A total of 13 IDIs were conducted with technical experts and 17 FGDs in groups of 6 participants on average, comprising a total of 96 informal workers from three selected communities each within Kumasi and Accra metropolis. Table 1 summarizes the characteristics of the participants. Among the 13 experts interviewed, only three were females, the mean age was 48 years, and 6 of them were managers in their respective units.
Of the 96 participants in the FGDs, 50 were from the Kumasi metropolis, 53 were males, and they had on average four dependent individuals. Most of the participants, 86 had ever registered for the NHIS, of which 33 were inactive and 3 were unsure (active or inactive) of the state of their current insurance status.
Table 1. Participants’ main characteristics
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Technical experts
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(n=13)
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Age, (in years) mean (range)
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48 (40 - 59)
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Gender
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Male
Female
|
10
3
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Years working in the institution, mean (range)
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12 (0.8 - 29)
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Role
|
|
Director
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4
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Deputy director
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3
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Manager
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6
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Informal workers
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Place of residence
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Accra (n=46)
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Kumasi (n=50)
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Total (n=96)
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Age, (in years) mean (range)
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39.5, (19 - 68)
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39. 4, (18 - 66)
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39.3 (18-68)
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Gender
|
|
|
|
Male
|
22
|
31
|
53
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Female
|
24
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19
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43
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Number of dependents mean (range)
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3.4 (0-30)
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4.8 (0-20)
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4.1 (0-30)
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Insurance status
|
|
|
|
Active
|
24
|
26
|
50
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Inactive
|
12
|
21
|
33
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Unsure (Don’t know)
|
2
|
1
|
3
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Non - registered
|
8
|
2
|
10
|
Perceived Benefits of MRS
Both users of MRS among informal workers and the technical experts included in the study perceived two major benefits created by the MRS. The first was improved convenience to renew NHIS membership, which in turn has increased the renewal rates. Convenience includes a simpler and more efficient renewal process, that is constantly available to individuals. It has improved access to renewal by reducing travel costs and waiting time.
"Formerly we used to travel long distances and queue at the various registration centres for renewal and new registration. With the introduction of the phone renewal approach, you can sit in the comfort of your home and do it without any stress." (FGD-Anloga)
Renewing a NHIS card has been made easy and less expensive. You don’t have to travel and pay transportation fares to and from any of the NHIS district offices to have your insurance renewed. You can do it wherever you are without hassle. The NHIA has seen an increase in renewals year in, year out”. (IDI- 012E)
The technical experts, particularly from the NHIA, reported a second benefit related to higher satisfaction with their daily work, as the workload has decreased and their offices are less crowded, as stated by a technical expert:
“… unlike before, you found people crowded and struggling to get their cards renewed for them. Now it’s easy, you can renew in the comfort of your home. So, there is no congestion in our offices” (IDI-004I)
Perspectives on enhancing the Mobile Renewal System through add-ons
Three major themes were identified regarding enhancing the MRS through add-ons (see Figure 1): (1) add-on-related factors, (2) institutional factors, and (3) individual factors that may facilitate or hinder the implementation and the use of the MRS and potential add-ons.
Figure 1. Overview of the themes, and categories identified from the data analysis
Add-on related factors
During the discussions, many ideas for add-ons to the MRS were raised by the participants, which potentially promote the NHIS uptake and renewal rates. In addition, the research group asked for participants’ opinions on a savings wallet as an add-on to facilitate savings for the NHIS renewal. This section presents the add-ons suggested and participants’ perspectives on their usefulness, along with reasons for adopting and using them.
The function of the add-on
Add-on(s) identified during the interviews and focus group discussions include reminders for the expiry date and the need to renew, mobile registration (currently not possible digitally), automatic renewal of NHIS policy, a savings wallet to save and pay your renewal premiums, and a facility locator.
Reminders
Before the introduction of the MRS, the insurance period on subscribers’ NHIS cards was updated with every annual renewal – i.e. they provided cards with printed start and expiry dates, which served as a reminder of the renewal period. After the introduction of the MRS, subscribers have no NHIS hard copy anymore, thus no printed reminder of their card’s expiry date. Therefore, it is more difficult for subscribers to know the expiry date and to remember to renew the insurance. One must make an active effort to check the insurance expiry date by following the prompts after dialing a (USSD) code. Usually, individuals find out that their insurance has expired only at the point of seeking healthcare service. While the MRS facilitates the procedure of insurance renewal, its digital nature hinders a timely renewal, as subscribers cannot know the expiry date easily.
