Akweongo et al. Global Health Global Health Research and Policy (2022) 7:4 https://doi.org/10.1186/s41256-022-00238-2 Research and Policy RESEARCH Open Access Community perceptions of enrolment of indigents into the National Health Insurance Scheme in Ghana: a case study of the Livelihood Empowerment against Poverty Programme Patricia Akweongo1* , Edmund Voetagbe1, Fabrizio Tediosi2, Dominic Dormenyo Gadeka1, Paola Salari3 and Moses Aikins1 Abstract Background: The Livelihood Empowerment against Poverty (LEAP) programme in Ghana as part of its beneficiary programme, identifies the poor/indigents for exemptions from premium payments in the National Health Insurance Scheme (NHIS). This paper sought to understand community perceptions of enrolling the poor in the NHIS through LEAP in order to inform policy. Methods: The study adopted a descriptive cross-sectional study design by using a qualitative approach. The study was conducted in three geographical regions of Ghana: Greater Accra, Brong-Ahafo and Northern region represent- ing the three ecological zones of Ghana between October 2017 and February 2018. The study population included community members, health workers, NHIS staff and social welfare officers/social development officers. Eighty-one in-depth interviews and 23 Focus Group Discussions were conducted across the three regions. Data were analysed thematically and verbatim quotes from participants were used to support the views of participants. Results: The study shows that participants were aware of the existence of LEAP and its benefits. There was, however, a general belief that the process of LEAP had been politicized and therefore favours only people who were sympa- thizers of the ruling government as they got enrolled into the NHIS. Participants held the view that the process of selecting beneficiaries lacked transparency, thus, they were not satisfied with the selection process. However, the study shows the ability of the community to identify the poor. The study reports varying concepts of poverty and its identification across the three ecological zones of Ghana. Conclusion: There is a general perception of politicization and lack of transparency of the selection of the poor into the NHIS through the LEAP programme in Ghana. Community-based approaches in the selection of the indigent are recommended to safeguard the NHIS-LEAP beneficiary process. Keywords: National Health Insurance Scheme, Ghana, Livelihood Empowerment against Poverty, Community perception, Community-based approach Background In the implementation of social health insurance, the need to protect the poor from paying premiums has led *Correspondence: pakweongo@ug.edu.gh to several initiatives on how to identify and target the 1 School of Public Health, University of Ghana, Accra, Ghana poor for exemptions. The concept of poverty is noted to Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creati vecom mons.o rg/l icen ses/ by/4. 0/. Akweongo et al. Global Health Research and Policy (2022) 7:4 Page 2 of 11 be complex and multi-dimensional and hence does not accommodation), oral health, eye services etc. It pro- apply to only the absence of money but includes food vides free maternal health care to all pregnant women security, access to basic health services, socioeconomic and post-natal care up to 90 days. It also covers Caesar- status, living conditions and possessions of assets [1]. ean delivery, emergency care and all drugs in the NHIA Getting access to health services is one of the most dif- (National Health Insurance Authority) Medicines lists ficult aspects of life especially, for the poor. In low- and and traditional medicines approved by the Ghana Food middle-income countries, the most poor often lack and Drugs Authority [7]. access to health services [2]. The connection between Eligibility for LEAP is based on poverty status and poverty and access to health services can be seen as having at least one of the three demographic conditions part of a higher phase, where poverty leads to ill health such as households with orphan or vulnerable children and ill health retains poverty [3]. The most poor in the (OVC), elderly poor and persons with extreme disability population are often weakly represented in public policy [8]. Initial selection of poor households is done through making. Public policy decisions are often taken behind a community-based process and is verified centrally with closed doors, as technocratic solutions with limited or no a proxy means test. Within the category of extreme poor, consultation, potentially resulting in lack of public own- the programme further targets households with one or ership, and weak accountability [4]. Nationwide multilat- more (a) persons who are over 65  years of age, (b) per- eral discourse, with government, employers and workers sons living with a severe disability, and (c) caregivers of as well as academics, civil society and others, is funda- orphans and vulnerable children. However, since 2016, mental to adopting optimal public policies. Public dis- as a result of the new initiative known as LEAP 1000, the course is required to guarantee social protection systems programme has also targeted households with a pregnant and a socially responsible retrieval expected at attaining woman and children below 1 year of age [9]. comprehensive development and social justice [4]. Observation of the LEAP approach to identifying