Edorium Journal of

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Original Article
 
The influence of socio-demographic characteristics on health care access among health insurance subscribers in Ghana
Seth Christopher Yaw Appiah
M.Phil. Sociology Student and Graduate Research Assistant, Department of Sociology and Social Work, College of Art and Social Sciences, Faculty of Social Sciences, Kwame Nkrumah University of Science And Technology, Kumasi, Ghana

Article ID: 100003P16SA2015
doi:10.5348/P16-2015-3-OA-3

Address correspondence to:
Appiah Seth Christopher
M.Phil. Sociology Student and Graduate Research Assistant, Department of Sociology and Social Work
College of Art and Social Sciences, Faculty of Social Sciences
Kwame Nkrumah University of Science And Technology, Kumasi
Ghana

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Appiah SCY. The influence of socio-demographic characteristics on health care access among health insurance subscribers in Ghana. Edorium J Public Health 2015;2:1–10.


Abstract
Aims: The socio-demographic characteristics of clients and their perception of quality of care play a major part in people's decision making process especially in service utilization. This study assesses the relationship between clients' socio-economic features as well as their perceived quality on health care utilization.
Methods: The study adopted a non-experimental cross sectional design in eliciting information from health clients who accessed health services in ten selected hospitals in the Kumasi Metropolis with a cluster sampling design to select 400 clients from ten health facilities which were purposely selected. The researcher used interviews and semi structured questionnaires to collect data and used SPSS version 20 for processing whiles descriptive and inferential statistics was supported with STATA 11.
Results: Perception about the quality of health provision influenced access of healthcare with NHIS cards. Clients who viewed the overall quality of health provision as good or very good were more likely to access healthcare with NHIS card as compared to those who rated the overall health provision as poor or very poor (OR=2.1; p < 0.01). Socio-demographic factors continuously play a strong role in influencing client's access to health care under the National Health Insurance Scheme (NHIS) as the high income groups still dominate in utilizing health care services under the scheme than the deprived and the poor.
Conclusion: Clients' perceptions and experiences with quality of health provision influence their utilization of healthcare under the NHIS scheme. Increased enrolment in the scheme should be supported with provision of quality services to enhance clients' satisfaction.

Keywords: Ghana, Health Insurance, Perception, Socio-demographic


Introduction

The government of Ghana in an attempt to increase and improve on health care access initiated the National Health insurance Scheme in 2003. The objective for the introduction of the NHIS was to provide basic healthcare services to Ghanaians through mutual and private health insurance schemes [1]. The National Health Insurance Scheme (NHIS) came into effect in 2004 at a time when out of 80% of patients who required health care at any given time, only twenty percent had access to health care [2]. The scheme was brought to offer affordable and quality health care services to Ghanaians.

Agyei-Baffour, Oppong and Boateng [3] report that despite the improvement in quality health care that the National Health insurance Scheme is facilitating in Ghana, implementation challenges continue to exist necessitating for proper reforms. Several factors aid in defining and understanding the drivers of health service utilization especially among health insured clients. This includes their socio-demographic features.

The Socio-demographic characteristics consider the location of the people, their income levels, religion, educational levels, ethnicity, and other social and cultural factors.

There exist a myriad of studies documenting on the influence of socio-demographic factors on membership renewal and subscription into NHIS [4] [5] [6] [7] [8].

Buor in his study reports that, closeness to the NHIS scheme office was preferred to than when it was farther [9]. This is further supported by Boateng and Awunyor-Vitor [1] in their study in the Volta region of Ghana where 72% of their study population disapproved of the convenience of the scheme office location. In the various studies conducted [10] [11] [12] [13] [14] [15], different demographic factors have different relationship with NHIS enrollment and subsequent renewal of membership.

In Jehu-Appiah [16] cross sectional study of a sample population of 13,867 individuals, with an average of 25 years and children under 18 years representing 49% of the sample, it was identified that more than two-thirds (67%) who were employed had relatively lower average income GH¢43.70 (US$29). This amount is thrice of what is required to renew NHIS membership. This amount will be difficult to raise for most people since the average annual cost of premiums per individual is GH¢14.00 with an additional registration fees of GH¢3.00. Unaffordability of premiums was cited as the most common reason for not enrolling (72%) and not renewing membership (61%).

