THE NATIONAL HEALTH INSURANCE SCHEME AND COMMUNITY ACCESS TO HEALTHCARE: A CASE STUDY OF ABOKOBI By Henry Yeboah Yiadom-Boachie (10235186) This Thesis is submitted to the University of Ghana, Legon in partial fulfillment of the requirement for the award of MPhil Social Work degree University of Ghana http://ugspace.ug.edu.gh 3 3 7 3 7 3 ' f y - University of Ghana http://ugspace.ug.edu.gh DECLARATION I hereby declare that this thesis is my original work undertaken under supervision at the Department o f Social Work, University o f Ghana, and that neither a part nor its entirety has been produced elsewhere for the award o f any degree or certificate. Published and unpublished literature that was reviewed has been duly acknowledged. Henry Yeboah Yiadom-Boachie (Candidate) SLoj j SUPERVISORS ...................................... Mr. P. K. Abrefah (Main Supervisor) Date: ............... ........................... . . . . . . . . . . . . . . . Dr. Kofi Ohene-Konadu (Second Supervisor) Date: a o / W s ’-oU ........................... University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to my beloved parents, Mr. George Yiadom-Boachie and Ms. Martha Yeboah. University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I would like to take this opportunity to thank my lecturers and supervisors Vlr. P. K. Abrefah and Dr. Ohene-Konadu for their guidance and support. They expressed keen interest in my work, read through the drafts and made recommendations. May God richly bless them. I am indebted to the management and staff o f Ga District Mutual Health Insurance Scheme (GDMH1S) for all the data they made available for the purpose o f this study. Many thanks go to the Management and staff o f Abokobi Clinic and Alpha Medical Centre who represented the public and private accredited health providers respectively and provided the needed information for the stud)'. A word o f gratitude also goes to the pastor and members o f the Presbyterian Church at Abokobi and the Ga Eat District Assembly for their support and the information provided. 1 thank the chief and elders o f Abokobi Traditional Council and the people o f Abokobi for permitting me to undertake this research in their community and supporting me to get the needed information. 1 also thank Ms Helen Dzikunu, the Programme Officer o f DAN1DA HSSO Accra, for her continuous moral support and invaluable contributions to this work. 1 am very much grateful to my wife, Mrs. Joyce Yiadom-Boachie, who always supported and encouraged me throughout my course and research work. I would also like to thank Ms. Linda Ofori-Nvarko o f Newmont Ahafo Development Foundation for her encouragement. Finally, 1 am grateful to all my colleagues and friends especially Messrs James Baalah and John V. Y. Amegashitsi for their encouragement and support. University of Ghana http://ugspace.ug.edu.gh ABSTRAC Given the fact that health is indispensable element o f human development and effective functioning in society, there is always the demand for healthcare services. However, demand for healthcare services cannot be met if one does not have the means to finance the care needed. It has therefore been a matter o f necessity to find strategic means o f financing healthcare. One major strategy increasingly recognized as a tool to finance healthcare provision is health insurance scheme. This study seeks to investigate the relationship between health insurance scheme and financial access to healthcare for community members. In other words, the study attempts to find out how health insurance schemes remove financial barriers o f access to healthcare and protect community members in case o f illness against fluctuating health expenditures. The study looks at the National Health Insurance Scheme o f Ghana, with particular reference to the Ga District Mutual Health Insurance Scheme (GDMHIS) and its impact on financial access to healthcare for the members o f the community o f Abokobi in the Greater Accra Region. It employs qualitative and quantitative data collection methods to solicit information from the community members o f Abokobi and stakeholders o f health insurance and health providers to establish the relationship between health insurance and financial access to healthcare. The results of the literatures reviewed for this study indicate that health insurance removes the financial constraints posed by cash and carry system o f healthcare delivery, and puts insured community members in a higher capability to meet their healthcare needs. The literatures also reveal that though several factors like time, distance and transportation, geographical barriers and University of Ghana http://ugspace.ug.edu.gh location o f health facilities influence access to healthcare, finance o f healthcare is the most serious factor that influences community members’ access to healthcare. Though health facilities may be available, if a patient does not have money to pay for medical care, he/she will be denied access to care. The findings o f this study reveal that for insured community members the health insurance scheme removes financial barriers o f access to healthcare, whereas the non-insured still face serious financial barriers o f access to medical care. It also reveals that the educated salaried workers have access to health insurance whereas the least educated, unemployed, farmers, petty traders are mostly not insured and therefore face financial barriers o f access to healthcare. The study recommends strategic measures to be adopted to sustain the scheme and to improve community members’ access to healthcare. It also challenges further research into health insurance scheme for informal sector workers and rural population who lack social security" and since they are unable to accumulate money to get insured, still face serious financial barriers o f access to healthcare. University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION.............................................................................................................................................. i DEDICATION..................................................................................................................................................ii ACKNOWLEDGEMENT............................................................................................................................ iii ABSTRACT..................................................................................................................................................... iv TABLE OF CONTENTS......................................................... vi LIST OF TABLES ........................................................................................................................................ x LIST OF FIGURES......................................................................................................................................xi ACRONYMS................................................................................................................................................ xii CHAPTER O N E .............................................................................................................................................1 INTRODUCTION ...........................................................................................................................................1 1.1 INTRODUCTORY BACKGROUND ................................................................................................. 1 1.2 STATEMENT OF THE PROBLEM .................................................................................................... 5 1.3 OBJECTIVES OF THE STUDY........................................................................................................... 8 1.4 RESEARCH QUESTIONS.....................................................................................................................8 1.5 RATIONALE OF THE STUDY............................................................................................................ 9 1.6 SIGNIFICANCE OF THE STUDY...................................................................................................... 9 1.7 THE STUDY AREA ...............................................................................................................................10 1.8 DEFINITION OF CONCEPTS............................................................................................................11 1.9 LIMITATIONS OF THE STUDY.......................................................................................................12 1.10 ETHICAL CONSIDERATIONS....................................................................................................... 13 CHAPTER TW O ......................................................................................................................................... 14 LITERATURE REVIEW ..............................................................................................................................14 2.1 PERSPECTIVES ON HEALTH INSURANCE.............................................................................. 14 2.2 FACTORS INFLUENCING ACCESS TO HEALTHCARE........................................................19 2.2.1 Finance o f Medical Care..................................................................................................................... 19 2.2.2 Allocation o f Health Institutions and Distribution o f Health Personnel..................................21 2.2.3 Distance and Transportation.............................................................................................................23 2.2.4 Time and Access to Healthcare........................................................................................................ 25 2.2.5 Social F acto rs................................................................................................ 26 University of Ghana http://ugspace.ug.edu.gh 2.3 RELATIONSHIP BETWEEN HEALTH INSURANCE AND ACCESS TO HEALTHCARE........................................................................................................................................... 27 2.4 MOTIVATION FOR OPERATION AND SUBSCRIPTION TO HEALTH INSURANCE SCHEME........................................................................................................................... 31 2.5 CHALLENGES FACING HE A ITH INSl JRANCE SCHEMES .......................................... 34 2.6 SUMMARY OF LITERATURE REVIEW .................................................................................... 39 CHAPTER THREE....................................................................................................................................40 HEALTHCARE DELIVERY IN GHANA.......................................................................................40 3.1 HISTORY OF HEALTHCARE DELIVERY SYSTEM IN GHANA......................................40 3.2 INTRODUCTION OF THE NATIONAL HEALTH INSURANCE SCHEME...................... 45 3.2.1 The National Health Insurance Act.................................................................................................45 3.2.2 The Establishment o f NHIS Council............................................................................................. 45 3.2.3 Types o f Health Insurance Schemes.............................................................................................. 46 3.2.4 Diseases and Drugs covered by the Scheme................................................................................ 48 3.2.5 Accessing Healthcare under the Scheme...................................................................................... 50 3.2.6 Exclusion List.....................................................................................................................................51 CHAPTER FOUR ............................................................................................................................. ........53 RESEARCH METHODS ..................................................................................................................... 53 4.1 APPROACH TO THE STUDY ..................................................................................................... 53 4.2 SAMPLING PROCEDURE.............................................................................................................. 53 4.2.1 The Target Population...................................................................................................................... 53 4.2.2 Sample Frame.....................................................................................................................................54 4.2.3 Sampling Technique..........................................................................................................................54 4.2.4 Sample Size.........................................................................................................................................56 4.3 PRIMARY DATA COLLECTION INSTRUMENTS ...........................................................57 4.3.1 Face-to-Face In terv iew ....................................................................................................................57 4.3.2 Self-administered Questionnaires...................................................................................................58 4.3.3 Focus Group Discussion.................................................................................................................. 59 4.3.4 Key Informant Interview..................................................................................................................59 4.4 SECONDARY DATA COLLECTION .......................................................................................... 60 4.5 DATA HANDLING ............................................................................................................................60 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE.........................................................................................................................................61 DATA ANALYSIS......................................................................................................................................61 5.1 INTRODUCTION..................................................................................................................................61 5.2 DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS................................................62 5.3 INSURED MEMBERS OF T1 IE NH1S............................................................................................ 67 5.3.1 Motivation for Membership and Registration...............................................................................67 5.3.2 Access to Healthcare and Problems encountered........................................................................71 5.4 THE NON-INSURED .......................................................................................................................... 76 5.4.1 Reasons for Non-membership o f the N H IS ...................................................................................76 5.4.2 Access and Utilization o f Healthcare............................................................................................... 77 5.5 ACCREDITED HEALTH PROVIDERS........................................................................................ 79 5.5.1 Background............................................................................................................................................79 5.5.2 Reimbursement.....................................................................................................................................80 5.5.3 Access to Healthcare from the Public Health Provider by the Insured....................................80 5.5.4 Access to Healthcare from the Private Health Provider by the Insured...................................81 5.6 GA DISTRICT MUTUAL HEALTH INSURANCE SCHEME................................................82 5.6.1 Registration o f Members and Renewal........................................................................................... 82 5.6.2 Access to Healthcare under the Scheme......................................................................................... 83 5.6.3 Working Relationship with Accredited Health Providers...........................................................84 5.7 PERCEPTION OF ACCESS TO HEALTHCARE BY THE INSURED AND NON-INSURED...............................................................................................................................85 5.8 PERCEPTION OF THE NHIS............................................................................................................86 5.8.1 Perception o f the Scheme by the Insured........................................................................................ 86 5.8.2 Perception o f the Scheme by the Non-insured...............................................................................88 5.8.3 Perception o f the Scheme by Health Providers..............................................................................89 5.8.4 Perception o f the Scheme by the GDMHIS................................................................................... 92 5.9 GENERAL PROBLEMS FACING THE SCHEME..................................................................... 92 5.10 CONCLUSIONS DRAWN FROM THE SURVEY....................................................................94 University of Ghana http://ugspace.ug.edu.gh CHAPTER S IX .............................................................................................................................................96 SUMMARY, CONCLUSION AND RECOMMENDATIONS..................................................... 96 6.1 INTRODUCTION...................................................................................................................................96 6.2 SUMMARY..............................................................................................................................................96 6.2.1 THE INSURED.................................................................................................................................... 97 6.2.2 THE NON- INSURED...................................................................................................................100 6.2.3 PROBLEMS FACING THE SCHEME...............................................................................................103 6.2.4 RELATIONSHIP BETWEEN HEALTH INSURANCE AND FINANCIAL ACCESS TO HEALTHCARE............................................................................................................................... 104 6.3 CONCLUSION...................................................................................................................................... 106 6.4 RECOMMENDATIONS.................................................................................................................... 106 REFERENCES............................................................................................................................................. 111 APPENDICES.............................................................................................................................................. 121 University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES TABLE PAGE 5.1 Sex.............................................................................................................................................................62 5.2 Age G roup ing ........................................................................................................................................ 63 5.3 Marital S ta tu s ........................................................................................................................................ 64 5.4 Educational B ackground.....................................................................................................................65 5.5 Ethnic G roup ing ................................................................................................................................... 66 5.6 O ccupation .............................................................................................................................................67 5.7 How members found the registration p ro cess ................................................................................ 70 5.8 Period within which members received their ID c a rd s ...............................................................71 5.9 Members who have accessed healthcare under the schem e........................................................ 72 5.10 Reasons for preference o f public or private health fac ility ....................................................... 74 5.11 Access and utilization o f healthcare by the non-insured .......................................................... 78 5.12 The Insured access to healthcare from a Public Health P rov ider............................................81 5.13 The insured access to healthcare from a Private Health P rov ider.......................................... 82 5.14 Fees for Registration and R enew al................................................................................................ 83 5.15 Cost o f Service to Scheme Members and Reimbursement.......................................................84 5.16 Perception of the NHIS by the in su red ......................................................................................... 87 5.17 Perception o f the NHIS by the non-insured................................................................................. 89 5.18 Conclusions drawn from the Field S u rvey ................................................................................... 95 x University of Ghana http://ugspace.ug.edu.gh FIGURE PAGE 5.1 Motivation for Subscribing to the N H IS .......................................................................................... 69 5.2 Health Facility mostly visited by NHIS Subscribers......................................................................73 5.3 Reasons for Non-Membership o f the N H IS .....................................................................................77 5.4 Sources oflncom e to Pay for Health Serv ices................................................................................. 79 LIST OF FIGURES University of Ghana http://ugspace.ug.edu.gh ACRONYMS AHP - Accredited Health Providers CBHl - Community Based Health Insurance CMH - Commission on Macroeconomics and Health DM HIS - District Mutual Health Insurance Scheme DWHIS - Dangme West Health Insurance Scheme EU - European Union GDP - Gross Domestic Product GEDA - Ga East District Assembly GDMHIS - Ga District Mutual Health Insurance Scheme GLSS - Ghana Living Standard Survey GSS - Ghana Statistical Service HI (HIS) - Health Insurance (Health Insurance Scheme) IGF - Internally Generated Fund ILO - International Labour Organization LI - Legislative Instrument MHO - Mutual Health Organization MI - Macro International MOH - Ministry o f Health NHIA - National Health Insurance Authority NHIC - National Health Insurance Council NHIS - National Health Insurance Scheme NLCD - National Liberation Council Decree University of Ghana http://ugspace.ug.edu.gh OPD - Out-Patient Department SSNIT - Social Security and National Insurance Trust 1'he Act - The National Health Insurance Act 2003 (Act 650) The Council - The National Health Insurance Council WHO - World Health Organization LIN - United Nations UNTGHP - United Nations Theme Group for Health-Partners University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 INTRODUCTORY BACKGROUND Health is an essential element for human survival and effective functioning in society. Health affects the poor and the rich, youth and old, literate and illiterate. As a result, health issues are major concern to every society and its members. In the absence of health, one is bedevilled by sickness - physical or mental. Sickness can beset any human being, incapacitating him/her from effectively performing their roles in society. Therefore, all possible measures need to be taken to prevent sickness and to cure whenever we fall sick. It is the responsibility of every human being to prevent sickness; likewise it is the basic right of everyone to receive healthcare (Zastrow. 1996). The question however is, do all members of the society have access to healthcare which is their right, or financial constraints prevent some individuals from accessing healthcare and adequately receiving medication? Does the desire to be healthy and to have access to healthcare in the face of illness still remain a distant goal for many individuals? It is estimated that 3.6 million people of Ghana require healthcare at any given time. Out of this number, only 720,000 people are able to access care due to their ability to finance the healthcare needed and/or availability' of health provider. This implies that 2.880 million people who need healthcare are not able to access it (Ghana Statistical Service, 2000). Studies conducted show that the 2.880 million people who are unable to access hcalthcare face geographical and/or financial barriers. Further studies reveal that financing of medical care is the most serious barrier to access healthcare (Turshen. 1999; Kwabia. 1996; Delnnyo et a!.. 1992). There is. therefore, the University of Ghana http://ugspace.ug.edu.gh need to improve efforts at reducing financial barriers to healthcare particularly by the poor and vulnerable members in the communities and to increase their protection against the risk of fluctuating health expenditures. Many governments o f both developed and developing countries have made efforts to provide quality healthcare as basic necessity for their citizens. It is a fact that a nation cannot be built by unhealthy citizens, rather healthy ones; which implies that there is the need for proper health financing and equal access to quality healthcare delivery'. However, health financing has become a major problem for many governments especially developing countries like Ghana. As a result, it is difficult to ensure that all people enjoy adequate access to healthcare. There has been so much reliance on external support for the health sector. In 1990 for instance, most sub-Saharan African countries obtained at least 25% of their health financing from external sources. In Ghana, 199 donors played very active role in financing the health sector in 1992 (ILO, 2000). However, such a trend is not sustainable in the provision o f quality healthcare for all Ghanaians. There is therefore the need for developing countries like Ghana to adopt a more pragmatic and sustainable approach in tackling the problem o f health financing. This has become imperative in recent years because, the nature o f external funding has changed with overall level of support reduced and a shift towards imposing specific conditionalities on receiving governments. Since governments cannot bear all the health cost o f its citizens alone, neither can the cost be borne by consumers themselves, which will mean total payment o f user fees for health facilities, there is the need to share the cost burden o f healthcare, so that health provision will be available to every member of the society. Thus, though healthcare University of Ghana http://ugspace.ug.edu.gh provision is a social responsibility of the state, inadequacy of resources makes it difficult for governments to ensure adequate access and utilization by all citizens. This is applicable to most developing countries whose public expenditure on health rarely exceeds an average five percent of Gross Domestic Product (GDP), or $10.00 per capita per year (United Nations. 1996). In Ghana as a whole, health takes only 4.5% of GDP (World Bank. 2000). Equitable allocation of resources to the various health sectors has remained a challenge. For instance, in 1980 in Ghana, spending on specialist tertiary care amounted to 40% of the health budget, yet this benefited only one percent of the total population; whilst primary healthcare spending was only about 15% o f the health budget (Gatrell et al., 2000). One method of healthcare financing is health insurance schemes which can reduce financial burden on access to healthcare. As of 2004. eighty percent (80%) of health financing in Ghana was through tax revenue and donor funds. The 20% was from internally generated funds (IGF) through out-of-pocket payments (Aikins, 2005). User fee payment has been replaced by health insurance, which has been proven to guarantee the individual’s financial access to healthcare, and reduce, if not remove, one’s vulnerability to paying out o f pocket at an unexpected moment when one falls sick. Access to health insurance has been found to improve access to healthcare and healthcare delivery. In Ghana, the national health insurance scheme was inaugurated in March 2004, following the enactment of the National Health Insurance Act 2003 (Act 650), which established a National Health Insurance Council (NHIC) with the mandate of implementing a national health insurance policy and registering, licensing and regulating, and supervising the operation of health insurance schemes among others. 3 University of Ghana http://ugspace.ug.edu.gh Research has shown that in developing countries where health insurance exists, insured patients have more financial access to healthcare than the non-insured. In a study o f the Bwamanda Hospital Insurance in the Democratic Republic of Congo (DRC), it was realized that utilization of health facilities increased among insured patients (Criel et al.. 1999). Also, in a study of the future prospects of voluntary health insurance in Thailand, Supakankunti (2000) discovered that greater use of healthcare was the result of the introduction of health card programme. It brought about an improvement in accessibility and use of healthcare and a high level o f consumer satisfaction among card holders. In their study of the impact of national health insurance on the use of health services by pregnant women in Taiwan, Chen et al. (2001) concluded from their observations that the use of prenatal and intrapartum care services, particularly for the more expensive services, increased substantially in Taiwan since the implementation of the national health insurance programme. Given the potential of health insurance in guaranteeing higher financial access and utilization of healthcare services, removing the vulnerability o f paying out o f pocket and mobilization of funds to capitalize the health sector, it becomes imperative that the impact of the scheme be studied in its wider dimensions. The major aim of this paper is to use empirical evidence drawn from a sample from the members o f the community of Abokobi in the Ga East District, supported by opinion leaders, health professionals and insurance administrators, to examine the impact o f the scheme as reflected on the community members’ financial access to healthcare under the scheme. 