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).
Table 1: Socio-demographic and economic background of respondents
Demographic characteristic
|
Number
|
Percentage (%)
|
Age group (Years):
|
|
|
<18
|
651
|
31.4
|
18-49
|
967
|
47.1
|
50-69
|
301
|
14.5
|
70+
|
147
|
7.1
|
Total
|
2,066
|
100.0
|
Sex:
|
|
|
Female
|
1583
|
76.6
|
Male
|
482
|
23.4
|
Total
|
2,066
|
100’0
|
Ethnicity:
|
|
|
Akan
|
1,273
|
61.4
|
Mole-Dangme
|
680
|
32.9
|
Other
|
82
|
4.0
|
Foreign
|
31
|
1.5
|
Total
|
2,066
|
100.0
|
Marital Status:
|
|
|
Married
|
1,099
|
53.2
|
Single-never married
|
504
|
24.4
|
Divorce-separated
|
81
|
3.9
|
Widowed
|
187
|
9.1
|
Living together
|
195
|
9.4
|
Total
|
2,066
|
100.0
|
Socio-economic characteristic
|
|
|
Level of education:
|
605
|
29.3
|
Never been to school
|
605
|
29.3
|
Primary
|
233
|
10.8
|
Junior High School/Middle
|
624
|
30.2
|
Senior High School/O & A Level
|
398
|
19.3
|
Tertiary
|
216
|
10.4
|
Total
|
2,066
|
100.0
|
Main occupation:
|
153
|
7.4
|
Agriculture
|
282
|
13.7
|
Professional/secretarial
|
153
|
7.4
|
Sales/services
|
432
|
20.5
|
Skilled manual craftsmanship
|
198
|
9.6
|
Unskilled manual labour
|
125
|
6.1
|
Unemployed
|
541
|
26.2
|
Others (i.e., aged/retired/students)
|
339
|
16.5
|
Total
|
2,061
|
100.0
|
Remittance from relatives:
|
|
|
Received remittance
|
1,094
|
52.7
|
Remittance type:
|
|
|
Cash Remittance
|
738
|
67.6
|
Gifts/in-kind
|
353
|
32.4
|
Total
|
1,091
|
100.0
|
Remittance frequency:
|
|
|
Weekly/daily
|
323
|
30.7
|
Monthly
|
249
|
23.0
|
Occasionally
|
501
|
46.3
|
Total
|
1,073
|
100.0
|
Monthly income (GHSa):
|
|
|
<150
|
375
|
31.0
|
151-300
|
290
|
24.0
|
301-450
|
127
|
10.5
|
451-600
|
146
|
12.1
|
600+
|
270
|
22.4
|
Total
|
1,208
|
100.0
|
a – Ghanaian local currency, Ghana cedis. GHS1 .00: USD 5.00 (2018)
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).
Of the 2,066 respondents, 52.7% (1094) received remittances from relatives or friends (Table 2). Cash remittances constituted 67.6% (738). Most remittances were received occasionally. The mean monthly income was GHS618.46 (USD123.69 ) with a median income of GHS300.00 (USD60) for those who reported actively working. Less than a third (31%) of the working population earned between GHS8.00 and GHS150.00 (USD30). Another 24% earned between GHS151-300 (USD30.2-60), showing that 55% of the respondents earned below the minimum monthly wage of GHS 320.00 (USD64.00) for Ghana in 2018. The distribution also showed a huge variation of those earning below the minimum monthly wage being twice the number that earned more than twice the monthly wage GHS600+ (USD120.00) (22.4%). The mean remittance was GHS187.17 (USD37.43) with a median remittance of GHS100.00 (USD20.00). 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 five 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 benefiting 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).
