Out-of-pocket Payments for Health Care Under the National Health Insurance Scheme in Ghana: What Do Clients Pay for?


 Background: The introduction of social health insurance in developing countries is an important policy to improve financial access to health care. In 2003, Ghana implemented a national health insurance scheme (NHIS) designed to promote universal health coverage and equitable access to health care. The scheme has largely been successful, yet it is confronted with many challenges threatening its sustainability. Out-of-pocket payments by insured clients is one such challenges of the scheme. This study seeks to examine the types of services that these unauthorized charges are made for, who pays these charges and how much clients pay out-of-pocket.Methods: This was a descriptive cross-sectional health facility survey. A total of 2066 respondents were interviewed using structured questionnaires at the point of health care exit in the Ashanti, Northern and Central regions of Ghana. Health facilities of different levels were selected from 3 districts in each of the three regions. Data were collected between April and June 2018. Using Epidata and STATA Version 13.1 data analyses were done using multiple logistic regression and simple descriptive statistics and results presented as proportions and means.Results: Of all respondents in the study 49.7% reported paying out-of-pocket for out-patient health care while 48.6% of insured clients paid out-of-pocket. 42% of the insured poorest quintile also paid out-of-pocket. Respondents suffered fever-malaria like symptoms (45.7%). Insured clients paid for consultation (75%) and drugs (68.5%) and 34.9% purchased drugs outside the health facility visited. The unavailability of the drugs (67.9%) and drugs not covered by the NHIS (20.8%) led to out-of-pocket payments. On average patients paid GHS33.00 (USD6.6) out-of-pocket. Compared to the Northern region, patients living in the Ashanti region were 4.4 times more at odds to pay out-of-pocket for health care. Conclusions: Insured clients of Ghana’s NHIS seeking health care in accredited health facilities make out-of-pocket payments for consultation and drugs that are covered by the scheme. The out-of-pocket payments are largely attributed to unavailability of drugs at the facilities. These out of-pocket payments occur in disadvantaged regions, among individuals and in all health facilities. Out-of-pocket payments under NHIS leads to inequity in access to health care.

The declaration of universal health coverage (UHC) as a policy for all countries comes timely as UHC seeks to ensure "all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of su cient quality to be effective, while ensuring that the use of these services does not expose the user to nancial hardship" (World Health Organization, 2010). The demand for social protection schemes as a way of mitigating against the effect of out-of-pocket payments and poverty is growing as social protection schemes prove successful in ghting against poverty.
Social protection schemes either voluntary and/or mandatory have been adopted by middle-and lowincome countries with the aim of increasing equity in access to health services and providing nancial risk protection, especially for the poor (Garcia-Subirats et al., 2013). The introduction of nancial protection schemes seeks to pool funds to protect individuals against catastrophic health expenditures.
Social health insurance reduces household vulnerability to high out-pocket payments for health services in times of illness through reduction in direct medical costs and loss of income due to ill health (World Health Organization, 2010). Sood et al., 2014 indicated that poor households covered under these schemes tend to have reduced mortality, better access to care and reduce health care expenditures. Outof-pocket payments by eligible households in this same study was also reduced by 64% for hospital admission fees (Sood et al., 2014).
Similarly, health care access increases for vulnerable groups covered under health insurance than for those not covered. Globally, evidence shows that social health insurance improves access to health care services (Garcia-Subirats et al., 2013; Kusi et al., 2015). There is also evidence that health insurance decreased out-pocket-payments between 16% and 18% in Vietnam with more substantial decreases for low-income households (Chang and Trivedi, 2003;Nguyen et al., 2012;Sepehri et al., 2006). However, outof-pocket payments among the insured are still high in other countries and this affects access to health care (Nguyen et al., 2012).
Ghana introduced a national health insurance scheme (NHIS) in 2003 as a form of health nancing mechanism. The NHIS aimed at improving nancial access to health care to all people living in Ghana irrespective of social status. Despite over a decade and half of the implementation of the NHIS, enrolment unto the scheme remains low. A more recent published study reports coverage of the NHIS to be 35% (Nsiah-Boateng & Aikins, 2018). A recent study found that being a member of NHIS signi cantly decreased the probability of unmet medical needs by 15% and that of incurring catastrophic out-ofpocket (OOP) health payments by 7% relative to no enrolment in the NHIS (Navarrete et al, 2019). Yet, over the years the NHIS has faced several challenges that threatens its sustainability. Amongst these challenges are; the huge bene t package, which covers 90% of the disease burden of Ghanaians has also been one of the highlights as it is observed to have signi cant implications for the nancing of health care under the scheme. Moreover, there are several studies that have reported poor quality of health care under the scheme (Alhassan et al., 2016;Atinga, 2012;Dalinjong, & Laar, 2012), a factor that is believed to contribute to the low level of enrolment among the populace. Worse yet, there is evidence that the insured are treated unfairly at health facilities, partly due to delays in reimbursement of payment to service providers. Therefore, providers give preference to patients that pay out-of-pocket (Duku et al., 2018). Also, it was reported that the currently uninsured perceived the quality of health care to be better than the currently insured in terms of waiting time, availability of medicines and so on (Duku et al., 2018).
The NHIS nancial management challenge due to ine cient nancial ows led to delays in payment of services provided to clients by providers. There are thus widespread unauthorized charges that insured clients are paying out-of-pocket which should not be the case. Macha et al (2012) reported Ghana to have the highest out-of-pocket payments of health care accounting for about 40% of total health care expenditure, followed by Tanzania at nearly 26% and South Africa at about 18%. This, notwithstanding the fact that over 70% of both public and private health facilities are credentialed NHIS facilities in Ghana (NHIS, report 2017). Macha et al (2012) further reported that patients whether insured or not, paid out-of-pocket for medicines at pharmacies due to stock-outs in public health facilities or due to poor understanding of what they are entitled to as clients of the NHIS. The question however remains, what type of services are these unauthorized charges being made, who pays these charges and how much do they actually pay out-ofpocket?