Demographic variables continue to feature prominently as a major determinant to renewal of membership. Among the reported studies, socio-economic factors which have association with NHIS enrollment and service utilization are gender as reported by Boateng and Awunyor-Vitor [1], marital status in the study of Boateng and Awunyor-Vitor, Trujillo and Liu and Chen [1] [17] [18], and occupation as indicated in the findings of Butler and Savage and Wright [19] [20] where employed respondents were found to be more likely to undertake coverage than unemployed. Boateng and Awunyor-Vitor [1] in study in 2013, found gender as a significant determinant of one's insurance status; however no significant association was established between occupation, educational status and enrollment in NHIS. Whiles health status has been found to be associated with NHIS enrollment decision as reported by Boateng and Awunyor-Vitor [1], findings by De Allegri et al. [10] in Burkina Faso suggest contrary.

In WHO study [21], one issue of concern regarding the refusal of members to renew their cards was the levels of incomes. The study indicated that people living in the remote, underserved areas of the country who are low income earners may not perceived the benefits of membership in the light of their low levels of income [4] [22]. Thus, though they appreciate the benefits of enrollment, they lack ability to enroll due to their poverty levels.

As indicated by WHO [21], 88% of urban dwellers who have higher incomes agreed that they were ever willing to renew their cards. This is compared with only 57% of their counterparts in the rural centers. A similar finding is reported by National development planning commission (NDPC) [23] who indicate that the level of registration in urban centers is 10% higher than the rural centers. As a result, the rural poor are unable to register by making payment into the scheme; a situation which has led some NGOs to pay the registration fee for the rural poor.

However, Boateng and Awunyor [1] study did not identify poverty levels as constituting a problem for health insurance subscribers as earlier studies by Basaza, Criel and Van Der Stuyft and Bruce, Narh-Bana and Agyepong [4] [22] have reported for health insurance in low-income countries like Uganda and Ghana. Socio-cultural and political values may play a role in health insurance subscription and health care access. During the commencement of the National health insurance in some areas, people refused to enroll themselves into the scheme due to political differences instead of the benefits that accrued from the scheme. This is however, gradually changing as many have realized the significance of the scheme to their health needs [21].

The socio-demographic characteristics of patients have well been established as instrumental factor that influence the utilization of health care [9]. Other researchers attest to the relationship that socio-demographic factors has with health care utilization than any other factor in influencing client's access to health care under the NHIS [4] [5] [6] [7] [15]. However, emphasis on addressing only socio-demographic factors such as levels of income, occupations, marital status and age in order to ensure health care utilization seems to be fading.

The quality of care has been a continued priority on the agenda of major health providing and regulating institutions including the Ministry of Health and the Ghana Health Service [24]. Other researchers including Boateng and Awunyor-Vitor, [1] Wiesmann and Jütting [25] and Asenso-Okyere et al. [26] think that, due considerations should also be given to clients' perception of care since it plays influential roles in health care utilization under the scheme. For instance, Alatinga and Williams [27] observed that the insured in NHIS think that the uninsured are generally given quality drugs as compared to them. Among the drugs perceived to be of inferior quality were paracetamol, a common painkiller that can easily be bought over the counter. In the opinion of De Allegri et al. [11], Lee et al. [28] and Turkson [29], quality can only be achieved by ensuring clients' participation and proper assessment about perceptions about quality of care.

Patient's perception of quality of care is critical in understanding the relationship between quality of care and utilization of health services and thus, should never be ruled out [30]. Though, clients' perceptions have been researched into by scholars such as Lee et al. [28] and Turkson [29], others including Arhinful [31] and Akazili Anto and Anoyoriga [32] admit that studies regarding perceptions about quality of health care and their impact on decisions to enroll into the scheme in Ghana are still limited. In Boateng and Awunyor-Vitor [1] study, respondents reported negative perceptions about the technical quality of care, and the adequacy of service delivery. Perceptions about quality were not limited to only technical, but also attitude of doctors and nurses. According to the findings, this influenced the decision of respondents to renew NHIS policy.