“… the date for the renewal escapes us [subscribers] because it is not available when you use the phone to renew your insurance. (FGD-Anloga).
Participants strongly supported the introduction of NHIS renewal reminders under the MRS to facilitate continued active coverage. Participants suggested sending them a simple and clear SMS or voice message in their local dialect when the expiration date is approaching, to remind them in time to renew their health insurance. A participant from Nima stated:
“So, they should remind us by sending us a message that by this date our insurance will expire. That can help a lot of us to renew on time. “(FGD – Nima)
Mobile registration
Currently, first-time registrants must visit the NHIA office in person, take a picture, and provide socio-demographic information such as name, date of birth, marital status, phone number, and community of residence to become a member. First-time registrants face the same access barriers to registering for the NHIS as those renewing it in person. Participants proposed that this first-time registration could be done remotely through a mobile device, like the MRS. This feature would have the same advantages as the MRS, namely convenience and saving travel time and costs. This could increase the enrollment of the insurance.
“… you would want people who don't have cards, who have never joined the NHIA. You want them to also have a very easy and convenient way, just like the renewal, to come on as first-time registrants to do the registration on the phone.” (IDI- 005I)
Automatic Renewal
Participants who are technologically illiterate or have challenges with literacy reported difficulties in renewing their NHIS with the MRS on their own, hence they depend on others to get it renewed. Participants suggested that the implementation of an automated NHIS renewal process could further simplify the process. After the reminder aforementioned would be sent, with the subscriber’s consent, the premium amount will be directly deducted from their MoMo account for the policy to be renewed automatically.
“ If you have money in your Momo account there should be an automatic renewal something that will automatically “kick in”, so that will remove the “human factor” and the problem with “I don’t know how to do it” will be a thing of the past” (IDI- 007E)
Savings wallet
Participants mentioned that a savings wallet add-on to the current MRS could be useful to low-income earners, as this may help them save for the NHIS renewal or allow friends and relatives to contribute to a timely renewal. Nevertheless, many participants perceived the NHIS premium to be affordable for subscribers and argued that it does not present a financial barrier to renewal, making such a wallet unnecessary.
“Our premiums are quite low. People pay as low as 22 cedis. And this is not an amount that I will see people trying to save towards” (IDI- 001I)
NHIS Facility Locator
An add-on that can locate and direct subscribers to NHIS-accredited facilities such as a pharmacy or a hospital within their communities may indirectly promote the use of the MRS. When the range of possible providers that can be accessed becomes more visible, the NHIS might be perceived as more useful and more worth being enrolled in. A participant explained that:
“A feature that would direct me to all the NHIS-accredited providers within a radius … of your locality. … like NHIS accredited pharmacies where I can just walk to … and then I'll get the medicine for, for free” (IDI- 001I)
Characteristics of the add-on
Beyond the add-ons, the participants mentioned that MRS and add-ons should have some characteristics such as data protection and transparency as well as a user-centered design to facilitate the adoption and use of the MRS and add-ons.
Data protection and transparency
Participants raised concerns about safeguarding their details and sensitive information, such as names, addresses, financial records, and other private data after subscribing to digital platforms. It was considered important to protect users' information from unauthorized access by scammers which may result in identity theft and financial fraud. This was seen as particularly relevant for tools that entail engaging in digital transactions, such as online purchases, banking, MoMo transactions, or any electronic interactions that involve the exchange of sensitive information.
Participants reported that clear and transparent communication regarding how their data is collected, processed, stored, and shared by mobile transaction apps, companies, and the government may enhance users' likelihood of adopting and utilizing digital platforms. Participants emphasized the importance of being kept informed about any transactions on mobile insurance renewals and savings. Receiving information from NHIA felt empowering, as it allowed participants to have a sense of control over their personal information and savings. Transparent communication and documentation were considered important to increase users' trust and confidence in the use of the MRS and could influence the adoption of the add-ons. As participants stated:
“Give them [users] receipts through text messages that ‘you have this amount in there’. This may help people to decide to use it if they believe that there is no “kuululu” [fraudulent activities] anywhere”. (IDI- 004I)
“They should put more security in such a way that no one can use either your insurance card number or any information from the insurance card to withdraw your money or use your money”. (FGD -Moshie Zongo)
User-centered design
Participants reported difficulties when attempting to complete the renewal procedure on their own, including the inability to read and understand the instructions and not being acquainted with the use of mobile phones. Therefore, the MRS and add-ons should be user-friendly and simple for those not experienced with the use of mobile phones.
