Towards a client-oriented health insurance system in Ghana Clinical Quality and Perceived quality of Care; experience from the NHIS 26-27 September, 2013 Mombasa, Kenya Christine Fenenga, PhD student Robert Kaba Alhassan, PhD student Stephen Duku PhD, student Edward Nketiah-Amponsah, PhD 1
Background Ghana s NHIS introduced in 2003 to replace cash and carry system In 2011, near to 70% of population (18 mil.) registered but active membership much lower (33%) Empirical evidence show differences in enrolment rate among the population (Asante, Aikins 2008) This RCT project started as 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 2
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 the most effective interventions that address these barriers? 3
Client-Provider Provider-Insurer Tripod Framework Perspectives of the 3 key stakeholder groups, allowing triangulation Client Client-Oriented NHIS System Provider Insurer 4
Set up research Selected Regions: GAR and WR Phase 1 Qualitative Phase (3Q 2011) Phase 2 Baseline Survey (1-2Q 2012) Phase 3 Interventions (1-4Q 2013) Phase 4 Follow up Survey/+ Qual.(1Q 2014) 5
Sampling Strategy 2 Regions (Western and Greater Accra) 8 Districts (Western Region) Purposive Selection 8 Districts (Greater Accra Region) Purposive Selection 4 Primary Health Care Facilities Per District 4 Primary Health Care Facilities Per District 30 Households Per Catchment Area of Health Care Facility 30 Households Per Catchment Area of Health Care Facility 6
Tripod with Focus on Provider Clinical Quality Issues Client Provider Quality healthcare Client-Oriented NHIS System Insurer 7
Methodology Qualitative 22 Individual in-depth interviews (IDIs) in private and public facilities in WR & GAR with managers and clinical staff Quantitative -Medical technical quality assessment tools: NHIA data, Essentials, Situation Analysis SA+ -Structured questionnaires on staff perceptions -Sample size Staff (n=324) Health facilities (n=64) - Use of bivariate and multivariate analyses 8
Profile of Health Facilities Surveyed Region Ownership Location Private N(%) Public N(%) Total N(%) Rural N(%) Urban N(%) Total N(%) GAR 19 (30) 13(20) 32(50) 16(25) 16(25) 32(50) Western 19(30) 13(20) 32(50) 20(31) 12(19) 32(50) Total 38(60) 26(40) 64(100) 36(56) 28(44) 64(100) 9
Technical (Clinical) Quality care situation per the NHIA accreditation data Figure 2: Mean percentage scores in five NHIA standard areas (n=64) 80% Mean Percentage Scores 70% 60% 50% 40% 30% 20% 10% 68% 63% 68% 53% 62% 0% Range of services Staffing Organization and management Safety and quality management Service delivery NHIA Core Standard Areas 10
Technical (Clinical) Quality care situation per the Essentials risk assessment tool Figure 2.1: Mean percentage scores in Essentials five patient risk areas (n=64) 60% Mean percentage scores 50% 40% 30% 20% 10% 28% 42% 36% 48% 22% 0% Leadership process and accountability Competent and capable workforce Safe environment for staff and patients Clinical care of patients Improvement of quality and safety Five patient risk areas 11
Figure 3: Relationship between NHIA and Essentials scores Overall NHIA Scores 40 50 60 70 80 20 30 40 50 60 Overall Essentials Scores 95% confidence interval Linear fit Observations 12
(Provider-Perceived Perceived Quality) Profile of Health Workers Interviewed (Survey) Region Ownership Location Private N(%) Public N(%) Total N(%) Rural N(%) Urban N(%) Total N(%) GAR 103(32) 74(23) 177(55) 87927) 90(28) 177(55) Western 82(25) 65(20) 147(45) 95(29) 52(16) 147(45) Total Total 185(57) 139(43) 324(100) 182(56) 142(44) 324(100) 13
Staff experience in private and public facilities Work conditions Private Public P-value Satis. Dissatis. Satis. Dissatis. f(%) f(%) Physical work environment(n=323) 161(50) 24(7) 87(27) 51(16) 0.000* Availability of modern equipment(n=322) Availability of consumables and logistics(n=323) Water supply(n=323) 139(43) f(%) f(%) 145(45) 40(12) 54(17) 87(27) 0.000* 169(52) 16(5) 99(31) 39(12) 0.000* 139(43) 46(14) 77(5) 77(5) 61(19) 0.000* Electricity supply(n=322) 143(44) 42(13) 89(28) 48(15) 0.001* Workload(n=322) 140(43) 44(14) 86(27) 52(16) 0.046* Availability of drugs for patients(n=322) Payment of financial incentives(n=316) 157(49) 27(8) 96(30) 42(13) 0.000* 56(17) 125(40) 16(5) 119(38) 0.000* Accommodation for staff(n=323) 68(21) 117(36) 36(11) 102(32) 0.193 Possibility for promotion(n=310) 85(27) 89(29) 78(25) 58(19) 0.025* 14