Notwithstanding the limitedness of research on examining client perception of quality of care, there is generally a difficulty in defining quality of care. The WHO [33] conceptualizes quality of care as one that has the features of being effective; thus the health care offered is evidence base and results in improved health outcomes for individuals and communities, based on need. The definition includes efficiency which concerns delivering health care in a manner which maximizes resource use and avoids waste. Quality of health care entails other dimensions such as the service being accessible. Accessibility demands that the services provided are timely. Moreover, the services are located within a geographical reach of the population it intends serving and that it directly meets the medical needs of the people. Quality of care equally examines the acceptable/patient-centered nature of the health care delivery focusing on the preferences and aspirations of individual service users and the cultures of their communities. The health care delivery must be seen to be equitable, thus not varying in quality because of personal characteristics such as gender, race, ethnicity, geographical location or socio-economic status [34] [35] .

It is one that is safe as it delivers care that minimizes risks and harm to service users. The dimensions of quality of care depict the variants in what constitute quality of care for health care users. While some study report an even provision of care in terms of quality for both insured and noninsured, the study by Devadasan et al. [36] and Darlinjon and Laar [37] reports that insured clients received better attention than uninsured clients. The objective of this paper is to examine socio-demographic characteristics as well as perceptions of care by NHIS card bearers and their relationship with access to healthcare with NHIS card.


Materials and Methods

Study Setting and Design
The study employed a cross-sectional study design using quantitative research approach. The study location was the Bantama and Kwadaso Sub Metro Councils. The Bantama Sub Metro Council is located at the north-western part of the Kumasi Metropolis. The population of the Sub Metro Council is about 533,464 according to the Ghana Statistical service. Bantama has mixed geographical features of urban, rural (as defined by having population less than 5000) and peri-urban. The sub-metro has all the various provider types and levels under the NHIS playing host to the KomfoAnokye Teaching Hospital (KATH), one of the two (2) national autonomous hospitals, Suntreso hospital, Kumasi South and Maternal and Child Health, and other clinics offering generalist and specialized health service. The Kwadaso Sub Metro Council constituted the other study setting. The Kwadaso Sub Metro Council was curved out from Bantama Sub metro. The sub metro council comprises fifteen communities which are sub-divided into nine electoral areas. It has a population of 220,798 according to the 2010 population and housing census (GSS, 2010).

In terms of health care access, the two sub metros utilize the same health facilities since they occupy the same land area but have been divided for administrative purpose.

Study Population and Sampling
Multistage sampling technique was used to select respondents for the study. The researcher purposively selected the Ashanti region out of the 10 administrative regions in Ghana after which the Kumasi Metropolis was selected. The Bantama and Kwadaso Sub Metro Council were randomly selected from the nine Sub Metro Councils which make up the Kumasi Metropolis. At the stage two, the two areas were divided into five clusters representative of the location of the various hospital within the two sub metro districts. Two hospitals each totaling ten were selected at random from within the five cluster areas. Forty respondents were sampled using the convenience method from each of the ten health facilities. The researcher selected Insured National Health Insurance subscribers conveniently at the hospital premises as they waited to receive medical attention. In all, a sample of 400 clients was selected for the study.All NHIS policy holders aged 18–70 years who gave their consent to participate in the study were eligible. The proportion of the population with the outcome attribute, thus insured NHIS clients, was taken as 50% (0.5), with a ±1.96 at 95% Confidence Level. The total sample size for the study was 400.

