Study area
The study was conducted in the Kintampo North Municipality of the Bono East Region, Ghana West Africa.
Study Design
This was a municipality-based descriptive cross-sectional study that employed quantitative data collection methods. Participants were recruited within a duration of 12 weeks in the Kintampo North Municipality.
Study Population
The population under study comprised healthcare workers within the Kintampo North Municipality who were in active service. A total of three hundred and Ninty-Seven participants were interviewed.
Inclusion and Exclusion Criteria
All healthcare workers within the Kintampo North Municipality who were in active service were given equal opportunity to participate in the study. Healthcare workers who were on retirement, those doing their national service, students on industrial/clinical attachments were not recruited to participate in the study. Healthcare providers who met the inclusion criteria but were unwilling to participate were excluded from the study.
Sample Size Estimation, Sampling Technique and Procedure
The sample size was estimated using Yamane’s formula of sample size estimation [12], with a confidence interval of 95% and margin of error of 5%. The municipality had an estimated total healthcare providers of 1061. The final sample size was estimated as 320 including a 10% non-response rate. Eventually, a total of 397 healthcare workers were recruited during the data collection period using google forms from October, 2021 to December, 2021. Proportionate stratified sampling technique was used to organize participants into two strata, Mechanized staff (849) and casual staff (212). In the second stage, portions of the sample size were allocated to the two categories based on their ratio to the total staff population (mechanized staff = 256 and casual staff = 64). In the final stage of the technique, a link to the google form questionnaire was sent to the WhatsApp platforms of each stratum. The first 397 entries by end of 31st December, 2021 midnight were used for the study.
Data Collection Tools and Procedures
The data was gathered using a structured questionnaire. The questionnaire was designed based on the objectives of the study to elicit information from the participants. The questionnaire was segmented into sections A and B. Whilst the Section A composed of the socio-economic and demographic characteristics of respondents, Section B consisted of the proportion of respondents with valid NHIS membership cards. The questionnaire was piloted among 15 healthcare workers in the Kintampo South District which shares geological boundary with the study setting and has similar socio-economic and demographic characteristics as those in the study setting. This was to ensure the reliability and consistency of the instrument. The appropriate corrections were effected before the actual data collection was carried out on the study participants. The questionnaire was digitized and shared on WhatsApp platforms made of only the study participants (healthcare workers in the Kintampo North Municipality). The digitized questionnaire was restricted in such a way that multiple responses from the same device were not allowed.
Statistical Analysis
Data was entered, cleaned and managed using Microsoft excel version 16. The data was later exported to Stata version 15 and analyzed. Gender, religion, marital status, educational level were coded as categorical variables. Age was collected as continuous variable and categorized during analysis. Descriptive statistics were used to present the proportions on background characteristics of the respondents at the univariate level. Binary and multiple logistic analysis were performed to establish the strength of associations between socio-demographic and socio-economic factors influencing the nonrenewal of NHIS membership. All variables with p-value <0.25 at the bivariate analysis level were selected and put into a multiple logistic regression analysis model for statistical significance (p-value < 0.05). Odds ratio with their corresponding 95% Confidence Interval were reported. A p-value < 0.05 was set as level of significance.
Demographic Characteristics of Respondents
The study surveyed 397 healthcare workers in the Kintampo North Municipality to assess the determinants of nonrenewal of the National Health Insurance Membership card. The demographic characteristics are presented in Table 1. The minimum age of the respondents was 20 years whiles the maximum age was 48years. The mean age of the healthcare workers was 31.3±4.7 years. The median age of these healthcare workers in the study was 30 years. Majority of the healthcare workers (51.9) were in age group 30-39 years, 42.1% were in age group 20-29 years while 6.0% were in age group 40-49 years. In terms of sex, the healthcare workers were approximately equally distributed with the females (52.1%) slightly edging out the men (47.9%). More than half of the healthcare workers (75.3%) were Christians. Majority of the healthcare workers (98.5%) reported having attended school before. The healthcare workers were of varying educational levels. Only 1.5% of the healthcare workers had no formal education. Majority of them (96.0%) had tertiary education. More than half of the healthcare workers (48.9%) were married while 1.5% were divorced (Table 1).
