median 2.0000

3rd Quartile 3.0000

Maximum 5.0000

1.8904 2.6696

2.0000 3.0000

1.1451 1.7082

A -S quared 1.26

P -V alue < 0.005

Mean 2.2800

StDev 1.3708

V ariance 1.8792

Skewness 0.260405

Kurtosis -0.416351

N 50

M inimum 0.0000

Anderson-Darling Normality Test


95% C onfidence Interval for Median

95% C onfidence Interval for StDev95 % Confidence Intervals

Summary for Education on NHIS

4.3.1 Test of Hypothesis II

A claim was made by the NHIS Director in an interview conducted that the public being

educated on the benefits and operations of the NHIS on an average of 5 times a month was

enough. The test of hypothesis II tested the claim against the belief of the general public in Accra

Metropolis that the average number of 5 times they are educated is not enough. The parameter of

interest is the mean number of times the public is educated in months.


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HO: 5; average number of times the public is educated is enough.

HA:


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clearly shows that the population mean of 5 is outside the interval range thus confirming the

average number of times the public is educated is not enough.

4.4.0 Raw data for processing time of NHIS cards (in weeks)

1 1 1 1 1 2 2 2 2 2

2 2 3 3 2 3 3 2 4 4

4 4 4 4 4 4 5 5 5 5

5 5 5 6 6 6 6 6 7 7

6 8 8 8 9 9 10 10 10 11


X(i=1, 2, 3n=11)where i=1, 2, 3 n=11 means the time taken to process the NHIS before delivery

to subscribers.


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9.67.24.82.4

Median

Mean

5.55.04.54.03.5

1st Quartile 2.0000

M edian 4.0000

3rd Quartile 6.0000

Maximum 11.0000

3.9249 5.4751

3.6717 5.0000

2.2783 3.3987

A -S quared 0.97

P-V alue 0.013

Mean 4.7000

StDev 2.7274

Va riance 7.4388

Skewness 0.574616

Kurtosis -0.480718

N 50

M inimum 1.0000

A nderson-Darling Normality Test


95% C onfidence Interval for Median

95% C onfidence Interval for StDev95 % C onfidence Intervals

Summary for Processing time of NHIS cards

4.4.1 Test of Hypothesis III

The Director of NHIS in an interview claimed the average time of 2 weeks to process NHIS

cards was normal. Test of hypothesis III sought to test this claim against the general belief that

average time taken to process NHIS cards is long. The parameter of interest is the mean time

taken to process NHIS cards in weeks.


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HO: 2 weeks; average processing time of NHIS card is normal.

HA: >2 weeks; average processing time NHIS card is long.

Since the skewness of 0.574616 is between -1 and +1 i.e. [-1


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clearly shows that the population mean () = 2 is outside the interval range thus confirming the

average time it takes to process NHIS cards is long.

4.5.0 Test of Hypothesis IV

This test sought to discover the relationship between attitude of NHIS staff and the patronage of

the NHIS. Both variables (i.e. attitude of the NHIS staff and patronage of NHIS) are all

qualitative variables measured on the ordinal scale and this therefore necessitated the use of the

Chi-square test of independence. The parameter of interest used here is the rho ().

Ho: =0; attitude of the NHIS staff does not influence its patronage. (Claim)

HA: >0; attitude of the NHIS staff does influence its patronage.


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4.5.1 3 by 3 Contingency table showing attitude of NHIS staff against patronage of the

National Health Insurance Scheme.


The expected values and Chi-square test figure were computed and tested by the SPSS 11v5

ATTITUDE * PATRONAGE Cross tabulation

PATRONAGE OF NHIS

TotalHigh Medium Low

ATTITUDE OFNHIS STAFF

Very Satisfactory Count8 5 3 16

Expected Count5.1 5.4 5.4 16.0

Satisfactory Count7 7 4 18

Expected Count

5.8 6.1 6.1 18.0Unsatisfactory Count

1 5 10 16

Expected Count5.1 5.4 5.4 16.0

Total Count16 17 17 50

Expected Count16.0 17.0 17.0 50.0

Attitude of

NHIS Staff

Patronage of National Health Insurance Scheme

High Medium Low Total

Very

Satisfactory

8 5 3 16

Satisfactory 7 7 4 18

Unsatisfactory 1 5 10 16

Totals 16 17 17 50


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Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square11.051(a) 4 .026

Likelihood Ratio 12.001 4 .017

Linear-by-Linear Association9.100 1 .003

N of Valid Cases

50

a 0 cells (.0%) have expected count less than 5. The minimum expected count is 5.12.