Data Collection and Statistical Analysis
The study used questionnaire in collecting data. Information on study participants included enrollment in National Health Insurance, NHIS renewal status and personal socio-demographic characteristics. The questionnaires was structured to elicit information such as age, gender, occupation, education, monthly income, marital status, self-perceived health status and perceptions of quality of care and NHIS. The questionnaire was pre-tested at the Tafo Government Hospital to check for internal consistency and absence of ambiguity and later edited. Content validity was carried out to test for the validity of the findings. External validity of the study was performed by comparing the findings to the extant literature that was reviewed.

The study's response rate was 98%. The study had two dependent variables; Health Care access and Utilization, the other was Perception of care). Whether subscriber had ever accessed healthcare under NHIS with the response {Yes=1; No=2} was the primary indicator for measuring dependent variable 'health care access and utilization'. The dependent variable; Perception of care had overall satisfaction of health care with the Likert scale response ranging from Excellent, Very Good, Good, Average, Poor, to very Poor as its Primary indicator for measurement. The selection of demographic variables was based on the extant literature. The demographic variables of age, sex, education,marital status, occupation, place of residence were examined.

Ethical Considerations
The researcher sought clearance from the University Ethical committee. Permission was sought from the administrators of all the hospitals involved in the study. Informed consent was obtained from the insured clients to obtain data for the study. Participation in the study was voluntary and anonymous.


Results

(Table 1) presents the socio-demographic characteristics of the 400 clients involved in this study. The mean age of the respondents was 30 years (+11) and 41.5% of the respondents were below age 25 years. Only 10.1% of the respondents were above age 44. Majority, 50.6% were females and about 13.5% of the respondents had no form of education while almost 45% of them had tertiary education. Majority, 56.9% of the respondents were single whereas 36.3% were married. More than half of the respondents, 51.0% of the respondents were students or unemployed whereas about 24.7% of them were traders. Other occupations cited among respondents included accountants, bankers, drivers, farmers, health workers and seamstress. Most (64.5%) of the respondents involved in the study were urban dwellers and majority 54.5% of the respondents have been members of the NHIS for a period between three and five years.

(Figure 1) indicates the graphical presentation of accessing healthcare with NHIS card by the respondents involved in the study. Majority 92% (368/400) of the respondents reported to have accessed healthcare with their cards at least once. Only 8% of them had never accessed healthcare with their NHIS card since they registered with the scheme. Majority 40.7% (150/368) of the respondents attributed the failure to use their cards to access health due to the fact that they normally do not fall sick. Other reasons cited were recently registered and low quality of healthcare under NHIS as shown in Figure 2.

Table 2 presents a bivariate analysis of the relationship between respondents' socio-demographic characteristics on their utilization of healthcare with the NHIS card. Only occupation (being a student or unemployed) and place of resident of the respondent had significant association with utilization of healthcare. As compared to being a trader, respondents who were students or unemployed had less odds of accessing healthcare with their NHIS cards (OR=0.2; p < 0.0. Most (64.5%) of the respondents involved in the study were urban dwellers and majority 54.5% of the respondents have been members of the NHIS for a period between three and five years. Again residing in a rural part of the Sub Metro's decreased one's likelihood of accessing healthcare with NHIS card as compared to those who resided in urban area (OR=0.4; p < 0.05). The age, gender, education and marital status of respondents had no significant relationship.

The perceptions of respondents about the quality of care and attitude of health staff influenced their decision to access health care with their NHIS cards. Not being informed about health condition by the physician and not informing client whether to return to facility or not significantly decreased the likelihood of accessing healthcare with their NHIS cards. Clients who viewed health providers' skills as good or very good were 1.9 times more likely to access healthcare with NHIS card as compared to those who viewed service providers' skills as poor or very poor (OR=1.9; p < 0.01). Finally, clients who viewed the overall health provision as good or very good were 2.1 times more likely to access healthcare with NHIS card as compared to those who rated the overall health provision as poor or very poor (OR=2.1; p < 0.01). This is given in Table 3.

Table 4 presents a stepwise regression analysis of the factors influencing decision to access healthcare with NHIS card. It involves the influence of socio-demographic analysis on accessing healthcare with NHIS card (model 1) as well as the combined influence of the socio-demographic characteristics and perceptions about health provision. In model 1, being a student or unemployed decreased the odds of accessing healthcare with NHIS card as compared to being a trader and this relationship was again observed in model 2.