the In a context of widespread poverty, determining who poor and vulnerable shows a mixed method approach really is poor can be challenging. Several processes have where a national poverty map generated through the been used to identify the poor including administra- Ghana Living Standards Survey is first used to rank the tive processes, community processes and mixed method regions and districts. Regions and districts selected approaches. Administrative processes involve a higher depend on their location on the poverty map. Subse- authority such as the ministry or government deciding on quently, the communities selected depend on their pov- who they define as poor. Thirteen percent of indicators erty ranking at the district level [10]. Hanson et  al. [11] used to assess poverty are often derived from household described six different mechanisms that have been surveys [1]. With the introduction of the National Health applied in the health sector, including resource allocation Insurance Scheme (NHIS), Ghana has been using the formulae, contracting NGOs, user fee exemptions, cash means test and, more recently, the eligibility to the Liveli- transfers, vouchers, and market segmentation strate- hood Empowerment against Poverty (LEAP) to identify gies. The LEAP applies the means test of cash transfers. the beneficiaries as poor for exemptions from premium However, the approach to identifying the poor, means of payments. LEAP is a social cash transfer programme, verification of the ‘real poor’ and how much it is able to established in 2008 and funds are disbursed bi-monthly reduce the leakage of the true poor into the wider pre- to beneficiaries. The programme is funded from reve- mium group needs to be evaluated. Inability to identify nues of the Government of Ghana (50%), donations from the real poor could lead to high health care expenditure the Department for International Development (DFID) with implication for sustainability of the NHIS. Addi- and a loan from the World Bank, which aims to provide tionally, community perception of this criteria for iden- cash and health insurance to extremely poor households tifying the poor and enrolling the poor/indigents into the across Ghana in order to alleviate short-term poverty and NHIS through LEAP has not been established. This paper encourage long-term human capital development [5]. sought to understand community perceptions of using The beneficiaries of the LEAP, however, must adhere to the LEAP programme in enrolling indigents into the some conditions such as sending their children to school NHIS in Ghana. In addition, the study explored reasons and avoiding child labour. for low NHIS enrolments and low renewals. All LEAP beneficiaries are also entitled to free reg- istration with NHIS. The benefit package of the NHIS Methods covers over 95% of all diseases that affect the Ghanaian Study design population [6]. It covers out-patient services and most- The study adopted a descriptive cross-sectional design by inpatient services (specialist care, most surgeries, cer- using community-based qualitative approach to under- vical and breast cancer, physiotherapy, hospital ward stand community perceptions of enrolling indigents into A kweongo et al. Global Health Research and Policy (2022) 7:4 Page 3 of 11 the NHIS through LEAP. Eighty-one IDIs and 23 FGDs and identification of the poor in community, registration were conducted with study participants. The study was renewal, use of NHIS for health services and perceptions conducted between October 2017 and February 2018 of enrolling indigents in the NHIS through the LEAP. in three geographical regions of Ghana. The qualitative method was used to solicit participants’ views in more Data collection detail about the enrolment of indigents. This has con- Data were collected by using In-Depth Interviews (IDIs) tributed to a better understanding of the criteria used to and Focus Group Discussions (FGDs). These qualita- identify the poor for enrolment into the National Health tive methods were employed because they produce very Insurance Scheme of Ghana and reasons for low NHIS rich source of data which reveal the world of the par- enrolment as well as low renewals. ticipants, their emotions and thoughts about the world around them [14]. This approach was also to offer the Study setting participants an atmosphere that encourages them to tell This study was conducted in three out of the 10 adminis- their own stories regarding the issues of LEAP and NHIS trative regions of Ghana, namely, Greater Accra, Brong- without interference. It was to provide them the flexibil- Ahafo and Northern regions. These regions represent ity, which in turn, allowed the investigator to seek further Ghana’s three ecological zones (southern, middle and clarification. northern zones). The regions are characterized by mixed In all, 23 FGDs and 81 IDIs were conducted across the urban and rural populations. The Greater Accra Region is three regions. The IDIs were conducted among various a coastal region with 4.94 million inhabitants and is the categories of health workers including nurses, midwives, region with the lowest poverty incidence in the south- physician assistants and health administrators, LEAP ern belt with poverty head count of 5.6%. Brong-Ahafo officers and NHIS officers. In addition, some of the inter- region is located within the middle belt with 2.85 mil- views were held with those