4 University of Ghana http://ugspace.ug.edu.gh 1.2 STATEMENT OF THE PROBLEM Specifically, the study looks at the Ghana National Health Insurance Scheme, with particular rel'erence to the Ga District Mutual Health Insurance Scheme (GDMHIS) and its impact on the community members of Abokobi in accessing healthcare. The GDMHIS is the district branch of the National Health Insurance Scheme that is mandated by law to provide health insurance services to the residents of Ga East and West Districts. The scheme is to help the residents of Ghana to get access to healthcare so that their health conditions will improve which will in turn boost labour productivity and overall development o f the nation. Statistics show that the health of Ghanaians has improved since independence as more infants survive after birth and people living longer than some decades back. Thus, between 1957 and 1998. for example, infant mortality dropped from 133 to 61 and life expectancy increased from 45 to 55 years (MOH, 1999). Though life expectancy has improved over the years, there is inequity and slow improvement in the health status of Ghanaians. Though the overall under five mortality rate declined from 154 per 1000 to 110 per 1000 births between 1988 and 1998, regional under five mortality rate ranged from 62 per 1000 births in Greater Accra to 171 in Northern Region (GSS and MI, 1999). According to the MOH (2001) report, the factors that contribute to these health problems are poverty, low female literacy rate, high population growth, poor nutrition, limited access to water and sanitation and poor performance o f the healthcare delivery system. Poverty contributes enormously to lack of access to healthcare. The UNDP (2007) reports that 44.8% of Ghana's population live below one dollar a day. This suggests 5 University of Ghana http://ugspace.ug.edu.gh that nearly half of Ghanaian population live in poverty. This situation poses a serious threat of financial barrier to accessibility of healthcare. Financial barriers in the form of user fees are manifested in three major ways, namely absolute lack of access, reduced access and delayed access to healthcarc. In a study conducted in the Northern Region of Ghana, three traditional support systems were found to play an important role in enabling households to access healthcare. Borrowing constitutes 29%. thirty-one percent (31%) of households receive assistance from relatives, friends and community contributions, and 40% rely on their own internal resources to finance their healthcare. The average spending on one bout of care sought was found to be 51,397 Cedis, approximately 5.14 Ghana Cedis (Apoya et al., 2001). The problem of poor access to healthcare has been significantly contributed by the cash and carry system, which was introduced as part o f the structural adjustment policies in the 1980s. The cash and carry system involved the wholesale withdrawal of government subsidies on health delivery, and the cost o f healthcare pushed unto the consumer. Thus, patients were asked to pay for full cost o f medication and care. Though the rationale was to replenish the cost o f healthcare, the cash and carry system posed a serious constraint that prevented a great number of the population from seeking medical care. The number of patients who utilized healthcare fell considerably. It created financial barriers to healthcare access especially for poor community members. The disabled, poor and accident victims were being asked to pay on the spot before getting medical attention. Patients who did not have the ability to pay for medical services were turned away from hospitals only to die at home. As a result, many people resorted to self-medication. Although the government introduced exemption policy for children under five years, pregnant women, the indigent and the elderly, it could not 6 University of Ghana http://ugspace.ug.edu.gh take out the effects of cash and carry on the poor (Waddington and Enyimayew, 1989; Dakpallah, 1988; Adams, 2002). Over the years, many Ghanaians have expressed yearning for an alternative to the cash and carry system. The National Health Insurance Scheme was introduced as a social intervention to replace the existing cash and carry system. The main goal of the NHIS is to provide accessible, affordable and good quality healthcare to all residents and citizens of Ghana, especially the poor and most vulnerable (NHI Act. 650). The study seeks to investigate whether this social intervention has actually made healthcare accessible to insured members o f the community. Statistics provided so far indicate that approximately 60% o f the community of Abokobi has registered with the scheme (GDMHIS, 2009). The question still remains why a lot more have not registered; whether they are still interested in the cash and carry system, or they do not have money to register. Since the introduction of the scheme there have been several complaints from the general public including the insured and accredited health providers. It is therefore important to find out how' members access healthcare under the scheme, and the challenges that confront the scheme administration and accredited health providers in their effort to provide the best form of services to the insured 7 University of Ghana http://ugspace.ug.edu.gh 1.3 OBJECTIVES OF THE STUD Y General Objective □ to investigate the relationship between health insurance and financial access to healthcare Specific Objectives □ to find out people's motivation for subscription or non-subscription to the scheme □ to investigate access to healthcare by insured members and the problems they encounter □ to find out the general problems involved in the scheme's operations □ to make recommendations for future development o f the scheme 1.4 RESEARCH QUESTIONS From the description of the problem situation and literature survey, the following research questions emerged: 1. What is the relationship between health insurance scheme and financial access to healthcare? 2. What are the motivating factors for someone's participation or non-participation in the health insurance scheme? 3. Has the NHIS helped insured community members to receive medical care without paying out of pocket? 4. What problems do community members encounter in accessing healthcare under the scheme? 8 University of Ghana http://ugspace.ug.edu.gh 5. What challenges do the NHIS administration and accredited health providers face in their complementary effort to make sure the scheme works effectively for the benefit of its members? 1.5 RA TIONALE OF THE STUD Y Most of the existing studies on health insurance schemes mainly look at the impact of the scheme on the health provider or the insurance scheme itself, and largely neglect the effects on the members. As the NHIS is at the initial developing stage, it is important to critically assess it at this introductory stage so that emerging problems can be easily tackled, whilst its resources be enhanced for accelerated development and sustainability of the scheme. It is against this background that this research is conducted, to investigate the impact of the scheme on community members' financial access to healthcare. 1.6 SIGNIFICANCE OF THE STUDY In order to improve the operations of the National Health Insurance Scheme and to ensure its sustainability, it is important to evaluate the impact o f the scheme on every resident of Ghana, particularly at the community level. The results o f the assessment will be used to inform scheme design and administration and put in place effective measures to improve and sustain it for the future. The research is also intended to bring to the fore the problems community members face in their attempt to subscribe to the scheme and access healthcare under the scheme. 9 University of Ghana http://ugspace.ug.edu.gh Collection, analysis and well-timed dissemination of baseline data will allow the NHIC to make any necessary adjustments to the health insurance programme. It is hoped that this study will add new values to existing ones. It will also be useful not only to policy makers in Ghana bul also have broader application, particularly for other countries in the sub-region that are considering to implement a national health insurance programme. 1.7 THE STUDY AREA The study covers Abokobi community. Abokobi is the capital of the Ga East District and about 25 kilometres north o f the national capital. It has a total land area of 1.000 acres, typically rural, and with a population projected to be 1,313 for 2008 (GEDA, 2006). Abokobi was chosen because of its uniqueness of community life and history. Though, the town is fast growing and facing the impact of modernity, the people still believe and live the life depicted by the African adage, “ I am because we are and since we are therefore I am” (Mbiti, 1996). In other words, the residents in the community live communitarian lives, whereby they seek the welfare of one another, as opposed to individualistic way of life in the city. Historically, it is an important town for the Presbyterian Church, whose missionaries legally acquired the land in the latter part of the 19lh century when they first arrived in the Gold Coast and set up a mission there (GEDA. 2007). The town is still an important centre for the Presbyterian Church of Ghana. According to the Clergy of the Presbyterian Church o f Abokobi, the Chief of the town is appointed by the Church. The Chief serves both the Church and the people and holds allegiance to them. 10 University of Ghana http://ugspace.ug.edu.gh Abokobi has a vocational school and a clinic that serves the community’s health needs. The town is not far from Pantang Hospital which also provides medical care to the community members. Other health facilities in the district where the people access healthcare include Alpha Medical Centre and Atomic Clinic. Though Abokobi is the district capital, there is no health insurance office situated in the town. The community members and the entire district access health insurance under the GDMHIS located at Amasaman. the capital of Ga West District. The GDMHIS is one of the district mutual health insurance schemes established by the Act and mandated to serve the residents of Ga District, including Abokobi. The scheme is managed by a managing director and six staff members. It serves its members as stated in the Act and the NHIS Regulations. 2004 (LI 1809). As at the end of 2008, the scheme had enrolled 310,000 members and works with 72 accredited health providers and 75 pharmacies not only in the district but also in other parts of Greater Accra Region (GDMHIS, 2009). 1.8 DEFINITION OF CONCEPTS For the purpose of this study, some operational definitions have been developed below: Health refers to the soundness of the human body and mind, free from illness or abnormality (Soukhanov, 1996). Healthcare refers to the prevention, treatment, and management o f illness and the preservation or mental and physical well-being through the services offered by the medical and allied professions (Soukhanov. 1996). University of Ghana http://ugspace.ug.edu.gh Health Insurance is a method whereby individuals or groups pull resources together into a formal pool of funds that is maintained specifically for the healthcare of the members in question. Access to healthcare is the right to utilization of health facilities. In other words, it is the ability of the patient to seek healthcare without barriers. Financial access to healthcare - It is the ability of a patient to pay for the cost of healthcare. It can be before or after receiving services from a health provider. Affordable healthcare -refers to healthcare that one can pay for at the point of illness. Adult population - the adult population in this context refers to persons who are 18 years and above. 1.9 LIMITA TIONS OF THE STUDY There are limited materials for the collection of secondary information on the topic. The study relied more on primary data. The statistics available on the population of the insured in the Ga East District were not up-to-date. 12 University of Ghana http://ugspace.ug.edu.gh 1.10 ETHICAL CONS1DERA T10NS Adequate supervision was done to ensure that ethical considerations were properly observed by research assistants. As part o f social work ethics, the views of respondents w'ere highly respected. Respondents were made aware of the purpose of the study and their consent sought. Permission was sought from the District Assembly, the Chief and the leaders of the Church. A joint meeting was held between the researcher with the assistants and the Chiefs, elders and leaders o f the Church to seek their consent. After the meeting, the researcher and the assistants were introduced to the congregation of Abokobi Presbyterian Church before embarking on data collection. 13 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 PERSPECTIVES ON HE A L THINSVRA NCE Wiesmann & Jutting (2001) discussed health insurance and healthcare from the perspective of an interaction between supply and demand. They argued that there is an interface between supply and demand for health insurance and healthcare. The object o f health insurance scheme is to reduce unaffordable or unforeseeable cost o f healthcare through calculable and regularly paid premiums. The question is: what are the interactions between supply and demand for health insurance and healthcare? Subscription to health insurance needs conviction, because one has to commit his/her money by paying a premium. The money is not refundable even if the subscriber does not use the scheme to access healthcare in a particular year. At any point in time when the subscriber falls sick and visits a health provider, their financial barriers to access healthcare are removed by the health insurance scheme. Even though they might not have money at the point of illness, and user fees might be too high w ith respect to their income, they can readily receive medical care at a health facility . This situation leads to three effects: effect on the insured members of the scheme, effects on health providers and effects on the insurance scheme (Wiesmann & Jutting. 2001). First, insured members no longer have to search for credit or sell assets in order to finance healthcare. They also recover more quickly from their illness since there are no delays in seeking care. Considering the laet that people in rural communities rely mainly on their labour productivity and on assets such as livestock for income 14 University of Ghana http://ugspace.ug.edu.gh generation, 3 serious decline of income can be prevented as productive assets are protected and people can return to work sooner. Income is stabilized and may e v e n - counting the sum throughout the year—increase. Consumption will be more stable and probably higher, thereby positively affecting the health o f all household members. Both increased consumption and better health contribute to overall income. In the mid-to long-term, the positive experience of some households or community members with health insurance in terms of immediate access to healthcare and benefits for their health may create trust in the new institution. It also encourages people to prolong their membership and convince others to join the scheme. Therefore, the demand for health insurance increases (Wiesmann & Jutting, 2001). Given the fact that people may be willing to spend more money on securing access to healthcare than they can actually pay as user fees at the time of illness, and that the healthy carry the financial burden o f illness together with the sick via the insurance scheme, additional resources may be mobilized for healthcare provision. Utilization of health facilities will probably increase, a desirable effect if one considers currently prevailing underutilization in developing countries (Muller et al.. 1996). A part of these resources could then be used up to expand access to healthcare. Under the assumption that there is net revenue generation in spite of higher utilization rates, the hospitals or health facilities will utilize the financial means to improve the quality of healthcare— for example, by increasing drug availability and purchasing extra necessary medical equipment. Improved healthcare will increase people's expectations of getting value for money in the case of illness, and will again enhance demand for health insurance (Wiesmann & Jutting. 2001). 15 University of Ghana http://ugspace.ug.edu.gh Assuming the first two effects actually materialize, one can imagine that new members join the scheme and hence membership enrolment increases. This could drive down the administrative cost of insurance provision per member. Risk pooling is therefore enhanced as more people participate. Consequently, risks become more calculable. Although the idea o f rising demand usually suggests rising prices, in this case, it could result in reduced premiums due to “ economies of scale” (McGuire et al., 1989). Lower premiums will probably once again increase demand for health insurance and coverage rates. Besides acting as an agency that expresses the interests and needs o f its members, the scheme can try to promote the use of preventive care and healthy behaviour. Health education and awareness o f health problems would improve public health outcomes and counteract cost escalation. Vogel (1990) also views health insurance as risk spreading whereby individuals or groups pull resources together into a formal pool o f funds that is maintained specifically for the healthcare o f the members in question. The pool o f funds is held by a third party, (or by the provider, in the case of Health Maintenance Organization, which relies on prepayment by its insurees), that pays for the health-care costs o f the membership of the pool. This third party can be a government social security or other public insurance fund-pool or any private fund-pool. The risks involved in the resource mobilization to pay for medical care is spread among all members o f the group instead of being borne by one person at the point of illness. In his research conducted on Health Insurance in Sub-Saharan Africa, Vogel found out that there are several types of health insurance schemes operated by different communities, firms, hospitals, missions, non-governmental and governmental 16 University of Ghana http://ugspace.ug.edu.gh organizations. He concluded that at some level of abstraction, a government healthcare system, financed through general tax revenues and provided without charge to the population could be considered to be an implicit form o f national health insurance. He also observed that in several parts of sub-Saharan Africa, many firms provide free healthcare to their employees and their families, either in the form of company-run clinics, or through contracts with private physicians and clinics. In some countries like the Democratic Republic of Congo (DRC), this kind of coverage is mandated by the government. At another level o f abstraction, this too could be considered to be health insurance, because in effect, the employer is required to maintain a pool o f funds for healthcare (analogous to a sinking fund for the depreciation of physical capital), and depending upon elasticities of demand for and supply o f labour, much of the premium may be shifted onto labour. In other countries like Zimbabwe, Vogel realized that employers voluntarily provide company clinics or pay for the healthcare of their employees and their families through contracts. According to him, human capital theory w'ould allow this practice to be considered to be providing health insurance, particularly for skilled and not-easily replaced employees. In effect, the employer is self-insuring against the loss o f skilled labour, particularly where the skilled labour is highly specialized, and hence highly scarce. Thus, healthcare risk-spreading mechanisms can either be mandated by government or government and the private sector can offer risk-spreading plans that are voluntary. Because one ol the major objectives of many government health insurance 17 University of Ghana http://ugspace.ug.edu.gh arrangements is usually to pool risks (or to redistribute the paying for the pooling of risk), participation in government arrangements is almost always compulsory. Vogel finally observes that governments implicit and explicit health insurance arrangements in sub-Saharan Africa can be broadly characterized as ranging from (A) free healthcare provided and financed for all citizens (e.g. Tanzania), or through (B) healthcare provided by government and financed through the general tax fund and through cost recovery (e.g. as existed in Ghana before the introduction of the NHIS), (C) compulsory Social Security for the entire formal labour market (e.g. Senegal). (D) a special health insurance fund for government employees (e.g. Sudan), (E) a discount at healthcare facilities for government employees (e.g. Ethiopia), (F) other public ■‘insurance” such as government employees being entitled to private medical care as a fringe benefit (e.g. Kenya), and finally (G) mandated employer coverage o f healthcare for employees (e.g. DRC). Likewise in the private sector, he observes (A) private insurance policies bought from insurance companies (e.g. Zimbabwe and South Africa), (B) small local voluntary risk pools (e.g. Rwanda), and (C) employers voluntarily providing medical care directly (e.g. Zambia) or providing medical care on contract with private healthcare providers (e.g. Nigeria). Each o f these arrangements spreads risk in varying degrees, and the incidence of the payment for the spreading of the risk also varies, depending upon elasticities of supply and demand for labour, and the progressivity of the tax system used to finance the government arrangements. University of Ghana http://ugspace.ug.edu.gh 2.2 FACTORS INFLUENCING ACCESS TO HEALTHCARE Studies have shown that several factors influence access to healthcare by community members. These factors include: nnancc of medical care, allocation of health institutions and distribution o f health personnel, distance and transportation, time and social factors. 2.2.1 Finance of Medical Care Finance o f medical care in terms of patients paying at the point of illness or even after treatment, plays a major role in the accessibility to healthcare. This is referred to as financial access to healthcare. Experience has shown that where fee-for-service sy stem exists, even if a patient is able to pay for transport fare and gets to a health facility, the person will neither be attended to nor be allowed to access healthcare if s/he does not have money to pay. Thus, f inancial barriers can prevent a person from receiving medical care from a health service provider which can result to serious consequences like death. Turshen (1999) observed in his study in the Republic of Congo that the introduction of user fees deterred many people from seeking healthcare, thereby leading to a sharp drop in the utilization of healthcare. It also happened in Ghana where the introduction of the Hospital Fee Regulation of 1985. under the Structural Adjustment Programme (SAP) led to a serious fall in health service utilization (Kwabia. 1996). In their study o f user satisfaction with health services in government health facilities in the Eastern Region of Ghana, entitled “What does the public want from us?” Delanyo et al. (1992) observed that high cost of services was the major cause o f user dissatisfaction, which resulted to high reduction of visits to health providers. 19 University of Ghana http://ugspace.ug.edu.gh Studies indicate that even in developed countries, cost o f healthcare can scare access and utilization. Cockerham (1978) observed that in the United States, lower-class persons under-utilized health services because of financial cost o f services and because of sub-culture of poverty that has failed to emphasize the importance of good health. McKinlay (1972) also points out that there are several cases of economic barriers which hinder access to healthcare in fee-for-service systems. High cost of medical care and low incomes appear to force some groups to change venues where they seek healthcare. In a study of Oklahoma City, the elderly were identified as attending hospital emergency rooms and outpatient departments for primary care due to the cost of private physicians (Bohland and French, 1982). Further studies conducted by other researchers establish similar trends. In a study that looks into the effects of bundling, an aspect o f the payment system, on dental utilization in Ontario, Canada, Porter et al. (1999) discovered that the volume and intensity of services received by adult patients increased when fee constraints were imposed on dentists. O ’Brien (1989) in his study of the effects of patient charges on the utilization o f prescription medicines in Britain, observed that increase in the real value of the prescription charge are associated with a reduction in the consumption of changeable drugs. Moreover, Sintonen and Maljanen (1995) used the supplier- inducement model to explain the utilization of dental care in Finland and found that the effect of money price was a significant factor which influenced utilization. This study underscores the fact that in developed countries, the cost factor would not affect demand for certain critical services (Buor, 2004). 20 University of Ghana http://ugspace.ug.edu.gh In another study of supplier-inducement on denial care in Norway, Grytten (1991) concluded that dentists in areas of excess supply were able to maintain their workload, with an increase in the demand for utilization of health services. This study also underscores the fact that, in developed countries, the cost factor would not affect so much the demand for certain critical services (Buor, 2004). In their studies to investigate the factors that influence people's willingness to pay for medical care. Gertler and Gaag (1990) concluded that the demand for healthcare is influenced by the ability to pay. 2.2.2 Allocation of Healthcare Institutions and Distribution o f Health Personnel Other researchers argue that the allocation of healthcare institution and distribution of health personnel in a particular community, district or region tend to affect people's access to health services. For instance, in most developing countries where the distribution of all categories of healthcare facilities tends to favour disproportionately the urban centres, those in rural areas face barriers of access to healthcare. It has been observed that the concentration of physicians in urban centres and the development of health services predominantly in towns deprive many rural communities of access to modern medical care (WHO, 1979). Philips (1986) found out in his research conducted in Metro-Manila region in the Philippines, that though the region contains 25% of the country's population, the region has only 43% of total hospital beds. He concludes that lack of hospital equipment prevents the health provider from serving more patients thereby reducing the number of patients who access care from the hospital. 21 University of Ghana http://ugspace.ug.edu.gh Also, in cases where doctors are not available, patients receive limited services or no service at all. In the case of Kenya, where it is estimated that only 10% of the country’s doctors serve rural areas, and that some 70% of all doctors are in urban private practice; and where doctor-to-population ratios range from 1:990 in the cities to 1:70,000 in rural areas, patients in rural areas only access limited services (Good, 1987). Even in urban areas, large disparities do exist (Bailey and Philips, 1990). Some communities have more health facilities and health personnel than others. Okafor (1984) in his research in rural Nigeria observed that variations exist in the spatial provision of health facilities between rural local government areas. In a further study of the spatial dimensions of accessibility to general hospitals in rural Nigeria Okafor (1990) realized that the problem of inadequate health services in rural Nigeria was worsened by poor location decisions which have resulted in various degrees of inaccessibility to existing health facilities. Though in the developed countries there are usually adequate primary care services, the distribution of health facilities is generally biased towards the urban centres. Though rural areas are served with hospital facilities, they are deprived of specialist services. As a result, people in rural areas go on referral to urban centres (Buor, 2004). In his study, Philips (1990) realized that in Western countries, residence in less desirable urban locations and socio-economic deprivation can lead to poor access to healthcare. This is because major health facilities are located at the privileged urban core. 22 University of Ghana http://ugspace.ug.edu.gh 2.2.3 Distance and Transportation It follows that distance from one’s residence or community and transportation can influence access to healthcare. Wilson et al. (1997) gathered from their study of the maternity home waiting concept at Nsawam in Ghana that distance from the hospital was. among others, one of the major reasons for poor utilization. In this study, focus groups were used. Also, in the Jasikan district in Ghana, distance played a major role in health service utilization (Institute of Development Studies, 1978). About three-fourth o f all registered patients come from within 4 miles and that over 90% living within 4 miles registered at a health unit. However, registration drops off quite sharply for those living further away, and only about one-tenth of the population living more than 6 miles from a health facility appeared to be registered at all in Jasikan. In their study of the effects o f distance from home on attendance at a small rural health centre in Papua New Guinea, Muller et al. (1998) found that attendance decreased markedly with distance. There was 50% decrease of the number of patients at a 3.5 kilometre distance. From the result o f their study most people will not travel further than 5 kilometres for basic preventive and curative care. In Nigeria, Stock (1987) found that at a distance of 5 kilometres from a dispensary , per capita utilization fell to less than one-third of the 0-km rate. An Indian study showed that the proportion of a community attending a dispensary decreased by 50% for every additional half-mile between the community and the facility (Frederiksen, 1964). These arguments notwithstanding, it must be noted that other factors like the nature of the illness, quality of care provided at the health facility and socio-economic status 23 University of Ghana http://ugspace.ug.edu.gh interfere with distance and cost of transportation. Stock (1983) observed in his study in rural Nigeria that people are willing to travel farther for more specialized services or better quality care. The quality of care provided and the type of services offered, like specialist services can alter distance-decay (Smith, 1979). Urgency of service can also interfere with distance. Ganatra and Hirve (1994) in their study on male bias in healthcare utilization for under-fives in a rural community in Western India found that parents were willing to travel grater distance to seek medical care for their sons, but would not do same for their daughters. This problem has a cultural background. It reveals the cultural dimension to the provision and reception of healthcare and their impact on a health insurance scheme. In developed countries, distance and transportation also play a role in access to health services both in rural and urban centres. In a study of the quality o f location as a principle in psychiatric healthcare planning in the Austrian State o f Tyrol, Meise et al. (1996) found an inverse relationship between the utilization of available facilities by patients and the distance from their homes. They concluded that longer distance resulted in lower utilization. Folland (1977) conducted a study o f distance on hospital use in South Dakota in the United States and found that a one-mile increase in the distance to a hospital decreases the hospital’s market share from that county by 1.7%. Other researches have also proved that in cases of severe illness, distance does not play much role. In a study of distance to general medical practice and its effect on revealed ill-health in rural Newfoundland, Girt (1973) confirms that gradients o f distances patients travel to seek healthcare are relative to the nature of illness. 