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Abstract
Background In 2018, Ghana’s National Health Insurance Authority (NHIA) introduced a mobile strategy to enhance re-enrolment and improve client knowledge of their entitlements. This study investigated how Ghana’s mobile strategy has influenced the NHIA’s responsiveness to clients in terms of patient rights and entitlements, equity and satisfaction with health services.
Methods We surveyed people (n=1700) in 6 districts who had renewed their insurance in the previous 12 months, using any strategy (mobile or manual). Multiple regression analysis examined correlation between individual characteristics and renewal modality. Policy documents on the mobile programme’s design and focus group discussions (n=12) on people’s experiences renewing their insurance were analysed thematically.
Results While the mobile platform was designed for mobile National Health Insurance Scheme (NHIS) renewal and to provide information about insurance entitlements, few people surveyed (20%) knew about these informational features. Among those who renewed their NHIS coverage, 58% did so on the mobile renewal platform. Mobile renewal was high among those with tertiary education and those in the higher wealth quintiles. Mobile renewal was considered convenient, but required literacy in English, a phone and a mobile money wallet. For those who lacked some or all of these prerequisites but wanted to use mobile renewal, mobile vendors emerged as valued facilitators.
Conclusion The mobile platform has increased the responsiveness of Ghana’s NHIS through offering clients a more convenient mechanism to renew their insurance policies. It does not, however, eliminate the one month waiting period for activating the card, does not provide prompts to reassure clients of their renewal and does not empower most clients with information on entitlements. To improve the adoption and use of the mobile renewal strategy, the NHIA should publicise the platform’s information-sharing functions and explore formally engaging mobile vendors.
- health insurance
- health policy
Data availability statement
Data are available on reasonable request.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Use of mobile platforms to increase renewal and enrolment of health insurance clients to improve access and utilisation of healthcare.
WHAT THIS STUDY ADDS
The study uses the health policy framework of health system responsiveness to explain health insurance responsiveness to its clients through three responsiveness domains.
The mobile renewal platform contributes to the National Health Insurance Scheme’s responsiveness through the domain of respect for client rights, service satisfaction and equity.
The contextual and content domains of the mobile renewal strategy interact to undermine the use of the mobile platform as clients are not empowered with knowledge of their entitlements.
This study highlights emergence of informal community mobile money vendors as intermediaries to facilitate mobile renewals for vulnerable populations in Ghana.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The context and processes of the mobile renewal platform do not empower clients with information on their health insurance entitlements and the NHIA needs to develop targeted support strategies to improve the adoption and use of the mobile renewal strategy.
National Health Insurance Authority (NHIA) to engage its clients on the mobile renewal strategy would need to highlight the information-sharing functions as well as the mobile renewal function of the mobile strategy.
The emergence of community mobile money vendors as intermediaries to provide services to those clients with lower literacy or without mobile wallet accounts would require the NHIA to engage mobile money vendors to enhance accountability to its clients.
Background
Universal health coverage, where all people have access to the healthcare they need without financial hardship, is being pursued in many countries through the implementation and expansion of health insurance programmes.1–4 However, in order to achieve universal health coverage, these health insurance programmes must overcome operational challenges including weak administrative and managerial capacity, poor client understanding of insurance entitlements and high overhead costs.5–7 These issues of poor health insurance responsiveness to client needs often manifest as low enrolment and renewal rates.6 8–10
Drawing on conceptualisation of responsive health systems by Murray and Frenk, responsive health insurance programmes can be understood as those that respect client rights in accessing insurance entitlements (dignity, autonomy, confidentiality) and that meet client expectations of service quality (promptness, basic amenities, accessibility and choice) in an equitable manner.11 Failures in these domains, such as registration or renewal processes that expose clients to disrespectful interactions with administrators or difficult-to-reach health insurance office buildings, can drive low uptake of health insurance.