= 9.488 (Appendix D: Chi-Square distribution table)

4.5.2 Decision Rule

If

, we fail to reject Ho

If

, we reject Ho in favour of HA

4.5.3 Interpretation

Since

, we reject Ho in favour of HA that says attitude of the

NHIS staff does influence its patronage.


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CHAPTER FIVE

5.0 DISCUSSION

5.1 INTRODUCTION

This chapter provides the summary, findings and recommendations of the research. These are

elaborated upon under the headings that follow.

5.2 SUMMARY AND CONCLUSIONS

The research looked into the causes of the decline of the NHIS in Accra Metropolis. The data

analysed discovered the following:

From the test of hypothesis I it was observed that This

therefore implies that there is enough evidence to conclude that the average cost of

registering the NHIS was high.

Observation made from test of hypothesis II indicated that ||

This also implies that sufficient evidence is available to prove that the average

number of times the public is educated is not enough.

Also on the processing time of NHIS cards in test of hypothesis III, the research revealed

that which simply means there was sufficient evidence

available to reject the null hypothesis that says the average time taken to process NHIS

card of a subscriber is normal in favour of the alternative hypothesis which says the

average time taken to process NHIS card of a subscriber is long.

From the test of hypothesis IV, it was observed that

This simply implies that attitude of the NHIS staff negatively influenced the


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patronage of NHIS in Accra Metropolis i.e. the null hypothesis that says the attitude of

NHIS staff does not influence its patronage is not the case.

Observation also gathered from the literature review as indicated by Dr. Felix Asante and

Dr. Moses Aikins espoused that a surprisingly high proportion of Ghanaians have not

heard of NHIS and this has been a major impediment to the patronage of NHIS.

5.3 RECOMMENDATIONS

In order for the NHIA to accomplish the goal of having all the members of the Accra Metropolis

subscribe to the NHIS, the following recommendations are made.

Cost of registering the NHIS should be further subsidized to enable the populace of Accra

metropolis subscribe to the scheme.

Instalmental payment can also be introduced to accommodate the poor who cannot meet

the cost at one time.

Management should modify the technology used in processing the NHIS cards. This

modification should be aimed at reducing the processing time to allow subscribers get

their cards as early as possible.

Staff of NHIA should be made to go through relationship management programme to

equip them with the necessary skills so as to serve the public well with minimal

complaints.

Intensified publicity of the scheme should be undertaken in earnest by management

especially within the Accra Metropolis.

The government should implement a policy that would ensure that hospitals and

approved pharmacies are well stocked with drugs to dispense to patients under NHIS.


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The policy should include the establishment of appropriate structures that would ensure

prompt payment of the cost of drugs to pharmacies and hospitals.


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CHAPTER SIX

6.0 APPENDICES

A. QUESTIONNAIRE 1

Topic: Patronage of the National Health Insurance Scheme [NHIS] in Accra Metropolis.

Purpose: This questionnaire is designed to collect data for academic purpose only. Information

given will be treated with absolute confidentiality. All information provided must represent the

respondents view on issues and may be facts and assumptions.

Please tick the appropriate box where necessary.

Subscribers Questionnaire

1. Sex: Male Female

2. Age: 18-24 25-30 31-40 41-50 51+

3. Marital Status: Never married Married Divorced

Widowed

4. a. Are you a subscriber to the National Health Insurance Scheme [NHIS]?

Yes No

b. if yes, was the staff friendly to you when you went for registration? Yes No

5. What type of health insurance scheme did you sign up for?

a. District mutual health insurance scheme


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b. Private commercial health insurance scheme

c. Private mutual health insurance scheme

6. How would you rate the attitude of the NHIS staff at the registration center?

Very Satisfactory Satisfactory Unsatisfactory

7. How much did you pay for the registration (GH)?

0-10 11-20 21-30 31-40 41-50

8. a. In your own opinion, was it expensive? Yes No

b. If yes, what do you think a fair price for registration of NHIS should be?

..

9. After you registered, how long did it take you to be issued with NHIS card (in weeks)?

0-1 2-3 4-5 6-7 8-9 10-11

10. Was it too long for you to get your ID card? Yes No

11. If yes, what duration do you think will be better for delivery of the cards?

12. What suggestion can you give to make delivery of ID cards very fast?

....................................................................