24 University of Ghana http://ugspace.ug.edu.gh 2.2.4 Time and Access to Healthcare Furthermore, other studies conducted in the area of healthcare accessibility show that time is an influencing factor on access to health services. The time that one takes to travel to the hospital, the waiting time at the health facility and waiting time for appointments afTect one's visit to a health provider. In developing countries, time as a barrier to health facility attendance is also influenced by the season of the year and the nature of the patient's business schedules. For instance, in farming area, a farmer would not like to spend much time traveling long distances for healthcare in a farming season; likewise the entrepreneur spending so much of his time seeking healthcare in peak seasons like Christmas. Both will look for alternatives unless it is a fatal illness (Buor, 2004). In the developed countries, results o f studies conducted on time and access to healthcare show that time affects hospital attendance. The distance between home and hospital measured in terms of the time one takes to reach hospital is a major obstacle to hospital attendance. It affects the quality of location of the health provider (Meise et al. 1996). The length of time one waits before consulting a doctor or the length of time one spends at a physician's office also affects utilization. In his stud) o f the effects of waiting time on health service utilization. Acton (1975) concludes that the length of time the patient spends in waiting at a physician's office is an important price that determines utilization levels. In a study of health, personal mobility and the use of health services in rural Norfolk, Bentham and Hayes (1985) observed that increased distance between residents and healthcare providers tends to decrease utilization. According to Aday and Andersen (1974), the problem of time on hospital attendance is mostly faced by rural farm residents because they have been found to have the highest 25 University of Ghana http://ugspace.ug.edu.gh traits o f consulting a physician. This could be explained by their low socio-economic status. 2.2.5 Social Factors Another variable that influences access to healthcare is social factor which refers to situations in which patients in a community consult doctors or general practitioners with whom they feel more comfortable and health facilities recommended by families and relations. In a survey on spatial pattern of attendance at general practitioner services in New Zealand. Hays et al. (1990) found that the Maori were less spatially bounded than other members of the sample population and patients sought healthcare from doctors who had been recommended by their families and relations. Studies conducted in developed countries show that many people have their personal or family doctors and prefer seeking healthcare from them. In a study o f location and population factors in seeking healthcare in Savannah. Georgia, Gesler and Meade (1988) observed that people who had lived in an area for a short time might have preferred to visit a doctor or clinic closer to their previous residence. 26 University of Ghana http://ugspace.ug.edu.gh 2.3 RELATIONSHIP BETWEEN HEALTH INSURANCE AND ACCESS TO HEALTHCARE Further studies have shown that health insurance has a direct relationship with financing of healthcare. In other words, health insurance influences community members' financial access to healthcare. It empowers insured community members to be able to afford medical care without directly paying out o f pocket at the point of illness. Researches have established that in developing countries where health insurance exists, access to healthcare is higher for insured patients than the non-insured. This is because enrolment in health insurance does offer households and community members income protection for serious health issues. A study conducted by Sulzbach et al. (2005) in six districts in Ghana: Nkoranza, Kwahu South, Ahanta West, Ajumako Enyan Essiam, Offinso, and Savelugu/Nanton, shows that uninsured respondents paid 10 - 20 times more for inpatient care than did insured respondents. Findings for maternity care payments were similar - insured women paid 3 - 5 times less for deliver)- care than did uninsured women. The research further reveals that health insurance enrolment was the most important predictor of being able to afford hospital care. According to their respondents, enrolment protected them from being detained in hospitals due to inability to pay the bills. Marginal insurance effects were found in relation to prenatal care, but insured women in Nkoranza were significantly more likely to deliver by caesarean. The combined effect of insurance enrolment and complicated deliver) provided protection from high out-of-pocket payments. 27 University of Ghana http://ugspace.ug.edu.gh Kaiser (2005) conducted a Health Insurance Survey in South Africa in 2003 to examine people's expectations and priorities for their healthcare coverage, attitudes towards employer-sponsored insurance and opinions about several alternative health insurance plans which were under consideration at the time. The research revealed that a large majority of elderly adults said that the most important reason to have insurance was to protect against medical bills (71%), rather than pay everyday health expenses. Similarly, nearly six in ten (57%) insured adults under age 65 years said they felt well protected by their insurance plan while nearly four in ten (38%) said they worried that they may have healthcare need that would not be covered by the health insurance scheme. Access to health insurance has been found to improve access to healthcare and has significant influence in developed countries. In a research on the response to health insurance by previously uninsured rural children in a school-based health insurance programme in Mississippi Delta, Tilford et al. (1999) found that the use of services increased. According to Fong (1999), in a research conducted on the influence of health insurance on non-urgent paediatric visits to the emergency department at the Children’s Hospital. Harvard Medical School. Boston, paediatric patients with private health insurance were more likely to present for emergency care for non-urgent reasons compared to the non­ insured. Also, research conducted by Lillard et al. (1999) on insurance prescription drugs and its effects on use and expenditures in a Medicare population in the United States showed University of Ghana http://ugspace.ug.edu.gh that insurance coverage for prescription drugs significantly increases the probability of use, but not total expenditures, among those who use prescription drugs. In another study o f health insurance and access to medical carc by children with special health needs, Aday et al. (1993) found out that in general, poor, minority children who lived with their mother or someone other than their parents, or those without insurance or an identifiable regular medical provider, were most likely to experience financial barriers to access healthcare, or were less apt to seek care than other children with comparable need. Sox et al. (1998) in a study o f the role of insurance in hospital admissions through the emergency departments in Boston and Cambridge, Massachusetts's academic hospitals concluded that uninsured patients with one o f three common chief complaints appear to be less frequently admitted to the hospital than are insured patients. In his 2004 External Evaluation of Jaman South Health Insurance Scheme in the Brong Ahafo Region, Aikins (2005) observed that access to healthcare in general was the main reason the insured gave for joining the scheme. Sixty percent (60%) of the respondents indicated that they registered because they wanted to have easy financial access to healthcare. In accessing the non-insured financial access to healthcare. Aikins found that 50% of the non-insured respondents fell sick and sought healthcare in 2003. O f these, about 96% were ill for between one to five times. Results indicate that the average health bill of the sick non-insured persons who visited a health facility' was 208,434.82 Cedis (approximately 20.84 Ghana Cedis) per visit. The highest cost was incurred al the pharmacy followed by clinic, hospital or health centre. His farther 29 University of Ghana http://ugspace.ug.edu.gh analysis by comparing these average bills to the scheme premium indicates that the average cost at the drug store is 18 times compared to the premium, 13 limes that of the clinic. 9 times the hospital cost incurred and 8 limes cost incurred at the community health centre. This shows a relatively high cost incurred by non-insured per visit compared to the one off payment of annual premium by the insured which entitles them to an unrestricted number o f healthcare any time of the year. In his research conducted in the Thies Region of Senegal to find out whether community based health insurance schemes improved poor people's access to healthcare in rural communities. Jutting (2003) concluded that the members o f les mutuelles de same (mutual health organizations) have a higher probability of using hospitalization services than non-members and pay substantially less when they need care. He observed how effective a health insurance scheme can work even in poor environments. With particular reference to the inhabitants o f Fandene. he observed that they had better access to healthcare, mainly due to the relatively short distance to hospital and a well-functioning scheme. The result was that members of the scheme sought healthcare more often than non-members do. Jutting concluded that in an area where most people were deprived of access to healthcare of good quality, the introduction of health insurance schemes can make a substantial difference. While low-cost, high frequency events are covered within the extended family, the risk of hospitalization is shared by the larger community. This has a potential positive eflect on the ability of households to smooth their consumption, on labour supply and labour productivity and on the health status of the people insured. 30 University of Ghana http://ugspace.ug.edu.gh 2.4 MOTIVATION FOR OPERATION AND SUBSCRIPTION TO HEALTH INSURANCE SCHEMES Research has shown that people operate and/or subscribe to health insurance schemes for many reasons, one of which is to have financial access to healthcare. Access to health insurance promotes access to healthcare which is a major tool to fight against poverty'. Access to healthcare brings about good health which boosts labour productivity, educational attainment and income and so reduces poverty'. A country's economic development is closely interrelated with the health status o f its population and efficient and equitable healthcare system is therefore an important instrument in breaking the vicious circle of poverty and ill health (Ahuja and Jutting, 2003). Akins (2005) indicates in his Evaluation o f Jaman South Health Insurance Scheme that access to healthcare in general was the main reason that the insured gave for joining the Scheme: easy financial access (50%) and easy access to healthcare (10%). The other reasons were security against illness (32%) and good quality' healthcare (6%). There is a concern about insulating the poor from any possible adverse consequences of cash-and-carry system of healthcare financing. As a result, health insurance is increasingly being recognized as a tool for financing healthcare provision in low- income countries. Of all the risks facing poor households, health risks probably pose the greatest threat to their lives and livelihoods. A health shock thrusts health expenditure on a poor household precisely at a time when they can ill-afford it due to income shortfall resulting from the shock (Ahuja and Jutting, 2003). Also, the uncertainty of the timings of illness and unpredictability o f its costs make financial provision for illness difficult for households receiving low and irregular income 31 University of Ghana http://ugspace.ug.edu.gh (Tenkorang, 2001). Given the strong link between health and income at low income levels, a health shock affects the poor the most (Peters et al., 2002). Many health risks such as those relating to illness, injury, disability, maternity and the like are considered to be eminently insurable as these risks are mostly independent or idiosyncratic, that is. not correlated among community members. Also, insurance separates time of payment from time of use of health services for each member, and thereby makes possible demand for such services by its members who would not have otherwise been able to afford the cost. Insurance is particularly beneficial to the poor who often bear high indirect costs of treatment due to their limited ability to mitigate risk on account of imperfect labour and credit markets (Ahuja and Jutting, 2003). Furthermore, most health insurance schemes operated in developing countries especially community-based health insurance schemes are considered to be pro-poor as they strengthen the demand side and thereby help the poor to articulate their own needs (Develtere and Fonteneau 2001). Thus, the potential benefit of these schemes is seen not just in mobilizing resources but also in improving and organizing healthcare services. Health insurance helps to cut down on out-of-pocket expenses. It helps to pay one’s health expenses and reduces financial hardship on the family . It serves as protection as most people are not financially prepared for the costs that occur when something goes wrong. People with health insurance are more likely to go to the hospital before their condition worsens and becomes more expensive to treat. People with diabetes, for instance, who do not have health insurance, have a higher mortality rate than people 32 University of Ghana http://ugspace.ug.edu.gh who have diabetes and health insurance. The rationale for the current wave of promotion of health insurance schemes in Africa is based on two main factors. First, the recognition that for African households, financial accessibility to quality healthcare is a strongly felt need. Second, the success of the Western European experience of social health insurance, initiated through small community health insurance schemes at the end of the I9lh and beginning of the 20,h century', suggesting that the financing of healthcare based on pooling of resources and risk-sharing may constitute a relevant policy option for African healthcare systems (Ba "mighausen and Sauerbom, 2002). The rationale for the establishment of the NHIS is to help residents in Ghana to have access to affordable healthcare. Since its operation in 2004. the NHIS has chalked successes. All across the country, the over 14,282,620 registered card bearing members of the scheme constituting some 69.73 percent of the population (2004 base population estimates) are getting treated without paying anything at the point o f use. for conditions that would have cost them millions of Ghana Cedis, under the former ‘Cash and Carry " system. Thousands of women receive free maternal and child care under the free maternal programme. Women undergo fibroid operations and breast and cervical cancer treatment with their NHIS cards as ‘Visa To Free Health Care". Men, especially those in rural areas who had long suffered from hernia get treated at no other cost than their transport to and from the health facility. People with chronic debilitating diseases such as diabetes testify to the immense benefits o f the scheme as they pay next to nothing towards the high cost of medication for various ailments (NHIA. 2010). The NHIS has come to be accepted by Ghanaians as one of the best social intervention programmes to be introduced in this country. Statistics gathered by the Research and 33 University of Ghana http://ugspace.ug.edu.gh Development (R&D) and the Operations Directorates of the National Health Insurance Authority indicate that, as at the end of November 2009, 14,282,620 Ghanaians were registered with the 145 District Mutual Health Insurance Schemes operating the country's healthcare system. The main motivation is to access to quality and affordable healthcare (NHIA, 2010). 2.5 CHALLENGES FACING HEALTH INSURANCE SCHEMES The existing health insurance schemes in developing countries, mostly community based, have limited resource mobilisation. Although, the resource mobilisation effected by way o f members' contributions varies greatly across schemes, majority- of schemes depend crucially on external funding for their sustainability. Likewise, although the schemes appear to extend coverage to low income populations who would otherwise be excluded from the benefits, the poorest o f the poor are not covered by the schemes (Jutting, 2001). Several studies on health insurance particularly community based health insurance schemes have reported the presence of adverse selection and moral hazard problems. Adverse selection problem arises when a person who anticipates needing medical treatment choose to buy insurance more often than others, resulting in higher insurance premium which drives out those persons who anticipate needing less medical treatment from the scheme. Adverse selection problem by limiting the membership and thereby the size of risk pool reduces the scope for risk diversification which tends to affect their financial sustainability (Ekman. 2001). In the context of CBHI schemes, the adverse selection problem arises not so much due to lack of information about risk probabilities to the insuring agency but because ol the need to keep insurance contract simple. The 34 University of Ghana http://ugspace.ug.edu.gh simplicity objective overrides efficiency objective, which prevents the insuring agency to charge differential premium and instead bases premium on community rating (Ahuja and Jutting. 2003). The moral hazard problem arises because of the tendency of individuals to behave, once they are insured, in such a w'ay as to increase the likelihood or size of the risk against which they have insured (Criel, 1998). Moral hazard problem too has implication on financial sustainability of a scheme, but in addition, it also has implications for costs of provision of such services. The moral hazard problem is of two kinds: ex ante moral hazard and ex post moral hazard problem. The ex ante moral hazard problem arises due to reduced care of health after joining a scheme. The ex post moral hazard problem arises due to over-consumption of medical services. The over­ consumption may be the result o f provider’s behaviour or due to patient's behaviour. When it comes to providing health insurance to the low income people through micro- insurance we argue that it is the ex ante rather than ex post moral hazard problem that is dominant and serious. Where supply of health care services is scarcer and is distributed among many people who demand such services, its over-consumption is unlikely to assume any serious proportion. Therefore, ex post moral hazard problem in low income communities is unlikely pose any great difficult in design of health insurance. Furthermore, in a low-income society there is considerable scope for risk reduction which does not take place due to lack of health information such as basic hygiene sense, cause-effect relationships, and preventive measures. Even where such know ledge exists, or is provided, the difficulty is in motivating the people to follow such advice. The challenge instead is of encouraging preventive and promotive care among people. 35 University of Ghana http://ugspace.ug.edu.gh which is a precondition for making health insurance viable and affordable (Ahuja and Jutting, 2003). In operating health insurance schemes in communities, the sustainability issue, which is affected by the quality and the size of risk pool, is not faced directly by the individuals (members) who participate in the scheme. The sustainability issue is faced by the organisers and by the scheme managers. The organisers need to provide incentives to managers for economising the costs. Broadly, there are three types o f costs faced by the managers of a scheme. The first relates to the claims cost that has a direct relation with the number of scheme members. The second relates to certain administrative expenses such as paying commissions for collecting premium from old and new members. These costs also vary with the number of members. Finally, there are certain fixed costs incurred for starting a scheme, referred to as start-up costs (Ahuja and Jutting, 2003). Often, lack of ability of the people to pay full insurance premium is considered to be the rational for providing external funding or subsidies. While there is no denying the fact that health insurance schemes in developing countries need some external funding or subsidies, the form that such funding or subsidies take can make or mar the performance and hence the sustainability of a scheme. These considerations, however, contrast with two pieces of empirical evidence. Participation of African households in health insurance schemes particularly community based remains limited notwithstanding a few isolated successes (Waelkens and Criel. 2004). Another challenges health insurance schemcs encounter is the political dimension. Is the development of solidarity-driven arrangements for healthcare financing really a 36 University of Ghana http://ugspace.ug.edu.gh political concern and a priority in the longer term? Do public authorities at local and central level have the political will to subsidize health insurance schemes and eventually to institutionalize the transfer of funds from richer to poorer population groups? Are they willing to go beyond lip service in that respect? If the political leaders are committed to supporting health insurance schemes, the schemes will be sustainable and vice versa. In the case of Tanzanian Community Based Health Insurance Scheme, the government, with the financial assistance of the Word Bank, tops up the revenues of the Fund by allocating subsidies equivalent to the members’ contributions (Chee et al., 2002). The case of China also is illustrative. In the frame of the ‘New Medical Cooperative System’, the central and local government each committed to pay 10 RMB Yuan in the insurance fund, in addition to the 10 RMB Yuan to be paid by the beneficiary (United Nations Theme Group for Health-Partners. 2003). The economic dimension poses a serious challenge to community members in their attempt to subscribe to health insurance schemes. Community members may be willing to join health insurance schemes but may not have money to pay for the premium. The question is whether there is a sufficient level of purchasing power for people to pay a financial contribution to health insurance schemes that cover, albeit only partially, the healthcare expenditure o f the insured group? Or is the household income level so critically low that the pre-payment of funds for possible future healthcare is not y e t or no longer, a realistic option in the light o f the numerous other basic needs people have to address? People’s economic background in terms of finances tends to affect enrollment and development of health insurance schemes (Ahuja and Jutting. 2003). 37 University of Ghana http://ugspace.ug.edu.gh Social dimension in terms of people’s interest and trust in the scheme administration also poses a challenge to health insurance schemes. Solidarity implies a certain level of shared identity and common interests; hence the need for a sufficiently strong social fabric. It is worth asking whether there is enough trust in local leaders and institutions such as health insurance schemes? Or is the collective experience with previously implemented financial arrangements to fund the costs of healthcare (or other basic needs for that matter) such that the necessary trust in such operations is jeopardized? In many cases, health insurance schemes collapsed because people refused to renew their membership in health insurance schemes because they had lost confidence in the management of the scheme (Ahuja and Jutting, 2003). Managerial and technical dimensions which look at the knowledge and skills in the operation of health insurance schemes and the quality of care provided tend to affect enrolment, membership and development o f the scheme. Thus, if the (perceived) quality o f care offered in the health services is sufficient to motivate people, they will surely purchase health insurance. In the case of African healthcare delivery systems, quality of care is not satisfactory; and in most cases health professional do not view health insurance as an opportunity for their professional development. In some circumstances, there is insufficient knowledge and skills among promoters of health insurance schemes. The schemes tend to lack innovations and there is so much bureaucracy in the health systems which oppose attempts to introduce well thought-out strategies for change and development (Jaffre' and Olivier, 2003). In a Guinea Community Based Health Insurance Scheme for instance, people generally distrusted initiatives taken by public authorities; the quality of care was reputed to be poor; premiums were not subsidized and large households had problems with paying them; 38 University of Ghana http://ugspace.ug.edu.gh and attempts to introduce change were viewed by the managers as a burden, or even a threat. (Haddad et al., 1998; Criel & Waelkens, 2003). The literatures reviewed above share many things in common. They indicate that the cost o f medical care can serve as a barrier to access healthcare. Even in developed countries, cost o f medical care prevents many people from accessing healthcare. There have been several cases of financial barriers in places where fee-for-service exists. The literatures also indicate that in developing countries where health insurance exists, access to healthcare is higher for the insured than the non-insured. Membership of health insurance scheme is an important predictor o f being able to afford medical care. The insured avoid the incidence of detention in hospitals for inability to pay their bills. The non-insured on the other hand have to pay out o f pocket at the point seeking healthcare. Financial access to healthcare has been the main motivation for joining a health insurance scheme. For the non-insured, their main reason for not joining health insurance schemes is that the premium and the registration fees are too expensive. 2.6 SUMMARY OF LITERA TURE REVIEW 39 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE HEALTHCARE DELIVERY IN GHANA 3 .I HISTOR Y OF HEALTHCARE DELIVER Y S YSTEM IN GHANA After independence in 1957. health services were offered free of charge in Ghana through public health facilities. Healthcare was financed solely from government tax revenues. There were no direct out-of-pocket payments in accessing health facilities. However, with a decline in the economy, it became difficult to sustain the free healthcare system. In the light of the needs of other sectors o f the economy, the government had to find alternatives to this health financing mechanism (Sulzbach et al., 2005). In the later part of the 1960s, nominal fees were introduced, but these proved insufficient to meet the needs of the health sector. In 1969, government introduced user fees when the first law. Hospital Fees Decree, 1969 (NLCD 360), was enacted enabling the collection of fees for health services. In later years, many other health laws were passed including the Hospital Fees Decree 1969 (Amendment) A ct 1970 (Act 325), the Hospital Fees Act of 1971 (Act 387) and their resultant Legislative Instruments particularly the Hospital Fees Regulation 1985 (LI 1313) which brought about a nation­ wide fee-for-service system. The Hospital Fees Regulation of 1985 (LI 1313) mandated fees to be charged for consultation, laboratory and other diagnostic services, medical, surgical and dental services, medical examinations and hospital accommodation. This marked the introduction of full cost recovery for drugs and medication known as "cash and carry". For health management this was interpreted as cost of replenishment (Adams, 2002). 40 University of Ghana http://ugspace.ug.edu.gh The effect of the cash and carry was a considerable decline in the utilization of health services in Ghana (Waddington and Enyimayew, 1989). In order to address the shortage of drugs, the government went ahead to push the cost recovery for drugs to the consumer. The implementation of the cash and carry system compounded the problem o f utilization, creating some financial barrier to healthcare access especially for the indigent in the community. The obvious explanation is as a result o f the falling economic growth and the numerous problems the government faced in financing health services. The introduction of the user fee affected the utilization of health services significantly. People resorted to self-medication and other means of curing diseases, and forgot about medical providers. It resulted in an enormous drop in the use of health facilities. Nationally, outpatient utilization fell from 4,468,482 in 1984 to 1,607,386 in 1985 and 2,051,501 in 1986 (Dakpallah, 1988). These confirm the effect o f poverty on utilization of health facilities. Various studies establish that poverty' is a predominant factor in utilization. High cost of services scare people away from seeking healthcare, and the worst affected people are low-income earners (Delanyo et al.. 1992). In order to cushion the burden o f out-of-pocket payment for healthcare, the government introduced an exemptions policy. The policy exempted children under the age of five, prenatal care for pregnant women, and healthcare for the indigent, the elderly (those above 70 years), and for disease-specific services. However, implementation problems at the district level meant that a significant number of clients who qualified for exemptions continued to face barriers in accessing basic healthcare. For example, in some hospitals, decision making was decentralized and exemption practices were 41 University of Ghana http://ugspace.ug.edu.gh inconsistent, so that exemptions would be granted for some but not for all services (Atim et al., 2001). Thus, exemptions could not alleviate the serious consequences of cash and carry on the poor. As a result, the government commissioned various studies into alternatives, principally insured-based ones. Initially, a lot of efforts were invested into investigating the feasibility o f a national health insurance scheme. Proposals to set up and run a national health insurance scheme (NHIS) were made in the early 1980s. Various experts were contracted by the Ministry o f Health (MOH) to study and make recommendations for setting up and running a national health insurance organization. The International Labour Organization (ILO), World Health Organization (WHO), European Union and London School o f Hygiene and Tropical Medicine all provided technical advice at the request of the Ministry. In August 1985, the MOH received definite proposal from a private consultancy group in a report entitled “A Feasibility study for the establishment of a National Health Insurance Scheme in Ghana”. The study proposed that a centralized National Health Insurance Company should be set up to provide a compulsory “Mainstream Social Insurance Scheme" for (i) all contributors to the Social Security and National Insurance Trust (SSNIT) and (ii) all registered cocoa farmers. The report also recommended pilot “rural-based community-financed schemes” for the non-formal sector but gave no further details or indication as to how the MOH was to do this. The major emphasis of the report was on the NHIS (Aikins. 