In Ghana, where this study took place, enrolment into the National Health Insurance Scheme (NHIS) was only 35% in 2017 and renewal 73%.12 These low rates have been found in part to be driven by weak administrative processes such as need for yearly renewal of health insurance membership, delays in issuing insurance cards for care access and inaccessibility of NHIS registration centres leading to high costs of enrolment and renewal.13 14 Community engagement in the implementation of the NHIS in Ghana is reported to be poor, with limited outreach education and widespread fear of asking questions about the package of services.15 As a result, few people understand their entitlements or demand the services that are due them.15
In other contexts, poor understanding of entitlements or difficult-to-navigate benefits have been found to reduce access to healthcare and can deter users from starting or renewing health insurance.16 17 Conversely, high health insurance literacy is associated with increased utilisation of health services.16 Community engagement programmes have been used to increase client’s understanding of their health insurance rights and entitlements, thereby overcoming barriers to retention and increasing access to services and financial protection.18–20
Increasing access to mobile phones and mobile banking, along with advancements in mobile technologies, have prompted innovations across health systems and payment for health services. In the health insurance market, mobile technologies have been employed to improve knowledge on benefit packages and to enable remote enrolment and renewal. In South Africa, for instance, clients can access information on their entitlements and renew their insurance membership from their mobile phones.21 In Kenya, clients can use the M-Pesa platform to renew their monthly insurance subscription.22
In 2020, 54% of Ghanaians over 5 years of age had a mobile phone.23 By 2017, 58% of the population over 14 years had a bank account and 49% had made or received digital payments in the last year.24 25 In December 2018, Ghana’s NHIS introduced a mobile renewal strategy to enhance renewal and improve client knowledge of their entitlements. Despite increasing use of mobile platforms for health insurance renewal, little is known about how these mobile platforms affect health insurance responsiveness (respect for client rights, service satisfaction and equity). This study investigates the impact of Ghana’s mobile strategy on the NHIS’s responsiveness to clients by exploring the mobile platform content (design and intended functionality), process (client experience and actual performance) and context (wider factors influencing performance) and how they interact to improve responsiveness of NHIS.
Overview of the National Health Insurance Scheme in Ghana
Ghana’s National Health Insurance Act was introduced with the vision ‘to ensure equitable and universal access for all residents of Ghana to an acceptable quality package of essential healthcare’.26 The NHIS covers the cost of outpatient and inpatient medical care for about 95% of the disease burden of Ghana. It is financed by a 2.5% charge out of the 17.5% Social Security and National Insurance Trust contributions for formal sector workers, a 2.5% levy on taxable supplies (eg, property and services), annual premium payment by insured clients which varies by geographical location (US$3.01 to US$3.93 in 2020) and donor support. Children (aged <18 years), the elderly (aged 70 years and over), indigents (poorest or core poor), pregnant women, Livelihood Empowerment Against Poverty beneficiaries (including widows and single-headed households) and Social Security and National Insurance Trust pensioners are exempted from paying premiums.27
Until 2018, the NHIS required manual registration and renewal at district health insurance offices. Members paid their premium as well as a registration fee for renewal. They then waited for their personal information to be updated in the system and received confirmation that the renewal had been successful. A client also got a receipt that was stamped to indicate that the process of renewal was completed. A biometric card was issued with the new expiry date. Due to network and system challenges, this renewal process could take 1–3 days to complete. In December 2018, the NHIS launched a mobile renewal service platform for its members. This service seeks to increase renewal rates and improve client knowledge of their entitlements.28 This study uses a triangulated mixed-method approach to understand the content, process and contextual factors that influence mobile re-enrolment of the NHIS. This analysis aims to inform policy to enhance the responsiveness of the mobile renewal strategy and NHIS more broadly to the needs of Ghanaians.
Conceptual framework
This study assesses the NHIS mobile renewal platform’s influence on the health insurance system’s overall responsiveness (figure 1) using the policy triangle framework (context, process and content) and the adapted system responsiveness framework by Molyneux et al. To do so, we assessed the mobile platform using an adapted version of framework by Molyneux et al29 and assessed its contribution to responsiveness through an adapted version of health system responsiveness framework by Murray and Frenk. Drawing from framework by Molyneux et al,29 we examined the platform’s (1) content, meaning the platform’s design, intended use, costs and promotion among the population; (2) process, meaning the platform’s actual uptake and client experiences using the platform and (3) context, meaning how the factors beyond the platform influence its use, such as features of the overall NHIS, mobile phone-related features and socioeconomic factors. Adapting the framework by Murray and Frenk on health system responsiveness to health insurance responsiveness, we assess the NHIS mobile renewal platform’s effect on three responsiveness domains: respect for clients’ rights and service satisfaction, with equity added as a third domain.11 We interpreted respect for client rights to include the subdomains of respectful interactions (including with insurance administrators and when renewing insurance), autonomy (including knowing one’s policy terms and entitlements) and confidentiality (including around use of insurance and financial data). We interpreted service satisfaction as the subdomains of promptness (including when renewing one’s policy), basic amenities (in terms of ease of renewing insurance), access to support (including to navigate renewal on the platform) and choice (including whether to use the mobile platform or other modalities). Equity considerations cut across these domains.