Perspectives of health workers on the effects of NHIS on quality care Figure 4: Health staff perspective on the effect of NHIS on quality healthcare Percentage of staff 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 12% 88% 81% 19% 86% 88% 14% 12% 72% 29% Little extent Great extent 0% Increased workload on staff (n=313) Reduced quality of time spent per patient (n=313) Patients no longer get quality drugs (n=310) Deteriorated health facility infrastructure (n=312) Increased staff motivation (n=313) Staff perceptions 15
Client-Provider Provider-Insurer Tripod Framework Perspectives of the 3 key stakeholder groups, allowing triangulation Client Client-Oriented NHIS System Provider Insurer 16
SH NHIS/healthproviders/ clients Methods used Qualitative Quantitative PAA 1.SDM SDM 2.IHH Clients NHIS/healthproviders/ clients Clients 3.KII 4.FGD 5.RVM 6.SM 7.HHS RVM SM Abbreviations: Stakeholder (SH) Participatory Action Approach (PAA) Stakeholder Design Meeting (SDM) Individual Health Histories (IHH) Key Informant Interviews (KII) Focus Group Discussions (FGD) Regional Validation Meeting (RVM) Stakeholder Meeting (SM) Household Survey (HHS) Intervention MyCare(IMC) NHIS/healthproviders/ clients 8.SM 9.IMC SM IMC Figure 1 PAA in Linked Trajectory of Methods 17
Quantitative Methodology (household survey) Location: Greater Accra and Western Regions Districts (Purposive Selection) 16 8 from each Region 64 Primary Health Facilities (4 from each District) Households (Random Selection) 1,920 (960 from each Region) 30 Households per catchment area of each Health Facility 7,097 Individuals Data collected with a semi-structured 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 18
Clients values and behavior related to illnesses, healthcare and health insurance Factors: Nature and severity Family traditional for HCP Earlier experience and trust in HCP Time of onset Distance/transport to HCP Availability of money Availability health insurance card Traditional Healer Selfmedication Drugstore Church God s Grace Professional Doctor 19
Key findings of perceptions of clients on services of providers and NHIS Client Reliabilityof NHIS services package Qualityof services (relational aspects) Drugs availability/ provision Information /interface complaints Information /interface complaints Comprehensive package Card production/ distribution Control supervision services HCP Provider Perceived concerns related to NHIS-HCP -Slow payment of claims -restrictions to doctor to prescribe NHIS 20
Some survey findings: Health seeking behavior First place to go when searching for care (n=3.623 of 7.097) Freq. % Public facilities 702 19,4 Health centers 940 25,9 Private facilities 1205 33,3 Mission clinics 335 9,3 CHPS/CHW 35 0,9 Chemical sellers 238 6,5 Traditional 124 3,5 Others 44 1,2 3623 100 This shows that only 3,5 % of the target population who visited a clinic in the past 3 months uses the folk sector 21
Survey findings: Trust in the healthcare provider Enrolled Not enrolled P value Attitude of staff strongly agree 1186 (43,9) 1448 (36,1) 0.000* agree 1162 (43,0) 1808 (45,1) Availability staff strongly agree 996 (37,0) 1169 (29,3) 0.000* agree 1101 (40,9) 1723 (43,2) Drugs availability strongly 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 complaints strongly agree 877 (32,5) 1023 (25,5) 0.000* agree SafeCare 820 Conference (30,3) 956 (23,8) 22
Level Clients Healthcare Provider NHIS Results Stakeholder Meeting Identified areas for improvement Involve community groups, clients and community leaders in communication, dissemination and monitoring of health services and health insurance services Clients to respect healthcare providers and insurance and understand limitations The NHIA to consider accreditation of qualifying traditional practitioners Health staff to improve attitude No discrimination in treatment and waiting time (insured versus non insured) Fair and transparent queue system Reliable availability of drugs Clear enrollment and renewal system and timely provision of NHIS-ID cards Information service package Regular enforcement NHIS services/regulations and clinical audits 23
Client-Provider Provider-Insurer Tripod Framework Insurers Perspective of Quality care Client Client-Oriented NHIS System Provider Insurer 24
In-depth Interviews (n=16) Qualitative methodology 8 interviews in 4 NHIA districts offices (Dangme West, Ga West, Ahanta West and Mpohor Wassa), 2 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 Quantitative methodology (household survey) As indicated under client study Bivariate and Multivariate Analyses 25