Again residing in a rural part of the Sub Metro's significantly reduced the likelihood of accessing healthcare with NHIS card (OR=0.4; p < 0.05) and this relationship was again observed in model 2, holding all variables constant. With the exception of providers' respect for clients' views, the perceptions about healthcare did not significantly influence clients' decision to access healthcare with NHIS in the multivariate analysis.

The summary of perceptions about attitudes of health personnel's in respect of dealing with NHIS subscribers is presented in Table 5. About 25% of the respondents strongly disagreed that healthcare provider's accord much respect to NHIS clients compared with non-insurers while only about 10% of the respondents strongly agreed to this. Majority (93.4%) of the respondents indicated that, service providers have time to listen to their problems. Only (10.5%) of the respondents revealed that, service providers are not sensitive to their request and complaints. About 49% of the respondents rated overall attitude of health service provider attitude under NHIA as good whereas only 3.6% indicated that their attitude was poor. About 83.6% of the respondents said they will recommend the services of the service

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Table 1: Socio-demographic characteristics of respondents


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Figure 1: Accessing health care with NHIS card.



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Figure 2: Reasons for not accessing healthcare with NHIS Card presently.



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Table 2: Results of bivariate analysis of relationship between socio-demographic characteristics and accessing health with NHIS card


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Table 3: Socio-demographic factors and health care access under the NHIS card


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Table 4: Multivariate analysis of factors determining decision to access healthcare with NHIS card


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Table 5: Patient assessment of service quality



Discussion

Examining the relationship among socio-demographic factors, perceptions of care and service utilization is key to maintaining client commitment and continued enrolment unto the National health insurance. This study used a questionnaire to examine how National health insurance card bearers utilized health service in relation to the socio-demographic factors and perceptions of service quality.

Although the NHIS has seen improvement in enrolment over the years as shown by Boateng and Awunyor-Vitor [1] , there is still the need to access client's satisfaction and utilization of healthcare with their NHIS cards. This study shows that majority of subscribers assessed healthcare with their cards whereas 8% (32/400) of them had never accessed healthcare with their NHIS cards since they registered with the scheme. Though a marginal proportion of respondents had never used their NHIS card since they registered, there remain a minimal 2.94% (12/400) subscribers who attributed their inability to access health care with their NHIS card to difficulty in getting money to renew. Another 5.8% (23/400) of subscribers cited low quality of service provision to the reasons why they did not access health acre with their NHIS card. Other reasons why subscribers were not accessing health care with their NHIS included not falling sick and low quality of service and the fact that they had recently registered under the NHIS. This indicates financial difficulty in terms of registering under NHIS.

Failure to meet clients' expectation about service quality at the various facilities contributed to the decision not to utilize health care with their NHIS cards; however, this does not significantly determine utilization of health care with NHIS card. This finding corroborate Boateng and Awunyor-Vitor [1] that income levels and poverty did not significantly influence health care access with NHIS card and contrast the positions of Jehu-Appiah [16], Basaza, Criel and Van Der Stuyft [4] and WHO [21] .

Previous studies by Boateng and Awunyor-Vitor [1] and Agyei-Baffour, Oppong and Boateng [3], report that demand for health care is determined by the quality of service provided and that even poor households limit their demand for health care when the services are of poor quality, but are less sensitive to changes in quality of service.

In De Allegri, Sanon and Sauerborn [10] study, calls for a better health needs assessment among poor rural dwellers was reiterated. The objective of such an assessment was to integrate rural poor dwellers into health insurance planning. This is reasonable and appropriate if access and equity goals of health insurance are to be realised. However, this prioritization seems not to have been acknowledged in health policy planning and interventions.