Conceptual framework of how the mobile renewal platform’s context, content and process can influence the health insurance scheme’s responsiveness in Ghana.
Methods
Study setting
The study was carried out in six districts, three each from the Greater Accra and Volta Regions of Ghana. Districts were classified by mobile renewal rate using the 2019 NHIS membership renewal database: high mobile renewal districts were those where mobile renewals composed 75%–100% of all renewals, medium were 50%–74% and low were below 50% of all renewals. Two districts were selected from each category, one in the Greater Accra Region and one in the Volta Region: Ashaiman and Akatsi municipalities represented high renewal districts, Korle Klottey and Keta represented medium renewal districts while Madina and Ho represented low renewal districts. Ashaiman, Korle Klottey and Madina are from the Greater Accra Region and Akatsi, Keta and Ho are from the Volta Region.
Study design and data collection
A mixed-method approach was used to obtain qualitative and quantitative information on the experiences of community members who renewed their health insurance. The use of mixed methods strengthened the study’s findings and conclusions by seeking convergence, corroboration and correspondence of results from the different methods that were used.30
Quantitative method
The quantitative component consisted of a cross-sectional survey among people who had renewed their insurance in the previous 12 months, using any strategy (mobile or manual). A multistage sampling approach was used to recruit the study participants. In the first stage, six districts were purposively selected to represent high, medium and low mobile membership renewal districts. The second stage involved a random selection of census enumeration areas based on the Ghana Statistical Service classification for each of the districts selected. Each enumeration area represented a community in this study. The third stage involved the selection of representative households or residential structures through a systematic random sampling. The households that had re-enrolled in the NHIS in the enumerated communities were interviewed. In a selected household, the household head was asked if they or any member of the household had renewed their NHIS membership. If no one in that household renewed their membership, the next household was selected as a replacement till the 300 sampled households in that district were interviewed. We gathered data on household insurance renewals, mode of renewal, knowledge and use of the mobile renewal platform, knowledge of information on the platform, the purposes for which clients accessed the platform, information frequently accessed, the perceived benefits of using the mobile renewal platforms and challenges in using the platform.
The survey questionnaire was administered using Research Electronic Data Capture by trained enumerators. The completion of the questionnaire lasted about 15–30 min.
Qualitative method
The qualitative component consisted of a review of policy documents and focus group discussions (FGDs) with community members. Participants were selected using a purposive sampling approach, seeking adults who had experiences with renewing their insurance membership via manual or mobile renewal. Two FGDs, one with men and one with women, were held in each of the 6 districts (12 FGDs total) and included between 6 and 12 participants. Data were gathered on the knowledge of the participants on the NHIS, benefits of the NHIS, reasons why people enrolled while others did not, awareness of the mobile renewal strategy and its aim, mode of renewal of membership, challenges in renewing NHIS membership using the mobile renewal platform. Notes were taken in addition to audio recording. The interviews were conducted in person by experienced research assistants and supervisors. Interviews were conducted in a language familiar to the participants.
Analysis
For the quantitative survey data, descriptive statistics were generated using Stata (V.15) for key variables such as enrolment in the NHIS, mode of NHIS renewal (mobile or manual) and functions of the mobile renewal platform. A bivariate analysis using χ2 test was then run to assess factors influencing modality of NHIS renewal (mobile vs manual) by age of respondents, marital status, sex of respondents, household head status, level of education, area of residence, wealth quintiles, NHIS membership category and district of respondents. Wealth quintile was defined based on household assets using principal component analysis. A multiple logistic regression analysis was conducted to assess the factors which influence mobile renewal.