2005). These problems prompted some healthearc facilities, championed by mission hospitals, to introduce insurance schemes managed jointly by the facility and the community as a 42 University of Ghana http://ugspace.ug.edu.gh strategy to avoid the problems associated with paying for services at the point of care (i.e. user fees). Thus, the oldest Mutual Health Insurance Schcme is at Nkoranza. St. Theresa’s Mission Hospital, in the Brong Ahafo Region which was established in 1989 (Atim et al., 2001). In 1997. the NHIS pilot project was formally launched in the Eastern Region, w-ith the view to covering four districts - New Juaben, Suhum/Kraboa/Coaltar, South Birim and South Kwahu. The objectives were stated in the presidential sessional address of that year as “ ... the National Health Insurance Scheme will contribute to resolving the cost o f healthcare. This year, a pilot insurance scheme will be implemented in the Eastern Region to test the work done so far. Its performance will be studied as well as the performance o f existing rural health insurance schemes ... so that problems can be identified and eliminated before implementation begins on a national scale” (Aikins, 2005).' In this regard, a National Health Insurance Scheme Secretariat wfas set up to undertake the preparatory work and to implement the NHIS programme. The NHIS Secretariat worked towards a nationwide extension of the pilot scheme by providing the needed public education and producing educational materials including relevant brochures and pamphlets. Soon after, the implementation of the pilot scheme stalled amid general debates about the strategic direction of health financing policy and the pilot scheme in particular. There was no consensus among the technocrats at the MOH about a government-run insurance schcme, and it seemed no need that it was only a small minority of them that favoured such a strategy (Atim et al., 2001). Aikins. M oses (2005). Jamun South Health Insurance Schcme. External 1-valuation. 2004. Accra: (Jncck M agazine Publications. P. 14. 43 University of Ghana http://ugspace.ug.edu.gh In late 1996, the MOH began designing a health insurance scheme for the non-formal sector in the Dangme West District. A lot of work was put into thinking through the design o f the scheme, consulting with community members and the district assembly as well as health providers. The European Union (EU) provided some financial support for this phase o f the work through the London School of Hygiene and Tropical Medicine. The scheme implementation started in October 2000 with the first insurance year running for a 12-month period from I*' October 2000 to 30lh September 2001 (DWHIS. 2003). A number o f health insurance schemes were established, which became models for other communities to replicate. The subsequent growth in mutual health organizations in Ghana was noteworthy. Whereas 47 MHOs existed in 2001, this number tripled to 159 by 2002, and it continued to rise to 168 by 2003. However, less than 40 percent of MHOs were functional at that time, and the combined total coverage they extended to the population was just one percent (Atim et al., 2001). Recognizing the problems that the cash and carry system posed to accessing healthcare, the government of Ghana declared its intention to abolish out-of-pocket payment for healthcare at the point o f service and replace it by health insurance. This approach takes cognizance of the fact that uptake of health insurance is dependent on the willingness of individuals to subscribe to it and also the attractiveness of the benefit package. Thus the implementation of the health insurance scheme would be a gradual process (Akor, 2002). 44 University of Ghana http://ugspace.ug.edu.gh 3.2 INTRODUCTION OF THE NATIONAL HEALTH INSURANCE SCHEME 3.2.1 The National Health Insurance Act In August 2003. the government of Ghana moved from planning to action by passing the National Health Insurance Act 2003 (Act 650). The primary goal o f the National Health Insurance Scheme is to improve access to and quality o f basic healthcare services in Ghana through the establishment of mandatory Mutual Health Organizations or district-wide insurance schemes. It spreads risks of incurring health costs over a group of subscribers. Thus, the larger the subscribers the lower the risk burden on the individual. The schemes is meant to assure equitable universal access to quality basic package of health services to all residents in Ghana without being required to pay out-of-pocket at the point of consumption of service. The long term objective is that within five to ten years every resident in Ghana will belong to a health insurance scheme that adequately covers him or her. The scheme is therefore guided by the principles of equity, risk equalization, cross-subsidization, quality care, efficiency in premium collection and claims administration, community or subscriber ownership, partnership and reinsurance. Ultimately, the scheme is intended to pool risks, reduce the individual burden and achieve better utilization rates, as patients do not have to pay out-of-pocket at the point of health delivery (Ministry of Health. 2004). 3.2.2 The Establishment of NHIS Council In addition to providing guidelines on the structure for the district insurance schemes, the HI Act 650 provides the legislative framework for the establishment of a regulatory body, the National Health Insurance Council (NHIC), to see to the implementation of a 45 University of Ghana http://ugspace.ug.edu.gh national health insurance policy that ensures access to basic healthcare services to all residents. The responsibility of the NHIC among others is to register, license and regulate and supervise health insurance schemes. It has the role of granting accreditation to healthcare providers and monitoring their performance; and to ensure that healthcare services rendered to beneficiaries of schemes by accredited healthcare providers are of good quality. It also determines, in consultation with licensed district mutual health insurance schemes, contributions that should be made by their members. The Council is mandated to approve health identity cards for members of schemes and to provide a mechanism for resolving complaints by schemes, members of schemes and healthcare providers. Also, it is the role of the Council to ensure that the basic healthcare needs of indigents are adequately provided for, and to manage the National Health Insurance Fund established under Part VI o f the Act. 3.2.3 Types o f Health Insurance Schemes The Act establishes three types of health insurance schemes: district mutual health insurance schemes, private commercial health insurance schemes, and private mutual health insurance schemes. Each scheme is to be registered and accredited by the Council. In the case of a district mutual and private mutual health insurance scheme, it is registered as a company limited by guarantee whilst a private commercial health insurance scheme is registered as a limited liability company under the Companies Code 1963 (Act 179). The Act mandates district assemblies to establish social or mutual health insurance schemes for the welfare of the residents of the district. It should enrol the residents into 46 University of Ghana http://ugspace.ug.edu.gh its membership through a specified contribution called premium and operate exclusively for the benefit of the members. The National Health Insurance Regulations 2004 (LI 1809) give exemption from payment on the basis of age. It states clearly in Regulation 56 that a person is not required to pay any contribution to a District Mutual Health Insurance Scheme if the person is: under eighteen years o f age and both parents or guardians are contributors; under eighteen years of age and whose parent or guardian is a contributor who has been proven by the scheme to be a single parent or guardian: a pensioner under the SSNIT scheme or someone who is seventy years or more. A child enjoys the minimum benefits as a dependent, and in the case of a person of seventy years of age or above, the person enjoys the minimum benefit under the scheme which s/he is a member in their own right. The indigent classified as a person who is unemployed and has no visible source of income; who does not have a fixed place of residence according to standards determined by the scheme; who does not live with a person who is employed and who has a fixed place of residence; and who does not have any identifiable consistent support from another person, who is not required to pay any contribution to the DMHIS. Besides the contribution by members of the scheme, a district mutual health insurance scheme shall be provided with subsidy from the National Health Insurance Fund. This implies that even though DMHIS is an independent organization, it operates within a framework of tight government regulations. 47 University of Ghana http://ugspace.ug.edu.gh The Act adds that a body corporate registered as a limited liability company under the Companies Code 1963 (Act 179) may operate as a private commercial health insurance scheme. Its membership may be open to all who wish to enrol. It is a business venture and as such cannot receive subsidy from the National Health Insurance Fund. It is also required as a condition for registration and licensing by the Council, to deposit a specified amount of money, as security deposit, with the Bank of Ghana. The contribution o f members may be determined by the governing body o f the scheme and shall be paid in such a manner and at such time as the governing body of the scheme shall determine. According to the Act, any group of persons resident in the country may form and operate a private mutual health insurance scheme. The scheme will be operated exclusively for the benefit of the members who contribute to the scheme and provide the members with such health benefits as the governing body of the scheme may determine. 3.2.4 Diseases and Drugs covered by the Scheme The National Health Insurance Regulations, 2004 (LI 1809) spells out the regulations guiding the registration and operations of all health insurance schemes. In addition, it provides the minimum healthcare benefits for the insured. The healthcare services specified in this part are the minimum healthcare benefits under the national health insurance scheme and shall be paid for by the schemes. They include out-patient services, in-patient services, oral health services, eye care services, maternity care and emergencies explained below: 48 University of Ghana http://ugspace.ug.edu.gh Out-Patient Services Out-patient benefits cover consultations which include review of both general and specialist consultations. Out-patients benefit from requested investigations including laboratory services, x-rays and ultrasound scanning; medication, namely, prescription drugs on National Health Insurance Scheme Drugs List, traditional medicines approved by the Food and Drugs Board and prescribed by accredited medical and traditional medicine practitioners; HIV/AIDS symptomatic treatment for opportunistic infection; out-patient/day surgical operations including hernia repairs, incision and drainage, haemorrhoidectomy. and out-patient physiotherapy. In-Patient Services In-patient services cover general and specialist in-patient care; requested investigations including laboratory investigations, x-rays and ultrasound scanning for in-patient care; medication, namely, prescription drugs on National Health Insurance Scheme Drugs List, traditional medicines approved by the Food and Drugs Board and prescribed by accredited medical and traditional medicine practitioners, blood and blood products: cervical and breast cancer treatment; surgical operations; in-patient physiotherapy, and accommodation in general ward. Oral Health Services In oral health services category, the scheme covers pain relief services, which includes incision and drainage, tooth extraction and temporary relief, dental restoration which includes Simple Amalgam Fillings and Temporary Dressing. 49 University of Ghana http://ugspace.ug.edu.gh Eye Care Services The eye services include refraction; visual fields; A-Scan; keratometry; cataract removal, and eye lid surgery. Maternity Care It covers antenatal care; deliveries, namely, normal and assisted; caesarean section; postnatal care. Emergencies All emergencies shall be covered. These refer to crisis health situations that demand urgent intervention and include medical emergencies; surgical emergencies including brain surgery due to accidents; paediatric emergencies; obstetric and gynaecological emergencies including caesarean sections; road traffic accidents; industrial and workplace accidents; dialysis for acute renal failure. In addition, certain health services are free for everyone, namely free public health services, which comprise immunization; family planning; in-patient and out-patient treatment of mental illnesses; treatment of tuberculosis, onchocerciasis, buruli ulcer, trachoma; and confirmatory HIV test on AIDS patient. 3.2.5 Accessing Health Services under the Scheme According to the NHIS Regulations, 2004 (LI 1809), the first point of attendance, with the exception of emergencies, shall be a primary healthcare facility, which includes Community-based Health Planning and Services (CUPS), Health Centres, District 50 University of Ghana http://ugspace.ug.edu.gh Hospitals, Polyclinics or Sub-metro Hospitals, Quasi Public Hospitals, Private Hospitals, Clinics and Maternity Homes. In localities where the only health Facility is a Regional Hospital, the General patient department shall be considered a primary healthcare facility. All healthcare services provided in these facilities shall be paid for by the District Mutual Health Insurance Schemes (DMHIS). In cases w'here the services are not available, all referred cases other than those in the Exclusion List shall be paid for by DMHIS. Emergencies shall be attended to at any health facility. 3.2.6 Exclusion List The NHIS Regulations, 2004 (LI 1809) also gives an exclusion list. The healthcare services specified in the list are not covered under the minimum benefits available under the National Health Insurance Scheme. However, health insurance schemes may decide to offer any of these as additional benefits to their members. According to the Legislative Instrument (LI 1809). the following diseases are not covered under the health insurance scheme and therefore fall under the exclusion list: rehabilitation other than physiotherapy; appliances and prostheses including optical aid, hearing aids, orthopedic aids, and dentures; cosmetic surgeries and aesthetic treatments; HIV retroviral drugs; assisted reproduction e.g. artificial insemination and gynaecological hormone replacement therapy; echocardiography; photography; angiography; orthoptics; dialysis for chronic renal failure; heart and brain surgery other than those resulting from accidents; cancer treatment other than cervical and breast cancer; organ transplantation; all drugs that are not listed on the NHIS Drug List; 51 University of Ghana http://ugspace.ug.edu.gh diagnosis and treatment abroad; medical examinations for purposes of visa applications, educational, institutional, driving license; VIP ward (accommodation); and mortuary services (LI 1809). 52 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESEARCH METHODS 4.1 APPROACH TO THE STUDY The study adopts both quantitative and qualitative methods. Quantitative implies an emphasis on processes and meanings that are rigorously examined or measured in terms o f quantity, amount intensity' or frequency, whereas qualitative focuses on interactive processes and events, and seeks answers to questions that stress how social experience is created and given meaning (Kreuger and Neuman, 2006). In order to obtain high validity, the research adopts strategies which include direct interviews, fast transcription of notes prepared in the interviews, and seeking cases of invalidation and triangulation. Triangulation is the combination of different data collection methods and multiple informants to illuminate the same thematic issue (GSS & MI. 1999). The use of multiple data collection methods and informants increase validity'. A good relationship developed with the target population was inevitable to help get reliable data for computation and analysis. 4.2 SAMPLING PROCEDURE 4.2.1 Target Population The population of Abokobi community is 1,313. The size of the target population is 750 people, which is 57% of the entire population (GEDA, 2007; GDMH1S. 2009). It includes all persons living in the community of Abokobi who are 18 years and above, both insured and non-insured. The GDMHIS and two health institutions representing 53 University of Ghana http://ugspace.ug.edu.gh the accredited health providers were also involved in the study to assess the operations o f the scheme and the services provided by the accredited health institutions. The study also involved opinion leaders, the chief and eiders of Abokobi. as well as the District Assembly and the Presbyterian Church at Abokobi. 4.2.2 Sample Frame It includes the list of people who are 18 years and above in Abokobi town. A separate list o f the insured was obtained from the GDMHIS. Thirty four people including the staff of the GDMHIS, Accredited Health Providers (AHP), Ga East District Assembly, and community members and opinion leaders were also involved in the study. 4.2.3 Sampling Technique The study made use of both quantitative and qualitative methods. The quantitative method used was a simple random probability sampling to draw a representative sample from the insured and non-insured community members. A simple random probability sampling was used in order to save time and cost and mostly to ensure accuracy. The qualitative method used was a purposive non-probability sampling to select people for Focus Group Discussion (FGD), in-depth and key informant interviews (Kreuger and Neuman. 2006). In order to select the sample size, a simple random sampling method was used. The numbers in the population were numbered from 1 to 750, five hundred (500) insured and 250 non-insured. Since there arc 750 members in the population, three digits were taken in order to give everyone the chance of selection. Thus, the range is from 001 to 54 University of Ghana http://ugspace.ug.edu.gh 750. A research assistant was asked to close her eyes to pick a number and she picked 10. Thus every 10lh member of the target population was selected for the interview. In all. a sample size of 75 adult community members was selected. Approximately, 788 people out of the estimated population of 1,313 have been registered with the NHIS. That represents 60% of the entire population. Out of the insured population, two hundred and eighty-eight (288) were children of 17 years and below representing 37%. That means 500 (63%) were registered adults (GDMHIS, 2009). The researcher and the assistants used the list of the insured with their names, gender and age, ID card and house numbers obtained from the GDMHIS to interview every 10lh insured member. Out of the list o f 500 insured members, 50 people were selected. The researcher and the assistants compiled a list of the non-insured adults in the community with the assistance of the catechist and the assembly member who is also the chairman of the board of GDMHIS. Out o f the 250 non-insured adults. 25 were selected using a simple random method. Thus every 10111 non-insured adult was selected for the interview. A purposive non-probability1 sampling method w»as used to select people for the Focus Group Discussion (FGD). These participants were purposively chosen on the basis of their in-depth knowledge in the research area and experience with the target population. A special permission was sought from each and every member of the group three months before the discussions could be held. 55 University of Ghana http://ugspace.ug.edu.gh Also, a purposive non-probability sampling technique was used to select individuals for key informant interviews. They included insured and non-insured community members, health personnel, staff from the Ga East District Assembly and officials from the NHIS. This method considered people who are abreast with the topic and willing to share their views. As a result, these individuals were officially consulted before they availed themselves for the interview. Finally, the GDMHIS and the accredited health institutions provided personnel from their outfits to assist in the study. They were purposively selected by their respective administrators or managers. 4.2.4 Sample Size The study sampled 75 people from the target population of Abokobi. In addition, nine health personnel were involved in the research - three people representing accredited public health facilities, three representing private health providers and three from accredited pharmacies. Four NHIS officials and two stafT members from the Ga East District Assembly helped in the study. The study also made use o f nine key informants, and sought information from ten opinion leaders including the chief and elders, and the leaders of the Presbyterian Church at Abokobi. In all, 109 people were involved in the study. 56 University of Ghana http://ugspace.ug.edu.gh 4.3 PRIMARY DATA COLLECTION INSTRUMENTS The research adopted both quantitative and qualitative methods for primary data collection. The quantitative research instruments used were structured face-to-face interview schedules and questionnaires which were both pre-coded and open ended. The Focus Group Discussion (FGD) and key informant interview were the main qualitative research instruments used. 4.3.1 Face-to-Face Interview Face-to-face interview method was used as a research instrument to solicit information from the insured and non-insured. Interview is a method of field investigation whereby the researcher meets his respondents and through the interaction, he/she asks specific questions to find answers to the research problem (Twumasi, 2001). An interview schedule was prepared for both the insured and non-insured. Information was obtained in a structured conversation in which the interviewer asked prearranged questions and recorded answers, and the respondent answered. The questionnaire covers the demographic characteristics of the insured and non-insured, motivation for membership and reasons for non-membership of the scheme, access to healthcare and problems encountered, perception and sustainability of the scheme. The interview schedules for the insured and non-insured are listed in Appendix 1 and Appendix 2 respectively. The face-to-face interview method was used because the pre-survey had shown that a great number of respondents formed a group who had only received basic or primary education, and therefore would not have been able to administer the questionnaires which were both pre-coded and open ended by themselves. The interview method ofTered flexibility as respondents were free to give responses which reflected their true 57 University of Ghana http://ugspace.ug.edu.gh position, and could seek clarifications from the interviewer. It also created an avenue for explanation and probing. The interview ensured high response rate. 4.3.2 Self-administered Questionnaires Self-administered questionnaires were designed for NHIS administration and accredited health providers. The NHIS administration was asked to provide information on the premium, annual enrolment, benefits o f the scheme, access to healthcare, benefits paid to health providers on behalf o f scheme members, working relationship with accredited health providers and requisition for reimbursement, challenges facing the scheme and sustainability of the scheme. The questionnaires for the accredited health providers centred on general questions about their establishment and personnel, payment system, access to healthcare by the insured including outpatient visits and admissions, health providers' benefits, NHIS and financial access to healthcare, problems facing the scheme and recommendations for the sustainability of the scheme. The questionnaires for the NHIS administration and accredited health providers are listed in Appendix 3 and Appendix 4 respectively. The questionnaires were both pre-coded and open-ended. This method was used because the respondents are experts in healthcare system and health insurance issues, and are able to produce the needed information. Moreover, the information sought from them is such that they would have to refer to records and documents and therefore needed enough time to complete the questionnaires. 58 University of Ghana http://ugspace.ug.edu.gh 4.3.3 Focus Group Discussion As part of the qualitative research, a Focus Group Discussion method was used to seek information from elders and opinion leaders of Abokobi. The members o f the group comprised a representative from Abokobi Traditional Council, the Assembly Member, the Reverend Minister, two health personnel from public and private accredited hospitals, a staff member from the GDMHIS, two insured community members and one opinion leader who is not insured. There were nine members who have some identifiable common interests, characteristics, and shared knowledge. It provided a common opportunity for the researcher and the members to discuss issues together and to verify common perceptions and divergent views. This method was cost effective and allowed in-depth exploration into the issues. It has flexibility and high face validity'. It gives an insight into a real life situation in capturing the reality from the group in the actual community. A guiding questionnaire designed for the discussions is listed in Appendix 5. The questionnaire is centred on people’s perception of the scheme and factors that influence access to healthcare, subscription to the scheme and non­ subscription by some community members, problems faced by the insured in accessing healthcare, general problems of the scheme and challenges faced by both the accredited health providers and scheme administration, and improvement in scheme administration and its sustainability. The researcher moderated the discussions while two assistants took notes. 4.3.4 Key Informant Interview In addition, key informant interview method was used to seek pertinent information from three members of the scheme, three scheme officials, three health personnel, two staff members from the district assembly, two non-insured persons and three opinion 59 University of Ghana http://ugspace.ug.edu.gh leaders. The researcher had an interactive discussion with each of them, where he sought information regarding personal experience with the scheme and some of the problems facing it. the relationship between the scheme administration and its members and accredited health providers, and between the assembly and the scheme administration; access to healthcare and problems encountered. Other information sought bordered on community mobilisation and sustainability of the scheme. These individuals have the knowledge of, and ability and willingness to discuss the topic. Unlike the structured face-to-face interview questionnaires, the key informant interviews were more interactive and less structured. 4.4 SECONDARYDA TA COLLECTION Documented literature on healthcare in general and health insurance in particular, official publications, research materials on the topic, materials from WHO. district assemblies, NGOs, MOH and records from health centres, health reports and journals were reviewed. All literatures used have been duly acknowledged. 4.5 DA TA HANDLING The data collected were checked and cross checked to ensure that all questions were well answered. The study made use of simple statistical tools to analyse the data gathered. Among these are the measurements of percentages and ratios that were derived from Statistical Package for the Social Sciences (SPSS). 60 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DATA ANALYSIS 5.1 INTRODUCTION This section analyses and presents the findings of the study based on the objectives. The chapter discusses data collected on health insurance and access to healthcare. It is based on the responses from the insured members, the non-insured, health providers, health insurance scheme officials and community elders and opinion leaders. The results are presented in tables and charts. The demographic characteristics of all the respondents, both the insured and non­ insured, are grouped under one sub-heading. The demographic characteristics are: sex o f respondents, age, marital status, educational background, religious background, ethnic grouping and occupation. Also, the perception o f access to healthcare by the insured and non-insured has been put under one sub-heading. The chapter also analyses the findings from the insured separately from the non­ insured. The data from the insured include the motivation for membership of the NHIS. access to healthcare and problems encountered and the health facility mostly visited by the insured, whereas data on the non-insured capture the reasons for non-membership o f the NHIS, access and utilization of healthcare and source of income for payment of health services. 