The study further assessed the socio-demographic differences among clients who utilize healthcare with insurance cards. Client's occupation (being a student or unemployed) and residing in a rural part of the study area significantly decreased one's likelihood of accessing healthcare with NHIS card as compared to those with jobs or resided in urban areas [21] [22]. Similar to this study, in previous studies by Butler [38] the employed were more likely to undertake coverage as compared to those unemployed and this indicates that they are most likely to access healthcare with NHIS card. The study by Boateng and Awunyor-Vitor [1], however found no significant association between occupation and enrolment in NHIS, a position contrasted to by this present study's finding.The relationship been occupation and uptake of insurance has also been investigated in previous studies where those employed were more likely to undertake coverage [3] [20][37]. This could be explained on the basis that the employed could earn income and therefore could afford the insurance premium. Again in this study, those residing in rural parts of the study setting were not likely to access healthcare with NHIS. This is supported by recent empirical evidence which reveals that the NHIS is falling short of its equity goals, with lower enrolment among the poor and rural dwellers [8] [15] [16] [34].

In the review by Preker and Carrin [35], it was reported that, that the poor of the poorest for whose sake social interventions like health insurance are designed are actually not reached despite reaching marginal levels of low income populations. The call for success in health insurance must consider meeting equity dimensions of the scheme's implementation.

Majority of NHIS subscribers did not consider much difference between the insured and uninsured in terms of how much respect health staff accorded them. Majority of them had positive perceptions about staffs' attitudes in terms of listening and being, sensitive to their requests and complaints. The general attitude of staffs to insured clients was rated as good and more than 80% indicated recommending NHIS to friends and colleagues citing spending less money on healthcare as major reason. The findings of this study in being in tandem with Alatinga and Williams [27], reported that, in the opinion of those who had insured and were using their cards and those who were not using their health insurance cards to access health care, no disparity existed in respect of preferential treatment from health service providers. Results from this study on perceived quality of care were similar to other studies which concluded that quality of health care given to clients was generally satisfactorily among both insured and non-insured [1] [22][27]. According to Devadasan et al. [36] and Dalinjong and Laar [37] a contrary finding was however identified where insured clients were examined more frequently and promptly than those who were not insured or those insured but for personal reasons did not access health care with their cards. However, in both studies, the non-insured clients were evaluated and offered their opinions contrary to the present study where only insured clients evaluation and perceptions of the difference in quality of health care between them (insured) and the non-insured was elicited.


Conclusion

The study has brought to the fore and adds to the surging studies about NHIS client satisfaction with health care accessed. The study presents that client perception has positive relationship with health service utilization. There is also a positive relationship between clients' socio-demographic characteristics and their utilization of health services under the National Health Insurance Scheme. However, there were specific socio-demographic variables that were associated with accessing health care with NHIS. This study calls for the need for due attention to be given to quality health care under the scheme so as to create good public image and a positive perception about the scheme. The government also has a core duty to examine the socio-demographic characteristics of citizens in the country so as to create favorable atmosphere that can increase utilization of health services under the scheme. Policies being enacted should consider factors such as the urban poor, the peri-urban and rural dwellers in urban districts. Thus, the scheme should be made flexible to reflect the socio-demographic features and economic conditions prevailing in the country if the equity goal of the national Health insurance scheme is to be met.


Abbreviations

NHIS- National Health Insurance Scheme
ILO- International Labour Organisation
NGO -Non-governmental Organisation


Acknowledgements

I am grateful to Victoria Ampiah for her assistance in data collection and entry.


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Author Contributions:
Seth Christopher Yaw Appiah – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2014 Seth Christopher Yaw Appiah. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



About The Author

Seth Christopher Yaw Appiah is an Mphil graduate and a Graduate Research Assistant at the Department of Sociology and Social Work / Faculty of Social Sciences / Kwame Nkrumah University of Science and Technology, Kumasi, Ghana). He earned the undergraduate degree in Bachelor of Arts Sociology and Social Work from the Department of Sociology and Social Work, Faculty of Social Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana). He has published eight(8) research papers in national and international academic journals. His research interests include (Medical Sociology, Reproductive health and Maternal and Child health related issues). He intends to pursue (PhD in Public Health or Medical Sociology in future.




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