enrolled as indigents under lion inhabitants and the region with the high poverty the NHIS as well as the poor identified by the commu- incidence in the middle belt with poverty head count of nities that were not enrolled. The FGDs were conducted 27.9%, while the Northern Region represents the north- with community members. Participants shared views on ern belt with a population of 3.06 million and with the their understanding and perceptions of poverty, criteria highest poverty incidence in this belt with poverty head for identifying the poor and perceptions of enrolling indi- count of 50.4% [12, 13]. Two districts with relatively gents into the NHIS through the LEAP. high enrolment of indigents from the 2015 membership The study objectives and scope were explained to all data of the NHIS were purposively selected from each of participants prior to their participation in the interviews. three study regions. These districts also have all the level Confidentiality was assured and with permission from of health facilities: Community-Based Health Planning participants, the interviews were recorded. Manual note- and Services (CHPS), Health centers, Hospitals, Clinics, taking was also carried out to complement the record- Laboratories, Chemical and Pharmacy shops. Addition- ing and to serve as a backup. Both the recording and the ally, the districts have well established District Health notes helped to ensure accuracy of data and also facili- Insurance Scheme offices and the proportion of indigents tated data analysis processes. Reflective interview guides within these districts ranged from 4 to 20% [14]. containing open ended questions were used in the study. Participants were interviewed in local languages spoken Study population and sampling in the three study regions. However, some of the partici- The study population included community members, pants who were comfortable and could speak English flu- health workers, NHIS staff and social welfare/social ently opted to be interviewed in English. development officers in the selected districts of the In order to minimize respondent bias and the risk of three regions. The majority of participants were com- reactivity, the questions were asked by following the cues munity members comprising of leaders and poor indig- from the participants. Appointments were booked with enous people. The participants were selected by using potential participants before the interviews were con- stratified purposive sampling method. This involved the ducted. All interviews and discussions took place where selection of participants across relevant groups deal- privacy was assured and at the convenience of the partic- ing with the same phenomenon where each group was ipants. Interviews and discussions lasted between 30 min homogenous enough so that cross-group comparisons and 2 h. could be made [15]. According to deMarrais [16], face- to-face interviews provide perspectives and insights into Data analysis special knowledge that only participants possess. Gener- Information gathered during the data collection was ally, information gathered included community definition manually analysed. Firstly, the conversation notes were Akweongo et al. Global Health Research and Policy (2022) 7:4 Page 4 of 11 developed into field note books at the end of each day Results and recorded interviews were transcribed verbatim in Identification of the poor for enrolment into the National Microsoft word. Verbatim transcription is the word- Health Insurance Scheme for-word reproduction of verbal data, where the written The qualitative interviews gathered from different stake- words are an exact replication of the audio-recorded holders (Table  1) shared light on community percep- words [17]. Participant validation was carried out to tions of poverty and the enrolment processes in the ensure trustworthiness and this was done by debriefing community. the analytical results with participants for agreement The views expressed by participants suggested that [18]. This was possible because initial transcription there was no consensus on the definition of a poor person was done immediately after the interview. Some of the in the community. However, the majority defined poverty transcribed data were transcribed and translated from as the inability of a person to afford basic necessities of a local language into English. The transcript and notes daily living. These activities of daily living included food, were read several times to get a sense of the entire data. clothing, and payment for health care and school fees of Secondly, the transcript was subjected to a qualitative children. Therefore, individuals in the community who content analysis to generate common themes ema- had challenges in meeting these needs in the community nating from the data: definition and identification of were classified as being poor. The following quotes illus- the poor in community, registration renewal, use of trate these points: NHIS for health services and perceptions of enrolling indigents in the NHIS through the LEAP programme. Poverty is when you farm and you are not able to get Thirdly, typical comments by the categories of partici- a good yield, feeding your family becomes a problem; pants: community members, health workers, NHIS staff you are unable to pay school fees, this is what we and social welfare officers/social development officers term as poverty (Male, FGD, NR). were