Identification of the poor for enrolment into the National Health Insurance Scheme
The qualitative interviews shared light on community perception of poverty and the enrolment processes in the community. There was no consensus on the definition of a poor person in the community. However, majority defined poverty in terms of ability to afford basic necessities of daily living. These activities of daily living included food, clothing, and payment for health care and school fees of children. Therefore, individuals in the community who had challenges meeting these needs in the community were classified as being poor. The participants were generally of the view that there were many poor people in the community. The following quotes illustrate these points:
“Poverty is when you farm and you are not able to get a good yield, feeding your family becomes a problem; you are unable to pay school fees, this is what we term as poverty” (Male, FGD, NR).
“The poor are persons who are not able to feed themselves and their children. They cannot pay the school fees of their children as well as hospital bills when they are sick. We have a lot of poor people in the villages but in Berekum here it may not be common” (female, FGD, BA).
Both FGD and IDI participants identified orphans, elderly, people who are sick and unable to work and people with disability as poor people in the community across the three study regions. Participants characterized widows as poor because they have no husband to take care of them. In the opinion of participants, widows who have children often find it challenging to cater for their children especially when they are unemployed. The following quotes support these assertions from participants:
“In this community we know each other very well; and we know the less privilege in this community, such as physically challenged, widows/widowers and orphans when such programme come into the community we encourage them to go and register so that they can benefit from such programmes” (Male, FGD, BA).
“The poor in the community are the orphans, people who are sick and cannot work and women whose husband have died living them with children to take care. They suffer a lot as they are not able to feed the children, take care of their fees and the children will always appear in dirty and torn clothes” (Female, FGD, NR).
“We have orphans, people with disability and those who are sick and cannot work are the poor people in this community. They need help because they have nobody to take care of them” (Male, IDI, GAR)
There were little variations in the definition of poor across Brong Ahafo and Northern regions. Table 2 provides a summary of participants’ definition and people identified as poor in the community across the three study sites.
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
• Cannot send children to school and pay school fees
• Sick person who cannot work or far
• Unable to renew insurance
• Cannot pay Hospital bill
• Widow
• Aged without a helper
• Inability to afford good clothing
|
• Orphan
• People with disability
• Dressing of their children
• Physical appearance
• Type of house the person lives in
|
Northern Region
|
• Inability to feed self and family
• Cannot send children to school and pay school fees
• Sick person who cannot work or far
• Unable to renew insurance
• Cannot pay Hospital bill
• Widow
• Aged without a helper
• Inability to afford good clothing
|
• Orphans
• Disability
• Children wearing tattered clothes
• Appearance and dressing
• Live in dejected houses without light.
|
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)
|
Identifying The Poor In The Community
In both IDI and FGD, participants were of the view that it was easy to identify poor people in the community. The poor people could be identified through their general appearance, type of house the person lives in, type of food they eat, inability to pay fees of the children and hospital bills. Some participants indicated that poor people often live in houses that have no electricity because they cannot afford to pay light bills, they or their children are often seen in tattered clothes and they are often withdrawn from the community. Hence, people who live in the community with the poor such as community leaders could be used to identify the poor.
“Identifying the people in this community is easy. We know them from the place they live, clothes they wear and the way they even talk and carry themselves around. They are often quiet and do not participate in community activities” (Male, IDI, BA).
“It is not easy to identify the poor, you can only identify the poor when the person is sick and can’t afford the medical bills, until someone comes to aid of the patient, you will not be able pay for them, again the physically challenge cannot work and cater for themselves, they live on receiving alms and live in houses without light because they cannot afford to pay the bill” (Male, FGD, NR).
Community Structures For Identifying The Poor
In both IDI and FGD, community members purported to know the people because they live with them and understand their situation. The use of community leaders including religious leaders were strategies that could be used to identify the poor in addition to simply doing a house to house identification. In their view, religious leaders know members of their congregation that are poor. Besides, poor people could be identified by health workers who attend to patients who are sick. This is because poor people are often unable to pay for the health care they receive. Both community members and health workers were of the view that the hospital could be used to recruit the poor. These suggestions are supported by the following quotes:
“Community leaders could be used to identify people. The church leaders know the people who are poor in their church. So if you want to identify poor people in the community, they should be contacted to assist” (Female, IDI, GAR).
“We have leaders in this community so they can be tasked to identify these people who are poor because they know them and after that the government should send someone in the form of a CID (Criminal Investigating Department) officer to confirm that the people selected are really poor, because some people may be left out if you ask just anybody to do the selection. This could lead to selecting those who are not poor rather to benefit from the support” (Male, IDI, GAR).