61 University of Ghana http://ugspace.ug.edu.gh 5.2 DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS The total percentage of females was 51% whereas males represent 49%. The insured females formed 52% whilst the non-insured females represent 48%. The insured and the non-insured males were 48% and 52% respectively. This has been represented in table 5 .1 below: Table 5.1 Sex Sex INSURED NON-INSURED OVERALL TOTAL Frequency Percent­ age Frequency Percent­ age Total frequency Total Percentage Female 26 52% 12 48% 38 51% Male 24 48% 13 52% 37 49% Total 50 100% 25 100% 75 100% SOURCE: FIELD DATA . 2009 Age is another important variable factor for this study. According to the NHIS Regulation Regulations, 2004 (LI 1809), children from age 0-17 years do not pay premium. The child becomes a member of the scheme by paying only the registration fee if the parent or guardian is a member of the scheme. This implies that if the parent or guardian is not a member the child cannot become a member by pay ing only the registration fee. The regulation also states that the aged (70 years and above) do not pay premium. They pay only the registration or administrative fee if they are subscribing for the first time. The study focused on adults who are 18 years and above. The youngest respondent was 20 years whilst the oldest was 78 years. Majority o f the respondents were aged between 29-38 years (27%), followed by ages 18-28 years which represent 21%. Ten percent (10%) of the insured and 4% of the non-insured 62 University of Ghana http://ugspace.ug.edu.gh were 69 years and above. This has been indicated in table 5.2. At age 69, people still pay premium and registration fee in order to become members of the scheme. Among the group o f respondents who were 69 years and above. 2% were 69 years whilst 6% were aged. Moreover. 4% of the non-insured was among the aged group. This person is a private medical practitioner who said that he did not see the need to register. All the aged respondents were insured. They took advantage of the free premium to become members of the scheme. Table 5.2 Age Grouping Age Group INSURED NON-INSURED OVERALL TOTAL Frequency Percent­ age Frequency Percent­ age Total frequency Total Percentage 18-28 11 22% 5 20% 16 21% 29-38 13 26% 7 28% 20 27% 39-48 6 12% 6 24% 12 16% 49-58 8 16% 4 16% 12 16% 59-68 7 14% 2 8% 9 12% 69+ 5 10% 1 4% 6 8% Total 50 100% 25 100% 75 100% SOURCE: FIELD DATA . 2009 For the marital status of respondents, the data indicate that the married respondents are more (45%) as compared to other groups. It was observed that the non-insured married persons (48%) were more than the insured married respondents (44%). The next larger group is the singles who form 27%; thirty two percent (32%) were insured and 16% were not insured. The widowed represent 18% for both the insured and non-insured. The divorced and the separated represent 7% and 3% respectively. Table 5.3 represents this information. 63 University of Ghana http://ugspace.ug.edu.gh Table 5.3 Marital Status Marital Status INSURED NON-INSURED OVERALL TOTAL Frequency Percent­ age Frequency Percent­ age Total frequency Total Percentage Married 22 44% 12 48% 34 45% Single 16 32% 4 16% 20 27% Widowed 9 18% 5 20% 14 18% Divorced 2 4% 3 12% 5 7% Separated 1 2% 1 4% 2 3% Total 50 100% 25 100% 75 100% SOURCE: F IELD DATA , 2009 Another important variable factor is the educational background of respondents. Seven percent (7%) o f all the respondents have no formal education. The total number of respondents with primary education also represents 7%. Majority (40%) o f the respondents both insured and non-insured have attained middle or junior high education, followed by tertiary (21%) and then vocational or technical education (16%). The data indicate that respondents who have attained secondary education form 9%. The insured respondents who have attained tertiary education formed 28% compared to non-insured tertiary graduates w'ho represent 8%. The non-insured graduates were two private medical practitioners who said that they did not see the need to register. It can be inferred that the higher a person's education, the more the opportunities available to the person to become an insured member. Table 5.4 represents this information. 64 University of Ghana http://ugspace.ug.edu.gh Table S.4 Educational Background Educational Background INSURED NON-INSURED OVERALLTOTAL Frequency Percent­ age Frequency Percent­ age Total frequency Total Percentage None 3 6% 2 8% 5 7% Primary 1 2% 4 16% 5 7% Middle School/JSS 21 42% 9 36% 30 40% Technical/ Vocational 7 14% 5 20% 12 16% Secondary 4 8% 3 12% 7 9% ! Tertiary 14 28% 2 8% 16 21% Total 50 100% 25 100% 75 100% ; SOURCE: FIELD DATA , 2009 Furthermore, the respondents have three main religious backgrounds. The main religions are Traditional which is 4%, Christian religion 95% and Islamic religion 1%. The insured Christians represent 96% whereas the non-insured Christians form 92%. The insured traditional religious believers form 4% and the non-insured also represent 4%. The 1% representation for Islamic religion is insured. The main ethnic groups are Ga/Adangbes, Ewes. Akans and Guans. The Ga/Adangbes have majority representation of 61% confirming the fact that the community is predominantly Ga/Adangbes. The Akans form 19% whilst the Ewes and Guans represent 17% and 3% respectively. This has been represented in table 5.5 below: 65 University of Ghana http://ugspace.ug.edu.gh Table S.S Ethnic Grouping Ethnic Group INSURED NON-INSURED OVERALL TOTAL Frequency Percent­ age Frequency Percent­ age Total frequency Total Percentage Ga/ Adangbe 28 56% 18 72% 46 61% Akan 13 26% 1 4% 14 19% Ewe 7 14% 6 24% 13 17% Guan 2 4% - - 2 3% Total 50 100% 25 100% 75 100% SOURCE: FIELD DATA . 2009 Also, the occupational background of respondents is considered under the study. Both the insured and non-insured salaried workers represent 21%. However, more salaried workers are insured (28%) compared to the 2% who are non-insured. The non-insured salaried workers are private medical practitioners who do not see the need to register. Three percent of the total number of respondents was students, with 4% insured and 2% uninsured. Majority of the respondents are self-employed business men and women who represent 57%. The retired respondents form 8% in all, whilst the unemployed represent 11%. From the findings indicated in table 5.6 below, it can be stated that salaried workers have more access to health insurance and healthcare than others. 66 University of Ghana http://ugspace.ug.edu.gh Table 5.6 Occupation Occupation INSURED NON-INSURED OVERALL TOTAL Frequency % Frequency % Total frequency Total Percentage Salaried Worker 14 28% 2 8% 16 21% Student 2 4% - 2 3% Self-employed/ Trade/Business 27 54% 16 64% 43 57% j Retired 5 10% 1 4% 6 8% I Oilier i 2 4% 6 24% 8 11% Total 50 100% 25 100% 75 100% SOURCE: F IELD DATA . 2009 5.3 INSURED MEMBERS OF THE NHIS 5.3.1 Motivation for Membership and Registration One major objective of the study is to find out the motivation for membership or non­ membership of the NHIS. For the insured members, an open ended question was asked to provide reasons for insuring in order of priority. The respondents provided two choices of answers - first choice and a second choice. The main factors which moved them to register are stated below in order of importance: to access affordable healthcare, to insure against possible future sickness which may be so serious that one will not be able to pay the hospital bill, due to the encouragement and testimonies by people especially the insured, because it was mandator)' to register at work place or school, and lastly, because of the projection of positive effects of NHIS by the media. 67 University of Ghana http://ugspace.ug.edu.gh It was observed that, 52% of the respondents indicated they joined the scheme because they wanted to get access to affordable healthcare. I hey understand that as an insured member, one pays nothing at all or very little amount of money at the point of seeking medical care from accredited health providers. This factor motivated them to seek membership into the scheme. The second group formed 30% of the insured respondents. They explained that one might fall sick at a time when there is no money, so it is safer for them to insure. Ten percent (10%) also shared the view that encouragement and testimonies from other insured members motivated them to register. The insured who have accessed healthcare under the scheme testified the positive effects of the scheme by way of accessing free medical care from accredited health providers. Six percent (6%) mentioned that they were registered into the NHIS because it was mandator)' at work place or school. In some institutions there is automatic membership into the scheme when one is recruited or admitted. Finally, 2% of the respondents mentioned that they were motivated as a result o f the projections of positive effects o f the NHIS by the media. For the second choice of motivation, 28% stated that they registered because they wanted to access affordable healthcare, whilst 32% expressed that they wanted to insure against possible future sickness. Encouragement and testimonies by those who were already insured was a motivational factor for 24% of the respondents, whereas another group who formed 10% of the respondents said that they insured because it w as mandatory at work place or school. The last group who form 6% expressed that they were motivated as a result of the projections of positive effects o f the NHIS by the media. Figure 5 .1 below illustrates the motivating factors for subscribing to the NHIS. 68 University of Ghana http://ugspace.ug.edu.gh Figure 5-1 Motivation for Subscribing to the NHIS ■ To access afforadable healthcare ■ To insure against future sickness • Encouragement and testim onies by people * Mandatory a t work place or school ■ Projection of positive e ffects of NHIS by the media The first step for one to access healthcare through the scheme is to register as a member by paying a premium and a registration fee. After the registration, an NHIS card is issued to the applicant within a period o f six months. To find out how members found the entire registration process and the period it took to receive their identity cards, they gave varied responses. Their responses were based on different factors including the time it takes to go through the registration process, the distance from one’s residence to the registration centre, the attitude o f the registrars, and the frequency o f visits to the registration centre before one is finally registered. The data indicate that 14% of the insured found the registration process very easy. 24% found it easy, 30% found it difficult whereas 32% found it very difficult This information has been represented in table 5.7. First Choice Second Choice Choice of Motivating Factor SOURCE: F IELD DATA , 2009 69 University of Ghana http://ugspace.ug.edu.gh Table 5.7 How Members found the Registration Process Perception Frequency Percentage Very easy 7 14% Easy 12 24% Difficult 15 30% Very7 difficult 16 32% Total 50 100% SOURCE: FIELD DATA . 2009. According to the GDMHIS, it takes six months for registrants to receive their ID cards after registration. The study indicates that, 42% of the insured received their cards in less than four months, whilst 38% received theirs between four to six months. This shows that 80% of the respondents received their cards within the stipulated period of six months. On the other hand, 20% received theirs after six months. Some of the insured who received their cards after six months explained that they could not go to the scheme office at Amasaman regularly to inquire about their cards. Others said they visited the office several times but they were always told that the cards were not ready. The information on the period within which members received their ID cards has been indicated in table 5.8. 70 University of Ghana http://ugspace.ug.edu.gh Table 5.8 Period within which members received their ID cards Period Frequency Percentage Less than four months 21 42% Four to six months 19 38% After six months 10 20% Total 50 100% SOURCE: F IELD DATA . 2009. 5.3.2 Access to Healthcare and Problems Encountered In order to find out whether members of the scheme have actually been able to use their cards to access healthcare after issuance, they were asked to provide information on the number of visits to accredited health providers every year from 2006 to 2008. In all, 72% of the respondents indicated that they used their cards to seek healthcare from accredited health providers, whilst 28% expressed that they did not use the cards because they did not fall sick. From 2006 to 2008, fifty three (53) members accessed healthcare under the scheme. In 2006, ten (10) people used accredited health facilities on the average of two visits, whilst in 2007 thirteen (13) members sought care from accredited health providers on the average of three visits. Finally, in 2008, thirty (30) people accessed healthcare under the scheme on the average of three visits. The responses are computed in table 71 University of Ghana http://ugspace.ug.edu.gh Table 5.9 Members who have accessed healthcare under the scheme Year Insured patients per year Average number of visits Total number of visits 2006 10 2 20 2007 13 3 39 2008 30 3 90 Total 53 2.8 149 SOURCE: FIELD DATA . 2009. In another instance, those who indicated they have accessed healthcare under the scheme from 2006 to 2008 were asked whether they were ever charged any fee. All the 72% of the insured who had used the insurance card to access healthcare said they were never charged any fee, neither before nor after treatment. Moreover, the data gathered from the field indicate that 44% o f the NHIS card holders visited hospitals to seek healthcare whilst 11% and 42% visited polyclinic and clinic respectively. Also, 3% indicated that they visited community health centre. The main reasons provided for visiting a particular health institution border on proximity of one's residence to the health facility and transportation. This has been represented in figure 72 University of Ghana http://ugspace.ug.edu.gh Figure 5.2 Health Facility mostly visited by NHIS Subscribers 11% SOURCE: F IELD DATA , 2009 The research also sought the preference o f the insured as far as health facility is concerned, asking if both accredited private and public health providers are located in the same community town or district, all things like proximity and transportation being equal, which o f the providers would they seek healthcare? Forty eight percent (48%) said they prefer public health facility, whilst 52% said they like private health facility. Table 5.10 indicates the reasons for the preference o f a particular health facility by the insured: 73 University of Ghana http://ugspace.ug.edu.gh Table 5.10 Reasons for Preference of public or private health facility Reason for choosing public or private health facility Frequency % Public 24 48% There are many doctors and facilities. 9 18% Public provider is closer to patient's residence. 11 22% Drugs are available. 4 8% Private 26 52% I They diagnose sickness before treatment. Most of them do laboratory test. 8 16% The medical staff are welcoming and patient 11 22% j There is less congestion ; , -................................. ...—.............................................. 7 14% SOURCE: FIF.LD DATA , 2009. Out of the 72% insured respondents who said they had used their ID cards to access healthcare, 48% indicated that they did not face any problem in accessing healthcare under the scheme. However, 24% said they faced problems in accessing healthcare under the scheme. The main problems expressed are explained below: One major concern was that the sickness diagnosed was not covered by the scheme. It was observed that the 7% of the insured who raised this problem have no idea of the various sicknesses covered by the scheme and those that are not covered. Ignorance of the scheme and its operations is a major problem. Apparently, many people do not know the diseases that are covered or not covered by the scheme. The sicknesses they mentioned were cancer treatment, optical and hearing aids. During the FGD, it was explained by the scheme officials that though most o f the diseases and drugs are covered by the scheme, not all diseases and drugs are covered because the scheme is newly introduced. As time goes on. more drugs and diseases will be added to the list. 74 University of Ghana http://ugspace.ug.edu.gh Moreover, 8% of the respondents also complained of delayed treatment. They explained that in public hospitals, the patients were made to wait for several hours before they could see a doctor. Even in some instances, those patients without cards who came late were given priority. This problem was addressed during the FGD and also explained during the key informant interviews by the accredited health providers. The accredited health providers explained that it was not deliberate on their part to delay insured patients. The insured have special folders, cards and numbers and reimbursement or claim forms. If a patient attends a particular hospital for the first time, special files will be prepared with their folders and all the necessary information needed. This takes a little time. However, emergency cases are treated special and patients are quickly attended to, whether they are insured or not. Furthermore, 9% of the insured interviewed expressed grave concern about the fact that on several occasions, they were told that particular medicines prescribed by the doctor were not available in the hospital. In such cases, they had to travel again to look for such medicines from accredited pharmacies. Some do not even know which pharmacies are accredited. During the key informant interview and the FGD. the medical personnel admitted that sometimes certain type of drugs or medicines may not be available in the hospital pharmacy, so the only option is to prescribe for the patient to buy from an accredited pharmacy. 75 University of Ghana http://ugspace.ug.edu.gh 5.4 THE NON-INSURED 5.4.1 Reasons for Non-membership of the NHIS To find out whether or not the non-insured have heard about the national health insurance scheme, all the 25 respondents (100%) said they had heard about the scheme. When asked why they were not insured, they provided the following reasons in order of importance: registration is too expensive (65%), registration is very difficult (21%), it is difficult to access healthcare under the scheme (6%), poor health services are provided under the scheme (4%), 3% said they seek treatment elsewhere and 1% gave other reasons like not being interested in the scheme. Thus, majority o f the non-insured interviewed attributed their inability to subscribe to the scheme to the fact that the premium and registration fees are beyond their reach. This has been represented in figure 5.3. Probing to find out why the registration process is difficult, some of them said they participated in the mass registration in 2005 but never got their ID cards. Others said they made the attempt to register but it was difficult traveling to the insurance office at Amasaman. The study investigated why some o f the non-insured felt it was difficult to access healthcare under scheme and the poor health services provided by the scheme. Though the non-insured had not accessed healthcare under the scheme, they insisted that some of the community members who were insured found it difficult to access healthcare from some accredited health providers and where they were able to access the care, cheap drugs were prescribed for them. 76 University of Ghana http://ugspace.ug.edu.gh Figure S3 Reasons for Non-Membership of the NHIS ■ Registration is expensive ■ Registration is difficult ■ Difficult to access healthcare under the scheme ■ Poor healh services provided tmder the scheme ■ Seek treatment elsewhere ■ Other SOURCE: F IELD DATA , 2009 5.4.2 Access and Utilization of Healthcare In order to check the financial access and utilization o f healthcare by the non-insured, they were asked to provide the number o f visits to health providers in the year 2008. the name o f the health facility and cost involved. Eight percent (8%) indicated that they did not fail sick, and for that matter did not seek healthcare from health providers. Out of die remaining 92% o f the non-insured interviewed, 76% said they fell sick and visited health providers in the said year, whereas 16% said they fell sick but took herbal medicines prepared by themselves. In all, 19 out o f 25 non-insured, that is 76% visited health providers fifty six (56) times and spent GH0 1,805.50 on medical bills. This implies that the non-insured spent an average of GHf!32.00 per visit to health facilities for healthcare which is far more than the minimum subscription fee to the NHIS. The 77 University of Ghana http://ugspace.ug.edu.gh frequency of health visits by the non-insured and the related costs are illustrated in table 5.11 below: Tabic 5.11 Acccss and utilization of healthcare by the non-insured Health Facility Number of Non-insured Number of visits by the non-insurcd Total cost Incurred (GHl) Abokobi Clinic 8 28 372.00 Pantang Hospital 3 13 1,020.50 Alpha Medical Centre 1 1 60.00 Mamobi Polyclinic 1 1 20.00 Greater Grace Hospital 1 1 50.00 | Ridge Hospital 3 11 253.00 Tema General Hospital 2 1 30.00 Total 19 56 1,805.50 SOURCE: FIELD DATA . 2009. In another instance, the non-insured were asked to provide the source from which they paid their medical bills in 2008. Twenty eight percent (28%) said they paid their medical bills from their family income; 20% borrowed money from relatives and neighbours; for 16% their bills were paid for by others, whilst 12% sold assets. This has been illustrated in figure 5.4. 78 University of Ghana http://ugspace.ug.edu.gh Figure 5.4 Sources of Income to Pay for Health Services SOURCE: FIELD DATA , 2009. 5.5 ACCREDITED HEALTH PROVIDERS 5.5.1 Background In all, two health providers were involved in the research, Abokobi Clinic which is a public health institution and Alpha Medical Centre which is a private facility. The public health provider has 27 staff - one doctor, 20 nurses, a pharmacist and four paramedics. The private health facility has 24 staff members - seven doctors and 12 nurses, an administrator, a pharmacist and three paramedics. For the type of agreement they have with the insurance scheme, the public health provider indicated a memorandum of understanding (MoU), whilst the private stated signed contract/agreement, The public health provider has worked with the scheme 79 University of Ghana http://ugspace.ug.edu.gh since 2006 and the administrator is responsible for the afTairs of the scheme. The private health provider has also worked with the scheme since 2006 and the staff responsible for the affairs of the scheme is the accountant. 5.5.2 Reimbursement Both health providers indicated that the scheme issues bank cheques to pay the bills for its members. With regard to the timeframe for reimbursement, the public health facility' is paid quarterly after inspection, whereas the private health facility is paid monthly after inspection. In assessing the reimbursement arrangement, they all said it is good. To explain why it is good, the public health provider said the scheme pays exactly what is sent to them. The private health facility said, generally the money is paid back, though it sometimes delays. 5.5.3 Access to Healthcare from the Public Health Provider by the Insured In 2006. the number of insured persons who visited the public health provider interviewed was 200. The males were 110 and the females were 90. In 2007, the number increased to 1000. four hundred and ninety-nine (499) males and 501 females; and in 2008 it further increased to 1,954, nine hundred and seventy-two (972) males and 982 females. The health provider added the aged to the adult population who accessed healthcare during this period. Table 5.12 illustrates the information on the insured who visited the public health provider from 2006 to 2008. 80 University of Ghana http://ugspace.ug.edu.gh Table 5.12 The Insured access to healthcare from a Public Health Provider YEAR AGE GROUP NUMBER OF PEOPLE WHO HAVE USED THE SCHEME TO ACCESS HEALTHCARE Male Female Total 2006 Children - 17 years and below 45 35 80 Adults -18 years and above 65 55 120 Total 110 90 200 2007 Children - 17 years and below 252 255 507 Adults - 18 years and above 247 246 493 Total 499 501 1,000 ] 2008 Children - 17 years and below 480 485 965 Adults - 18 years and above 492 497 989 Total 972 982 1,954 SOURCE: FIELD DATA . 2009. In 2006. the total number of visits by insured patients recorded by the health provider was 680. In 2007, the number increased to 3,085 and in 2008. it increased to 6.861. 5.5.4 Access to Healthcare from the Private Health Provider by the Insured In 2006, the total number of insured persons who visited the private health provider was 450, two hundred and thirteen (213) males and 237 females. In 2007, the number increased to 1,814 insured members, 744 males and 1.070 females. Finally, in 2008, a total number of 2,420 insured members accessed healthcare from this hospital - 979 males and 1,441 females. This has been illustrated by table 5.13 below: 81 University of Ghana http://ugspace.ug.edu.gh Table 5.13 The Insured access to healthcare from a Private Health Provider YEAR AGE GROUP NUMBER OF PEOPLE WHO HAVE USED THE SCHEME TO ACCESS HEALTHCARE Male Female Total 2006 Children - 17 years and below 42 46 88 Adulls - 18 to 69 years 163 179 342 Aged - 70 years and above 8 12 20 Total 213 237 450 2007 Children - 17 years and below 233 236 469 Adults - 18 to 69 years 462 758 1.220 Aged - 70 years and above 49 76 125 Total 744 1,070 1,814 2008 Children - 17 years and below 309 366 675 Adults - 18 to 69 years 578 960 1.538 Aged - 70 years and above 92 115 207 Total 979 1,441 2,420 SOURCE: FIELD DATA . 2009 In the year 2006. the hospital recorded 1,361 visits by the insured both outpatient department (OPD) and admissions. In 2007, there were 6.271 visits and in 2008. the total number of visits was 8,465. 5.6 GA DISTRICT MUTUAL HEALTH INSURANCE SCHEME 5.6.1 Registration of Members and Renewal Membership of the NHIS goes with the payment o f a premium and registration fee. This lasts for one year. Membership after a year is subject to renewal which implies 82 University of Ghana http://ugspace.ug.edu.gh payment of a renewal fee. The registration and renewal fees paid by members are provided in table 5.14 below. Tabic 5.14 Fees for Registration and Renewal Year Fees (GHfi) Registration Renewal 2005 15.00 15.00 2006 15.00 15.00 2007 18.00 18.00 2008 20.00 20.00 SOURCE: F IELD DATA , 2009. According to the GDMHIS administration, the waiting period for one to receive his/her health insurance card after registration is six months. But in practice, some registrants receive their cards within six months while others get theirs after months. However, for renewal of membership, it takes one day. They explained that because the staff members are inadequate, they are not able to process all the documents for the cards to be issued within the stipulated time frame. 5.6.2 Access to Healthcare under the Scheme In 2006, the GDMHIS worked with 21 accredited health providers in Greater Accra and some parts of Eastern Region where 11,748 members of the scheme accessed healthcare. A total number of 166,534 insured persons accessed healthcare in 2007 from 65 accredited health providers, and in 2008. seventy two (72) health providers served 248,859 insured members. 83 University of Ghana http://ugspace.ug.edu.gh 5.6.3 Working Relationship with Accredited Health Providers From the point of view of the GDMHIS administration, the working relationship with the health providers who serve their scheme members is friendly and positive. Both parties have been collaborating well to provide the best of healthcare to insured members. On the question of reimbursement, it takes an average of 12 weeks for the scheme to reimburse health providers they work with. However, sometimes the reimbursement delays and the scheme is not able to reimburse the full claim at a goal. If that happens, the health provider applies for reinsurance from the National Health Insurance Authority (NHIA). The reports the Scheme gets from the health providers indicate that the delay in the payment of their claims is very worrying and distressful to them. Notwithstanding, the health providers also admit that the scheme has provided a strong financial base to some of them, if not all. Table 5.15 shows the number o f health facilities that served the Scheme members from 2006 to 2008 and the cost implications. Table 5.15 Cost of Service to Scheme Members and Reimbursement YEAR NUMBER OF FACILITIES NUMBER OF INSURED TOTAL AMOUNT REQUESTED TOTAL AMOUNT REIMBURSED 2006 21 11,748 15,196.86 14,815.76 2007 65 166,534 1,098,578.50 1,077.049.90 2008 72 248,859 6,325.815.62 3,928,114.70 ; SOURCE: FIELD DATA. 2009 84 University of Ghana http://ugspace.ug.edu.gh 5.7 PERCEPTION OF ACCESS TO HEALTHCARE BY THE INSURED AND NON-INSURED The research also sought the views of the respondents regarding access to healthcare. Respondents were asked to indicate the factors that mostly influence their access to healthcare. Majority of the respondents, representing 75% of the insured and 74% of the non-insured indicated that their access to healthcare is mostly influenced by finance, which is their ability to pay for the health service. The non-insured stressed that their access to healthcare is mostly impeded by financial barriers. Time access which looks at the period of time one takes to travel to the hospital, the waiting time at the health facility and waiting time for appointments affect one’s ability to seek healthcare. Three percent (3%) of the insured and 4% of the non-insured indicated that time really influences their access to healthcare. Distance and transportation was also noted as a variable that affects people’s access to healthcare. This factor looks at the distance from one’s residence to a health provider and the means of transport to reach the health facility. Eight percent (8%) of the insured and 7% of the non-insured expressed that this factor affects their access to healthcare. Location o f health facility is another variable that influences people’s access to healthcare. This also includes the availability o f health facility in a particular community. Where a community does not have a health facility but people have to travel far to access healthcare, the residents may not frequent the health facility except when it is very critical. Four percent (4%) of the insured and 6% of the non-insured indicated that location of health facility influences their access and utilization of healthcare. Finally. 10?/o of the insured and 9% of the non-insured felt that social access influences their decision to seek healthcare. 'I he social factor refers to situations where patients in a community consult doctors or 85 University of Ghana http://ugspace.ug.edu.gh general practitioners with whom they leel more comfortable and the health facilities recommended by families and relations. 5.8 PERCEPTION OF THE NHIS The study sought to find out people’s experience before the introduction of the health insurance scheme and after the scheme and what they think about the sustainability of the scheme. All the respondents including the accredited health providers and the scheme officials expressed disgust for the existing cash and carry system and welcomed the newly introduced health insurance scheme which has come to replace the cash and carry. 