The policy documents were analysed to assess the mobile platform’s design and intended use. The FGDs were transcribed and analysed thematically based on the following domains: knowledge about NHIS; reasons why community members enrol with the NHIS; awareness of existence of the mobile renewal platform, knowledge of the mobile renewal platform; aim of the mobile renewal initiative; uses of mobile phone in the community; challenges with renewing via the mobile renewal platform and how challenges were addressed by community members.
Patient and public involvement
This study did not include patients. Members of households in the general population were the research participants and their experiences, preferences and priorities related to the mobile renewal platform provided the basis for the recommendation for policy direction. The purpose of this research is to enhance the experiences of the research participants by making health insurance responsive to them, but they did not participate in the research design and in the setting of the research questions.
Results
We present our results grouped according to our framework’s components on the mobile platform’s content, process and context, drawn from Molyneux et al.29 The ‘Content’ section is drawn primarily from our review of policy documents to explain how the mobile platform was designed and its intended use. The ‘Process’ section presents our findings from the quantitative survey and FGDs on mobile user profiles, determinants of mobile (vs manual) renewal and users’ experiences. The ‘Context’ section draws on all three data sources (documents, survey and focus groups) to explain factors beyond the mobile platform itself that influenced its use. In the ‘Discussion’ section, we build from these results to explain the influence of the mobile renewal platform on the overall responsiveness of Ghana’s NHIS.
Content: mobile renewal platform’s design and intended use
Design features and intended use: clients access the mobile platform by dialling *929# on any mobile network in Ghana. The mobile renewal platform is accessible through the mobile network and requires a smartphone, advanced feature phone or a mobile phone with basic features.31 Options are presented in written text, in English, and users navigate through pressing buttons on the phone’s screen. The platform presents four options: (1) check policy expiry date, (2) renew NHIS membership, (3) access a summary of the NHIS benefit package and (4) access a list of medicines covered by the scheme and the NHIS call-centre numbers for further information. To renew using the mobile platform, clients enter their 6-digit policy number and pay using a mobile wallet. Once the client renews the membership, the health facility or provider system is updated with the renewal. When a client visits the health facility, their card is then activated to enable access to health services. As part of the NHIS system, apart from children under 5 years and pregnant women, members must wait for 1 month to have their cards activated for use after renewal or registration.
The mobile platform gives alerts before expiration of the membership. If one chooses the renewal option, the client must have sufficient balance on the mobile wallet before they can complete the transaction.
Renewing a policy, whether by phone or in person, requires paying the premium (US$3–US$4) and renewal/registration fee (US$0.58). Most marginalised people who are exempt from paying the premium must still pay the renewal/registration fee. However, indigents and pregnant women are fully exempt from paying either fee; because of this full exemption they cannot renew their membership through the mobile platform and instead must register physically at the health insurance offices.
Costs/Savings associated with renewal on mobile platform: dialling in to the service is free of charge and someone with zero credit on their phone can access this service. Mobile renewal requires paying an added convenience charge of Ghana Cedi (GHS)1.00 (US$0.12). However, mobile renewal allows clients to save time and money that would have been spent on transportation and waiting at the district health insurance office.32
Promotion of platform among population: there was a national launch of the mobile renewal platform and sensitisation workshops in various regions in the country. There were radio programmes providing information on the benefits of mobile renewal. The benefits of the nationwide roll out of the mobile renewal strategy to clients were further explained as reducing waiting time and giving reminders on expiry dates.
I also heard about the NHIS renewal on radio, television and also, from the NHIS office. There is a notice on the wall about renewal of the NHIS on phone and the code is *929#. Some of the options that come are policy validity, renewal, membership and others. (Male, FDGs, Akatsi)
Process: uptake of the mobile platform and client experiences with its use
Information about actual uptake and client experience of the mobile platform is drawn from our survey and FGDs. The survey was completed by 1700 households, representing about a 94.5% response rate (table 1). Those without any formal education were 16% (n=281) and those with basic education (primary and junior high school) were >50% of the study population (53%; n=892). Fifty-seven per cent (n=979) of the households lived in urban areas. Almost three-quarters (74%, n=1257) of the respondents were in the premium paying category of the NHIS.