“The assembly men and women in the sub-districts know their people and they are in contact with them even though we have community health nurses who go for home visits and outreaches they could reach out to them but those will be very few. The assembly man is from the town and stays with them, he is therefore in a better position to identify the poor people. So we could contact the assembly men to help identify the poor and register them for free” (36 years midwife, IDI, BA).
“…the hospital is one of the places you can use to identify the poor because they cannot afford to pay the hospital bill after treatment. They cannot even buy food when they have been admitted in the hospital” (Female, FGD, NR).
Table 3 presents a summary of community strategies participants identified as means of identifying the poor across the three study sites.
Table 3
Community strategies for identifying poor proposed by respondents
Region
|
Community Strategies to Identify the poor
|
Brong Ahafo
|
• Use of community leaders (chiefs and assembly members)
• Use of religious leaders
• House to house Identification
• Use of Social Welfare Officers
• Use of Health facilities (attendees who are unable to pay for care they received).
|
Greater Region
|
• Community leaders (chiefs and assembly members)
• Use of religious leaders.
|
Northern Region
|
• Use community leaders
• Use of religious leaders
• House to house identification
• Use of social welfare officers
• Attendees who are unable to pay for the care they have received.
|
Reasons For Low Nhis Enrolment And Low Renewals
Both IDI and FGD participants acknowledged the importance of the NHIS in increasing access to health care. Participants cited poverty and cost of treatment as some of the reasons for registering. However, some participants did not renew their membership. Some participants were also of the view that people with NHIS were given poor quality of service when they attended health care facilities or were still made to pay for the services even when they had active cards.
“What I have to say is that the reason why people are not enrolling is that when you use the card all you get as drug is paracetamol, sometimes even paracetamol that cost 1 cedi 50 pesewas (US$0.20) you will be told that it’s not covered” (Male, FGD, GAR).
“When you have the card and go to hospital, you will be told that this drug is not there or is not covered by the insurance. So many of us do not register or renew the card because of that. If they want people to register or renew their card, it should cover all medicines and sickness” (Female, FGD, NR).
“There is a discrimination between those who have the insurance and those who don’t have the insurance. Those with insurance are packed aside and then priority is given to those who have money to pay. The doctors do not even pay attention to you when you go there with a condition. A child can be rushed to the hospital with high temperature but they won’t even bother to attend to the child. So if you want better health care and proper medicine you go without the card” (Male, FGD, BA)
Despite this, health workers who participated in this study did not agree that they provided differential services to insured and non-insured clients. All clients go through the normal procedure in the health facility and are provided with client-specific health care.
“When the person comes and is an insured client, she will go through the normal procedure and goes away without any charge except that the person will need some drugs that we don’t have at our end and we will write and the person will go and buy it outside. Other than that if the person is having the insurance and we have everything, then the person will go through the process from beginning till he goes away without any further charge. But for the non-insured, they will also go through the normal process but will be billed and will have to pay before taking their drugs then they go” (Midwife, BA)
Another reason for non-renewal was the challenges involved in the process. Apart from the renewal centres located far away from the community, the process is also characterized by delays. To get a card renewed will require spending several hours at registration centres and in some instance one will have to go to renewal centres several times before being served. The following support these points:
“I am registered because with the card you get free treatment at the hospital when you are sick. If you are poor and you don’t register then you will struggle to pay hospital bill. So the insurance is good for everybody especially the poor but renewal is the problem, you have to travel far to the centre for renewal. The last time, I have to go there three times before they could renew my card” (Male, IDI, NR).
Livelihood Empowerment Against Poverty (leap) For Enrolling The Poor
Interviewees were aware of the existence of LEAP in the community and indicated that it was a useful intervention in reducing poverty in the country. The following quotes support these points:
“The LEAP money helps us a lot because I have two children in school and I use some of the money to pay for their fees and use the rest to care for the family. I have used the rest of the money to buy fowl and if I am out of money, I could sell one and use the money for something” (Female, IDI, BA).
“We have LEAP in this community and is very useful. I know people who are benefiting from it and it is helping them a lot” (Female, FGD, NR)
However, there was a general belief that it has been politicized and only people who are sympathizers of the ruling government are selected to benefit from such programme. In a response to a question on knowledge about LEAP in the community, an IDI participant stated the following in the Northern region of Ghana:
“There is LEAP in this community but it has been politicized. When they came, they only sent it to communities that have party faithful and they are benefiting from it. It was when they called the assemblyman that the LEAP team will be coming to pay beneficiaries in one town that I got to know about the LEAP programme and the beneficiaries here. It angered other community members that they are not benefiting from the LEAP programme but I explained that it will get to their turn” (IDI AS.)