5.8.1 Perception o f the Scheme by the Insured Finding out whether the insured would like that every member o f their household and community be covered under the scheme, there was a 100% response yes, and gave the same reasons as their motivation for insuring. However, on the question of improvement of financial access to healthcare, 96% of the respondents said the NHIS has improved their financial access to healthcare and 4% said otherwise. The reasons mentioned to support their claims are illustrated in table 5.16. 86 University of Ghana http://ugspace.ug.edu.gh Table 5.16 Perception of the NHIS by the insured PERCEPTION OF THE NHIS BY THE INSURED Reasons why the scheme has improved access to healthcare and health delivery in the community Frequency Percent -age Free prenatal and post-delivery healthcare for mothers and their babies. Mothers and their babies are no more detained by health providers for their inability to pay medical bills as it existed during the cash and carry system. 11 22% Easy access to affordable healthcare any time one is sick. The community members are now aware that they can use the ID cards any time they fall sick. The cash and carry system deterred patients from seeking care. 10 20% There are evidences of testimonies by people who got free treatment and medicines. Even those who underwent surgical/caesarean operations did not pay any money. This was not the case during the cash and earn- system. 8 | 16% More people go to hospital for treatment regularly even with the slightest illness, which at first they would have resorted to herbal treatment or self-medication in the community. 6 12% More health personnel have been posted to the community clinic to meet the high demand for healthcare as a result o f the introduction of NHIS. 5 10% Fanners and people in the non-formal sector, the aged and indigents frequent the community clinic, which was not the case during the cash and carry system. 3 6% It has reduced financial burden on the families of the insured. The money that should have been spent on medical care is now used for something else. 5 10% : j Reason(s) why the scheme has not improved access to healthcare and health delivery in the community i It has increased outpatient department (OPD) visits and admissions without corresponding increase and expansion of health facilities 2 4% | I I j Total 50 100% I SOURCE: FIELD DATA . 2009 87 University of Ghana http://ugspace.ug.edu.gh 5.8.2 Perception o f the Scheme by the Non-insured The non-insured were asked whether the NHIS has actually replaced the cash and carry system and made healthcare accessible and affordable to the community members. Ninety two percent (92%) of the respondents affirmed with reasons that the scheme has replaced the cash and carry system and made it possible for the insured to frequent health providers for medical care without paying out o f pocket, it has also reduced financial burden on the families of the insured. Moreover, for the insured, the scheme has reduced the incidence o f resorting to self-medication by using herbs, and buying medicines from drug stores without prescription. However, 8% of the non-insured interviewed shared the view that the NHIS has not made healthcare accessible and affordable even to the insured. One said, “the fact that many people visit hospitals does not mean that healthcare has been made accessible and affordable. It can only be accessible and affordable to people if there is a corresponding increase in the number of health personnel and expansion of health facilities, and the availability' and willingness o f the health personnel to serve patients well.” Table 5.17 shows the perception of the NHIS by the non-insured. 88 University of Ghana http://ugspace.ug.edu.gh Table 5.17 Perception of the NHIS by the Non-insured PERCEPTION OF THE NHIS BY THE NON-INSURED Reasons why the scheme has made healthcare accessible and affordable to people Frequency Percent -age Many community members now frequent health providers and get treatment more than before. 11 44% Some of the insured community members testify that the scheme has reduced financial burden on the families of the insured. Money that should have been used to pay medical bills could also be used meet other family needs. 9 36% Many community members have reduced self-medication. Formerly, many community members could not afford medical care and so resorted to treating themselves and their children. 3 12% Reason(s) why the scheme has not made healthcare accessible and affordable to people It increased outpatient department (OPD) visits and admissions without corresponding increase and expansion of health facilities 2 8% Total 25 100% SOURCE: FIELD DATA , 2009 5.8.3 Perception o f the Scheme by Health Providers According to the accredited health providers, the scheme has helped their facilities to get additional revenue. The number of patients who seek healthcare has increased since the scheme was introduced. The more patients they attend to the more revenue they generate for the health facilities. Some o f the health providers made a comparative analysis of the cash and earn, period and the present period. They explained that before the introduction of the NHIS, the number of patients that sought medical care from their outfits was minimal compared to the present time. The private health providers 89 University of Ghana http://ugspace.ug.edu.gh expressed that now a great number of patients feel comfortable to access healthcare from them and that increases their revenue claims from the scheme. The health providers also indicated that the scheme has made it possible for the indigents who hitherto, could not pay their medical bills, have financial access to healthcare. They expressed that there were some people in the community who would never prefer private medical care, but with the introduction of the scheme, they are not afraid to seek healthcare from any health facility, provided they are accredited. Furthermore, the health providers looked at the present state of women's reproductive health, that it is far better compared to the cash and cam period where a large number of women were afraid to go to hospitals. As a result of the introduction o f the scheme, women access free prenatal, post-delivery and maternal care. During the fee-for- service system, women who could not pay their medical bills after delivery were detained with their babies in the hospitals. Some of the patients who were discharged absconded without paying their medical bills. However, the scheme has influenced the facilities negatively as sometimes available drugs are not adequate making it difficult to serve patients. Once patients are attended to and the doctor prescribes the needed drugs, the patients expect that the drugs should be provided by the hospital's pharmacy and not to go to town to look for the drugs in a pharmacy. Patients have to locate accredited pharmacies where they can get the drugs. Another serious concern expressed by the health providers is the delay in the payment of claims. According to them, the average of twelve weeks which the scheme takes to reimburse providers is to long, and such delays are very worrying. They added that 90 University of Ghana http://ugspace.ug.edu.gh sometimes they are disappointed because after the long delay, they are told to apply for reinsurance from the National Health Insurance Authority. This really affects their operations as it takes long time to plough back profits for further investment. The health providers explained that, before claims are paid to them, the scheme administration vets the claims sent to them. But most o f the time, personnel are not available to vet their claims. The claims therefore lie in the NHIS office for a long time. The providers have to make several follow ups before they are finally reimbursed. One major worrying situation mostly expressed by the public accredited health providers is the increased number o f patients who visits the health facilities. But unfortunately, there is no corresponding increase in the expansion of health facilities, and the rate of increase in the number of health personnel is not so encouraging. As a result, there is always pressure on the health personnel. Facilities at the outpatient department (OPD) and admission beds are woefully inadequate. Again, some of the insured members always put pressure on the medical personnel, seeking to be treated first before the non-insured instead of first-come-first-serve. It sometimes create disturbance at the outpatient department (OPD). as the non-insured would not like to be discriminated against because they are not insured. Also, some members of the scheme feel that once they visit the health facility, they should not be given any prescription form to obtain medicines from other accredited pharmacies. They do not understand why the accredited health facility should not have ail drugs. 91 University of Ghana http://ugspace.ug.edu.gh 5.8.4 Perception o f the Scheme by the GDMHIS The scheme administration sees the scheme to be stable, with solid financial backing. The number of client base is large, increasing yearly. Il has rich human resource. Moreover, the scheme administration keeps in touch with all the accredited health providers to ensure that clients get the best treatment. It has also been able to gain the confidence of most of its subscribers and get feedback from them. The scheme has helped the members to have easy financial access to healthcare, easy utilization of health care and has improved revenue to accredited health facilities. However, it faces the challenges o f inadequate logistics, inadequate number of personnel, and politicization o f the scheme. 5.9 GENERAL PROBLEMS FACING THE SCHEME The respondents mentioned various degrees o f problems confronting the scheme and its members as well as the health providers that serve the scheme members. Majority of the respondents, representing 82% indicated that the registration system o f the scheme is ineffective. Registrants go through a lot o f hassle before getting registered. The Abokobi situation is disturbing because they do not have NHIS office there, though the town is a district capital. The town is also far from the NHIS office at Amasaman. It would be easier for the community members to register or renew their membership through the NHIS agents but majority o f the members interviewed (73%) have the perception that the agents will abscond with their money, as experienced during the mass registration in 2005. Moreover, the delays in the release of ID cards discourage people from registering. For some people, it took more than eight months to receive their ID cards. 92 University of Ghana http://ugspace.ug.edu.gh Untimely, reimbursement of claims as expressed by the accredited health providers and affirmed by the GDMHIS administration is also another problem facing the scheme. This really affects the operations of the health providers that work with the scheme. It would not motivate the health providers to give off their best in the healthcarc deliver)'. It was equally observed that there is inadequate public education on the scheme, its benefits, accredited health providers in a particular area or district, and diseases and drugs covered by the scheme. Many insured members lack basic knowledge about the scheme, for instance, the drugs and diseases covered under the scheme. It was surprising to hear from some respondents that they do not even know where the scheme office is located. Another problem facing the scheme is inadequate logistics. The results of the research reveal that the logistical base of the scheme is woefully inadequate. Logistics in the form of computers and printers, photocopiers, binding machines and materials, information technology backing, are pressing needs. The scheme administration also faces the problem of lack of vehicles for effective outreach programs, community visits and sensitization. In order to embark on community outreach and sensitization programs, the scheme officials need vehicles. The GDMHIS covers a very wide area, three districts some o f whose villages have deplorable roads. As a result, the officials find it difficult to reach out to most community members in very remote villages to assess the performance of the scheme and their access to healthcare under the scheme. 93 University of Ghana http://ugspace.ug.edu.gh Again, the results indicate that there are undue delays in accessing healthcare in some health facilities under the scheme. Some of the health facilities with particular reference to public health providers discourage members in their attempt to access healthcare at the point o f illness by unduly delaying them access to a doctor or drugs. According to scheme administration, this concern had reached them and they were talking it over with those health providers. Another issue of grave concern expressed by majority of the respondents is the fear of the effects of politicization of the scheme. They expressed that the NHIS is experiencing unnecessary politicization which may affect the sustainability o f the scheme. The officials of the scheme especially the top hierarchy feel insecure as they may be removed from office as a result of change in government. 5.10 CONCLUSIONS DRA WN FROM THE SURVEY From the field data gathered, some conclusions have been drawn. Table 5.18 gives a brief summary of the conclusions draws from the field survey. 94 University of Ghana http://ugspace.ug.edu.gh Table 5.18 Conclusions drawn from the field survey Indicative Variable Empirical Data Year Total2006 2007 2008 Number o f people who access healthcare under the GDMHIS increases annually 11.748 166.534 248,859 427,141 Number o f insured visits to accredited public health providers increases yearly. 860 3,085 9,680 13,625 Number of insured visits to accredited private health providers increased yearly. 1,867 7.271 11,325 20,463 Number of accredited health providers increases annually. 21 65 72 72 Total amount of benefits paid to health providers for members increased annually (GH0) 14,815.76 1.077.049.90 3,928,114.70 5,019,980.36 The insured face less financial barriers of access to healthcare than the non-insured 30 out of 50 insured members interviewed visited health providers 103 times in 2008 but did not pay anything, whereas in the same year. 19 out of 25 non-insured 1 interviewed indicated they visited health providers 56 times ; and paid 1,805.50 Ghana Cedis. SOURCE: FIELD DATA 2009 Available data from GDMHIS on 72 accredited health service providers reveal that, an average o f about GH017.00 is spent per visit to the health facilities by the members of the scheme. The data also indicates that the average number of visits by a scheme member per year is three (3) times. This implies that an average of GHc 51.00 is paid on behalf of a member for the three visits. This amount is more than twice the GDMHIS 2008 annual subscription fee of GH£ 20.00. On an individual basis, the results show that some insured members visited health facilities five (5) times in 2008. In this exceptional situation, it would mean that an average amount of GHc 85.00 was spent on each member. 95 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX SUMMARY, CONCLUSION AND RECOMMENDATIONS 6.1 INTRODUCTION The findings of this study are discussed in this chapter with particular reference to health insurance and financial access to healthcare which are fundamental to human life and essential topic in Social Work. Health insurance has been proved to promote financial access to healthcare, which in turn promotes the well-being of the human person. This chapter looks at the objectives and research questions and holds them together against the findings to investigate whether they relate or depart from each other. The literature survey has also been employed to refute or buttress the findings. The chapter brings to the fore the field experiences and the literature review including the benchmarks to be adapted which will serve as recommendations for the development and sustainability of the scheme. 6.2 SUMMARY In the field of Social Work, one will be much interested in finding out the health needs of people and measures that can be adopted to meet these needs. One will also be interested to find out the various factors that influence access to health insurance and for that matter access to healthcare. It is also crucial to social workers to investigate "why some individuals are insured and others are not?" How can the contributing factors be addressed so as to ensure social adjustment and enhancement of social functioning? The study draws a conclusion that, to enlarge poor and rural population access to healthcare, membership of health insurance scheme is an important element and a valuable first step. 96 University of Ghana http://ugspace.ug.edu.gh 6.2.1 The Insured One specific objective of the study is to find out the situation of the insured, their motivation for insuring, their access to healthcare and problems they encounter. This was to fulfil some of the aspirations of social work by investigating community needs like health insurance scheme as a social intervention to solve a vital health problem of financial barrier of access to healthcare, so that community members can effectively perform their roles in the society'. The data indicates that majority (68%) of the insured have children. Out of this. 46% have children who are 17 years and below. Their motive is that by registering as members of the scheme, their dependents who are less than 18 years will have the right to membership by paying only an administrative fee. The explanation is based on Regulation 56 of the National Health Insurance Regulations. 2004 (LI 1809). which exempts children under 18 years from paying premium if their parent or guardian is a member of the scheme. It follows that, if a child's parent or guardian is not insured, that child does not have the right to be insured and to access healthcare under the scheme. The data also reveals a vast difference between those with tertian1 education and other levels o f education. Education has been found to be an important variable that influences access to health insurance and for that matter access to healthcare. Those with higher education are salaried workers who have permanent jobs or well- established business men and women. Majority of the respondents with tertiary education were insured except three medical doctors who are private practitioners. It goes to affirm that a worker in the formal sector who is a SSNIT contributor and whose 97 University of Ghana http://ugspace.ug.edu.gh premium is deducted at source has more access to NHIS and healthcare than the one in the informal sector without social security who has to pay cash in order to be insured. Under the motivation for membership, majority of the respondents (52%) indicated affordability o f healthcare as the main reason for registering. They registered because the scheme pays the medical bills of its members. This affirms the results of other studies where most o f the respondents indicated affordability as their main reason for membership o f a health insurance scheme (Jutting, 2003: Aikins, 2005; DAN1DA. 2008), In addition, encouragement and testimonies by the already insured community' members served as a motivational factor for many respondents (34%). This implies that if better services are provided to the insured, they will in tum propagate the positive effects o f the scheme in their communities, thereby attracting more members to the scheme. Majority' (62%) of respondents faced difficulties in the registration process. Even in the initial stages of registration people face problems. Moreover, it is generally difficult to register because of the distance of the health insurance office from the community . Respondents also expressed difficulty in getting their identity cards after registration. These problems that registrants face in their attempt to join the scheme can discourage them from pursuing the registration and membership processes. Registration of members and acquisition of ID cards has been noted as a major problem facing registrants since the introduction of the NHIS (DWHIS. 2006; DANIDA. 2008). On the average, the insured access healthcare under the scheme thrice a year from accredited health providers. The average amount of money spent on each insured 98 University of Ghana http://ugspace.ug.edu.gh person per visit is GH017.00 and GH051.OO per year. Majority of the insured (48%) who used their ID cards to access healthcare said they found no problem accessing health services under the scheme. For others, the main problems they encountered were mostly either the sickness reported is not covered by the scheme or drugs prescribed are not covered under the scheme. The scheme clearly states in its regulations the type of diseases and drugs covered and those that are not. Under normal circumstance, registrants are supposed to have this basic knowledge prior to registration, because one has to be satisfied with the services of the scheme before seeking membership, thereby making an informed decision. The results o f the research conducted by DANIDA (2008) in the Kwaebibirim and Asutifi Districts show that 20% of the respondents had not heard about the scheme at the time o f conducting the survey. Many Ghanaians lack basic information on the scheme. They have no idea about any drug list and diseases covered or not covered by the scheme. As a result, they always want to get free medical care for all sicknesses and drugs free of charge. If they are not provided they would want to fight accredited health providers. It is worth noting the preference of patients as far as health providers are concerned. The results from the field survey proved that majority of the scheme members prefer seeking healthcare from private accredited health providers to public accredited health providers. This implies that if more health providers are accredited, there will be competition and patients will have a choice at the end. With the supplier-inducement model for health services (Feldman and Sloan, 1988). we understand that contract physicians or private medical doctors who receive their income from fee-for-item payment, have an incentive to compensate for lack of patients by inducing demand for services. However, salaried physicians receive a salary which is independent of output. 99 University of Ghana http://ugspace.ug.edu.gh Even though increased competition For patients reduces the availability of patients, they have no financial incentive to induce. As a result good doctor-patient relationship is not so much taken into account by the salaried medical doctor, whereas the private medical practitioner takes that into account. Thus, a lot oF patients take social access into consideration, and would like to visit health Facilities where doctors and other health personnel are not only welcoming but also play the role of the patient’s advisor as well as offering medical care. This also explains the fact that for many community members, encouragements and testimonies by the insured on their access to healthcare under the scheme serve as a motivating Factor for insuring or not insuring. The kind o f treatment the insured patients receive From health providers will have effect not only on their current health status, but also the Future membership oF the scheme and in the long run the development and sustainability of the scheme. 6.2.2 The Non-insured According to the NHI Act 2003 (Act 650), the aged are not supposed to pay any premium. However, the scheme administration charges an administrative fee. The research reveals that out of the total number of the aged respondents (18%). eight percent (8%) were not insured. Thus the administrative fee of GHtf 4.00 is not within the reach oF many aged people. Though they are willing to register, the administrative fee deters them from becoming members of the scheme. Surprisingly, 4% o f the retired had also not insured at the time oF the survey. The retired are exempted from paying both premium and administrative Fees. The respondent is a private medical doctor who docs not see the need to register. 100 University of Ghana http://ugspace.ug.edu.gh Unlike the insured parents who registered not only for themselves but also for their children, by paying only an administrative fee for the children, the children of the uninsured parents and guardians face financial barriers o f access to healthcare because their parent or guardian is not insured. This problem was sadly expressed by the uninsured parents, because even though they might have the administrative fees to insure their children, once they are not insured, their children cannot also be insured on the basis of Regulation 56 of the National Health Insurance Regulations, 2004 (LI 1809). On the other hand. Article 2 paragraph I of the Children’s Act clearly states that ■‘the best interest o f the child shall be paramount in any matter concerning a child."' Also. Article 3 adds that “no person shall discriminate against a child on the grounds of gender, race, age, religion, disability, health status, custom, ethnic origin, rural or urban background, birth or other status, socio-economic status or because the child is a refugee.” It can be easily deduced that these children are discriminated against on the basis o f the socio-economic status of their parent(s) or guardian(s). Their health interest which is access to health insurance and access to healthcare is not paramount to the state and its adult population in general. Majority of the non-insured (64%) were self-employed business men and women. They were all in the informal sector, mostly petty traders and peasant farmers, whose earnings are from hand-to-mouth. They are not able to save money towards the registration and acquisition of NHIS membership. The effect is that they will continue to face financial burden in accessing healthcare as long as they remained uninsured. Concerning reasons for non-membership of the scheme, majority o f the non-insured, representing 65%, indicated that the premium and the registration fees are beyond their reach. In other words, the registration for membership is too expensive. The results of a 101 University of Ghana http://ugspace.ug.edu.gh similar survey conducted by DANIDA (2008) indicate that 42.1% of the respondents in the Asutifi District and 18.8% in the Kwaebibirim District said they did not register because the premium was too expensive. Even though they were allowed to pay in instalments, 40.7% were not able to pay the second instalment in Kwaebibirim, whilst 56.2% in the Asutifi District were not able to renew their registration. All these people were in the low quintile on the list o f Wealth Index Quintiles (WIQ). Studies conducted on the existing community' based health insurance organizations before the introduction o f the NHIS showed that many people were not members o f the schemes because they could not pay the stipulated premium. The premium was too expensive for them. Thus, those from the rich quintile register more than those from the poor quintile (DWHIS, 2003; Aikins. 2005). On the question of access to healthcare by the non-insured, the results o f the survey show that the non-insured spend an average of GHe32.00 per visit to health facilities, and each person made an average o f three visits in the year. This amount paid for only one visit to a health provider is more than the premium paid for the whole year. But the question still remains why they are not able pay the premium which is less than a one­ time medical bill? The answer is simple. They do not have money readily available to pay the premium, but when they fall sick, they are able to borrow money or seek support elsewhere. It follows that, the non-insured device different methods of paying their medical bills. Whereas 28% of the non-insured were able to pay from their family coffers as indicated by the survey. 20% had to borrow money. 16% had their bills paid by someone else and 12% also sold their assets. It can be inferred that majority of the non-insured (48%) 102 University of Ghana http://ugspace.ug.edu.gh face serious financial barriers o f access to healthcare. The question is how long can a patient borrow money, or seek support from someone or sell an asset in order to pay for healthcare? This result confirms the results of a study conducted in the Northern Region where three traditional support systems were found to play an important role in enabling households to access healthcare. Borrowing constituted 29%, thirty-one percent (31%) o f households received assistance from relatives, friends and community contributions, and 40% relied on their own internal resources to finance their healthcare (Apoyaetal.. 2001). 6.2.3 Problems facing the Scheme The survey indicates that the NHIS faces several problems in its operations which in turn affect its membership. One major problem is the registration of members especially the community of Abokobi in particular. Registration is cumbersome and frustrating to members of the community as it involves following up one's ID cards at Amasaman which is far from the community. This discourages many people from registering especially the aged. The contributing factor is that the NHIS does not have an office at Abokobi. The accredited health providers expressed the problem of untimely reimbursement of claims. Sometimes, after ail the delays. GDMHIS administration writes to them to seek reinsurance from the NHIS Authority. The private health providers expressed worry about this problem affecting their operations because they are not able to pay their workers, not talking of expanding their facilities. 103 University of Ghana http://ugspace.ug.edu.gh It was equally observed that there is inadequate public education on the scheme, its benefits, accredited health providers in a particular area or district, and diseases and drugs covered by the scheme. Many insured members lack basic knowledge about the scheme, for instance, the drugs and diseases covered under the scheme. It was surprising to hear from some respondents that they do not even know where the scheme office is located. The survey also reveals that the scheme faces the problem of inadequate logistics and lack of vehicles to run an effective outreach programme. The logistical base of the scheme is woefully inadequate. Looking at the wide area covered by the GDMHIS, w ithout vehicular support, the scheme cannot reach out to communities to listen to their problems, assess the impact o f the scheme and to educate them on the scheme. Another issue o f grave concern expressed by majority of the respondents is the fear of the effects of politicization of the scheme. They expressed that the NHIS is experiencing unnecessary' politicization which may affect the sustainability o f the scheme. The officials o f the scheme especially the top hierarchy feel insecure as they might be removed from office as a result o f change in government. 