abridged into meaningful summary statements The poor are persons who are not able to feed them- and further condensed to form themes. The authors selves and their children. They cannot pay the school then critically reviewed the transcription and the fees of their children as well as hospital bills when analysis to discuss the entire results to ensure that the they are sick. We have a lot of poor people in the vil- themes and summary statements reflect participants’ lages (female, FGD, BA). views. Statements of the respondents were presented as Both FGD and IDI participants across the three study quotes to substantiate the views expressed. regions identified orphans, elderly, people who are sick Table 1 Background information of participants Participants information Greater Accra Brong Ahafo Northern (NR) Total (GAR) (BA) Data collection strategy FGDs 7 8 8 23 IDIs 14 32 35 81 FGDs number/sex Males 4 4 4 12 Females 3 4 4 11 Number of participants in FGDs Males 38 40 40 118 Females 25 39 38 102 IDIs sex Males 8 16 23 47 Females 6 16 12 34 Type of participants Community members 13 21 17 51 Health workers 0 6 10 16 NHIS staff 1 2 4 7 Social welfare officer/development 0 3 3 6 officer A kweongo et al. Global Health Research and Policy (2022) 7:4 Page 5 of 11 and unable to work and people with disability chal- Identification of the poor in the community lenges as poor people in the community. Participants In both IDI and FGD, participants were of the view that also characterized widows as poor because they did not it was easy to identify poor people in the community. have husbands to take care of them. They observed that The poor people could be identified through their gen- widows with children often found it difficult to cater for eral appearance, type of house the person lives in, type these children especially when they were unemployed. of food they eat as well as their inability to pay children school fees and hospital bills. Some participants reported In this community we know each other very well; that poor people often lived in houses with no electric- and we know the less privilege in this community, ity because they could not afford to pay light bills, they such as physically challenged, widows/widowers or their children were often seen in tattered clothes and and orphans when such programme come into the they were often withdrawn from the community. Partici- community, we encourage them to go and register pants perceived that people who lived in the community so that they can benefit from such programmes with the poor for instance, community leaders could be (Male, FGD, BA). employed to identify the poor. The poor in the community are the orphans, people who are sick and cannot work and women whose Identifying poor people in this community is easy. husbands have died leaving them with children to We know them from the place they live, clothes they take care of. They suffer a lot as they are not able wear and the way they even talk and carry them- to feed the children, take care of their fees and selves around. They are often quiet and do not par- the children will always appear in dirty and torn ticipate in community activities (Male, IDI, BA). clothes (Female, FGD, NR). We have orphans, peo- It is not easy to identify the poor, you can only iden- ple with disability and those who are sick and can- tify the poor when the person is sick and can’t afford not work are the poor people in this community. medical bills, until someone comes to his/her aid, They need help because they have nobody to take such a person will not be able to pay. Again the phys- care of them (Male, IDI, GAR). ically challenge cannot work and cater for them- selves, they live on receiving alms and live in houses There were little variations in the definition of the poor without light because they cannot afford to pay the across Brong Ahafo and Northern regions. Table 2 pro- bill (Male, FGD, NR). vides a summary of participants’ definition and people identified as poor in the community across the three study sites. Community structures for identifying the poor In both IDIs and FGDs, community members purported to know the people because they lived with them and also Table 2 Participants’ definition and people identified as poor across the three study regions Region Definition of poor Identification of the poor Brong Ahafo Inability to feed self and family Orphan Cannot send children to school and pay school fees People with disability Sick person who cannot work or far Dressing of their children Unable to renew insurance Physical appearance Cannot pay Hospital bill Type of house the person lives in Widow Aged without a helper Inability to afford good clothing Northern region Inability to feed self and family Orphans Cannot send children to school and pay school fees Disability Sick person who cannot work or far Children wearing tattered clothes Unable to renew insurance Appearance and dressing Cannot pay Hospital bill Live in dejected houses without light Widow Aged without a helper Inability to afford good clothing Greater Accra region Sick person who cannot work Orphans People with disability Dressing of the person and family members Physical appearance (tattered and dirty clothes) Akweongo et al. Global Health Research and Policy (2022) 7:4 Page 6 of 11 had fair understanding of their situation. The community midwife, IDI, BA). leaders including religious leaders