Demographic characteristics of household survey respondents
The focus group participants had all renewed their health insurance during the last 12 months but only 28 of 120 FGD participants had used the mobile platform.
Uptake and forms of use: of the 1700 households surveyed (all of which had renewed their NHIS membership), 988 (58%) renewed using the mobile renewal platform (table 2). Eighty-six per cent (575) of those who renewed via the mobile platform owned phones while only 83% (256) of those who did so manually owned phones. Close to 80% (790) of the 988 who renewed their NHIS membership via the mobile platform did not know that the mobile platform offered any other functions (20% knew). Few members (table 2) knew that they could check the expiry date of their membership (12.2%, n=120), access the list of medicines included in the insurance package (3.2%, n=31), access details on the health services included in the benefit package (2.6%, n=26) or that the mobile platform provided a toll-free number for complaints and enquiries (2.1%, n=21).
Multiple logistic regression of factors influencing NHIS mobile renewal
After adjusting for sociodemographic characteristics (age, sex, area of residence, etc), NHIS renewal by mobile (as opposed to manual) was significantly more likely among those with the tertiary education (compared with no education), richest quintile (compared with poorest) and district of residence (table 2). Residents of Ho, Akasti and Keta districts of the Vola Region outside Accra were on average six times more likely to renew their membership using the mobile renewal platform compared with Osu Klottey in the Greater Accra Region. The Greater Accra Region being cosmopolitan, and the capital of Ghana is wealthier and has several health services and insurance options than the Volta Region.
Experience of use: the focus group participants who used the mobile platform were pleased to have saved time and money from having to travel to the health insurance office for manual renewal.
It makes renewal of the NHIS easy and fast. No need to spend money to travel to the office for renewal. (Female, FGDs, Ho)
I also think they implemented this to save time. This is because, whenever you want to renew the insurance at the office, people are always many, long queues and waiting times. Mobile phone platform renewal saves a lot of time. (Female, FGDs, Keta)
Right now, as I sit here, I can decide to renew. I don’t have to go there. I don’t have to waste transportation, so it has been very helpful. (Female, FGDs, Ashaiman)
Need for and ability to access assistance: those who struggled to navigate the platform due to low literacy or low digital capacity asked others to complete the mobile renewal on their behalf. Vendors were mentioned as key actors who helped people renew their insurance card. Vendors were money mobile agents who operated a business of money transfers and took advantage of the mobile renewal strategy to offer that service at a fee. They charged GHS1.00 toGHS2.00 (US$0.12 to US$0.24) per renewal in addition to the GHS1.00 fee charged by the NHIA. Mobile vendors used their phones to renew for those who did not own mobile wallets while clients with mobile wallets rather offered their own phones to vendors to renew for them.
Most of them do it [renew] through the phone, even the market women who have little knowledge about it [renewal platform], they know is done on phone even though they can’t do it themselves they let people help them to do it, because [it] is easy and saves time. (FGD Male Akatsi)
Because we are aged people who have problems with their eyes and they cannot operate a simple phone, they find it difficult. So, we have these people [vendors] who help them out. (Male 1, IDI, Korle Klottey)
Some of them they can’t read especially some of the elderly people. Even some when you tell them that they can do it on their phones they say ‘how will I do it? I can’t see with my eyes or the phone inside I don’t know inside I can’t do it’. (Female community mobile vendor)
However, some people did not feel comfortable asking for help from vendors because renewing one’s health insurance on the mobile platform required inputting their mobile money password. If a client gave their password to a vendor for use during mobile renewal, the vendor could use the password to make other purchases too.
Some people cannot renew the NHIS on their phones because they are not familiar with the use of phones and if help is sought, it mostly results in theft cases since the person helping out with the renewal will require your mobile money secret code. People who help also increase the cost of renewal for us. (FGD Akatsi, R9)
Trust: respondents noted that renewing one’s health insurance on a mobile platform felt less certain than renewing it in person. This was primarily because the NHIS mobile renewal platform did not provide any confirmation of successful renewal, which left users unsure about their insurance status. They expected some sort of confirmation, akin to the post-it placed on the back of one’s health card to confirm successful manual renewal.