The idea to change it into a smart-phone app to enrich user experience was welcomed, but participants were quick to suggest that developers should maintain the USSD form of the existing MRS, which works on all kinds of phones including non-smartphones [yam phones] and upgrade it with additional functionalities to make it simple and easy for subscribers to use. Arguments considered that this ensures that the MRS is not restricted to only a few with smartphones and access to an internet connection.
"What this brings to mind is internet issues, the development should be done for everybody to be able to use. Meaning it can be done as an App requiring the internet and smartphones. We should also consider the other group of people in rural areas with poor internet connectivity and probably have a “Yam phone” [non-smart phone]. So, we should not restrict it, it should be usable on both USSD and App." (IDI- 008E)
“The system should be simple and easier for people to follow. Should be concise and easy for everyone whether you are well-educated or not, so that you can do it yourself”. (FGD- Nima)
Institutional factors
Participants mentioned institutional factors that may promote or hinder the use of the MRS and the add-on(s). These included stakeholder involvement, funding, policy and regulation, and available user support.
Stakeholder involvement
To ensure that an acceptable intervention is developed, stakeholders, informal workers, and technical experts were engaged to gather inputs and feedback on the use of MRS. This inclusive approach allows those designing interventions to understand the needs of people, identify ways to address those needs and ensure that the interventions (solutions) are developed to meet their needs. This could further promote ownership and utilization by potential users. A participant explained:
" It’s not just you designing the program. You need to seek the opinion from the users and other relevant institutions for their inputs, then after development test it out to make sure that it is an acceptable product to them" (IDI- 002I)
Funding
To ensure the success of such new add-on(s), it is important to allocate enough funds to the tool and ensure financial stability by including the add-on to the national funding schemes and using long-term contracts. Financial security enables long-term planning of all necessary activities such as organizing meetings and community engagements with technical experts, implementors, and potential users. Moreover, it enables awareness-raising campaigns after deploying the add-ons among end-users. These activities were perceived as costly and critical milestones necessary to ensure that a successful, appropriate, and acceptable add-on(s) is developed. It was therefore not surprising that participants identified the availability of funding for the development and implementation of the add-on as one of the key factors that may guarantee their success. This is how a participant shares his view:
“… it all depends on who is funding the project [the add-on tool(s) development], and how deep the person's pocket is, if funding is available, I think, 80% of the challenges will be solved, the rest is people" (IDI- 002I)
This implies that stakeholders in this study perceive funding challenges as major obstacles to the development and implementation of the add-ons.
Adequate network and technological infrastructure
Participants perceived mobile-phone network failure as one of the main barriers to the use of the MRS, which, if not resolved, could also hinder the adoption and use of add-ons. A participant lamented:
“Clearly it [the problem] is the networking issues. It can be very annoying and time- consuming. There are times you must do it over and over, I mean repeatedly. The poor network is the main problem they need to work on, or it will affect the use of MRS and any mobile technology” (IDI- 013 E)
In that same vein, participants also noted that the smooth functioning of mobile technology operations relies heavily on the presence of a strong and reliable database server to store, process, and transfer information. Implementing an add-on(s) might require expanding the technological infrastructure to accommodate the increased workload due to the introduction of the add-on(s). This is to improve internet stability and avoid delayed response or feedback on transactions and or the renewal processes. Participants expressed that upgrades and or expansion of technological infrastructure are key to ensuring a seamless renewal process.
"Again, for the implementation stage, do we have the needed resources in place infrastructure-wise, if there is the need to expand, we should do that to avoid interruptions of workflow.” (IDI- 008E
Capacity building for NHIS workers and availability of support for add-on users
The participants highlighted the significance of having information technology (IT) experts who can develop the add-on tool and provide regular maintenance services. These experts should further train the NHIA staff to understand the functioning of the system. This could empower the NHIA staff to help users with challenges such as delayed feedback on renewal status or incorrect deductions. Offering this assistance has the potential to improve user satisfaction and encourage the utilization of the MRS and the adoption of the add-ons. Participants explained that:
“Involving IT experts is very crucial; their role is very important in developing as well as maintaining the intervention. Our guys, I mean the MIS (Management Information Systems ) team is good, and I know they can support” (IDI-06I)
" When people have challenges (using the add-on), where do they seek help or solution and whom do they call? I think the service providers should first train their staff on the use of the system or interventions and they should have a call center available 24/7 where users with challenges can have some assistance" (IDI- 002I)
Unfamiliarity with mobile-phone-based tools or difficulties operating a mobile transaction can be resolved by disseminating clear guidance on how to use it, creating awareness, and teaching potential users of the existence, usefulness, and how to use the MRS and the add-on(s). Learning how to renew the NHIS policy may boost an individual’s confidence and increase their willingness to use the MRS and any add-on(s).