Study design
This was a descriptive cross-sectional health facility survey. It was conducted among patients accessing out-patient care services at different levels of the health system in three regions of Ghana. The three regions selected were the Northern, Central and Ashanti.

Data collection methods
Quantitative data collection approach was used to gather information about services patient paid for and how much they paid out-of-pocket. Patients were interviewed at the point of exit of the health care system using structured questionnaire. Data for the study was collected from April 2018 to June 2018.

Sample size and sampling method
About 688 patients were interviewed in each region. One district per region was rst randomly selected and in each selected district, three health centres, the district hospital and two Community-based Health Planning and Services (CHPS) compounds were then randomly selected based on size of attendance at each of these health facilities. The number of patients interviewed at each level of the health system was proportional to the size of out-patient-department attendance of that facility. The number of attendances at CHPS facilities was much lower than anticipated and thus more interviews were carried out at the health centre levels than in CHPS compounds. Interviews with patients at the teaching hospital in the Ashanti region could not be conducted as they required their own ethical review board review of the proposal and due to time constraints, the interviews were done at the district and regional hospitals in the Ashanti region.

Data management and Analysis
Data was entered using Epidata and analyses were done using STATA Version 13.1. The study sought to establish the proportion of insured patients paying out-of-pocket for health care and to assess the determinants of paying out-of-pocket and the costs of care. The main outcome variable was the proportion of patients insured and paying out-of-pocket. Socio-economic status was measured using the wealth index where household assets and possessions of patients interviewed were used to construct the wealth index. Households were divided into ve quintiles with rst quintile representing the poorest household and the 5 th quintile representing the least poor household. Data on household consumption expenditure was also gathered to calculate the proportion of household expenditure on health care. A multiple logistic regression was run to establish the association between being insured and paying out-ofpocket for health care. The type of services paid for are presented as proportions and percentages while the costs of health care and household consumption are presented as means and totals.

Socio-demographic and economic characteristics of respondents
Of the 2066 respondents who participated in the survey 47% were in the age bracket 18-49 years ( Table  1). There were more females 76.7% (1591) who accessed health care than males. Most respondents were Akan 61.4% (1273). This was not surprising, as the Ashanti and Central regions are Akan speaking communities. A little over 50% (1099) were married and 9.4% (195) of the respondents were living together. The average household was 5.6 ( Table 1). Less than a third (30.2%) of the participants completed Junior High School with 29.3%(605) without any formal education (Table 2). Those with secondary or higher education were 29.7% (614). Thus, it is not surprising that 26.2% (541) reported being unemployed and with 20.5% (432) in the sales and services industry. Those working in the agriculture sector were 13.7% (282). Those who had retired from active service or aged were 11.7% (241).
The mean monthly household recurrent expenditure of GHS678.00 (USD135.60) was similar to mean monthly income reported by the respondents. Non-recurrent expenditure was slightly higher than the mean monthly recurrent expenditure