6.2.4 Relationship between Health Insurance and Financial Access to Healthcare The study reveals the significance of health insurance in accessing healthcare which is vital to human survival and growth. The data indicates that health insurance schemes reduce financial barriers of access to healthcare. Thus, it makes healthcare affordable and accessible to community members. Health insurance gives subscribers the right to 104 University of Ghana http://ugspace.ug.edu.gh utilization of health facilities without direct payment to the health provider. It is a means o f achieving an end. which is free treatment from accredited health providers. It reveals that the number of people who access healthcare under the scheme, the visits to accredited health providers and the number of accredited health providers increase every year. Compared to the non-insured, the insured have no financial barriers of access to healthcare. Their one-time payment of premium and registration fees affords them the privilege to access healthcare three times on the average in a particular year. The medical bill o f one non-insured person on visit is more than the premium paid for the whole year. As the number of accredited health providers increases the insured have option to access healthcare from different health providers. With the acquisition o f membership, the insured will not only have access to healthcare but also have the choice o f seeking healthcare from among many health providers. They can seek healthcare from a private or public health provider of their choice. Therefore, the insured have no fear of financial barriers in seeking medical care unlike the non-insured who have to pay out of pocket and may be limited to seeking care from particular health providers. In a nutshell, the survey proves that health insurance has the potential in guaranteeing higher financial access and utilization of healthcare services and removing the vulnerability of paying out of pocket. 105 University of Ghana http://ugspace.ug.edu.gh 6.3 CONCLUSION The main purpose of the study is to find out the relationship between health insurance scheme and financial access to healthcare. T he relationship established is that health insurance scheme empowers community members to get medical care from accredited health providers without painstakingly paying out of pocket at the point o f accessing healthcare. It also sought the reasons why some community members opted or not opted for the NHIS. For the insured, the main reason for joining the scheme is to be able to get affordable healthcare. Thus, the NHIS makes it possible for them to pay for medical care. On the part o f the non-insured, the main reason for not opting for the scheme is that the premium is too expensive. The non-insured are not able to afford the cost o f membership o f the scheme. The effect is that they do not only suffer paying huge medical bills, but also their children under 18 years are not able to access care under the scheme because their parent or guardian is not insured. The main problem faced by the insured in accessing healthcare under the scheme is the disease or drug that is not covered by the scheme. Generally, the scheme faces the problem of inability to pay health providers on time, inadequate logistics and vehicles for outreach programs. 6.4 RECOMMENDA TIONS The NHIS administration needs to establish an office at Abokobi as a point of reference to serve the residents of Ga East District. The distance from the town to the NHIS office vvas seen as a barrier to registration. The community members travel to Amasaman to register and to collect their identity cards, which costs them a lot. 106 University of Ghana http://ugspace.ug.edu.gh However, as an interim measure, the Scheme officials can collaborate with the administration of Abokobi Clinic to register members at their premise. In this case, the people will have more confidence in the scheme's registration than agents visiting houses to register people. The GDMHIS would have to consider allowing payment in instalments by community members. It must be noted that participation in health insurance schemes is not cost free and requires a minimum of income which the most disadvantaged do not have at their disposal. Therefore, policy makers should reconsider that it may be very difficult, if not impossible, to reach the poorest part o f the population when promoting participation in health insurance schemes. In order to reach the poorest members of the community, the cost of registration would have to be heavily subsidized for members of the community. These people cannot be grouped among the indigents but their condition is such that they cannot pay the full amount of the premium. It is worth recommending that registrants should be allowed to pay the premium in instalments to help those in the non-forma! sector to participate in the scheme. The direct impact would be by preventing impoverishment due to catastrophic health expenditures. The indirect impact would be by ensuring access to healthcare and thereby improving health, thus allowing the individual to take advantage of economic and social opportunities. There is the need to consider integrating health insurance into micro-finance schemes. For instance, to guide the self-employed and the owners of small and mediums scale enterprises and their families to be able to pay their premium. The 'susu’ method can be adopted by the scheme administration where small scale businessmen and women pav 107 University of Ghana http://ugspace.ug.edu.gh their premium in the form of 'susu' to selected scheme officials or Savings and Loans Companies so that they can be registered when they reach the full amount. The NHIS needs to deepen its relationship with accredited health providers and encourage more private health providers to get accreditation. The results o f the survey indicate that people prefer accessing healthcare from accredited private health providers to accredited public health providers. It implies that if both accredited facilities are located in the same community, the insured would surely seek care from the private health provider. There is also the need for the scheme to facilitate the payment of claims, increase visits to accredited health providers and ensure timely vetting of claims. The NHIS needs to be a networking scheme. This administration of the scheme should speed up the process of making the scheme national and networking, so that all registered members can access healthcare from any accredited health provider in any part of the country. This is necessary and urgent because sickness is unpredictable, and irrespective of the place one falls sick, one should be able to access healthcare under the scheme in any part of the country. A long term measure as a nation is to critically look at the education o f medical doctors and health personnel for the country. Information from the MOH (2007) indicates that the nation aims at achieving a doctor-population ratio o f 1:6.000 by the year 2011. For the past years, statistics indicate that doctor-patient ratio in this country is not encouraging. For instance, in 2005 the ratio was estimated to be 1:10.700. In the Northern Regions, the situation is very woeful. The doctor-patient ratio in most 108 University of Ghana http://ugspace.ug.edu.gh districts is 1:95.000. The University of Ghana Medical School (UGMS) average yearly output of 82 doctors for the past five years is inadequate, compared to the health needs of the population. There are many graduates now who intended to pursue medicine at the undergraduate level. Though they qualified, they were not admitted because of the limited number o f intake. What prevents us as a nation from expanding our health and educational facilities and investing more into medical education so that more students can be admitted into our medical schools? There is also the urgent need to review Regulation 56 of the National Health Insurance Regulations. 2004 (LI 1809). The regulation states that “a person who is under eighteen years o f age and both of w hose parents or guardians are contributors: under eighteen years o f age and whose parent or guardian is a contributor who has been proven by the scheme to be a single parent or guardian is not required to pay any contribution to a District Mutual Health Insurance Scheme but is entitled in the case o f a child to enjoy the minimum benefits under the scheme as a dependant." The implication is that if the parent or guardian is not insured, the child cannot enjoy the right to healthcare by virtue of being a child. There is also the need to consider a policy where children will have access to free medical care, independent of the parent or guardian's health insurance status. The appointment of chief executive officers of the NHIS should not be done on the basis of political affiliation. They should serve as civil servants and cam on with the knowledge gained and experiences acquired in the service. 109 University of Ghana http://ugspace.ug.edu.gh The scheme administration needs to increase public education to create awareness of the benefits o f the scheme and encourage people to register. The study reveals that the public education on the scheme is still inadequate. Many people know that the scheme exists but do not know much about its operations, diseases and drugs covered, accredited health providers especially private health facilities and pharmacies. Basic information on the scheme and its operations should be published and given out to community members. An important policy implication of this study is that, it is critical to move away from resource mobilization instruments that are based on point-of-service payments. If pre­ payment and risk-sharing can be encouraged, they are likely to have serious impact on individuals and communities. Health insurance schemes should be considered as the most important element to enlarge poor and rural population access to healthcare. In order to overcome the existing limitations of the scheme, broader risk pools are required. In particular, the role of the government should be strong. Since the NHIS is a newly introduced social intervention to solve the health needs of the people of the Ghana, the scheme still lacks resources in terms of human and material. The government needs to allocate more resources to the scheme, by recruiting additional personnel and providing logistics and vehicles. There is the need to encourage social inclusion. Since majority of the non-insured are from the non-formal sector, the research challenges further study in the field of integrating health insurance into microfinance schemes. 110 University of Ghana http://ugspace.ug.edu.gh REFERENCES Acton, J. P. (1975). Non-monetary factors in the demand for medical services: some empirical evidence. Journal o f Political Economy. 85: 595-614. Adams, I. (2002). Implementation of user fee policy in Ghana: A review of the issues (Part I). Bulletin o f Health Information: October - December 2001. March 2002 1 (2&3). Aday. L. A., et al. (1993). Health Insurance and utilization of medical care for children with special care needs. Medical Care. 31(11): 1013-1026. Aday. L. A., and Andersen M. R. (1974). A Framework for the Study o f access to Medical Care. Health Services Research. 9: 208-220. Ahuja. R.. and Johannes Jutting (2003). Design of Incentives in Community Based Health Insurance Schemes. New Delhi: Indian Council for Research on International Economic Relations. Aikins, Moses. (2005). Jaman South Health Insurance Scheme. External Evaluation. 2004. Accra: Uneek Magazine Publication. P. 14. Akor, S. A. (2002). Establishing Health Insurance in Ghana: The District-wide Mutual Health Organization Approach. A technical paper prepared for the Ghana Macroeconomics and Health Initiative. Apoya, P., et al. (2001). Health seeking behaviour and coping strategies to household to health financing constraints in Northern Region of Ghana. Tamale: Community Partnership for Health and Development. Asfaw, A. (2003). Cost of illness, demand for medical care, and the prospect of community health insurance schemes in the rural areas of Ethiopia. Frankfurt: Peter Lang Eds. Atim, C-, et al. (2001). A Survey of Health Financing Schemes in Ghana. Partners for Health Reformplus. Bethesda, MD: Abt Associates Inc. University of Ghana http://ugspace.ug.edu.gh Bailey, W„ and Philip D. R. (1990). Spatial patterns of use of health services in the Kingston Metropolitan Area, Jamaica. Social Science and Medicine. 30(1): 1- 12. Bentham, G„ and Haynes R. (1985). Health, personal mobility and the use of health services in rural Norfolk. Journal o f Rural Studies. 1: 231 -239. Bohland, J.. and French P. (1982). 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CA: Brooks/Cole Publishing Company. 120 University of Ghana http://ugspace.ug.edu.gh APPENDICES UNIVERSITY OF GHANA, LEGON DEPARTMENT OF SOCIAL WORK APPENDIX 1: INTERVIEW SCHEDULE FOR INSURED MEMBERS THE NATIONAL HEALTH INSURANCE SCHEME AND COMMUNITY ACCESS TO HEALTHCARE: A CASE STUDY OF ABOKOBI HENRY YEBOAH YIADOM-BOACHIE I am a graduate student of the Department o f Social Work. University o f Ghana, Legon. I am conducting a research on “The National Health Insurance Scheme and Community Access to Healthcare: A Case Study of Abokobi”. This is part o f the requirements for my academic work and 1 would be happy for your patience and openness in responding to these questions. All information provided will be treated confidential and used only for academic purposes. INTERVIEW SCHEDULE FOR INSURED MEMBERS A) Demographic Characteristics 1. Sex of respondent (please tick). M ale__ Female 2. Age 3. Marital status a) Married____ b) Single____ c) Widowed___ d) Divorced___ e) Separated___ f) Other (specify) 4. Number of children a) 17 years and below b) 18 years and above University of Ghana http://ugspace.ug.edu.gh 5. Educational level a) No formal education (none) b) Primary'____ c) Middle school/JSS____ d) Secondary school/SSS _ e) Technical/vocationul____ 0 Tertiary________ 6. Religion: a) Traditionalist _ b) Christian____ c) Islam____ d) Other (specify) 7. Ethnicity a) Ga/Adangbe_ b) Akan___ c) Ewe___ d) Guan___ e) Other (specify) 8. Occupation a) Salaried Worker___ b) Student/pupil___ c) Self-employed/business/trader d) Retired___ e) Other (specify)____________ 9. State any other work you do that provides you secondary source of income. 10. Average monthly income: B) Motivation for Membership of NHIS and Registration 11. When were you registered under the scheme? Please tick. a ) 2005 ____ b )2006 ____ c ) 2007 ____ d ) 2008 ____ 122 University of Ghana http://ugspace.ug.edu.gh 12 Please give reason(s) why you enrolled as a member of the NHIS, in order of importance. i)......................... ..... .............................................................................. i i i)________________________________________________________________________ 13 How did you find the registration process? a) Very easy___ b) Easy ___ c) Difficult___ d) Very difficult___ 14 How long did it take you to receive your HIS ID card? a) Less than four months___ b) Four to six months____ c) After six months____ 15. Is any other member(s) o f your household registered and benefiting from the scheme? Yes No 16. If Yes. how many? (Ref. question 15) 17. If No, why are they not registered and benefiting from the Scheme? 18. Would you have liked that every member of your household and community be covered under the scheme? Yes N o_____ 19. Provide reason(s) for your answer 123 University of Ghana http://ugspace.ug.edu.gh C) Access to Healthcare and Problems Encountered 20. Which of the following factors do you think mostly influence your access to healthcare? a) Time you spent al the health facility (time access)___ b) The money you have to pay before and after treatment (financial access)___ c) The distance from your house to the health facility (distance decay)___ d) Location o f health facility in your town/community' (location of health facility ) _ e) Recommendation by your relations to see a particular doctor (social accessibility) 21. How many times did you fall sick and used the scheme to seek health care? (Skip Q20 and Q21 if you have not sought healthcare under the scheme) : Year Number of visits to health facility ! 2006 2007 < j 2008 Total number of visits 22. Were vou charged any fee(s) before or after accessing healthcare? Yes ' No 23. Which health facility did you access medical care? a) Hospital____ b) Polyclinic____ a) Clinic__ c) Community Health Centre____ 24. If both are accredited which would you mostly prefer? a) Public health facility______ b) Private health facility____ 25. Give reason(s) for your answer to question 23. 26. Did you face any problem(s) in accessing healthcare under the scheme? (Skip Q 24 to 0 26 if you have not used the scheme) Yes No 124 University of Ghana http://ugspace.ug.edu.gh 27. I f Kej, what was the problem(s) 28. If you did not face any problem(s) what made it easy for you to access healthcare? D) Perception of the Scheme 29. Would you say that financial access to healthcare in the community has improved with the introduction of the NHIS? Y e s _ N o_____ 30. Give reason(s) for your answer to Q 27 E) Sustainability of the HIS 31. What do you think can be done to improve and sustain the scheme? 32. Any other comment? Thank you. 125 University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA, LEGON DEPARTMENT OF SOCIAL WORK APPENDIX 2: INTERVIEW SCHEDULE FOR THE NON-INSURED THE NATIONAL HEALTH INSURANCE SCHEME AND COMMUNITY ACCESS TO HEALTHCARE: A CASE STUDY OF ABOKOBI HENRY YEBOAH YIADOM-BOACHIE I am a graduate student o f the Department of Social Work, University of Ghana, Legon. I am conducting a research on “The National Health Insurance Scheme and Community Access to Healthcare: A Case Study of Abokobi”. This is part of the requirements for my academic work and I would be happy for your patience and openness in responding to these questions. All information provided will be treated confidential and used only for academic purposes. INTERVIEW SCHEDULE FOR THE NON-INSURED A) Demographic Characteristics 1. Sex of respondent (please tick). M ale___ Female 2. Age 3. Marital status a) Married____ b) Single____ c) Widowed__ d) Divorced___ e) Separated___ f) Other (specify) 4. Number of children a) 17 years and below b) 18 years and above 126 University of Ghana http://ugspace.ug.edu.gh 5. Educational level a) No formal education (none) b) Primary'____ c) Middle school/JSS____ d) Secondary school/SSS____ e) Technical/vocational____ 0 Tertiary________ 6. Religion: a) Traditionalist _ b) Christian___ c) Islam____ d) Other (specify) 7. Ethnicity a) Ga/Adangbe_ b) Akan___ c) Ewe___ d) Guan___ e) Other (specify) 8. Occupation a) Salaried Worker___ b) Student/pupil__ c) Self-employed/business/trader d) Retired___ e) Other (specify)____________ 9. State any other work you do that provides you secondary source of income. 10. Average monthly income: B) Reasons for Non-membership of NHIS 11. Have you heard about the NHIS that provides benefits to healthcare? Yes No _ 127 University of Ghana http://ugspace.ug.edu.gh 12. What is your main reason(s) for not joining the NHIS? a) Registration is too expensive___ b) Registration is difficult___ c) Difficult access to healthcare under the scheme_____ d) Poor health services are provided under the scheme__ e) Seek treatment elsewhere___ f) Other (specify) ___________________ _ _ _ ___ ____________ C) Access and Utilization of Healthcare 13. Which of the following factors do you think mostly influence your access to healthcare? a) Time you spent at the health facility (time access)___ b) The money you have to pay before and after treatment (financial access)___ c) The distance from your house to the health facility (distance decay)___ d) Location of health facility in your town/community (location of health facility)_ e) Recommendation by your relations to see a particular doctor (social accessibility) 14. State how many times you sought medical care in 2008. the name of health facility and the cost involved. (Skip Q 14 and 15 if you did not seek health care this year) VISITS HEALTH FACILITY COST INCURRED GW 1 2 3 4 5 6 7 ! 128 University of Ghana http://ugspace.ug.edu.gh 15. If you sought medical care in 2008, from whal source did you pay your medical bill(s)? a) From my (family) income____ b) Borrowed money____ c) Someone paid for m e____ d) Sold an asset(s)____ e) O ther _ _ _ _ __ D) Perception of the HIS 16. Do you think financial access to healthcare has improved in the community with the introduction of the NHIS? Yes No 17. Give reason(s) for your answer to Q16. G) Community Mobilization and Sustainability of the Scheme 18. What do you think the Scheme can do to encourage you to join? 19. Give suggestion(s) on how to improve on the Scheme and to make it sustainable. Thank you very much. 129 University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA, LEGON DEPARTMENT OF SOCIAL WORK APPENDIX 3: QUESTIONNAIRE FOR NHIS ADMINISTRATION THE NATIONAL HEALTH INSURANCE SCHEME AND COMMUNITY ACCESS TO HEALTHCARE: A CASE STUDY OF ABOKOBI HENRY YEBOAH Y1ADOM-BOACHIE I ain a graduate student o f the Department of Social Work. University of Ghana. Legon. I am conducting a research on "The National Health Insurance Scheme and Community Access to Healthcare: A Case Study of Abokobi". This is part of the requirements for my academic work and 1 would be happy for your patience and openness in responding to these questions. All information provided will be treated confidential and used only for academic purposes. QUESTIONNAIRE FOR NHIS ADMINISTRATION A) Premium 1. Give the registration and renewal fees from 2005 to 2008 Year Fees (GH Registration Renewal 2005 2006 I 2007 ............ I 2008 H 130 University of Ghana http://ugspace.ug.edu.gh B) Annual enrolment 2. Please, fill the annual enrolment below. YEAR AGE GROUP NUMBER INSURED/REGISTERED Male Female Total Children - 17 years and below 2005 Adults - 18 to 69 years Aged - 70 years and above Total Children - 17 years and below 1 2006 Adults - 18 to 69 years Aged - 70 years and above J Total ! Children - 17 years and below | Adults - 18 to 69 years 2007 Aged - 70 years and above 1 Total | - Children - 17 years and below 2008 Adults - 18 to 69 years J Aged - 70 years and above Total i C) Benefits of the Scheme 3. Tick the benefit(s) of the scheme to the members of the district i) easy financial access to healthcare by the insured___ ii) easy utilization of healthcare by the insured___ iii) has improved the provision of modern healthcare___ iv) has improved revenue to health facilities___ v) other (specify) 131 University of Ghana http://ugspace.ug.edu.gh 4. Kindly provide information on those who have used the scheme to access healthcare from 2006 to 2008. D) Access to healthcare through the scheme 1 YEAR r ................-.......................................... AGE GROUP NUMBER OF INSURED WHO | 1IAVE ACCESSED HEALTH­ CARE Male Female Total Children - 17 years and below Adults - 18 to 69 years 2006 Aged - 70 years and above 1 i 1 I Total 2007 Children - 17 years and below f1 i Adults - 18 to 69 years 1 Aged - 70 years and above i j Total ~ j Children - 17 years and below 1 ! 2008 Adults - 18 to 69 years j fI i Aged - 70 years and above 1 1 Total ! i 5. Has the NHIS improved financial access to healthcare in communities under your operations? Y es____ N o____ 6. Ifl'e j. provide indicators. 7. If No, what are the reasons? University of Ghana http://ugspace.ug.edu.gh 8. Provide the amount you pay to health providers on insured members annually, from 2006 to 2008. E) Benefits paid to Health Providers on behalf of members ! YEAR AMOUNT IN CEDIS j 2006 2007 2008 TOTAL F) Working relationship with accredited health providers and requisition for reimbursement 9. What type of working relationships exists between you and the accredited health providers? 10. How long does it take to reimburse returns from health facilities? Please tick. 1 week_ 2 weeks__ 4 weeks__ 8 weeks__ Other (specify)________________ 11. Please, provide information on requisition for reimbursement below YEAR NUMBER OF FACILITIES NUMBER OF INSURED TOTAL AMOUNT REQUESTED TOTAL AMOUNT REIMBURSED 2006 [ 2007 2008 | 133 University of Ghana http://ugspace.ug.edu.gh 12. What measures or actions are resorted to when the scheme is unable to reimburse in time or could not reimburse? 13. State feedback or reports received from health facilities G) Challenges 14. State feedbacks received from the registered members under the scheme, a) Challenges/problems facing members of the scheme: b) How are the problems of registered members solved? 134 University of Ghana http://ugspace.ug.edu.gh H) Sustainability 15. Since its establishment, how do you rate the stability of the schcme? Tick one. i) Very stable_____ ii) Stable_____ iii) Unstable_____ iv) Very unstable___ 16. Give reasons for your answer to Q15. 17. State the most effective strategies used to mobilize resources and membership to the scheme. Resource i ) ________________________________________________________________________ ii ) ________________________________________________________________________ iii )________________________________________________________________________ iv )________________________________________________________________________ v ) _________________________________________________________________ Membership i ) _________ ii )_________ iii )________ iv )________ v ) ________ 18. What do you consider to be the major strengths and weaknesses of the scheme? a) Strengths 135 University of Ghana http://ugspace.ug.edu.gh b) Weaknesses I) Recommendations 19. Make recommendations in the following areas which will help improve and sustain the scheme. a) Mobilization o f new members and retention of the already insured. 1) _____________________________________________________________ 2 ) ______________________________________________________________ 3) _________________________________________________________________ 4) ____________________________________________________________________ 5 ) _____________________________________________________________________ b) Financial management of the scheme 1) _________________________ 2) ____________________________ 3) ____________________________ 4) ____________________________ 5 ) ____________________________ c) Viability and sustainability of the scheme 1) ____________ 2) 3) _______________________________ 4) _______________________________ 5 ) ________________________________ Thank you very much. 136 University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA, LEGON DEPARTMENT OF SOCIAL WORK APPENDIX 4: QUESTIONNAIRE FOR ACCREDITED HEALTH PROVIDERS THE NATIONAL HEALTH INSURANCE SCHEME AND COMMUNITY ACCESS TO HEALTHCARE: A CASE STUDY OF ABOKOBI HENRY YEBOAH YIADOM-BOACHIE I am a graduate student of the Department of Social Work. University of Ghana, Legon. 1 am conducting a research on “The National Health Insurance Scheme and Community' Access to Healthcare: A Case Study of Abokobi”. This is part of the requirements for my academic work and 1 would be happy for your patience and openness in responding to these questions. All information provided will be treated confidential and used only for academic purposes. QUESTIONNAIRE FOR THE ACCREDITED HEALTH PROVIDERS A) Genera! Questions I. State the date of establishment of this health institution. 2. What is the ownership of the institution? Please tick a) Public_____ b) Private_____ 3. How long have you operated as health institution? 4. Provide information on the staffing of the institution. Staff Males Females Total No. of doctors No. of nurses | Administrators .......................1 Pharmacists Paramedics Total 137 University of Ghana http://ugspace.ug.edu.gh 5. What sort of agreement do you have with the National Health Insurance Scheme? Please tick. a) Memorandum of Understanding (MoU)___ b) Signed contract/agreement___ c) Other (specify)___________________________ _________________ 6. Since when have you been serving the scheme and its members? I ick the year. a) 2005 ____ b) 2006____ c) 2007 _ _ d ) 2008 ____ e) 2009 7. Who is responsible for the affairs of the scheme in this health institution? a) Administrator____ b) Accountant/accounts officer __ c) Other (please specify)_______________________________________ B) Payment System 8. What mode of payment does the scheme use to pay the health bills of its members? a) Bank transfers____ b) Bankers' draft____ c) Bank cheques____ d) Cash____ e) Other (specify)_________________________________________________________ 9. Tick as appropriate the timeframe for reimbursement. a) Monthly_____ b) Quarterly_____ c) Biannually____ d) Annually_____ e) Other (specify)________________________________ 10. How would you assess the reimbursement arrangement you have with the scheme? a) Excellent___ b) Very good___ d) Good___ e) Satisfactory___ 0 Poor__ 138 University of Ghana http://ugspace.ug.edu.gh 11. Explain your answer to question 10 above. C) Access to healthcare by the insured 12. Indicate the number of insured people who have accessed healthcare from 2006 to 2008. i YEAR AGE GROUP NUMBER OF PEOPLE WHO HAVE USED THE SCHEME TO ACCESS HEALTHCARE | Male Female j Total Children - 17 years and below j 2006 Adults - 18 to 69 years | Aged - 70 years and above Total j Children - 17 years and below 1 1 1 2007 Adults - 18 to 69 years Aged - 70 years and above Total ! Children - 17 years and below 1 Adults - 18 to 69 years I 2008 Aged - 70 years and above 1 Total j L. 13. What were the total outpatient visits and admissions of the insured from 2006 to 2008? OPD visits for 2006_______________ Admissions for 2006____________ OPD visits for 2007___________ Admissions for 2007____________ OPD visits for 2008 Admissions for 2008 ____ 139 University of Ghana http://ugspace.ug.edu.gh 14. State feedbacks you receive from registered members of the scheme regarding the problems they face in accessing healthcare. 15. How are the problems mentioned above solved? D) Health Providers’ Benefits 16. State your annual income from the scheme from 2006 to 2008. Annual income for 2006: GH Cedis_________________________ Annual income for 2007: GH Cedis_________________________ Annual income for 2008: GH Cedis_________ 17. What do you consider to be the positives effects of the scheme to your operations? ii) _____________________________________________ ________________ iii) _______________________ iv) ________________________ v ) ______________________________________________________________ vi) ____________________________ vi) ______________________________________________________________ 140 University of Ghana http://ugspace.ug.edu.gh 18. What has been the negative influence of the scheme to your operation? i) - ____________________ ii) iii) iv) v) E) NHIS and Financial Access to Healthcare 19. From your experience and records on healthcare delivery over the years, would you say financial access to healthcare has improved with the introduction of the NHIS? Yes No 20. If Ke.v. provide indicators (what shows that the NHIS has improved financial access to healthcare?). 2 1 .1 f No. w hat are the reasons? 