During the FGDs in Brong Ahafo region, participants also generally agreed that LEAP has been politicized and many beneficiaries are actually not poor. They advocated for the use of chiefs to distribute such welfare schemes for the community in future as illustrated:
“Like my brother said if there is such help it should not be passed through politician but rather the chiefs who will get opinion leaders to assist them identify and distribute the money. This will help but as for our politicians they look out for their political interest and select their party members, so it should be through the chiefs who will select opinion leaders to help identity the poor” (Male, FGD).
The selection of beneficiary districts and communities is often based on criteria which has items such as the level of poverty in the community based on the Ghana poverty map, access to health care and schools in the community. The following quotes from participants indicates how districts and communities are selected for LEAP:
“In fact doing the selection exercise here, a team from Accra met with the municipal implementation team and the criteria they considered was for communities that are most vulnerable, then accessibility to health facilities and accessibility of schools and other social amenities and those were the criteria used in selecting the communities” (Social Development Officer, IDI, BA).
People who are above 65 years without any help, orphans, people with disability and pregnant women with children under one year are automatic beneficiaries of LEAP. Selected beneficiaries are verified in the community before disbursements are made to them.
“In fact the categories are the aged who are 65 years and above without any support and the severely disabled without means of livelihood and orphans and vulnerable children, pregnant woman and those with children under 1 year. These are the criteria for selection on to the LEAP” (Social Worker, IDI, BA).
“….We collect information from collateral source before we get to the homes to elicit from them whether actually they are poor. When you pay visit to a place and then you ask collateral sources around then you go into the household you see some of the characteristics. And then we try to also look at our criteria and fit it in and see whether it will merit him or her. We don’t just pick people often; we have to go through certain criteria. We need to go through certain things to justify that this man when they say he is poor he is poor” (Social Development Officer, NR)
Nonetheless, participants generally were of the view that the process of selection of beneficiaries was not transparent as it is deemed to be politicized. Hence, only people who have political inclination to the incumbent government get selected. This process to them creates a situation where many poor people in the community are left out whilst others who in their opinion are not qualified to benefit get selected.
“We were asked to come and write our names and that the government was going to support the poor and needy but when the support came, we the poor and needy were not added to the list. You rather see people who are strong and healthy enjoying the package. I know a woman whose husband had died and no help coming from anyone but she doesn’t get the government package. There is community here where the assemblyman is beneficiary of LEAP. She is strong and working” (Female, FGD, BA).
“The process is not transparent at all. In my community they came and took the names and when they came back to distribute the money, some names were dropped from the list. We have people who live in this community who are very poor and yet they were not given anything. But others who are better were rather given the money” (Male, FGD, NR).
“Truly, when the registration for LEAP was on going they told us they were registering old persons and poor people. Two old women in my household registered including some young ladies from other households. But when the date was due for them to come for their monthly monies the names of the two old ladies were omitted, while, the young ladies had theirs” (Male, FGD, GAR).
Some assembly members interviewed also alluded to the fact that the selection criteria are not transparent enough and community leaders are not involved in the process. For example, an assemblyman in the Brong Ahafo Region had this to say in an interview:
“Yes we have some of the LEAP in this community, when it came we heard the information and we gathered the people but the category for selection is not known to any assembly member and even when it’s time to pay them no assembly member or committee member is in the known so we don’t even know the schedule of payment and the time they come neither do we know how much they are given” (Assemblyman, IDI, BA)
Participants were of the view that involving more community leaders could improve the process of selecting beneficiaries and make the process more transparent. Also, community sensitization on the process and selection criteria could help disabuse the belief about the politicization of the process and enhance transparency.
“The public should know and be informed about the activities and processes. The chief and opinion leaders should know so they could get the whole community members informed. Once the announcement is done, it will make everyone aware of the process and all the people involved can benefit from the process so that it will not be given to just some selected few in the community” (Male, IDI, BA).
“There is need to educate community members about the process of selecting the people and involve the chiefs and opinion leaders. In doing that people will see the process more transparent than what they do now. Just come to write names and return with few names as beneficiaries. That is why people think it is given to only party members” (Male, FGD, NR).
“We do partner with the social welfare and then enroll the poor onto the scheme. Social welfare has identified these poor people through the LEAP and we are also able to enroll them free of charge into NHIS” (Male NHIS staff, IDI, NR).
“…. Yes, the monthly thing [LEAP] there are conditions attached to it. The conditions are that people living within the LEAP catchment households should not allow their children to be trafficked. They shouldn’t allow their children to go to Kayayei, children of school going age should be sent to school and then pregnant women should attend ante natal and post-natal care” (Social Development Officer, IDI, NR).
“We get this list from LEAP and also use that to enroll them into NHIS for free. All LEAP beneficiaries also get registered for free” (NHIS worker, IDI, BA).