were people that could …the hospital is one of the places you can use to be employed to identify the poor in addition to house-to identify the poor because they cannot afford to pay house identification. In their view, religious leaders could the hospital bill after treatment. They cannot even easily identify poor members among their congregation. buy food when they have been admitted in the hospi- Besides, poor people could be identified by health work- tal (Female, FGD, NR). ers who attend to patients at the health facility level. This was because poor people are often not in the position to Table  3 presents a summary of community strategies pay for health care services they received. Both commu- participants identified as means of identifying the poor nity members and health workers were of the view that across the three study sites. the hospital could be used to recruit the poor. These sug- gestions are supported by the following quotes: Reasons for low NHIS enrolment and low renewalsIDI and FGD participants acknowledged the importance Community leaders could be employed to identify of the NHIS in increasing access to health care. However, poor people. The church leaders know the people some participants did not renew their membership with who are poor in their church. So, if you want to iden- NHIS because members were given poor quality health- tify poor people in the community, they should be care services when they visited health care facilities. Oth- contacted to assist (Female, IDI, GAR). ers maintained that they still needed to pay for services We have leaders in this community, so they can be even though they had active cards and that discouraged tasked to identify these people who are poor because them from renewing their NHIS cards. they know them and after that the government should send someone, for instance, a CID (Criminal What I have to say is that the reason why people are Investigating Department) officer to confirm that the not enrolling is that when you use the NHIS card, people selected are really poor. The reason is that what you get like drugs is paracetamol. Sometimes, some people would be left out if you just ask just eve- even paracetamol which cost 1 cedi 50 pesewas rybody to do the selection. This could lead to select- (US$0.20) you will be told to pay and it’s not covered ing those who are not poor tobenefit from the sup- (Male, FGD,GAR). port (Male, IDI, GAR). When you have the card and go to hospital, you will The assembly men and women in the sub-districts be told that this drug is not there or it is not covered know their people and they are in contact with them; by the insurance. So, many of us do not register or even though we have community health nurses who renew the card because of that. If they want people go for home visits and outreaches, they could reach to register or renew their card, it should cover all out to them but those will be few. An assembly man medicines and sicknesses (Female, FGD, NR). is from the community and stays with them; he is, Negative attitudes from health workers and discrimina- therefore, in a better position to identify poor peo- tion against NHIS card holders also affected renewal and ple. So, we could contact the assembly men to help enrollment into NHIS according to views shared by par- identify the poor and register them for free (36 years ticipants. One participant put it as: Table 3 Community strategies for identifying the poor proposed by respondents Region Strategies to identify the poor Brong Ahafo Employment of community leaders (chiefs and assemble members Employment of religious leaders House to house identification Employment of social welfare officers Use of health facilities (attendees who are unable to pay for care they received) Greater Accra region Community leaders (chiefs and assembly members) Employment of religious leaders Northern region Employment of community leaders Employment of religious leaders House to house identification Employment of social welfare officers Attendees who are unable to pay for the care they have received A kweongo et al. Global Health Research and Policy (2022) 7:4 Page 7 of 11 There is a discrimination between those who have was a useful intervention in reducing poverty in the the insurance and those who don’t have the insur- country as demonstrated in the following quotes from ance. Those with insurance are packed aside and the interviews: then priority is given to those who have money to pay. The doctors do not even pay attention to you The LEAP money helps us a lot because I have two when you go there with a condition. A child can be children in school and I use some of the money to rushed to the hospital with high temperature but pay for their fees and use the rest to care for the fam- they won’t even bother to attend to the child. So, if ily. I have used the rest of the money to buy fowls so you want better health care and proper medicine, that when I am out of money, I could sell one and you had better go without the card (Male, FGD, BA) use the money for something (Female, IDI, BA).We have LEAP in this community and it is very use- Despite this, health workers who participated in this ful. I know people who are benefiting from it and it is study did not agree that they provided differential ser- helping them a lot (Female, FGD, NR) vices to insured and non-insured clients. According to them, all clients went through the