Table 2: Socio-demographic and economic background of respondents by region
Items
|
Study regions
|
Ashanti (%)
|
Central (%)
|
Northern (%)
|
Age:
|
|
|
|
<18
|
30.0
|
26.6
|
37.9
|
18-49
|
41.9
|
47.1
|
51.2
|
50-59
|
10.8
|
9.2
|
3.3
|
60-69
|
8.8
|
7.8
|
3.6
|
70+
|
8.5
|
9.3
|
4.0
|
Total (n)
|
692
|
688
|
688
|
Sex:
|
|
|
|
Female
|
73.1
|
77.1
|
79.9
|
Male
|
26.8
|
22.9
|
20.1
|
Total (n)
|
692
|
688
|
683
|
Level of education:
|
|
|
|
Never been to school
|
23.6
|
15.0
|
49.4
|
Primary
|
10.3
|
13.4
|
8.7
|
Junior High School/Middle
|
34.3
|
43.3
|
13.5
|
Senior High School/O & A Level
|
22.1
|
16.9
|
19.1
|
Tertiary
|
9.7
|
12.3
|
9.3
|
Total (n)
|
691
|
687
|
687
|
Occupation:
|
|
|
|
Agriculture
|
4.4
|
17.3
|
21.0
|
Professional/secretarial
|
10.1
|
8.1
|
5.4
|
Sales/Services
|
23.1
|
19.1
|
22.5
|
Skilled manual craftsmanship
|
10.7
|
12.2
|
7.4
|
Unskilled manual labour
|
6.6
|
10.6
|
2.1
|
Unemployed
|
29.5
|
22.0
|
31.1
|
Other (i.e., retired)
|
15.7
|
10.7
|
10.6
|
Total (n)
|
637
|
654
|
672
|
Wealth quintiles:
|
|
|
|
Poorest
|
2.2
|
16.7
|
45.5
|
Very poor
|
9.8
|
28.7
|
22.1
|
Poor
|
23.2
|
18.7
|
17.7
|
Less poor
|
31.2
|
17.8
|
8.9
|
Least poor
|
33.6
|
18.1
|
5.7
|
Total (n)
|
682
|
663
|
560
|
Monthly income (GHSa):
|
|
|
|
<150
|
27.3
|
32.7
|
32.7
|
151 – 300
|
29.4
|
21.6
|
21.7
|
301 – 450
|
10.1
|
12.0
|
9.2
|
451 – 600
|
14.2
|
13.1
|
8.9
|
600+
|
19.1
|
20.3
|
27.6
|
Total (n)
|
367
|
449
|
392
|
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 significant. 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 (Table 3). The choice of a health facility was based on three main factors; proximity 40.9% (845) of the facility to the patient, NHIS credentialed facility 29.6% (611) and availability of doctors 21.5% (444). Patients reported using hospitals and health centres more for all levels of severity of illness 41.4% (855) with only about 18.6% (384) using these facilities only during severe illness. Patients who presented at the out-patient-department with fever and malaria like signs and symptoms were 47.5% (981) and nearly a quarter of patients 23.4% (485) were there for a review of their condition recommended by the health provider from a previous visit. (Table 3).
Table 3: Health Care Services Accessed by Patients
Utilization of health care service
|
Number
|
Percentage (%)
|
Usual Care source
|
Health Centre
|
790
|
38.2
|
Government-Hospital
|
1,187
|
57.5
|
Pharmacy-drug
|
19
|
0.9
|
Private-facility
|
70
|
3.4
|
Total
|
2066
|
100
|
Reason for choice
|
Proximity
|
845
|
40.9
|
Lab
|
62
|
3.0
|
Drugs available
|
104
|
5.0
|
NHIS Credential
|
611
|
29.6
|
Medical Doctors available
|
444
|
21.5
|
Total 2066 100
|
Level of Severity of illness for Choice of Health Facility
|
Severity of illness
|
384
|
18.6
|
Moderate/mild
|
827
|
40.0
|
All levels of severity
|
855
|
41.4
|
Total 2066 100
|
Signs and symptoms presenting
|
Fever-malaria like
|
981
|
47.5
|
Difficult-in-breathing
|
203
|
9.8
|
ENT-toothache
|
115
|
5.6
|
Injury
|
104
|
5.1
|
Review
|
485
|
23.4
|
Eye infection
|
103
|
5.0
|
Hypertension-diabetes
|
55
|
2.6
|
Skin Infections
|
20
|
1.0
|
Total
|
2066
|
100
|
Type of health Services provided to Patients at the Out-Patient-Department
Over 76.6% (1583) of patients reported consulting with the health care provider and 14.8% (306) reported being supplied with drug only without consultation (Table 4). After consultation, 87.3.% (1382) were prescribed at least one drug. Twenty-nine percent (459) were prescribed two drugs and 25.8% (408) were prescribed three drugs. There was an observed pattern in the number of drugs prescribed and number of these drugs that were supplied by the pharmacy or dispensary of the health facility the patient visited. On average 75.6% (686) of all drugs prescribed were supplied by the pharmacy or dispensary of the facility the patient visited (Table 4). However, of those who were prescribed with two drugs, 77.1% (354) of these drugs were supplied by the health facility they obtained care from. For those who were prescribed three drugs, 79.5% (365) received all the three drugs prescribed from the health facility. Of those prescribed with four drugs only 70.2% (188) were supplied with all four drugs (Table 4) in the health facility they obtained care from . Thus, close to a quarter of all the drugs prescribed were not supplied by the health facility the patients visited.