In the past, after renewal at the office, the previous year is always covered with a sticker which creates awareness that the card has been renewed. Nowadays, after renewal on the mobile phone, you do not get to know if the process has been successful or not until you go to the hospital. We only get to know the status of the card when we get to the hospital, which is not very encouraging. (FGD, Ho R6)
Respondents recounted instances where they thought renewal had been completed on the mobile platform only to find out later that the process had not been successful, for unknown reasons.
I renewed it for someone via the mobile renewal platform, and they said the person should wait for one month but after the one month still it is not working. (Male 3, IDI, Ashaiman)
Context: factors beyond the platform that influence its use
Insurance programme features: not wanting to or not remembering to renew NHIS at all would reduce uptake of the mobile renewal platform. While all 1700 households surveyed had renewed their health insurance and thus did not provide information on non-renewal, the FGD participants noted that some people forgot to renew until they needed to access healthcare.
Mobile phone factors: of the 1700 households surveyed, 1462 (86%) owned a phone and 1018 (60%) had a mobile wallet. Focus group participants explained that many could not use the platform because of limited capacity to navigate the mobile phone (“we do not know how to use our phones to renew it” Ashaiman Male R5), and not having a mobile banking account (“if you have not registered with mobile money, you cannot do it” Male, Madina, R8). Poor cellular network coverage was another contextual barrier that limited mobile renewal.
Network is a barrier. Sometimes after renewing the card, because the network is very slow, there will be no feedback to be sure if the renewal was successful or not. (Female, FGDs, Keta)
The implementation of renewal on the phone is helping most of us but the only problem is with the network. When you are in your house, it is very difficult to access network and carry on with the renewal so you must go out of the town to a place you will get access to the network before you can renew it. (Male, FDGs, Akatsi)
As described in ‘context,’ after mobile renewal, the local health facility is notified and must then activate the policy. When mobile connectivity is poor, health facilities may not receive notification of a policy renewal or may be unable to remotely activate the client’s coverage.
Socioeconomic and geographic factors: as shown above in the multilinear regression analysis, use of mobile renewal (compared with in-person renewal) was higher among the most educated and wealthiest people in all the districts. Low literacy was emphasised in the FGDs as a contextual barrier to using the mobile renewal platform. Residing outside Accra (the urban centre) was strongly associated with higher use of the mobile platform, likely because people outside Accra live farther away from in-person renewal locations. Inability to pay the NHIS premiums and lack of proof of exemption from premiums were not assessed in the survey because all households had renewed their membership. These factors were not mentioned by FGD participants.
Discussion
This research explored the NHIS mobile renewal platform’s content, process and context to understand its contribution to the NHIS’s responsiveness. The mobile renewal platform for the NHIS enhances responsiveness by offering convenience, accessibility, real-time updates and automation. It simplifies the renewal process, reduces administrative burdens, ensures data security and provides a platform for continuous improvement based on user feedback.
In terms of content, the platform was designed for mobile NHIS renewal and to provide information about insurance entitlements and to inform insurance enrollees of the toll-free number for complaints or enquiries. A mobile money wallet is required to use the mobile platform to pay one’s premium, renewal/registration fee and mobile user charge. Pregnant women and indigents have their premium and renewal fees waived but cannot renew using the mobile platform. In terms of process, close to three-quarters of people surveyed who renewed their NHIS chose to do so on the mobile renewal platform. The overwhelming majority of mobile platform users did not know that the mobile platform also provided key information about the NHIS. Mobile phone vendors were often asked to help navigate the insurance renewal platform for people with low literacy and digital skills, although this brought the risk of fraud because it required sharing one’s mobile wallet passcode. Some respondents felt that mobile renewal was less trustworthy than in-person renewal because there was no physical proof of renewal. Contextual factors that influenced citizen use and experiences with the mobile platform included having access to a smartphone and internet, having a mobile money wallet account, being highly educated and wealthier and having digital skills and literacy to navigate the renewal platform.