13. Do you often watch television? Yes No


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14. a. Do you often see advertisements or documentaries of NHIS on television?

Yes No

b. If yes, how many times have you seen the advertisements or documentaries in a

week?Enumerator to calculate for number of times in a month:

0 1 2 3 4 5

15. What other suggestions do you have for NHIS secretariat?

................................................................................................................

THANK YOU VERY MUCH


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B. QUESTIONNAIRE 2

Topic: Patronage of the National Health Insurance Scheme [NHIS] in Accra Metropolis.

Purpose: This questionnaire is designed to collect data for academic purpose only. Information

given will be treated with absolute confidentiality. All information provided must represent the

respondents view on issues and may be facts and assumptions.

Please tick the appropriate box where necessary.

Employees Questionnaire

1. Sex: Male Female

2. Age: 18-24 25-30 31-40 41-50 51+

3. Marital Status: Never married Married Divorced Widowed

4. Position in NHIS Secretariat:

5. a) Is the registration fee charged for registration of NHIS uniform?

b) If uniform, how much is charged for registration of NHIS by the secretariat (GH)?

0 -10 1120 2130 31-40 41-50

c) If not, what is the average amount charged (GH)?

0-10 11-20 21-30 31-40 41-50

6. a. Do you have any additional charge placed on subscribers? Yes No

b. If yes, how much? GH .


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7. How many times do you normally advertise or make documentaries on the benefits and

operations of NHIS in a week?

0 1 2 3 4 5

8. Do these advertisements or documentaries yield any positive result from the public?

Yes No

b. If yes, to what extent in terms of patronage?

9. How long does it take to process the form of a subscriber before his/her NHIS card is

delivered?

0-1 2-3 4-5 6-7 8-9 10-11

10. In your own opinion, is the duration normal? Yes No

11. a) Does the secretariat have a any target number of subscribers it expects within a period?

Yes No

b) If yes, what period is used to estimate the target number?

Monthly Quarterly Annually

12. Can you please give us the target number? _____________


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13. What is the level of patronage of NHIS by the public comparing it with the target

number?

High Moderate Low

14. What suggestion do you have that you think will help improve upon the patronage of

NHIS in Accra Metropolis?

............................................................................................................................ ................

................................................................................................................................................

................................................................................................................................................

THANK YOU VERY MUCH


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C. Standard Normal Distribution Table


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D. Chi-square Distribution Table


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CHAPTER SEVEN

7.0 BIBLIOGRAPHY

1. Donald R. Cooper & Pamela S. Schindler, Business Research Methods, Seven Edition.

2. Dr. Kobena Gyapea Erbyn, Research Methods: Process Approach for the design and

analysis of Research in Business and Social Sciences, October, 2009.

3. Dr. Felix Asante and Dr. Moses Aikins, Does NHIS cover the poor?, July, 2008

4. en. wikipedia.Org /wiki/Accra

5. Ghana Statistical Services, 2002; Drechsel et al., 2004

6. George Frempong, An evaluation of the National Health Insurance Program in

Ghana,2009

7. Lind A. Marshal G. Mason D., Statistical Techniques in Business Economics, McGrew-

Hill Irwin, 11th Edition, Pages 605-608.

8. Retrieved July 2010 from http://www.nhis.gov.gh/?CategoryID=216

9. Retrieved July 2010 from

http://www.ghanaweb.com/GhanaHomePage/features/artikel.php?ID=44014

10. Retrieved 2010-08-05;A repository of all districts in the republic of Ghana". Ghana

Districts. http://ghanadistricts.com/districts/?r=1&_=3&sa=5724

11.Retrieved September, 2010 from

http://www.nhis.gov.gh/?categoryid=158&articleid=82&searchparam=search

(September, 2010)
http://www.nhis.gov.gh/?CategoryID=216http://www.ghanaweb.com/GhanaHomePage/features/artikel.php?ID=44014http://ghanadistricts.com/districts/?r=1&_=3&sa=5724http://ghanadistricts.com/districts/?r=1&_=3&sa=5724http://www.nhis.gov.gh/?categoryid=158&articleid=82&searchparam=searchhttp://www.nhis.gov.gh/?categoryid=158&articleid=82&searchparam=searchhttp://ghanadistricts.com/districts/?r=1&_=3&sa=5724http://ghanadistricts.com/districts/?r=1&_=3&sa=5724http://www.ghanaweb.com/GhanaHomePage/features/artikel.php?ID=44014http://www.nhis.gov.gh/?CategoryID=216

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