Social capital and active membership in the Ghana National Health Insurance Scheme - a mixed method study

International Journal for Equity in Health

Inge Hutter⁴  Wouter Poortinga¹  Daniel K. Arhinful²  Alice Ogink⁵  Edward Nketiah-Amponsah²  Christine J. Fenenga³ 

[1] Cardiff University, Wales, UK;University of Ghana, Accra, Ghana;Amsterdam Institute for Global Health and Development, Amsterdam, 1100 DE, The Netherlands;International Institute for Social Studies, The Hague, The Netherlands;PharmAccess Foundation, Amsterdam, The Netherlands

关键词: Ghana;    Active membership;    Health insurance;    Clients;    Social capital;   

Others  :  1231278
DOI  :  10.1186/s12939-015-0239-y

 received in 2014-12-10, accepted in 2015-10-08,  发布年份 2015

【 摘 要 】

Background

People’s decision to enroll in a health insurance scheme is determined by socio-cultural and socio-economic factors. On request of the National health Insurance Authority (NHIA) in Ghana, our study explores the influence of social relationships on people’s perceptions, behavior and decision making to enroll in the National Health Insurance Scheme. This social scheme, initiated in 2003, aims to realize accessible quality healthcare services for the entire population of Ghana. We look at relationships of trust and reciprocity between individuals in the communities (so called horizontal social capital) and between individuals and formal health institutions (called vertical social capital) in order to determine whether these two forms of social capital inhibit or facilitate enrolment of clients in the scheme. Results can support the NHIA in exploiting social capital to reach their objective and strengthen their policy and practice.

Method

We conducted 20 individual- and seven key-informant interviews, 22 focus group discussions, two stakeholder meetings and a household survey, using a random sample of 1903 households from the catchment area of 64 primary healthcare facilities. The study took place in Greater Accra Region and Western Regions in Ghana between June 2011 and March 2012.

Results

While social developments and increased heterogeneity seem to reduce community solidarity in Ghana, social networks remain common in Ghana and are valued for their multiple benefits (i.e. reciprocal trust and support, information sharing, motivation, risk sharing). Trusting relations with healthcare and insurance providers are, according healthcare clients, based on providers’ clear communication, attitude, devotion, encouragement and reliability of services. Active membership of the NHIS is positive associated with community trust, trust in healthcare providers and trust in the NHIS (p-values are .009, .000 and .000 respectively).

Conclusion

Social capital can motivate clients to enroll in health insurance. Fostering social capital through improving information provision to communities and engaging community groups in health care and NHIS services can facilitate peoples’ trust in these institutions and their active participation in the scheme.

【 授权许可】

   
2015 Fenenga et al.

【 图 表 】

Fig. 1.

Fig. 2.

Fig. 3.