Table 4: Type of Services Accessed by Patients
Service Provision
|
Number
|
Percentage (%)
|
Services received at Facility
|
Maternal-child
|
68
|
3.3
|
Consultation
|
1,583
|
76.6
|
Laboratory
|
44
|
2.1
|
Drugs
|
306
|
14.8
|
ENT-Eye-tooth
|
32
|
1.6
|
Hospital Admission
|
33
|
1.6
|
Total 2,066 100
|
Number of Drugs Prescribed Among those who consulted
|
No drug prescribed
|
201
|
12.7
|
One drug prescribed
|
247
|
15.6
|
Two drugs prescribed
|
459
|
29.0
|
Three drugs prescribed
|
408
|
25.8
|
Four or More drugs prescribed
|
268
|
16.9
|
Total
|
1583
|
100
|
Number of drug prescribed Received for those prescribed with 2 or more drugs
|
Received All 2 drugs prescribed
|
354
|
77.1
|
Received All 3 drugs prescribed
|
365
|
79.5
|
Received All 4 drugs prescribed
|
188
|
70.2
|
Average of all drugs received
|
686
|
75.6
|
Insurance Status of Patients
Many respondents in this survey held a valid NHIS card at the time of the interview. The proportion of all patients with a valid NHIS card was 90.3% (1722/1,907) 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 significant (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-of-pocket for health care.
Table 5: Out-of-pocket payments for health care by All patients
Payment for Health Care
|
Number
|
Percentage (%)
|
Paid for services
|
1027
|
49.7
|
Services paid for
|
|
|
Laboratory investigations
|
44
|
4.4
|
Drugs
|
326
|
32.4
|
Consultation
|
657
|
64.0
|
Total
|
1027
|
100
|
Cost of care paid for (GHS)
|
|
|
1-20
|
683
|
66.5
|
21-40
|
177
|
17.2
|
41-60
|
77
|
7.5
|
61-80
|
16
|
1.6
|
81-100
|
74
|
7.2
|
Total
|
1027
|
100
|
Receipts received for services paid for
|
|
|
No receipts given
|
441
|
42.5
|
Receipts for all services
|
379
|
36.6
|
Receipts for some services
|
217
|
21.0
|
|
1027
|
|
Ever paid for services
|
456
|
47.7
|
Most recent payment
|
|
|
Days ago
|
66
|
15.9
|
Weeks ago
|
322
|
77.4
|
Months ago
|
28
|
6.7
|
Total
|
456
|
100
|
Proportion of drugs prescribed patient purchased outside health facility patient visited
|
717
|
34.9
|
Reason for purchasing drug
|
|
|
Drug unavailable at facility
|
487
|
67.9
|
Not covered by NHIS
|
149
|
20.8
|
Expensive at facility
|
7
|
1.0
|
Don’t know
|
74
|
10.3
|
Total
|
717
|
100
|
Facility Type and out-of-pocket Payments
|
|
|
CHPS
|
91
|
40.7
|
Health Centre
|
881
|
42.7
|
District Hospital
|
864
|
54.6
|
Tertiary
|
226
|
51.8
|
Out-of-pocket payments at district and regional hospitals were slightly higher than those of tertiary hospitals but the differences were not statistically significant (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).
Most patients (66.5%) paid between GHS1.00 (USD0.20) and GHS20.00 (USD4.00) for consultation and drugs (Table 5 ).