22. List the major problems you consider to be facing the scheme. 1) ____________________________ University of Ghana http://ugspace.ug.edu.gh F) Recommendations 23. In your opinion, what do you think can be done to improve and sustain the scheme? Thanks so much. 142 University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA, LEGON DEPARTMENT OF SOCIAL WORK APPENDIX 5: FOCUS GROUP DISCUSSION QUESTIONS GUIDING THE DISCUSSION 1. Whai is the community members' perception of access to healthcare? In other words, what factors greatly influence people’s access to healthcare in this community? 2. What is the general perception of the NHIS in this community? 3. Why are many community members' not subscribed to the scheme? 4. What problems do people face in accessing healthcare under the scheme? 5. Has the NHIS improved community members' financial access to healthcare? If it has. what are the indicators? If it has not, what factors contribute to its inability to improve insured members' financial access to healthcare? 6. What are the general problems of the scheme and challenges faced by both accredited health providers and the NHIS administration? 7. What do you think can be done to improve and sustain the scheme? 143 University of Ghana http://ugspace.ug.edu.gh APPENDIX 6: LIST OF MEDICINES FOR 2009 C o d e C Jen e ric n am e , d o s a g e f o rm , s t r e n g th 11 n it o f P r ic in g P ro p o s e d P r ic e s 51 1 rO R IN I 5-1 luorouracil Injcclion. 5n mg ml 10 Ml. 8.00 AC E T A /.IN l A celu /o lam ide Inieeiion. 5 t > mg Ainpoul c 22.00 A C ETA Z TA t A cetu /o lam ide Tablet. 25(1 mg 1 able! 0.06 I h e r b y d c l A ccty lsalicy lic Acid 1 ablet. 75 mg I D ispersib le) Tablet 0.03 \CF.TN I.INI Acety Icystcinc Inieeiion. 2*)<> mu ml 1 Ml 1.2 ACETYLTA 1 Acety Isalicy lie A cid lab le l. .'00 mg Tablet 0.01 ACTC LOC R l Acyclov ir C ream . 5% 2 ( . 6.00 A C IC LO EO I A cyclov ir Eye O in tm ent, 3% 4.5 0 14.75 A C i n o i M Acyclov ir Injection. 250 mg \ i.il Vial 34.00 ACIC L O S 1 2 Acyclov ir Suspension , 200 m g 5 ml 20 ML 44.40 AC1CI.OTAI A cyc lo \ir l ah le l. 200 mg fable! 0.80 ACTC’HAPO l Acti\ ated C harcoal I’ow der. 50 g 50 G 0.75 ADRENA IM Adrenaline Injection. 1 mg ' 1ml <1:1000) 1 ML 0 .40 ADRENAIN2 Adrenaline Injection. 1:10.000 Ampoule 5.20 ADRIAM IN1 Adriam ycin In jection . 50 mg Ampoule 32.00 ALBENDSY1 A lbendazo le Syrup. 100 mg 5 ml 10 Ml 131 ALBENDTA1 A lbendazo le Tablet. 200 mg Tablet 0.60 ALBENDTA2 A lbendazole Tablet. 400 mg Tablet 1.20 ALLOP t'TA I A llopurinol t ablet. 100 mg Tablet 0.12 A LLO P l TA2 A llopurinol Tablet. 300 mg 1 able! 0.20 A L l IIYDM II A lum inium Hydrox ide M ixture 100 ML 2 .00 M l H VDTA 1 Alum inium H ydroxide lub lc l. 500 mu lub le t 0.02 \M IAC IIN I Am ino Acid Solution Inieeiion. I0"„ 1 Ml 0.04 AMI AC IIN2 Am ino Acid Solm ion Inieeiion, -0",, 1 Ml 0.06 \ Ml NOPIN 1 Aminopliy(line Inieeiion, 250 mg III ml Vial 0.95 144 University of Ghana http://ugspace.ug.edu.gh C od e G en e r ic n am e , d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed P r ice s AM IODATAI Am iodarone 1 ablet. 2011 mg 1 uhlel 0.55 AM ITRITAI Am itrip ty line ta b le t. Id nig 1 ablet 0.05 VMITRITA2 Am itrip l> line lab le l. 25 nig 1 ablei 0.10 AM ITRITA3 Am itrip ty line l ab lel. 50 mg 1 ablet 0.20 AMLODITA1 Am lodipinc t ablet. 5 nig 1 ablet 0.12 AM I.ODITA2 Am lod ip inc ta b le t. In mg lab le l 0.22 AMOARTPO l Amodiaqu ine *■ A rtesunale G ranu lar Powder. 75 mg - 25 mg Sachet 0 3 6 A M 0A R T P 0 2 Amodiaqu ine • A rtesunale G ranu lar Powder. 150 mg * 50 mg Sachet 0.40 AMOARTTAI Amodiaquine * A rtesunale 1 ablet. 150 mg < 5 120 m e (2 4 's ) 1 Course 5.00 \R TLUM TA 2 Artem clher 1 l.iim elim lrine l ablel. -In mg • 2-10 mg ( I2 's ) 1 Course 4.30 145 University of Ghana http://ugspace.ug.edu.gh C od e G en e r ic n am e , d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed P r ic e s \ R T u ivn u Artem ether ' 1 um elan irinc Tahlel, 80 mg > 4X0 ins (6 's ) 1 Course 4.30 V T E H Y im i Atenolol * llyd roeh lo rth iazide Tablet. 50 mg ' 25 mg 1 ablet 0.50 VIEIIN DTA2 Atenolol 1l\d ro ch lo r lh ia /id e Tablet. (100 mg 1 2 5m g l 1 ablet 1.04 A T l.N O i.IM Atenolol Injection. 500 m ierogram /m l Injection 2.00 \T E \O L T A I Atenolol Tablet. 25 mg Tablet 0.03 ATENOLTA2 Atenolol Tablet. 50 mg Tablet 0.06 ATENOLTA3 Atenolol 1 ablet. 100 mg I ablet 0.08 ATORVATA 1 Alorvastalin Tablet. 10 mg Tablet 1.16 \ TORVATA2 A to r\a s ta lin Tablet. 20 mg Tablet 2.00 ATROPIID I A tropine 1 > e D rops. 1% 10 ML 3.50 ATROPIIN1 Atrop ine Injection. 0 .6 mg/nil I ML 025 A Z1TH RCA I Azithrom ycin C apsule . 250 mg Capsu le 0.85 A Z ITH R S l; 1 Azithromycin O ral Suspension , 200 mg.'5 ml 15 ML 5.57 A Z IT H R S l'2 Azithrom ycin O ral Suspension. 200 mg/5 ml 30 ML 5.69 BADOESIN1 Badoe's Solution Injection. 1000 ml 1000 ML 4.00 B EA C SAO II Benzoic A cid + Salicy lic A cid O intm ent. 6%+3”o 25 G 1.50 BECDIPG .A1 Bcclom etasone d ip rop ionate Inhaler. 50 m icrogram metered dose (200 doses) Inhaler 24.75 B ECD IPGA 2 Bcclom etasone d ip rop ionate Inhaler. 100 m icrogram metered dose (200 doses) Inhaler 38 .00 BECD1PGA3 Bcclom etasone d ip rop ionate Inhaler. 200 m icrogram metered dose (200 doses) Inhaler 30.00 B EN B EM .O l Benzy 1 B enzoate Lotion . 25% 1 ML 0.03 BENDROTA1 Bcndro llu ineth iazidc Tablet. 2.5 mg Tablet 0.05 BKNDROTA2 Bendro flum eth ia /ide Tablet. 5 mg Tablet 0.07 BENPERSOI Benzoyl Peroxide C ream . 5% 30 G 6.00 BKNPERS02 Benzoyl I’ero.vide C ream , 10“ n 30 G 7.00 BENZATINI Ben /alrop ine Injection. 1 mg/m l 1 Ml. 3.00 146 University of Ghana http://ugspace.ug.edu.gh C od e G en e r ic n am e , d o sa g e rorin , s tr en g th U n it o f P r ic in g P rop o sed Pr ice s B F .N /.A I IA 1 B en /atrop ine Tablet, 2 mg 1 ablet 0.06 BK \Z V I.IN I Den/} Ipcnieillin Injection, 1 M l1 Vial 0 .30 H IN /A 1 I \ 2 Ben /y lpcn ic illin Injection, 5 M l1 Vial 0.55 i n r w o i D i Bctaxolol IIC l 1 : \ e D rops. 0 .5” i> 5 ML 7.00 BKT \ AI.CR1 Betam ethasone \ alera lc C ream . O.(l5"0 15 G 4 .00 HI 1 \ Al.C'RZ Betam ethasone V alerate cream . 0 .10 o 15 G 4.50 BIS VC OT A 1 Bisacodyl T a b le t 5 mg 1 ablet 0.02 BROMOCTA 1 Itrom ocrip linc ta b le t. 2.5 mg lab le l 0.84 Bt DESOGA1 Budesonide DPI. 100 in ierogram (100 Doses) Inhaler 26.00 B l DESOGA2 Budesonide DPI. 200 m icrogram (100 Doses) Inhaler 36.40 B l DFORGAI Budeson ide • l orm oterol Inhaler X0 m icrogram 4.5 m icrogram |6D Doses) Inhaler 31.80 B ID FO RCA 2 Budeson ide + Form otero l Inhaler 160 in ierogram 4.5 m icrogram (60 Doses) Inhaler 63.00 B t PIN A IM Bupivaca ine In jection . 2.5 mg/m l Ampoule 1.70 B l PIVA1N2 Bupivacaine In jection . 5 mg/m l 4m l Am p 1.68 CALAM ICRI Calam ine C ream . 15% 15 G LOO CA l.AM II.O I Calam ine l.o tion . 15% 100 ML 1.47 C ALCARTAI Calcium C arbonate Tablet. 500 mg 1 ablet 0.30 CALC1FTAI Calcifero l Tablet. 10,000 units Tablet 0.75 C A IX L l INI Calcium G luconate In jection . 100 m g ml in 10 ml Vial 3.00 T H E N A I I H A Calcium w ith V itam in 1) Tablet. (97 nig « 10 m icrogram ) lab le l 0.04 C APKCITAI Capecitab ine Tablet. 500 mg 1 ablet 8.00 C ARBAMTAI C arbam a/ep inc Tablet, 100 mg Tablet 0 .20 { \RHAM TA2 C 'a rb anw cp in e Tablet. 200 mg Tablet 0.24 ( ARBAMTA3 t 'a rb am a /ep in e Kustainud-Kclcasc 1 ablet, 2yay mg Tablet 0.30 < U IUAM TA4 ( a rh am a/cp inc Susta ined -ke lease 1 ablet, 400 mg 1 ablet 0.50 147 University of Ghana http://ugspace.ug.edu.gh C od e G en e r ic n am e , d o sa g e fo rm , s tr en g th U n it o f P r ic in g P ropo sed P r ices C ARBIMTA1 C aih im a /o le Tahlel. 5 mg 1 ublel 0.30 C ARBIMTA2 C arb inu i/o le la b lc t. 20 mg 1 ablet 0.80 t \RBOCC A l Cuibocisic inc C apsu le . .375 mg < apsule 0.40 I \R B (K "SV I Carhocistc ine Syrup Paed iatric . 125 m g '5m l 100 ML 4.00 C VRBOC 2 Carbocislc inc S \ru p . 250 mg 5ml 100 Ml 4.50 CEKACl C A l Cefac lo r C apsule . 250 mg Capsule 0.95 C EEAC LC \2 Cefac lo r C apsule . 500 mg Capsule 1.50 C EFACLS l 1 Cefac lo r Suspension. 125 m g 5ml 100 ML 7.50 CK .K A tl.S 12 Cefac lo r Suspension, 250 m g 5ml 100 ML 10.00 CKKO I A IM Cefo tax im e Injection. 500 nig V ial 10.00 CF.KOTAIN2 C efo tax im e Injection. 1 g Vial 15.00 C EFTRHM C eftriazone Injection. 250 mg Vial 3-50 CEKTRIIN2 C eftriazone Injection. 500 mg Vial 4.00 CEKTRIIN3 Ceftriazone In jection , Ig Vial 5.25 ( F.Fl ROIN1 Cefurox im e Injection. 750 mg V ial 5 2 5 C E F l R O S l'l C cfurox im c Suspension. 125 mg/5m l 70 ML 9.80 CE F li ROTA1 C efurox im e T a b le t 125 mg Tablet 0.80 C E F l1 ROTA2 Cefu rox im e Tab let, 250 mg Tablet 1.50 CETIRISV1 C ctiriz ine Syrup. 5 mg/5m l 1 M l 0.6 CETIR ITA I C etir i/in e Tablet. 10 mg Tablet 0.10 CETR IM SO l Cetrim klc Solution 200 Ml 2 2 5 CH I.ORACA ! Chloram phen ico l C apsu le . 250 mg Capsu le 0.02 C IILORAEDI Chloram phen ico l l ar D rops. 5% 10 Ml 1.00 t IIIOUAKO I Chloram phenicol 1 ye O in tm ent. 1% 5 C. 1.00 < III.ORAI1M Chloramphenicol 1 \ c D rops. o.5°n 10 Ml 1.00 C 111.ORA IN 1 Chloramphenicol Injeelion, 1 g 1 C. 0.70 < H IO R A S t'l Chloramphenicol Suspension . 2.50 mg 5 ml ion Ml 1.00 148 University of Ghana http://ugspace.ug.edu.gh C od e G en e r ic n am e , d o sa g e fo rm , s tr en g th Unit o f P r ic in g P rop o sed P r ice s CH l.ORHCR I Chlorhex id ine C ream , 1% 15 (, 3.00 CHI .OR IIM tt 1 C lilo rh e \id in e M outhw ash. u 2'’.. 20(1 Ml 3.50 C HLORHSO l Chlorhcv id inc Solution . 2 .5% 100 Ml 2.30 C III PIIKSV 1 Chlorphenam inc S \ru p . 2 mg'"? ml 100 Ml 1.00 C H l.PHETA I Chlo rphenam inc Tablet. 4 mg 1 ablet 0.01 C HI PROIN 1 C h lo rp rom a/in e Inieeiion. 25 m g/m l in 2 ml V ial 0.43 CH t.PROTV I C h lo rp rom a/in e l ab lel. 25 mg 1 ablel 0.05 C H t .P R O T \: C 'h lorprom a/ine 1 ablet. 50 mg Tablet 0.06 C H IPR O T A3 C h lo rp rom a/in e lab le l. 11)0 mg fable! 0.08 C H R K H IM Cholera R ep lacem ent F luid In jection , (5 :4 :1 ) 500 ml 500 M i­ 1.50 C l PR O UD 1 C iprofloxacin E \e D rops. 0 .3% ll) M l. 4.00 C l PROKIN 1 C iprofloxacin Infusion, 2 m g/m l in 100 ml Vial 2.45 CIPROKTAI C iprofloxacin 1 ablet, 250 mg Tablet 0.20 C IPROFTA2 C iprofloxacin Tablet. 500 mg Tablet 0 3 0 CLARITCAI C la rilh ro n n c in Capsule. 250 mg C apsule 1 3 0 C I.AR ITCA2 C larith rom ycin C apsule , 500 mg Capsu le 2 3 8 CLARITSU I C la rilh ro n n c in Paediatric Suspension, 125 mg 5 ml 100 ML 22.00 CL INDACAI C lindam ycin C apsu le . 150 mg Capsule 1.00 CL INDA IM C lindam ycin Injection. 150 m g/m l in 2ml Vial 11.00 C L INDASO l C lindam ycin Solu tion . 1% 30 ML 18.00 C U N DASH 1 C lindam ycin Suspension . 75 mg/5m l 100 M l 10.25 CLOHYDCR C lo irim a /o le + H ydrocortisone C ream . 1% + 1% 1 5 0 3.20 C I.OPROCHI Clohclasol Propionate C ream . 0 .05% 15 0 1.50 C I.OTR ICR I Clo trim azo le C ream , 1% 15 C> 3.00 C I.OTRIC R2 C lo irim u /o lc C ream . 2% 15 C> 3.00 CLOTRIVPI C lo trim a /o le Pessary. 100 m g (' Pcss. 2.80 149 University of Ghana http://ugspace.ug.edu.gh C od e G en e r ic n am e , d o s a g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed P r ices C I.OTR IVP2 C lo trim a /o le Pessary. 200 nig 3 Pcss. 3.20 t I.OTRIVP3 ( 'lo iriin .i/o lc Pessary . 51)0 mg 1 Pe.ss. 3.50 < l .O W C INI t 'lo x ac illin Injection. 250 nig Vial 0.50 CLOXACIN2 Cloxucillin Injection. 5(10 ing Vial 0.65 C OAMO.XINI Amoxicillin - C lavu lan ic A cid Injection. 500 nig + 100 mg V ial 5.60 COAVIOXIN2 Amoxicillin • C lavu lan ic A cid Injection. Ig Vial 8.90 CO AM OX S lll Amoxicillin • C lavu lan ic A cid Suspension, 250 mg - 62 mg 70 ML 5.60 COAMOXSU2 Amoxicillin C la \ u lan ic A cid Suspension . 400 mg - 57 mg 70 VII 7.00 COAMOXTA 1 Am oxicillin + C lavu lan ic A cid Tablet. 500 mg + 125 mg Tablet 0.80 COAMOXTA 2 Amoxicillin - C lavu lan ic A cid Tablet. S75 m g + 125 mg Tablet 0.96 CODEINTA1 Codeine Tablet, 30 mg Tablet 0.15 CONOESTA1 Conjugated l lestrogen Tablet. 625 m icrogram Tablet 0.60 CONOESVC I Conjugated O estrogen V aginal cream , 625 m icrogram g 1 G 0.40 COOENOTA1 Conjugated O estrogen + Norgestero l Tablet. 625 in ierogram + 150 m icrogram Tablet 120 CORANTEO l Corticostero id + A ntib io tic F.ve O intm ent 10 Ci 3.50 CORANTID I Corticostero id + A ntib io tic live D rops 10 M l. 4.00 COTR IM SU I C o trim oxa /o le Suspension . (200+40) m g/5 ml 100 M l. 1 3 0 C OTRIMTAI Cotriinox .i/o le Tablet. (400+80) mg Tablet 0.02 O C I.OPIDI Cyelopcn to la te 1 ye D rops. 1% 5 M l. 7.50 C VC l.O PIN I C yclophospham idc Injection, 500 mg Arnpoul e 6.00 0 MOURCA 1 Cytid ine M onophospale+ 1 iridine D isphospatc C apsule 0 .50 OAKKOWINJ n a rrow 's Solu tion Injection, 1 lulfSlreiigth 250 ml 250 Ml 1.60 150 University of Ghana http://ugspace.ug.edu.gh C od e G en e r ic n am e , d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed P r ice s D E -SO tH IM Dextrose in Sodium Chloride In travenous Inlii- ion. 4 i"„ in 0. IK“« (250 m il 250 M l. 1.50 DESOCIHN2 1 K'Miosi‘ in Sodium ( 'h lo ridc 1 n lru \enous Inlii'-ion 5“<• in tl ')” „ (50o ml) 500 Ml 1.61 DEXAMEEOI Dexamctliasonc 1 ye O inlm ent. 1% 5 (. 2.00 D E W MF 11)1 Dcxam ethasone l-,\e D rops. 1 •*.. s M l. 6.25 DEXAM EIM 1 V vnncllUMme Injection, 4 mg ml 1 Ml. 0.40 D EXAM E IM 1 V \anictl)u>oiic Injection. 8 mg/2m l \ ial 0.40 D E X AM E IM Dcxam elhasonc Tablet. 500 m icrogram lab lc t 0.02 DEXTRO IM Dextrose Infusion. 5% (250 ml) 250 M l. 130 DEXTROIN2 Dextrose Infusion. 5% (500 m l) 500 Ml 1.60 D EXTRO IM Dextrose Infusion. 10% (250 nil) 250 ML 1 30 DEXTROIN4 Dextrose Infusion. 10% (500 m l) 500 Ml 1.60 DEXTROIN5 Dextrose Infusion. 50% (50 ml) 50 ML 1.80 D IAZEPIM D ia /cpam In jection . 5 mg/m! in 2 ml Vial 0 3 0 DIAZEPRSI D ia /cpam Rectal l ubes, 2 mg/m l Rectal Tube 5.00 DIAZEPTA1 D ia /ep am 1 ablet, 5 mg Tablet 0.01 DIAZEPTA2 D ia /cpam Tablet. 10 mg tab le t 0.01 DICLOECAI D iclo fenac C apsu le , 75 mg Capsule 0.40 D ICLOFCE l D iclofenac Gel 30 G 2.00 D IC I .O IIM D iclofenac In jection . 25 mg/m l ML 0 3 3 D l( LOEREI D iclofenac Supposito ry . 50 mg Supp. 0 3 0 DK LOERE2 Diclofenac Supposito ry . 100 nig Supp. 0.65 DK LOFJ A 1 D iclofenac Tablet. 25 mg Tablet 0.07 DICLOETA2 Diclofenac ta h lc l. 50 mg lab lc t 0.06 D IE S IITA I D icthylsiilbocslrol Tablel. 1 mg lab lc t 4.00 DIESTITA2 Dicthylstillxiestrol ta b le t. 5 mg 1 ablet -> University of Ghana http://ugspace.ug.edu.gh C o d e G en e r ic n am e , c lo su re fo rm , s tr en g th U n it o f P r ic in g P rop o sed P r ice s DIGOXIEL1 D igoxin Elixir. 50 m icrogram ml 1 ME 0.46 O L S U A AR A D igoxin Injection. 250 m icrogram /m l 1 ME 1.80 MGOX1TAI D igoxin ta b le t. 62.5 m icrogram Tablet 0.05 DIGOXITA2 D igoxin Tablet. 125 m icrogram 1 ablet 0.08 D1GOXITAJ Digoxin Tablet. 250 m icrogram Tablet 0.05 DIHPIPC'AI D ihydroartem isin + P ipcrai|u inc capsules .'20 mg + 411 mg 8‘s 4.00 DIHPIPPO l D ihydroartem isin + P ipcrai|u ine G ranu lar Powder, 10 mg + SO mg Sachet 0 3 2 D«»n DRTA1 Diliydrocodeinc lab le l. 30 mg Tablet 0.20 D IPHENTA 1 D iphenhydram ine Tablet. 25 mg Tablet 0 2 5 DISOPYCA1 Disopyram ide Capsule. 100 mg Capsule 0.50 DISPHOIN1 D isopyram ide Phosphate In jection , 10 mg/m l 5ml Vial 9 .50 DOCETAIN I Docelaxel In ieeiion . 40 m g ml Ampoul e 180.00 DOMPERTA1 Domperidone Tablet. 10 mg Tablet 0 .40 DOPAMHN1 Dopam ine Injection. 40 m g/m l in 5 ml Vial 6.00 DOXAPR1N1 Doxapram Injection. 20 m g/m l in 5 ml Vial 3.60 DOW CVCA J Do.xycycline C apsule . 100 mg Capsule 0.06 EPHEDR IM Ephedrine MCI injection. 30 mg/m l Ampoul e 2.60 EPHEDRND1 Ephedrine Nasal D rops. 0 .5% 10 ME 1.90 EPHEDRND2 Ephedrine Nasal D rops, 1% 10 ML 2.00 ERGOMEIN1 I.rgom ctrine Injection, 0.2 mg/m l 1 ML 0.30 ERGOMEIN2 Ergom etrine In jection. (1.5 m g 'm l 1 ML O 1. © ERGOM ETA1 Ergom etrine Tablet. 0.5 mg Tablet 0.05 ERGOTATA 1 Ergotam ine ta b le t. 2 mg Tablet 0.30 ERVTIIRINI Erythromycin Injection. Ig Ampoul e 15.00 ERYTHRSYI Erythromycin Syrup. 125 mg/5 ml 100 ME 1.50 152 University of Ghana http://ugspace.ug.edu.gh ( 'o t ic G en e r ic 11111110, d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed P r ice s ERYTHRTAI Erythromycin lub lc i. 250 my I ablet 0.08 KSOMEPCA1 Ksom epra/o le Capsule. 2o mg ( apsulc 2.00 KSOMKPC A2 1 .someprazolc Capsule. In mg ( apsulc 3.00 ETHOLESOI 1 ihanolam ine O lcale Solution. 5" ml 1 ML 1.30 H \ DRALINI Hydralazine Injection. 20 mg Vial 6.00 HYDRALTA l Hydralazine Tab let. 25 mg Tablet 0.20 HVDROCCR1 1 lydrocorlisone C ream . 1% 15 G 2.50 HVDROCEOI 11 ydrocortisone 1 yc O in tm en t l°o 15 C. 4.00 HVDROC ID l Hydrocortisone l ye D rops. 1% 5 G 5.00 i n DROX1NI 1 lydrosocobalam in Injection. 1 mg ml 1 Ml 0.60 IIVOBUTIM llyo sc in e Hutylbrom idc Injection, 20 mg ml 1 Ml 0.30 lO OB l/TTA 1 1 lyosclne HutyIbroinide I'ablet. 10 mg 1 ablet O.OS HYSOSUINI Hydrocortisone Sodium Succinate Injection. 100 mg Vial 0.80 155 University of Ghana http://ugspace.ug.edu.gh C od e G en e r ic n am e , d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed Pr ice s IB t'PROSt! 1 Ibuprolen Suspension . 10(1 mg/5 nil 100 Ml. 1.50 IBt PROTAI Ibupro len l ublct. 200 mg 1 ahlct 0.01 IBI PR 0TA 2 Ibupro len Tablet. 400 nig 1 ablet 0.02 IM IPRATA 1 Im ipnim ine Tablet, 25 mg 1 ablet 0.06 IM ’RMIIN 1 Insulin p rem ixed (30/70) IIM Injection. 100 units ml in 10 ml Vial 25.00 INSSOL1M Insulin Soluble TIM. 100 units/m l in 10 ml Vial 25.00 IVTRALSOI Intralipid Solu tion ( for T P \ !) 100 M l. 20.00 1RODFAINI Iron D cu ra ii Injection. 50 m g'm l 1 M l. 0 3 0 IROPOLCA1 Iron (III) Poly m altose C om plex C apsule Capsule 0.12 IRO PO l.S l'1 Iron ( ti l) Polym altose C om plex Suspension 150 ML 2.50 IR O S l’C IN l Iron Sucrose Injection. 20 mg/m l Ampoule 14.00 ISOD INTA l Isosorbide D in itrate Tablet, 10 ing Tablet 1.20 ISO INSIN l lsophane Insulin Injection (TIM). 100 units nil in 10 ml \ ial 25.00 ITRACOCA 1 Itraconazo le C apsu le , 100 mg Capsule 6.00 ITRACOSUI Itraconazo le Suspension . 10 mg/m l 30 ML 38.00 ITRVCOTAI Itraconazo le T ablet, 20 mg Tablet 4.50 K E TAM I IN I K e tam in e In je c tio n . lO m g in l in 2 0 m l 20 ML 3 .0 0 KE TAM I IN 2 K e tam in e In je c tio n , 5 0m g /n il in 10 ml 10 ML 4 .5 0 KETOCOCR1 Ketoconazole C ream . 30g Tube 3.50 KETOCOTA ! Kctoconazo lc 1 ablet. 200 mg Tablet 0 3 5 LABETAIN 1 Labetalol In jection . 5 mg/m l 1 ML 0.40 LABETATAI Labetalol Tablet. 100 mg Tablet 0.40 1. VBFTATA2 l abetalol l ablel. 200 mg Tablet 0.60 I.AC TU I.LII l actu lose 1 kjuid '. I 3.7 g ;5 ml 500 M l. 8.25 1 1 VNODIA1 l.cvu thyrox ine Sodium 1 uhlct. 25 m ierogrum Tablet 0.08 LEVSODTA2 Lcvothyroxine Sodium tab le t. 50 m icrogram Tablet 0.09 156 University of Ghana http://ugspace.ug.edu.gh C o d e G c n c r i c n am e , d o s a g e f o rm , s t r e n g th U n it o f P r ic in g P ro p o s e d P r ic e s l .K \ SODTA 3 l.ev o tln ro v in c Sodium lab le l. 100 m icrngram 1 ablel 0.15 1 ID ADR IN I I .idocainc * A drenaline ( 'arlridgc. 2o my nil • II :S0,(KHV 1 100,0001 Cartridge 0.55 1 IDADR IN 2 1,id o c a in c * A d re n a lin e Injc-ction. Mlmg ml + 5m ts ; m l Vial 2 .oo 1 IDADR IN 3 1 idocainc * A drenaline Injection. 20mg ml • 5mcc ml Vial 2.50 I.IOOC AC R I 1 idocainc (. ream . 2 - 4% 15 G 2.50 M D O C A G E l 1 idocainc G el. 4% 15 G 3.00 I .I IK X A IN2 I idocainc Injection. 2% in 20 nils 20ml \ ia l 1.50 U D O C A IN 3 1 idocainc In jection , 20 mg ml in 5 ml Vial 1.50 LIDOC ASP I 1 idocainc Spray . 10% 50 Ml 12.00 I.ISHV OTA t l.isinopril + Ih d ro ch lo r th ia /id e 1 ablet. (10 mg + 12.5 mg) lab le l 1 20 L IS IIYD TA 2 Lisinopril * 1 lyd ro eh lo rlh ia /id e la b le l. (20 mg + 12.5 mgi Tablet 1.50 L IS IN O TA I L isinopril l ab le l. 2.5 mg Tablet 0.65 L JS INO TA 2 l.isinopril T ablet. 5 mg Tablet 0.20 L IS IN O TA 3 l.isinopril la b le l. 10 mg Tablet 0 2 5 L1S INOTA 4 Lisinopril T ablet, 20 nig Tablet 0 2 0 LODOXA ID 1 I.odo.vam ide Eye D rops. 0 .1% 10 M l. 12.00 LO PERACA 1 1 opcram ide C apsu le . 2 mg Capsule 0.10 L O R A ZE IN I L o ra /ep am In jection . 4 mg/m l Ampoule 1.00 I.ORAZ .ETA I l.o ra /ep am Tablet. 1 mg Tablet 0 2 0 LORA ZETA 2 l o ra /ep am Tablet. 2 mg Tablet 0 2 5 I.O RA ZETA 3 l.o ra /ep am 1 ablet. 2.5 mg Tablet 0 3 0 l .O S A R IT A I 1 .osartan Tablet. 25 mg Tablet 1.60 I .O SA R IT A 2 l.osartan Tablet. 50 mg 1 ablet 0.40 LO SARTTA 3 1 .osartan la b le l. 100 mg Tablet 2.50 a t i sm o ygy n y Magnesium Sulphate Inieclion. 20” ,. 10ml \m P 1.10 157 University of Ghana http://ugspace.ug.edu.gh C od e G cn e r ic n am e , d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed Pr ice s M A t;s i i l . lN 2 M agnesium Sulphate Injection. 50% lOmlAm P 1.30 M U . s t I.POI Magnesium Sulphate Salt 1 ( i 0.02 M VGTRIMH Magnesium Crisilieaie M ixture 100 Ml 0.80 MAGTK ITA l Magnesium Irisilica te 1 ahlei. 500 mg 1 ablci 0.02 M W M I IM Mannilol Injection. 10",, 500 ML 3.50 M AW IT IN 2 Mannitol Injection, 20",, 100 Ml 5.00 MATRALM II Magnesium Trisilicale ' A lum inium H ydroxide Mi.xture 100 ML 2.50 M M R M T A I Magnesium 1 risilieate + A lum inium 1 lydroxide Tablet 1 ablci 0.05 M EBENDS l 1 M ebendazo le Suspension . 100 mg/5 ml 30 ML LOO MEBENDTA1 M ebendazo le Cablet. 100 mg 6 Tablets 1 2 0 MEBF.NDTA2 M ebendazo le Tablet. 500 mg Tablet 1.20 MF.BF.VETAI M ebeverine Tablet. 135 mg Cablet 0.40 MEDACETA1 M edroxyprogeste rone A cetate Cablet. 5 mg Tablet 0 3 6 MEFACICAI Mefenam ic A cid C apsule . 250 mg Capsule 0.15 M EFACITAI Mefenam ic A cid Tablet, .500 mg Tablet 0.18 M ERC IR SO I Mcrcurochrom c Solu tion 15 ML 0.60 M ETCELID I Methyl C ellu lose Lye D rops. 0 .3% 10 ML 4.00 M ETFORTA ! Metform in Tablet. 500 mg Tablet 0.05 METHOTIN I Methotrexate In jection . 5 m g/2 ml \m pou le 2.00 METHOTIN2 Methotrexate In jection . 50 mg/2 ml -\m poule 4.00 METHOTTAI Methotrexate Tablet, 2.5 mg tab le t 0.55 V1ETHOTTA2 Methotrexate Tablet. 10 mg Tablet 0.50 M ET IIV tTA I M elhyldopa l ab lct. 250 mg Cablet 0.15 MKTOC I.IN1 Metocloprum idc Injection, 5 mg ml in 2 ml Vial 0.30 METOCI..SVI Meloelopram ide Syrup. 5 m g 'm l 1 Ml 0.05 MF IOC l.TA I Meloelopram ide 1 ablet, 10 mg 1 ablet 0.20 158 University of Ghana http://ugspace.ug.edu.gh C od e G en e r ic n am e , d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed P r ice s M ETOLATA1 Mclolazonc Tablet, 5 mg 1 ablcl 0.10 METHONIN1 M etronidazole Injection. 5 mg/ml in I ill) ml Vial 1.50 MF.TRONRE1 Metronidazole S uppos ito ry 500 nig Supp. 0.60 METRONSl'1 Metronidazole Suspension. 100 mg/5 ml la s benzoate) 100 Ml 1.00 METRONS12 Metronidazole Suspension, 200 mg/5 ml las b en /oa tc) 100 M l. 1.30 METRONTA1 Metronidazole l ablel, 200 mg lab lel 0.02 METRONTA2 Metronidazole Tablet, 400 mg 1 ablcl 0.03 M IC H \D C R I M iconazole + H ydrocortisone C ream . 2% + 1 15 G 4.25 M ICONAORJ M ieona /o le Cream , 2% 15 (i 2.50 M ICONAOGI M iconazole Oral Gel. 25 mg/m l 4 0G 15.00 M ICONAVPJ M iconazole Ovule. 400 mg 3 5.00 M IDAZO IN t M idazolam Injection, 5 mg/nil Ampoule 5.00 M IDAZOTA1 M idazolam Tablet. 15 mg Tablet 1.10 M ISOPRVP1 M isoprostol V aginal Tablet, 200 m icrogram lab le l 1.00 MORPHIINJ Morphine Injection, 10 mg/ml 1 ML 0.20 MORPHIIN2 Morphine Injection, 10 mg/m l (P reservative Tree) Ampoul e 5.00 M ORSILTA 1 Morphine Sulphate Tablet. 10 m g (Slow release) Tablet 1.50 MORSULTA2 Morphine Sulphate Tablet, 30 mg (Slow release) Tablet 3.00 M l'LT IVDR I Multivitam in Drops 20 ML 2.50 MULTIVSYI Multiv itam in Svrup 100 ML 1.00 V llL T lV T A l Mulliv itam in Tablet 10 Tabs 0.02 NALID1TAI Nalid ix ic Acid Tab let, 500 mg Tablet 0.12 NA I.OXO IM Naloxone Injection, 400 m icrogram /m l 1 M1, 4.75 NEOBROTA1 Neostigm ine D romide Tablet. 15 mg Tablet 1.00 NEOMVCTAI Neomycin Tablet, 500 mg Tablet 0.75 NKOSTIINI Neostigm ine Injection, 2,5 mg Ampoule 2.50 University of Ghana http://ugspace.ug.edu.gh C od e G en e r ic n am e , d o s a g e fo rm , s lr e n g lh U n it o f Pr ic in g P rop o sed P r ic e s N IFEDICAI NiIcilipinc ( apsulc, 10 mg Capsule 0.20 NIKK.OITA1 NiIcdipine lab lc t. 10 mg (slow release.) Tablet 0.13 NIFEDITA2 Nifedipine 1 ablel. 20 mg (slow release) 1 ablel 0.09 M F EM T .U Nifedipine Cablet. 30 mg (( il I S) 1 ablet 0.30 M TROFTAI Nitrofurantoin 1 ablel. 100 mg 1 ablel 0.05 NORETHTAI Norcthislcronc 1 ablel. 5 mg 1 ablet 0.18 NVSTATOII Nystatin O intm ent. 100.000 IU 30 C. 12.30 NVSTATSl.il Nystatin Suspension. 100.000 lU /m l 15 ML 5.00 W ST A T TA I Nystatin Pessary. 100.000 IU Pessary 0.20 NVSTATTA2 Nyslalin 1 ablel. 500.000 (II Tablet 0.20 OM EPRA IM Omeprazole Injection. 10 mg Vial 5.00 OMEPRAIN2 Om epra /o le Injection. 40 mg Ampoul c 6.00 O.MEPRATA1 Omeprazole Tablet. 20 mg Tablet 0.24 ORRESAPOI Oral Rehydration Sails Powder Sachet 0.03 OXVTOCIN1 Oxytocin Injection, 5 units/m l Ampoule 0.20 OXVTOCIN2 Oxytocin Injection. 10 unils/m l Ampoule 0.20 PACL IT IN 1 Paclilaxei Injection. 6 mg/nil Ampoule 160.00 PARACEREI Paracetamol Suppository . 125 mg Supp 0 2 5 PARACERE2 Paracclamol Suppository , 250 mg Supp 0.30 PARACERE3 Paracetamol Suppository . 500 mg Supp 0.50 PARACKS 11 Paracetamol Suspension. 250 mg/5 ml 125 ML 1.00 PARACESVI Paracetamol Syrup. 120 mg/5 ml 100 ML 0.80 PARACETA l Paracetamol Tablet. 500 mg Tablet 0.01 PA RAFT'!,II Paraffin 1 iquid 100 ML 1.80 PKM SE IM Pentam idine Isetionale Injection. 300 mg vial Ampoule 45.70 PET IIIM N I Pethidine Injection. 50 mg/ml in 2 ml Vial 1.20 160 University of Ghana http://ugspace.ug.edu.gh C od e G en c r ic n am e , d o su g c fo rm , s tr en g th U n it o f P r ic in g P rop o sed Pr ice s PHENOBEM Phenoharbital 1 lixir. 15 mg/5 ml 100 M l. 1.40 PHENOBINI Phcnobarhital In jection , 200 mg/ml 1 ml Ampoule 0.50 PIIENOBTA t Phcnobarhitul Tablet. 30 mg Tablet 0.01 PHENOBTA2 Phcnobarhital l ab lel. 60 mg 1 ablet 0.02 PHENO l.IN I Phenol 5% in A lmond Oil Injection 50 ML 3.00 PHENYTCA l I'heii} loin Sodium Capsule. 50 mg Capsule 0.08 PHENYTCA2 Phcnvtoin Sodium Capsule, 100 mg Capsule 0.08 PH EW T IM Phenyloin Injeelion, 50 mg/m l Ampoule 3.30 PHENYTTA1 Phcnvtoin Sodium Tablet. 100 mg Tablet 0.10 PHEPE.NTA1 Phenoxv methyl Penicillin Tablet. 250 mg 1 ablet 0.03 PHYTOM INI Phytom enadione Injection. 1 mg/ml Ampoule 1.00 PHYTOM IN2 Phylom enadione Injection. 10 mg/m l Ampoule 0.80 PILOCAID1 Pilocarpine Eye D rops. 2% 10 ML 5.50 PILOCAID2 Pilocarpine Eye D rops, 4% 10 ML 7.80 P iO G L lTA l P iog lita /one Tablet. 15 mg Tablet 0.18 PIOGLITA2 Pioglitazone Tablet. 30 mg Tablet 025 PIRACETAI Piracctam ( ablet. 800 mg tab le t 0.87 PIROXICA2 Piroxicam C apsule . 20 mg Capsule 0.02 POTCHLINI Potassium Chloride Injection, 20 mF.q/10 ml V ial 2.40 POTCHLTAI Potassium Chloride Tablet, 600 mg (enteric coated) Tablet 0.15 POTCTTMII Potassium C itra te M ixture HP 100 ML 1.00 POVIDOO Il Povidone iod ine O in tm en t 10% 10 G 2.50 POYIDOSOI Pov idonc Iodine aqueous solution. 10% too ML 2.30 PR A /JQ T A 1 Pra/iquan te l 1 ablet. 600 mg 1 ablet 0.45 PRA ZO SIA t P ra/o s in 1 ablet, 500 m icrognnn tab le t 0.20 PREDM ID I Prednisolone 1 vc D rops, 0 .5% 10 ML 2.30 161 University of Ghana http://ugspace.ug.edu.gh C od e (• c n iT ic n am e, d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed Pr ices PREDMHW Prednisolone 1 \ c 1 >rops. I"„ 10 Ml, 2.80 PR EDM 1 VI Prednisolone 1 .ihlcl. s n it lab le l 0.02 PRII 0 < IM Pnlocainc Injection. In me ml 5 1 Simple 1 incius (puediali'ic) BP( 100 ML 1.50 S | \ 1 I , |N S \ 2 Simple 1 incur. UPC 100 ML 1.50 163 University of Ghana http://ugspace.ug.edu.gh C o tic G en er ic AFAmo, d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed P r ice s S IM V AS TA 1 S im vastatin lab le l, 10 mg 1 ablcl 0.40 S IM V ASTA2 S inn I ablet, uyy mg 1 ablet 0.80 S IM V A S IA J Simvastatin lab le l. 40 mg 1 ablet 2.00 S IM VA STA 4 sim vasta tin 1 ablet. Xu mi: Tablet 3.00 s o w s i o n Soothing Agent - Local Anaesthetic • Steroid O intment 15 G 7.35 S O V N S IR I . 1 Soothing \g cn t * Local A naesthetic Steroid Supposito r\ Supp 0.50 SODB IC TM Sodium B icarbonate Injection. X.4'’n in 10 nil Vial 1.00 S O tM 'H I .IM Sodium Chloride Injection, 0.45% (250 m li 250 ML 1.50 SO D C IIL IN 3 Sodium Chloride Inlusion. 0.')“o (500 m il 500 ML 1.60 SO D CH LN D I Sodium Chloride Nasal Drops. ().*>% 10 ML 1.50 SO D V A IX A I Sodium Valproate Capsule. 200 mg Capsule 0.40 SODYALCA 2 Sodium Valproate Capsule (S low Release). 500 mg Capsule 0.93 SODVALSY1 Sodium Valproate Syrup. 200 mg 5 ml 300 ML 40.00 SODVALTA I Sodium Valproate 1 ablet. 200 mg Tablet 0 2 8 SOOANAO II Soothing A gent + Local A naesthetic O intm ent 15 G 5.00 SOOANARK 1 Soothing \g e n t + Local A naesthetic Suppository Supp 0.50 SP IRONTA I Spironolactone Tablet, 25 mg Tablet 0 3 0 SP IRONTA2 Spironolactone T ab le t 50 mg Tablet 0.40 STREPTIN I Streptokinase Injection. 100.000 un il-\ia l Vial 7.00 STREPTIN2 Streptokinase Injection, 250,000 unit-vial Vial 15.00 STREPT1N3 Streptokinase Injection. 750.000 un il- \ia l Vial 23.00 SULFASTA I Sulfasalazine fab lc t. 500 mg Tablet 0.50 S lI .P H A lD I Sulphacetam ide live D rops. 10% 10 ML LOO SI I.PVRTA I Su lladosinc P \ rim ctham inc 1 ahlet. 525 mg Tablet 0.10 TAM OX ITA 1 1 am osifen 1 ahlet. 10 nig Tablet 0.15 I \M O \IT A 2 lam o s ilcn lab le l. 20 mg Tablet 0.20 TAM .S r i.C A I 1 nnsulosin 1 apsulc. 400 m icrogram Capsule 2.30 164 University of Ghana http://ugspace.ug.edu.gh ( o d e ( • c n c r ic n am e, d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed P r iccs IK R A /0 1 \ l 1 e ra /o s in 1 ablcl. 2 mu Tablet 1.00 H K \ / O r \ 2 1 v ra /o s in 1 ablcl. 5 injj Tablet 1.50 IK R B IM Al 1 c rb ina lm e 1K 1 1 ablcl. 250 mg lab le l 1.50 TESENAJM 1 cslostcronc Lnanlate Injection. 250 mg in Iml Ampoule 18.30 T ET t M IDI 1 clracainc 1 \ c 1 )rops. 0 .5% 10 Ml. 5.00 1ETRACCA I 1 elracveline Capsule. 250 mg Capsule 0.04 TETR ACEOI 1 c lra o c lin c 1 \ c l)in lm cnl, 0 .5% 5 0 1.25 TETRAC > 0 2 Tetracycline l y e O intm ent. 1% 5 G 1.00 THEOPIIT .A1 1heophy IIme l ablel, 200 mg (slow release) Tablel 0.25 TH IAM IIM Thiamine Inieeiion. lo o mg Vial 0.80 TH IVM ITA I 1 hiam ine 1 a b le t 50 mg Tablet 0.09 T H IA M IIM I h iam ine lab le l. 100 mg Tablel 0.12 T IABENTA I T iabenda /o le T ab le t 500 mg Tablel 0.78 T IMM AL .ID I 1 imolol M alcalc I s e Drops. 0.5% 10 ML 6.40 T IM DACA I Im idazo le Capsule, 500 mg Capsule 2 3 0 T IR O H IM 1 irofiban Infusion. 50 m icrograms-ml 100 ML 110.00 T IROH IN 2 I'irofiban Infusion. 250 m icrograms/m l iconcentrale) 100 ML 180.00 t o l b i r r A i 1 olbuiam ide T ab le t 500 mg lab le l 0.20 TRAAC 1C A 1 Tranexam ie Acid Capsule. 250 mg Capsule 0.50 TRAAC IIM rrancxam ic A cid Injeclion. 100 mg ml Ampoule 1.00 TRAAC ITAI 1 ranexam ic Acid T ab le t 500 mg Tablel 1.00 T R IH .I I VI 1 rif luopcra /ine T ab le t 1 mg Tablet 0.20 TR IF I.UTA2 Trifluoperazine T ab le t 5 mg la b le l 0.20 TR IHEXTAI trihexyphen idy l lab le l. 2 mg Tablet 0.03 TRIHKXTA2 Trihexyphenidyl T ab le t 5 mg Tablel 0.06 VKRAPA IA I Verapam il 1 a b le t 411 mg 1 ablet 0.10 VEKAPATA2 Verapam il 1 a b le t SO mg Tablel 0.15 165 University of Ghana http://ugspace.ug.edu.gh C od e O n e r i c n an u s d o sa g e fo rm , s tr en g th U n it o f P r ic in g P rop o sed P r ice s \ \ \ K I \ R I \ l Warlarin la l 'le l, 1 mg 1 ahlcl 0.15 V\ \ K 1 \ K T \ 2 \ \ arfarin 1 ahlcL .' mg 1 ahlel 0.18 \ \ \ K I V R T U Warfarin 1 ahlcl. 5 mg (scored) 1 ahlet 0.18 \ \ V T I - O R I N l Water for Injection 10 ML 0.10 Source: NHIA (2010). List of Medicines. Retrieved on 20lh April 2011 from lutp://\vw\v.nhis.gov.gh/?CategoryID=158&ArticleID=1096. 166 University of Ghana http://ugspace.ug.edu.gh