Socio-demographic and Economic Characteristics by Region
In all the three regions, most of the respondents were in the 18-49 years age category (Table 2). Those under ve years of age and less than 17 years were on average 30% (208) in the Ashanti region, 26.6% (181) in Central region and over 37% (255) in the Northern region. This group are exempted from paying NHIS premium thus bene ting from free health care services. Over 70% of the respondents in each region were females. Women in their reproductive age and who are pregnant are also exempted from paying national health insurance premium. There were variations in the levels of education by region. Close to 50% (339) of respondents in the Northern region had never been to school compared to 23.6% (163) in the Ashanti region and 15% (103) in the Central region (Table 2). a -Ghanaian local currency, Ghana cedis.
The socio-economic status of respondents in each region showed 45.5% (255) of those in the Northern region to be in the poorest quintile. The Ashanti region reported more patients in the least poor quintile (33.6%) than in Central (18.1%) and Northern regions (5.7%). These differences were statistically signi cant. However, monthly earnings did not vary much by region. Most participants earned between GHS8-150 (USD1.60-30.00..) and GHS151-300 (USD30.20-60.00.) per month ( Table 2).

Utilization of Health Care Services by Respondents
Most patients who participated in this survey used in the last 6 months the government hospital 57.5% (1187) and government health centres 38.2% (790) for health care services (    1,907) and similar pattern was observed at the regional levels ( Figure 1) . Northern region reported the highest NHIS coverage of 94% and the least coverage was observed in the Ashanti region (87.9% (Figure 1). The proportion of males with valid NHIS card was 87.4% (368) while the proportion of females with valid NHIS card was 91.1% (1349) and these differences were statistically signi cant (P<0.000).

Out-of-Pocket Payment for Health Services
Close to 49.7% (1,027) of all patients reported paying for health care for the condition they reported with at the health facility. Sixty-four percent (657) paid for consultation and 34.2% (326) paid for drugs (Table   5).
Of those who paid for these services, 42.5% (441) did not get a receipt for the services paid for. Patients reported ever paying for services at the same health facilities. Close to forty-eight percent (456) reported ever paying for these services in previous visits to the health facilities. For the most recent payments, 77.4% (322) paid weeks ago before this survey (Table 5).
Out-of-pocket payment for health care services occurred at all level of health facilities. On average close to 41% (441) of patients who visited the CHPS and 43%(881) health centres paid for health care while an average of 53% of those who visited district, regional and tertiary health facilities also paid out-ofpocket for health care. Out-of-pocket payments at district and regional hospitals were slightly higher than those of tertiary hospitals but the differences were not statistically signi cant (P>0.05).
Of all drugs prescribed, 34.9% (717) were purchased outside the health facility visited ( Table 5). The main reasons why the drugs were not supplied by the health facilities patients visited were: unavailability of the drug 67.9% (487) and the drugs prescribed not being covered by the NHIS 20.8% (142).

Out-Of-Pocket Payment for Health Services by Insured Clients
Ninety percent of patients (1,722) who accessed health care at all health facilities in the regions had a valid NHIS card and 8% (153) had a valid NHIS card but could not show it at the time of the survey ( Table   6). Patients with valid NHIS cards who paid for health care were 46.9% (803) which is slightly lower than all patients 49.7% (1027) who reported paying for health care.  Table 6).
However, over 55.6% of NHIS members earned in the range of GHS8.00 to GHS300.00 (Table 6). The average health care costs paid per client was GHS33.1 representing 11% of the median income of GHS300.00 (USD60.00) of patients.
NHIS clients paying-out-of-pocket for health care varied by region with 62.4% (431) of those from the Ashanti region paying out of pocket with much lower payments observed in the Central 48.2% (335) and Northern regions 35.2% (238) and these differences were statistically signi cant (P<0.001) as shown in Figure 2. There were regional differences in type of services paid for. Most patients in the Ashanti and Central regions paid more for consultation while patients in the Northern region paid more for drugs than the other regions ( Figure 3). The differences in type of services paid out-of-pocket by region were statistically signi cant (P<0.001).
The distribution of out-of-pocket payments by socio-economic index showed that the proportion of the poorest that are paying out-of-pocket is similar to that of the least poor. Using both the wealth index generated using household assets and possessions and the monthly household expenditure of households, both indices showed that 42% of the poorest quintile paid out-of-pocket and a similar proportion 43% of the least poor quintile paid out-of-pocket ( Figure 4) for health care. Thus, though the average paid out-of-pocket was GHS33.00 with 55% paying in the range of GHS1.00 -20.00 (USD0.20-USD4.00) and GHS21.00 -40.00, (USD4.2-8.00) many of the poor earned between GHS8.00 -150.00 (USD1.6-30.00). Thus, the out-of-pocket payments are borne more by the poorest quintile who earned in this range.
Multiple Logistic regression of the determinants of Out-of-pocket payments for health care Sex, age, the level of education, validity of NHIS card and mean monthly income were not statistically signi cant determinants of out-of-pocket payments at the 5% level of signi cance. However, the 60-69 age group , the GHS451.00-GHS600 mean monthly income group , the type of remittance and the type of health care given were statistically signi cant determinants of out-of-pocket payments at the 10% level of signi cance. Region was a statistically signi cant determinant of out-of-pocket payments. Thus, compared to the Ashanti region, patients living in the Central region had 0.36 increased odds (CI: 0.25-0.50) of paying out-of-pocket for health care. Similarly, those living in the Northern region had about 0.26 folds increased odds of paying out-of-pocket compared to patients in the Ashanti region. Also, whereas the odds of paying out-of-pocket for health care services is 1.28 higher for poorer households than the poorest households, the odds of paying out-of-pocket for health care services is 2.02 higher for the least poor households than the poorest households (Table 6).