【 参考文献 】

• [1]Ahern MM, Hendryx MS. Social capital and trust in providers. Soc Sci Med. 2003; 57(9):1195-1294.
• [2]Alesina A, Ferrara EL. Who trusts others? J Public Econ. 2002; 85(2):207-234.
• [3]Arhinful D. The solidarity of self-interest. Research report. African Studies Centre, Leiden; 2003.
• [4]Aryeetey GC, Jehu-Appiah C, Spaan E, Agyepong I, Baltussen R. Cost, equity, efficiency and feasibility of identifying the poor in Ghana’s National Health Insurance Scheme: empirical analysis of various strategies. Trop Med Int Health. 2011; 17(1):43-51.
• [5]Bourdieu P. The forms of capital. Handbook of theory and research for the sociology of education. Richardson JG, editor. Greenwood, New York; 1986.
• [6]Coleman JS. Social capital in the creation of human capital. Am J Sociol. 1988; 94:95-120.
• [7]Coleman JS. Foundation of social theory. Harvard University Press, Cambridge; 1990.
• [8]Criel B, Waelkens MP. Declining subscriptions to the Maliando Mutual Organisation in Guinea-Conakry (West Africa): what is going wrong? Soc Sci Med. 2003; 57:42-48.
• [9]Cullen M, Whiteford H. The Interrelations of Social Capital with Health and Mental Health- Chapter 2 Social capital: definitions and framework. Commonwealth of Australia 2001.ISBN 0 642 50330 3. 2001.4-13.
• [10]Dalinjong PA, Laar S. The National Health Insurance Scheme: perception and experiences of health care providers and clients in two districts of Ghana. Heal Econ Rev. 2012; 2:1-13.
• [11]Derbile EK, Geest S. Repackaging excemptions under National Health Insurance in Ghana: how can access to care for the poor be improved? Health Policy Plan. 2013; 28:586-595.
• [12]Donfouet H, Essombe E, Mahieu P, Malin E. Social capital and willingness-to-pay for community based health insurance in rural Cameroon. Global J Health Sci. 2011; 3(1):142-149.
• [13]Donfouet H, Mahieu P. Community-based health insurance and social capital: a review. Heal Econ Rev. 2012; 2:5. BioMed Central Full Text
• [14]Fenenga CJ, Boahene K, Arhinful DK, Rinke de Wit TF, Hutter I. Do prevailing theories sufficiently explain perceptions and health-seeking behavior of Ghanaians? Int J Health Plann Manag. 2013.
• [15]Fenenga CJ, Nketiah-Amponsah E, Bailey A, Hutter I. A Participatory Action Approach for Client-centered Health Insurance. Int J Action Res. 2015.
• [16]Flynn R, Williams G, Pickard S. Markets and networks: contracting in community health services. Open University Press, Buckingham; 1995.
• [17]Fukuyama F. Social captital and civil society. IMF working paper. 2000.
• [18]Granovetter M. The strength of weak ties: a network theory revisited. Sociol Theory. 1983; 1:201-233.
• [19]Granovetter M. Economic action and social structure: the problem of embeddedness. Am J Sociol. 1985; 91(3):481-510.
• [20]Guion LA, Diehl DC, McDonald D. Triangulation: establishing the validation of qualitative studies. IFAS Extension University of Florida. 2011; 2011:1-3.
• [21]Hendryx MS, Ahern MM, Lovrich NP, McCurdy AH. Access to health care and community social capital. Health Serv Res. 2002; 37(1):87-103.
• [22]Hennink M, Hutter I, Bailey A. Qualitative research methods. Saga, London; 2011.
• [23]Hsiao W. Unmet health needs of two billion. Is community financing a solution. Health. Nutrition and Population, Washington; 2001.
• [24]Jehu-Appiah C, Aryeetey G, Spaan E, Hoop T, Agyepong I, Baltussen R. Equity aspects of the National Health Insurance Scheme in Ghana: who is enrolling, who is not and why? Soc Sci Med. 2011; 72(2):157-165.
• [25]Jones VN, Woolcock M. Using mixed methods to assess social capital in low income countries: a practical guide. Brooks World Povert Institute Working Paper 12. University of Manchester, Manchester; 2007.
• [26]Kanchebe E, Geest S. Repackaging excemptions under National Health Insurance in Ghana: how can access to care for the poor be improved? Health Policy Plan. 2013; 28(6):586-595.
• [27]Kawachi I, Kim D, Coutts A, Subramanian S. Commentary: reconciling the three accounts of social capital. Int J Epidemiol. 2004; 33(4):682-690.
• [28]Kleinman A. Concepts and model for the comparison of medical systems as cultural systems. Social Science and Medicine. 1978; 12:85-93.
• [29]Makinen M. Private Health Sector Assessment in Ghana. Working paper. The World Bank, Washington; 2011.
• [30]Ministry-of-Health & Service, G. H. (2010). Annual Report. Ghana (Ed.).
• [31]Mohseni M. Social Capital, trust in the healthcare system and self-rated health: the role of access to health care in a population-based study. Soc Sci Med. 2007; 64(7):1373-1383.
• [32]National Health Insurance Authority. Annual Report, Accra; 2010.
• [33]Ghana Health Insurance Review: September 2012 – February 2013 edition. NHIA, Accra; 2013.
• [34]North DC. Institutions, institutional change and economic performance. Cambridge University Press, Cambridge; 1990.
• [35]Poortinga W. Social Capital: an individual or collective resource for health? Soc Sci Med. 2006; 62(2):292-302.
• [36]Poortinga W. Social relations or social capital? Individual and community health effects of bonding social capital. Soc Sci Med. 2006; 63(1):255-270.
• [37]Putnam RD, Leonardi R, Nanenetti R. Making Democracy Work: civic traditions in modern Italy. Princeton University Press, Princeton; 1993.
• [38]Sachs J. The end of poverty: economic posibilities for our time. Pengiun press, New York; 2005.
• [39]Subramanian SV, Kim DJ, Kawachi I. Social trust and self-rated health in US communities. A multi level analysis. J Urban Health. 2002; 79(4):S21-S34.
• [40]Szreter S, Woolcock M. Health by association? Social capital, social theory, and the political economy of public health. Int J Epidemiol. 2004; 33(4):650-667.
• [41]Thom D, Hall M, Pawlson G. Measuring patients’ trust in physicians when assessing quality of care. Health Aff. 2004; 23(4):124-132.
• [42]Todd DJ. Mixing qualitative and quantitative methods: triangulation in action. Adm Sci Q. 1979; 24:602-611.
• [43]Turkson PK. Perceived quality of healthcare delivery in a Rural District of Ghana. Ghana Med J. 2009; 43(2):65-70.
• [44]WHO. (2003). World Health Survey 2002–2003.
• [45]Health systems financing: the path to universal coverage. The World Health Report 2010. World Health Organization, Geneva; 2010.
• [46]Woolcock M, Harper R. Social Capital, a review of literature. Paper of the office of the National Statistics. Office of the National Statistics, London; 2001.
• [47]Zhang L, Wang H, Wang L, Hsiao W. Social capital and farmer’s willingness-to-join a newly established community-based health insurance in rural China. Health Policy. 2006; 76(2):233-242.