Qualitative Research Findings Quality of NHIS Services to Clients 1. Determinants of Quality Ease of Registration and registration time Waiting period to acquire NHIS card and the accuracy of information on cards Availability of information on benefit package Attitude of NHIS staff. Quality of NHIS Services to Health Providers 2. Determinants of Quality Health providers accreditation process Prompt payment of claims Monitoring of provider service quality to clients 26
Quality of Health Provider Services to Clients 1. Determinants of Quality Attitude of health staff Professional competence Drug quality and availability at health facility Diagnosis processes Waiting time at health facility Appropriate application of DRG tariffs in claims 2. NHIA concerns with the Quality Health Provider Services (Selected) Patients are asked to pay for services covered by the NHIS and health providers make claims for these services from the NHIA. Perception that NHIS patients spend longer times at the health facilities Perception that NHIS patients are given inferior quality and less safe drugs. Perception that NHIS patients are disrespected and badly treated by staff at health facilities. Low literacy levels prevent patients from asking questions of procedures performed or treatment given. Health providers submit claims for procedures and treatments not given. 27
NHIS Responsibilities Client Client-Oriented NHIS System Provider NHIS Accreditation Claims Payment Monitoring of Providers 28
Perception on Quality of Services at Nearest Accredited Health Facility Perception Proportion of Household Heads (Agree or Satisfied) Respectful treatment from Doc/Med. Asst. /Nurses Organized and fair queuing system at health facility Availability of all prescribed drugs at health facility Insured Uninsured 85.5% 78.7%** 84.7% 74.6%** 68.5% 57.4%** Equal treatment for insured & uninsured patients 62.1% 51.0%** Satisfaction with waiting time at health facility 70.7% 56.7%** Source: COHEiSION Project Survey, 2012 N = households Pearson Chi-Square (p-value) **:Significant at 1% or better) 29
Perception on Quality of NHIS Services Perception Proportion of Household Heads Agree or Satisfied Insured Uninsured Adequacy of NHIS benefit package 82.2% 68.6%** Adequacy of 3 months waiting period to receive ID card 23.8% 16.1%** Convenience of ID card distribution 59.8% 39.7%** Too high NHIS Premium 49.2% 47.1%** Satisfaction with registration and renewal processes Satisfaction with distance from home to NHIS office 71.5% 42.1%** 51.3% 35.7% ** Source: COHEiSION Project Survey, 2012 N = households Pearson Chi-Square (p-value) 30
Clients: Relational aspects quality are poor Triangulating Client and Provider Perspectives on Quality Care Facility to file complaints HC Providers: Quality is good but need for more staff, equipment & logistics Attitude of staff Availability of drugs Fair queuing system Adequate equipment Rational use of drugs Quality of care Sufficient trained staff Transparent information Qualitative Quantitative HH survey: Quality is good except for Facility to file complaints (80% dissatisfied) and queuing time (40% diss. ) Availability of staff NHIA and ESS: low quality standards 31
Policy implications Overall quality situation in sampled facilities is generally low per the Essentials and NHIA accreditation data 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. NHIS is generally perceived as not detrimental to quality care except in perceived increased workload on staff and delayed reimbursement of providers. Improving on the financing mechanisms for the NHIA is necessary to ensure financial sustainability of the NHIS Essentials tool results positively correlate with the NHIA accreditation scores suggesting the former could be a complementary assessment tool for quicker preaccreditation assessment over shorter time. 32
Policy implications: Medical technical quality indicators perceived by providers 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 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) In contrast with clients views of HC quality which is largely related to relational factors, providers relate quality to medical technical aspects, creating a gap between perceptions of clients and providers The NHIA considering accreditation of certain traditional practitioners 33