Community-based health financing scheme in the Kassena Nankana-District in the Upper East Region of Ghana: an operational feasibility study

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Financing of health care in Ghana has been a major challenge to the government since the late 1 960s. Provision of health care in the immediate post independence era was virtually free. However, following the economic crisis beginning from the late 1960s through the early 1980s, successive governments were compelled to adopt cost recovery measures in the form of nominal fees (1969) and user fees (1985) with the ultimate objective to improve the quality of care in the country. Unfortunately, these measures resulted in marked declines in the utilization of services throughout the country with the rural communities being the worst affected. In addition, delayed reporting for medical attention, a rise in the number of quack doctors, self- medication, an increase in morbidity and mortality rates are now more or less permanent features in the country’s health delivery system. Consequently, a public debate ensued on the need to find an alternative financing approach that is more effective and affordable to majority of the population especially the poor. The outcome of this debate is a call on government to pursue with vigour a health insurance policy with emphasis on social insurance for the formal sector and mutual health organizations (MHOs) for the rural non-formal communities, hence, this study. This study was based on the hypothesis that the operational feasibility of a community- based health insurance scheme is positively related to favourable socioeconomic and demographic conditions. It was a cross-sectional study with regard to primary data and retrospective with respect to secondary data. Both quantitative and qualitative data were collected with the help of techniques, which included literature search; semi-structured interviews; FGDs, and key informant interviews. Thirty communities out of a total of about one hundred and fifty seven were selected by means of purposive sampling. This sampling technique was used in order to ensure that both urban and rural characteristics of the district were taken into account. In the case of the compounds and households, systematic and simple random sampling methods were used respectively for their selection. The findings of the research revealed that there is a reasonable basis for a community based health insurance scheme to be considered in the district even though the financial situation of the population is not encouraging enough. For instance, the study has established that over 42.0% of the sampled households are in extreme poverty i.e. earning incomes less than ¢500, 000.00 per adult per annum; whilst over 65.0% fell below the current estimated lower poverty line of about 1,000,000.00 per adult per annum. The average annual income in the district was found to be ¢1, 628,000.00, whereas, the mean annual household health expenditure was ¢l 52,316.67. In terms of regularity of income, over 45.0% of the household’s sampled earned income on yearly basis and this is in consonance with the main occupation (farming) of the people who mostly harvested their crops once a year, whilst 32.0% formed the proportion that earned income monthly. In spite of the weak financial situation of the populace, an overwhelming 98.3% of households were willing to join the insurance scheme, thus, affirming the social acceptability of the insurance concept. The preferred choice of health benefit for which households wanted to join the scheme was both outpatient and inpatient care. However, analysis has established that the populace will benefit more if coverage is limited to inpatient care at least during the first two years of operationalisation of the scheme. Furthermore, majority (6 8.7%) of households prefer to contribute the insurance premium with cash payments. However, a significant 29.3% of households expressed their desire to pay the premium in the form of both cash and material items. With regard to the design of the scheme, the indirect type (MHO) was the preference of the populace with the management team to be constituted from amongst the community members. Areas that require more detailed study include: • Service quality in the district with emphasis on drug availability • “Ability to Pay” (ATP) founded on basic needs and opportunity cost of payment strategies • Identification of community based organizations or social groups to support the scheme. In the meantime, a per capita annual premium of the range ¢25,000.OO - ¢30.000.OO has been found to be fair and feasible, but this needs to be revised as and when necessary to reflect prevailing inflationary trends.
A thesis submitted to the Department of Community Health, School of Medical Sciences, College of Health Sciences Kwame Nkrumah University of Science and Technology in partial fulfilment of the requirements for the award of in Health Services Planning and Management, 2003