Table 1: Demographic characteristics of respondents
Variables
|
Frequency
|
Percentage
|
Age group
|
|
|
20-29
|
167
|
42.1
|
30-39
|
206
|
51.9
|
40-49
|
24
|
6.0
|
|
|
|
Sex
|
|
|
Female
|
207
|
52.1
|
Male
|
190
|
47.9
|
|
|
|
Level of education
|
|
|
No formal education
|
6
|
1.5
|
SHS
|
10
|
2.5
|
Tertiary
|
381
|
96.0
|
|
|
|
Religion
|
|
|
Christianity
|
299
|
75.3
|
Islam
|
79
|
19.9
|
Traditional
|
19
|
4.8
|
|
|
|
Marital status
|
|
|
Single
|
159
|
40.0
|
Married
|
194
|
48.9
|
Co-habitation
|
38
|
9.6
|
Divorced
|
6
|
1.5
|
Socioeconomic characteristics of respondents
Most of the healthcare workers (98.5%) had a form of a certificate. About half of the healthcare workers (46.3%) have diploma. Some of the healthcare workers (1.5%) did not have any form of qualification at all. Most of the healthcare workers (82.9%) were mechanized. Majority of the healthcare workers (75.3%) were clinical staff. Most of them (40.1%) had worked for 3-7 years only. Majority of the healthcare workers 41.6% earn at least 2000 Ghana Cedis while 2.6% of them earn less than 500 Ghana Cedis on monthly basis (Table 2)
Table 2: Socioeconomic characteristics of respondents
Variables
|
Frequency
|
Percentage
|
Qualification
|
|
|
None
|
6
|
1.5
|
Certificate
|
66
|
16.6
|
Diploma
|
184
|
46.3
|
Undergraduate
|
90
|
22.7
|
Postgraduate
|
51
|
12.9
|
|
|
|
Employment status
|
|
|
Casual
|
68
|
17.1
|
Mechanized
|
329
|
82.9
|
|
|
|
Category of health staff
|
|
|
Clinical staff
|
299
|
75.31
|
Non-Clinical Staff
|
98
|
24.69
|
|
|
|
Working experience
|
|
|
< 3 years
|
101
|
25.4
|
3 -7 years
|
159
|
40.1
|
8 years and above
|
137
|
34.5
|
|
|
|
How much do you earn monthly
|
|
|
<500
|
14
|
3.6
|
500-999
|
23
|
5.9
|
1000-1499
|
77
|
19.9
|
1500-1999
|
112
|
29.0
|
>2000
|
161
|
41.6
|
Proportion of respondents with valid NHIS membership cards
The proportion of respondents who were willing to renew their NHIS membership upon expiration was 81.9% [(95%CI = 77.5 - 85.1)] (Figure 1).
Most healthcare workers in this study 94.0% had NHIS membership card. Out of these, majority 70.7% had a valid NHIS membership card. Most of the healthcare workers (40.0%) with expired NHIS membership card did not renew their membership for at least 7 months while 24.4% of them had their cards expired between 0-3 months and 4-6 months respectively
(Table 3).
Table 3: NHIS membership
Variables
|
Frequency
|
Percentage
|
Do you have NHIS membership card?
|
|
|
No
|
24
|
6.0
|
Yes
|
373
|
94.0
|
|
|
|
If "Yes" to question 13, is your NHIS membership card valid?
|
|
|
Maybe
|
64
|
17.2
|
No
|
45
|
12.1
|
Yes
|
263
|
70.7
|
|
|
|
If "No" to question 14, how long has your NHIS membership card expired?
|
|
|
0 - 3 months
|
11
|
24.4
|
4 - 6 months
|
11
|
24.4
|
7 months and above
|
18
|
40.0
|
Don’t know
|
5
|
11.1
|
Barriers to renewal of NHIS membership
When asked about factors that prevented healthcare workers from renewing their membership, 212 (19.8%) indicated forgetfulness as the reason why they did not renew their NHIS membership. Those who could not renew their membership due to busy schedules were 191 (17.9%) while 4.5% of the healthcare workers did not renew their NHIS membership card because they preferred spiritual homes to attending a healthcare facility. Details are as shown figure 2.
Motivators for the renewal of NHIS membership
When quizzed about what should be done to encourage healthcare workers to renew their NHIS membership cards on time, it was observed that 271 (29.0%) expressed that strict measures should be put in place to stop self-medication. About a quarter of the healthcare workers were of the opinion that more institutional NHIS offices should be created so that members can easily renew their membership when it expires. Some of the healthcare (8.7%) workers were of the view that membership renewal should be deducted at source (Figure 3).
Demographic factors influencing the nonrenewal of health insurance membership
Multiple logistic regression analysis was performed on all variables with p-value < 0.25 at 95% confidence interval. Adjusted odds ratio showed that level of education, religious affiliation of healthcare workers and their marital status were significant predictors of nonrenewal of health insurance membership in the Kintampo North Municipality. Healthcare workers who have attained tertiary education were 5 times more likely not to renew their NHIS memberships compared to those without a formal education. Also the healthcare workers who were affiliated to Christianity were 2.8 times likely not to renew their expired NHIS membership card compared to the traditional believers. Those who were divorced were 0.076 times likely not to renew their expired NHIS membership cards compared to those who were single. All other demographic characteristics were not significantly associated to nonrenewal of expired NHIS membership card (Table 4).