Discussion
The objective of this study was to determine the services NHIS clients pay for, the actual amounts clients paid out-of-pocket, those paying out-of-pocket and the determinants of out-of-pocket payments. Out-ofpocket payments are occurring at all the levels of health facilities. In lower level health facilities, patients made out-of-pocket payment as much as 40% and in hospitals as much as 53%. Forty-six percent of NHIS clients with valid card reported out-of-pocket payments for Out-Patient-Department (OPD) services in this study. Over two-thirds of these patients presented with fever and malaria-like signs and symptoms.
This is consistent with the report of Ghana Health Service where malaria was the leading cause of admission in hospitals nationwide in 2018 (Ghana Health Service, 2019).
This level of out-of-pocket payment is con rmed in previous studies where NHIS clients pay between an average of GHS13 -17.50 out-of-pocket when seeking treatment (Dalinjong et al., 2018;Abuosi et al., 2016). Similarly, a reported 7-18% of insured households incurred catastrophic health expenditure in the Eastern and Central regions of Ghana (Aryeetey et al., 2016). Moreover, in this study as many as 48.6% of clients report ever paying for health care in previous visits, further implying that paying out-of-pocket does occur. Patients pay 11% of their median monthly income of GHS300.00 as out-of-pocket payments. As much as 42% of the poorest quintile and 43% of the least poor both pay out-of-pocket for health care, yet the poorest earn less than the current monthly minimum wage in Ghana (GHS320.00). There were regional differences in out-of-pocket payments with those in the Ashanti region reporting more out-of-pocket payments than those in the Northern region. The variation reported between the two regions could be attributed to the general poverty level variations between these two regions (Ghana Statistical Service, 2014). Generally, the Ashanti region is considered to be more economically vibrant than the Northern region, a situation that puts the people in Ashanti region in a better economic position than their counterparts in the Northern region. Therefore, service providers will be more inclined to expect out-ofpocket payments from the people in Ashanti compared with their colleagues in the Northern region.
Paying for services is attributed to unavailability of prescribed drugs or prescribed drugs not covered by the NHIS. The hospitals usually procure medical supplies and drugs on credit and pay suppliers later.
This is a common practice based on the original design of the NHIS which reimbursed service providers some weeks after service provision, when claims have been submitted to the National health insurance authority for payment (Ministry of Health, 2004). However, the chronic delay in claims payment means regular stockout of drugs or deliberate reluctance of service providers to give drugs to NHIS patients who visit their facilities. Therefore, as a coping strategy, service providers often make NHIS clients pay for drugs in order to keep their health facilities operational. The reasons for paying for consultation fees were however not alluded to.
A range of household characteristics were found to be the key predictors of paying out-of-pocket for health care services . Households in the poor and the least poor category were strong predictors of incurring out-of-pocket health payments. This nding is consistent with previous studies conducted in Sub

Consent to participate and publication
All study participant signed an informed consent form before the interview. We also had permission to publish ndings from this study.

Data and material availability
The data is part of an ongoing study. In view of that we are restricted from sharing the large data set.
However, the data contained in this manuscript are available upon a reasonable request to the corresponding author.

Competing interests
The authors declare that they have no competing interests

Funding
The manuscript is part of the research project 'Health systems governance for an inclusive and sustainable social health protection in Ghana and Tanzania' funded by the Swiss Program for Research on Global Issues for Development. This is a joint programme by the Swiss National Science Foundation (SNSF) and the Swiss Agency for Development and Cooperation (SDC). The funder of the study had no role in the study design, data gathering, analysis and interpretation, or in writing of the report. The corresponding author had full access to all the data in the study and had nal responsibility for the decision to submit for publication.

Authors' contributions
The Out-of-pocket study was designed by PA in collaboration with MA and FT. Out-Of-Pocket Payment by Socio-economic Index