Evaluation of Ghana's National Health Insurance Scheme (NHIS)'s mobile renewal service intervention

Abstract

Background: Taking advantage of technological advancement, the National Health Insurance Authority (NHIA) of Ghana launched the Mobile Renewal Service (MRS) in December 2018 to allow the National Health Insurance Scheme (NHIS) subscribers to renew their membership on mobile money platforms in Ghana. The MRS intervention offers a simple, quick, and cost-effective method for NHIS Subscribers to renew their membership annually without physically visiting an NHIS district office. However, there has yet to be any rigorous evaluation of the effectiveness of this intervention. Also, there is limited understanding of the barriers and facilitators influencing the adoption of the intervention from the perspective of NHIS subscribers and the intervention implementers in West Africa. Therefore, this thesis seeks to contribute knowledge on the effectiveness of MRS in Ghana and provide empirical evidence on the barriers and facilitators influencing the adoption of MRS. This contribution could offer evidence-informed policies that could have significant public health implications by ensuring timely insurance renewals and continuous insurance coverage, which could potentially prevent mortalities and morbidities due to health accessibility interruptions. Methods: The thesis adopted multiple approaches, including a literature review, interrupted time series analysis and a Delphi study. Twenty-five studies in West Africa were reviewed to understand how they approached this research topic, identify knowledge gaps on mHealth around the evaluation of mobile renewal service, establish what is known about the topic, and provide the research questions and methodological directions for this thesis. After that, an Interrupted Time Series Analysis (ITSA), using an Ordinary Least Squares (OLS) regression model, was fitted to examine and evaluate the effectiveness of MRS using secondary data from the NHIS’s membership database. Afterwards, stakeholders (NHIS subscribers and policy implementers) were engaged through online survey platforms to explore their perspectives on barriers to MRS adoption and interventions to tackle the identified barriers. Structural equation modelling, Delphi and thematic analyses were then conducted to ascertain the barriers and facilitators affecting the implementation of MRS and the need for more evidence on the critical drivers of adherence to MRS. Results: The literature review identified research scarcity on the evaluation of mHealth utilisation and a lack of evidence on the critical drivers of adherence to MRS adoption from the perspective of users and policy implementers. The ITSA showed that the MRS intervention significantly increased NHIS subscription renewal compared to the conventional/manual renewals (Coefficient = 6.06; p<0.05), resulting in a statistically significant decline in manual renewals over a 60-month period (p<0.05). On facilitators of MRS usage, the subscribers highlighted factors, such as time and travel cost saving, convenience and comfort of renewal, as the key drivers of MRS adoption while the implementers. These findings were corroborated by the policy implementers as they also indicated that ease of use and operational convenience, perceived usefulness, and affordability are the critical enablers of MRS adoption. However, there was divergence in their perspectives on the barriers to MRS adoption. For example, while the policy implementers indicated that illiteracy, poverty and resistance to change as the key barriers to MRS adoption, the subscribers mentioned peer pressure and community endorsement, and the platform’s engagement appeal as the key challenges to adopting MRS. Notwithstanding, they both agreed that network connectivity is a significant barrier to using the MRS intervention. Conclusion: The MRS intervention has significantly increased NHIS renewals, translating into an uninterrupted access to healthcare through health insurance. To upscale the potential of the MRS intervention, the NHIA could consider addressing key barriers, such as network connectivity, to ensure the continuous uptake of the intervention to enhance healthcare accessibility in Ghana.