Table 4: Demographic factors influencing the nonrenewal of health insurance membership
Variables
|
Binary logistic regression
|
Multiple logistic regression
|
|
cOR
|
95% CI
|
p-value
|
aOR
|
95% CI
|
p-value
|
Age
|
|
|
|
|
|
|
20-29
|
Ref
|
|
|
Ref
|
|
|
30-39
|
1.089
|
0.648 - 1.829
|
0.748
|
0.832
|
0.456 - 1.518
|
0.548
|
40-49
|
2.709
|
0.606 - 12.102
|
0.192
|
4.595
|
0.702 - 30.085
|
0.112
|
|
|
|
|
|
|
|
Sex
|
|
|
|
|
|
|
Female
|
Ref
|
|
|
Ref
|
|
|
Mae
|
0.711
|
0.427 - 1.184
|
0.19
|
0.627
|
0.361 - 1.086
|
0.096
|
|
|
|
|
|
|
|
Level of education
|
|
|
|
|
|
|
No formal education
|
Ref
|
|
|
Ref
|
|
|
SHS
|
0.667
|
0.087 - 5.127
|
0.697
|
0.574
|
0.07 - 4.685
|
0.605
|
Tertiary
|
4.953
|
0.978 - 25.096
|
0.053
|
5.616
|
1.049 - 30.069
|
0.044*
|
|
|
|
|
|
|
|
Religion
|
|
|
|
|
|
|
Traditional
|
Ref
|
|
|
Ref
|
|
|
Christianity
|
2.905
|
1.090 - 7.743
|
0.033*
|
2.875
|
1.026 - 8.056
|
0.045*
|
Islam
|
2.297
|
0.779 - 6.775
|
0.132
|
2.719
|
0.864 - 8.556
|
0.087
|
|
|
|
|
|
|
|
Marital status
|
|
|
|
|
|
|
Single
|
Ref
|
|
|
Ref
|
|
|
Married
|
1.436
|
0.820 - 2.515
|
0.206
|
1.194
|
0.636 - 2.244
|
0.581
|
Co-habitation
|
0.594
|
0.266 - 1.327
|
0.204
|
0.609
|
0.258 - 1.435
|
0.257
|
Divorced
|
0.242
|
0.047 - 1.258
|
0.092
|
0.076
|
0.011 - 0.555
|
0.011*
|
*Significance (p<0.05)
Socioeconomic factors influencing the nonrenewal of health insurance membership
All the socio-demographic factors were statistically significant at the bivariate level (p<0.05). However, employment status, category of health staff monthly salary lost their significance in the multiple logistic regression model. After adjusting for other variables in the multiple logistic regression model, there was 8.4 folds increased odds of NHIS nonrenewal among postgraduate participants compared to those without formal education (aOR = 8.419, 95% CI = 1.037 - 68.327). With all other socio-demographic factors controlled for, those with working experience of at least 8 years were 63.6% less likely to renew their health insurance membership compared those who have worked for less than 3 years (aOR = 0.36, 95% CI = 0.153 - 0.868). All other factors that were not statistically adjusted were not significant after adjusting (Table 5).
Table 5: Socioeconomic factors influencing the nonrenewal of health insurance membership
Variables
|
Binary logistic regression
|
Multiple logistic regression
|
|
cOR
|
95% CI
|
p-value
|
aOR
|
95% CI
|
p-value
|
Qualification
|
|
|
|
|
|
|
None
|
Ref
|
|
|
Ref
|
|
|
Certificate
|
11.2
|
1.804 - 69.532
|
0.01*
|
5.52
|
0.804 - 37.902
|
0.082
|
Diploma
|
7.436
|
1.313 - 42.103
|
0.023*
|
3.44
|
0.522 - 22.67
|
0.199
|
Undergraduate
|
11.846
|
1.966 - 71.396
|
0.007*
|
7.024
|
0.96 - 51.385
|
0.055
|
Postgraduate
|
12.571
|
1.927 - 82.01
|
0.008*
|
8.419
|
1.037 - 68.327
|
0.046*
|
|
|
|
|
|
|
|
Employment status
|
|
|
|
|
|
|
Casual
|
Ref
|
|
|
Ref
|
|
|
Mechanized
|
2.17
|
1.192 - 3.949
|
0.011*
|
1.888
|
0.765 - 4.655
|
0.168
|
|
|
|
|
|
|
|
Category of health staff
|
|
|
|
|
|
|
Non-clinical staff
|
Ref
|
|
|
Ref
|
|
|
Clinical staff
|
1.791
|
1.034 - 3.101
|
0.038*
|
1.062
|
0.508 - 2.221
|
0.872
|
|
|
|
|
|
|
|
Working experience
|
|
|
|
|
|
|
< 3 years
|
Ref
|
|
|
Ref
|
|
|
3 -7 years
|
0.375
|
0.177 - 0.796
|
0.011*
|
0.351
|
0.157 - 0.784
|
0.011*
|
8 years and above
|
0.448
|
0.206 - .974
|
0.043*
|
0.364
|
0.153 - 0.868
|
0.023*
|
|
|
|
|
|
|
|
How much do you earn monthly
|
|
|
|
|
|
|
<500
|
Ref
|
|
|
Ref
|
|
|
500-999
|
2.7
|
0.633 - 11.509
|
0.179
|
3.563
|
0.718 - 17.668
|
0.120
|
1000-1499
|
3.375
|
1.01 - 11.279
|
0.048*
|
2.579
|
0.574 - 11.591
|
0.217
|
1500-1999
|
3.917
|
1.213 - 12.651
|
0.022*
|
3.12
|
0.691 - 14.084
|
0.139
|
>2000
|
3.275
|
1.058 - 10.142
|
0.04*
|
1.763
|
0.358 - 8.677
|
0.486
|
*Significance (p<0.05)