normal procedure in However, there was a general belief that the program has the health facility and were provided with client-specific been politicized and only people who are sympathizers health care. of the ruling government were selected to benefit from the programme. This was reported in 15 FGDs of male When the person comes and he/she is an insured cli- and females and in 30 of the in-depth interviews. In a ent, he/she goes through the normal procedure and response to a question on knowledge about LEAP in the goes away without any charge except that the person community, a participant of the IDIs in the Northern needs some drugs that we don’t have at our health region had this to say in the quote below: facility and we write for the person to go and buy outside. Other than that, if the person is having the There is LEAP in this community but it has been insurance and we have everything, then the person politicized. When they came, they only sent it to will go through the process from beginning till he/she communities that have party faithful and they are goes away without any further charge. But, for the benefiting from it. It was when they told an assem- non-insured, they also go through the normal pro- blyman that the LEAP team would be coming to pay cess but they are charged to pay before taking their beneficiaries in one town that I got to know about drugs and go (Midwife, BA) the LEAP programme and the beneficiaries here. It angered other community members that they Another reason for non-renewal was the challenges are not benefiting from the LEAP programme but I involved in the process. Apart from the renewal centres explained that it will get to their turn (IDI AS.) located far away from the community, participants com- plained about the delays in the processes. To get a card In the FGDs in Brong Ahafo region, participants gen- renewed could require spending several hours at registra- erally agreed that LEAP had been politicize and many tion centres and in some instance, one would have to go beneficiaries were actually not poor people. Participants to renewal centres several times before being served. The advocated for the employment of chiefs to distribute following quotes support these points: such welfare schemes for the community in the future as illustrated in the quote below: I am registered because with the card you get free treatment at the hospital when you are sick. If you Like my brother said if there is such help, it should are poor and you don’t register then you will strug- not be passed through the politician but the chiefs gle to pay the hospital bills. So, the insurance is good who will get opinion leaders to assist them to iden- for everybody especially the poor, but renewal is the tify and distribute the money. This will help but our problem because you have to travel far to the cen- politicians look for their political interest and select tre for renewal. The last time, I had to go there three their party members. So, it should be through the times before they could renew my card (Male, IDI, chiefs who will select opinion leaders to help identity NR). the poor (Male, FGD). The selection of beneficiary districts and communities was often based on the criteria which included the level Livelihood Empowerment against Poverty (LEAP) of poverty in the community by using the Ghana poverty for enrolling the poor map, access to health care and schools in the community: Participants were aware of the existence of LEAP pro- In fact, doing the selection here, a team from Accra gramme in the community. They perceived that LEAP Akweongo et al. Global Health Research and Policy (2022) 7:4 Page 8 of 11 met with the municipal implementation team and were dropped from the list. We have people who live the criteria they considered were for communities in this community and are very poor and yet they that are most vulnerable, then accessibility to health were not given anything. But others who are better facilities and accessibility of schools and other social off were given the money (Male, FGD, NR). amenities and those were the criteria used in select- Truly, when the registration for LEAP was on going, ing the communities (Social Development Officer, they told us they were registering old and poor peo- IDI, BA). ple. Two old women in my household registered People who were above 65  years without any help, including some young ladies from other households. orphans, people with disability and pregnant women But when the date was due for them to come for their with children under 1  year were reported as automatic monthly money the names of the two old ladies were beneficiaries of LEAP. Selected beneficiaries were veri- omitted, while the young ladies had theirs (Male, fied in the community before disbursements were made FGD, GAR). to them. Some assembly members who were interviewed also In fact, the categories are the aged who are 65 years alluded to the fact that the criteria were not transparent and above without any support and the severely and coupled with the fact that community leaders were disabled without means of livelihood and orphans not involved in the selection process. An assemblyman and vulnerable children, pregnant woman and those in the Brong Ahafo Region had this to say in the quote with children under 1 year. These are the criteria for below: selection on to the LEAP (Social Worker, IDI, BA). Yes, we have some of