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: Out-of-pocket Payments by the Insured
Health care payment by Insurance Status
|
Number
|
Percentage (%)
|
Respondents with Valid NHIS card and seen
|
1722
|
90.3
|
Valid NHIS not seen
|
153
|
8.0
|
No Valid NHIS Card
|
32
|
1.7
|
Total
|
1,907
|
100
|
Paid out of Pocket with valid NHIS card seen
|
803
|
46.9
|
Services paid for as NHIS valid card holder
|
|
|
Consultation with Valid card seen
|
1295
|
75.3
|
Card not seen
|
102
|
68.5
|
NHIS valid card purchased drugs
|
|
|
Card seen
|
1079
|
63.2
|
Card not seen
|
111
|
75.0
|
Proportion of NHIS earning income
|
998
|
56.0
|
Monthly income by NHIS clients (GHS)
|
|
|
8-150
|
318
|
31.9
|
151-300
|
238
|
23.9
|
301-450
|
101
|
10.1
|
451-600
|
120
|
12.0
|
600+
|
121
|
12.1
|
Total
|
998
|
|
Average health care costs (GHS)
|
33.1
|
|
Average Income of NHIS Clients (GHS)
|
574.7
|
|
Average Household size of NHIS clients
|
4.7
|
|
Of those who held a valid NHIS card that was seen, 75.3% (1,295) paid for consultation and 63.2% (1,079) paid out of pocket for drugs, and 26% paid for both consultation and drugs. Of those with valid NHIS cards who could not present them, 68.5% (102) paid for consultation and 75% (111) paid for drugs (Table 6).
The proportion of NHIS clients in this study earning income was 56% (998). The median monthly income of NHIS clients was GHS300.00 (USD60.00) while the mean income was GHS574.72 (USD114.94). 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 significant (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 significant (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 significant determinants of out-of-pocket payments at the 5% level of significance. 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 significant determinants of out-of-pocket payments at the 10% level of significance. Region was a statistically significant 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).
Table 6: Predictors of Out-of-Pocket Payments
Variable
|
Odds ratio
|
P-Value
|
CI
|
Sex
|
Female (B)
|
|
|
|
Male
|
1.26
|
0.172
|
0.90-1.75
|
Age group of Patient
|
Less than 6 years (B)
|
|
|
|
Age 6-17
|
1.6
|
0.120
|
0.88-2.90
|
Age 18-49
|
1.1
|
0.663
|
0.72-1.67
|
Age 50-59
|
1.09
|
0.774
|
0.62-1.90
|
Age 60-69
|
0.46
|
0.019**
|
0.24-0.88
|
Age 70 and above
|
0.82
|
0.561
|
0.41-1.62
|
Level of Education
|
Never been to School (B)
|
|
|
|
Primary
|
1.33
|
0.298
|
0.78-2.28
|
JHS/Middle
|
0.84
|
0.398
|
0.56-1.26
|
SHS/O/A Level
|
0.87
|
0.566
|
0.55-1.39
|
Tertiary
|
0.97
|
0.901
|
0.55-1.6
|
Region
|
Ashanti (B)
|
|
|
|
Central
|
0.36
|
0.000**
|
0.25 - 0.50
|
Northern
|
0.26
|
0.000**
|
0.16-0.40
|
Wealth Quintile
|
Poorest (B)
|
|
|
|
Poorer
|
1.28
|
0.297
|
0.80-2.04
|
Poor
|
1.79
|
0.015**
|
1.12-2.88
|
Less Poor
|
1.39
|
0.175
|
0.86-2.24
|
Least Poor
|
2.02
|
0.007**
|
1.21-3.37
|
Type of Remittance
|
Cash Remittance (B)
|
|
|
|
Gifts/in-kind
|
1.27
|
0.095*
|
0.96-1.69
|
Validity of NHIS Card
|
Valid NHIS Card (B)
|
|
|
|
No Valid NHIS Card
|
0.71
|
0.148
|
0.44-1.13
|
Service Provided
|
Maternal-Child (B)
|
|
|
|
Folder Records
|
6.85
|
0.141
|
0.53-88.92
|
Lab Investigation
|
412.05
|
0.000**
|
32.58-5211.62
|
Drugs
|
15.16
|
0.011**
|
1.87-122.95
|
ENT-Eye
|
15.36
|
0.022**
|
1.49-158.12
|
Consultation
|
33.13
|
0.001**
|
4.26-257.60
|
Admission
|
103.69
|
0.000**
|
10.76-998.90
|
Monthly Income
|
Less than GHS300 (B)
|
|
|
|
GHS151-300
|
0.98
|
0.899
|
0.68-1.41
|
GHS301-450
|
1.33
|
0.245
|
0.82-2.14
|
GHS451-600
|
1.81
|
0.011**
|
1.14-2.87
|
GHS600+
|
0.99
|
0.979
|
0.65-1.52
|
B is the base category; *p < 0.1 ( 10 % level of Significance) ; **p < 0.05 ( 5 % level of Significance)