"They have to make a lot of noise in terms of awareness about the intervention. They must visit people in their homes, and marketplaces to teach them how to use it step by step to help them use the tool"(IDI013E).
Policy and Regulation
Obtaining approvals from regulatory bodies for the implementation of the intervention, particularly, the savings wallet, was deemed a significant factor among most technical experts. Concerns were raised on the legal and practical ability of a public agency to collect and store the NHIS premiums.
“Collecting money from clients is a source of public funds. Is the money being held by NHIA or where is the money being kept? There should be a policy implication, so maybe a change of, uh, law or something. You can't just go ahead and implement. And the policy should link with maybe, um, financial administrative Act”. (IDI- 003I)
Individual factors
Individual factors that may promote or hinder the use of the MRS or add-ons identified include experience with mobile phone transactions, insurance literacy, having responsibility over dependents such as children or parents, and taxation.
Experience with mobile phone use and transactions.
Experience with mobile phone transactions can be a facilitator or barrier to the use of new interventions, depending on whether the experience was positive or negative. A positive experience such as having access to a mobile phone and competency in its use may positively influence the individual’s intention to adopt and use an add-on. Familiarity with other mobile phone platforms for transactions such as MoMo reduces potential concerns or hesitancy to use the MRS and add-ons. As one technical expert captured the common perspective among participants:
“If I can use my phone for other purposes like sending messages, transferring money from my MoMo account, once I already know how to use the phone, it will help me to use the new intervention” (IDI- 005I)
Likewise, past negative experiences such as having fallen victim to mobile payment fraud, reduced trust in adopting any form of digital payment such as the savings wallet. Trust plays a significant role when it comes to digital payment adoption and use, as expressed by a technical expert:
“If you’ve ever been a victim of mobile money fraud, that alone is enough to prevent you from trusting such initiative [saving wallet]. Experience with fraudsters will deter people from using it” (IDI- 010E)
Insurance literacy
Insurance literacy includes understanding the role of insurance in spreading the risk of the cost of illness over time and across people. Participants perceived that good insurance literacy is an important factor that may increase subscribers’ willingness to keep their NHIS active and utilize the MRS and add-ons. This is how a technical expert expressed the role of insurance literacy in the willingness to renew NHIS:
" … Some people will tell you, ‘I don't fall sick’, such people will not opt for the insurance, let alone to renew, or use any intervention [mobile tool]. But those who know the benefits of health insurance and understand the concept [of insurance] would use it" (IDI- 004I)
Responsibility over dependents
Participants who were responsible for others such as family members – children, spouses or parents, or other acquaintances – reported that financial responsibility and health status increased the awareness and willingness to lower financial risks associated with the costs of illness. That included taking low-risk or prudent decisions and safeguarding the financial protection of their dependents’ needs and risks, including healthcare. A dedicated savings wallet or account potentially relieves the financial burden of the family head and or guardians since it allows incremental savings toward NHIS renewal as expressed by the participants below.
" I cater for four people, and they all have health insurance, and they all must renew at the end of the year. And it will be a huge amount and I may find it difficult to just pay it outright. Then if the savings are there it can help me to just pay"(FGD - Korle Gonno)
"let's say you have a mother or father who is aged and needs to visit the hospital more often and maybe it gets to the end of the year, and he has not been able to renew his or her card, and he or she needs to be in the hospital,"(FGD- Korle Gonno)
Taxation
Currently, using the MRS to renew an NHIS membership requires that the premium is paid digitally through the MoMo account. The introduction of electronic transaction user fees (e-levy) could negatively affect mobile payment utilization due to perceived extra charges on use. This could hinder the acceptance and utilization of mobile payment services, hence affecting the use of the MRS as well as the savings wallet. As mentioned by a participant below.
“Right now, what will prevent me from using the savings wallet is the charging system on it. I am referring to the recent e-levy charge imposed on our digital transactions” (FGD- Korle Gonno)