the LEAP in this community. ….We collect information from collateral source When it came, we heard the information and we before we get to the homes to elicit from them gathered the people, but the category for selection is whether actually they are poor. When you pay a visit not known to any assembly member and even when to a place, you ask collateral sources around, and it’s time to pay them, no assembly member or com- then you go into the household, you will see some of mittee member is in the known. So, we don’t even the characteristics. Then, we also try to look at our know the schedule of payment and the time they criteria, fit it in, and see whether he/she merits it. come, either do we know how much they are given We don’t just pick people; we have to go through cer- (Assemblyman, IDI, BA) tain criteria. We need to go through certain things to justify that this man, when they say he is poor, he is Some participants suggested that involving more com- poor (Social Development Officer, NR). munity leaders could improve the process of selecting beneficiaries and could make the process more transpar- Nonetheless, participants were of the view that the pro- ent. Also, community sensitization on the process and cess of selecting beneficiaries was not transparent as it selection criteria could help disabuse the belief about the is deemed to be politicized. Hence, only people who had politicization of the process and enhance transparency. political inclination to the incumbent government were selected. According to the participants, this process cre- The public should know and be informed about the ated a situation where many poor people in the commu- activities and processes. The chiefs and opinion lead- nity were left out, whilst others who, in their opinion, ers should be informed, so they could get the whole were not qualified to benefit were selected. community members informed. Once the announce-ment is done, it will make everyone aware of the We were asked to come and write our names and process and all the people involved can benefit from the government was going to support the poor and the process, so that it will not be given to just some needy, but when the support came, we the poor and selected few in the community (Male, IDI, BA). needy were not added to the list. You see people who There is need to educate community members about are strong and healthy are enjoying the package. the process of selecting the people and involve the I know a woman whose husband had died and no chiefs and opinion leaders. In doing that, people will help coming from anyone but she doesn’t get the gov- see the process more transparent than what they do ernment package. There is an assemblywoman who now. Just coming to write names and returning with is beneficiary of LEAP. She is strong and working few names as beneficiaries make people think it is (Female, FGD, BA). given to only party members (Male, FGD, NR). The process is not transparent at all. In my commu- We do partner with the social welfare and then nity, they came and took the names and when they enroll the poor onto the scheme. Social welfare has came back to distribute the money, some names identified these poor people through the LEAP and A kweongo et al. Global Health Research and Policy (2022) 7:4 Page 9 of 11 we are also able to enroll them free of charge into The participants were therefore of the view that involv- NHIS (Male NHIS staff, IDI, NR). ing more community leaders could improve the process of selecting beneficiaries and also make the process more transparent. Discussion Our study shows that there existed no consensus on This paper sought to understand community perceptions definition of who the poor are. However, the majority of using the LEAP programme in enrolling indigents defined poverty in terms of ability to afford basic neces- into the NHIS in Ghana. The study findings show that sities of daily living. The criteria used to identify the participants are aware of the existence of LEAP and its poor included people who are unable to feed themselves benefits. The study, however, reveals some negative per- and their family members, people who cannot pay their ceptions of enrolling indigents into the NHIS through the children school fees, sick persons who cannot work, the LEAP. There was a general belief that the programme has elderly people without a helper,, orphans, people with been politicized and therefore favours only people who disability and the poor quality of house the persons live are sympathizers of the ruling government. Participants in. This confirms that the concept of poverty is complex also noted that the process of selecting beneficiaries lacks and multi-dimensional and does not apply to only the transparency. As a result, communities are not satisfied absence of money but includes food security, access to with the entire selection process. These findings are con- basic health services, socioeconomic status, living con- sistent with a study on the success of interventions tar- ditions and possessions and assets as noted in an earlier geted at the poor where errors of inclusion and exclusion study [1]. Moreover, these various concepts of poverty are often a result of efforts to “vote catch” by politicians varied across the three ecological zones or regions. This and plain rent-seeking [19]. An earlier study by Tesliuc clearly shows that poverty is a context-specific phe- [20] highlighted the advantages and disadvantages of nomenon [25]. However, the community has a clear using local actors to select the poor. Whereas it generates understanding of who the poor are and moreover, the accurate information on who to select as the poor may identification of the poor should be context specific. also generate conflict. Our findings confirm earlier stud- Additionally, this suggests that the community would be ies where despite the improvement in the exemption cri- in a better position to identify the core poor under the teria of NHIS and the general increase in the awareness LEAP to be enrolled into NHIS when they are involved of LEAP, the LEAP does not adequately resolve the prob- in the programme.  Previous studies have reported that lem of excluding the poor from the NHIS [21, 22]. Addi- where a critical analysis of various methods of identifying tionally, it raises more questions as to who qualifies to poor households is carried out, the community criteria of be exempted and who is not under the NHIS. It is there- classifying the poorest members correlated with means fore not surprising that an earlier study reported that testing and the proxy mean testing considered as the gold about 30% of the 65% of the NHIS members who were standard [26, 27]. exempted from paying premiums could indeed afford to Our study further shows that participants acknowl- pay [23]. Moreover, our study shows a lack of compli- edged the importance of the NHIS in increasing access to ance with the conditions under the LEAP programme. health care, but cited cost of treatment as the main rea- However, this could be because the beneficiaries and son that affected participants’ decision to get enrolled in potential beneficiaries are not aware of the sanctions the NHIS. Participants further mentioned poor quality of regarding non-compliance. An earlier study with similar care, out-of pocket payment, far travel distance to NHIS findings on lack of transparency and political interfer- registration/renewal centre and delays in the process, ence, reported that those perceived biases could possibly discrimination and negative attitude of health workers be as a result of errors that resulted from practical dif- towards insured clients as barriers to low NHIS enrol- ficulties in ensuring effective targeting within such rural ment. Our findings are consistent with earlier studies contexts and inaccurate data on household poverty sta- reporting factors, such as lengthy waiting times at regis- tus within the informal sectors of rural communities [24]. tration centres, occasional shortage of registration mate- Based on the broad coverage of our study in three eco- rials and perceived poor quality of healthcare services, logical zones of Ghana, our findings indicate that the use provider attitudes and peer pressure as major barriers of community structures could reduce the practical diffi- to enrolment [28–30]. In 2019, the NHIS introduced the culties in targeting the poor, as the eligibility for LEAP is use of mobile phone renewal strategy to address some of based on poverty status and having a household member the challenges related to waiting time and travel distance in at least one of three demographic categories: house- affecting the scheme and to further digitize enrolment in holds with orphan or vulnerable children (OVC), elderly the near future [31]. poor, or persons with extreme disability unable to work. Akweongo et al. Global Health Research and Policy (2022) 7:4 Page 10 of 11 Although the study was conducted in three geographi- Declarations cal regions representing the three main ecological zones of Ghana (southern, middle and northern zones), there Ethics approval and consent to participateThe protocol for the study was reviewed and approved (GHS-ERC 01/05/2016) were limitations. It must be noted that as a qualitative by the Ghana Health Service Ethics Review Committee. study, the findings from this study implementation con- text and dynamics are only applicable to other contexts of Consent for publicationAll study participant signed an informed consent form before the interview. similar characteristics. The political context influencing We also had permission to publish findings from this study. selection of indigents in this study may not be applicable in other settings. Competing interestsThe authors declare that they have no competing interests. Author details 1 School of Public Health, University of Ghana, Accra, Ghana. 2 Swiss Tropical Conclusions and Public Health Institute (Swiss TPH), Socintrasse 57, 4051 Basel, Switzer- There is a general belief that the LEAP process has been land. 3 Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, politicized and therefore favours only people who are Switzerland. noted to be sympathizers of the ruling government. Received: 16 December 2020 Accepted: 8 August 2021 Participants are also of the view that the process of selecting beneficiaries lacks transparency. The involve- ment of community leaders such as chiefs, opinion leaders and religious leaders could improve identifica- References tion of the poor. There is therefore the need for stake- 1. Morestin F, Grant P, Ridde V. Criteria and processes for identifying the holders such as NHIA (National Health Insurance poor as beneficiaries of programs in developing countries. Univ Montréal. 2009. 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