Taken together, we found that the mobile platform contributed to the NHIS’s responsiveness (according to our adapted conceptualisation of responsiveness from Murray and Frenk) by increasing some aspects of respect for client rights, service satisfaction and equity. The mobile renewal app allows NHIS clients to renew their health insurance policies directly from their smartphones or mobile devices.11 This eliminates the need for clients to visit NHIS offices physically, stand in queues or go through cumbersome paperwork. This level of convenience encourages more clients to renew their policies promptly and makes the scheme responsive. The mobile platform provided real-time updates to clients regarding the status of their renewal application. Clients receive notifications when their renewal is successfully processed, avoiding uncertainty about the progress of their request. This immediate feedback enhances client satisfaction and confidence in the NHIS’s responsiveness. Similarly, the platform includes features for clients to provide feedback about their renewal experience. This feedback loop enables the NHIS to identify areas for improvement and make necessary adjustments to continually enhance the responsiveness of the app and the renewal process.
However, we also identified several persistent gaps in these responsiveness domains. The first domain in responsiveness is respect for client rights. Within this domain, the mobile renewal platform positively affected the subdomain ‘dignified treatment and interactions’ by reducing the need for in-person interactions with NHIS administrative staff and increasing client comfort and convenience. The mobile platform is designed to increase the subdomain of respect for client rights called ‘autonomy, knowledge of entitlements’ by making it easy for clients to know their drug and health service entitlements and where to access the complaints or enquiries hotline. However, few people are aware of these information features. Limited awareness or knowledge of the scope of health insurance benefit packages is an issue, including in other West African countries.33–35 Increasing client knowledge of entitlements can increase the use of healthcare services and increase re-enrolment.33 35 36 The final subdomain, ‘confidentiality’ was not enhanced by the mobile renewal platform. Those who required help using the mobile renewal platform were vulnerable to compromised confidentiality. The family member, friend or mobile vendor who helped them would have access to their mobile wallet password and know whether they fell into a vulnerable socio-economic class.
The second domain in responsiveness is service satisfaction. The mobile renewal platform did not affect the subdomain ‘promptness’ because whether the person renewed in-person or used the mobile renewal platform, the 1 month waiting period before one’s new policy is activated still applied. The service satisfaction subdomain ‘amenities in terms of interface and ease of use’ was improved with the mobile renewal platform. The mobile renewal app allows NHIS clients to renew their health insurance policies directly from their smartphones or mobile devices. This eliminates the need for clients to visit NHIS offices physically, stand in queues or go through cumbersome paperwork. This level of convenience encourages more clients to renew their policies promptly thus making the scheme responsive. In-person NHIS renewal was widely considered inconvenient.7 37 38 NHIS office locations were not easy to access for many clients and collecting one’s new NHIS card was laborious and a disincentive for membership renewal.7 The mobile renewal platform was widely valued for eliminating travelling time to renewal offices and waiting time at renewal offices. With the mobile renewal platform, the renewal process is streamlined and automated. Clients can input their information directly into the app, reducing the chances of errors compared with manual data entry. This leads to faster processing times, as the app can instantly validate information and approve renewals if all criteria are met.22
Mobile renewal increases the final subdomain of client satisfaction, ‘choice’, because clients retain the option of manual renewal. However, to have genuine choice one needs to know about their options. Lack of public awareness of the mobile renewal option may explain the variation in renewal rates across the districts. In other settings, limited knowledge of health technology was a major barrier to adoption and use.39
The final domain of responsiveness is equity. In some ways, we found the mobile renewal platform to be pro-equity: those who live farthest away from manual renewal locations, which are found in urban areas, benefit the most by not having to travel and those who were exempt from premiums were equally likely to use it to register their renewal as those who paid premiums. In other ways, however, it is regressive. The poorest, whose premium and registration fees are both waived, cannot renew on the mobile renewal platform and thus must continue to bear the cost of transportation to physically register at the health insurance centres.
Use of the mobile platform was skewed towards the wealthiest, and those with tertiary education, which echoes findings from another study in Ghana.37 The platform requires knowledge of English literacy, and access to a mobile wallet. The ability of clients to use mobile devices and navigate digital platforms is crucial. Opening and using a mobile wallet is free but one needs to have a minimum balance in the wallet to pay for transaction charges and to keep the account active. Mobile money transfers of GHS50.00 (US$6.00) require a minimum balance of 1% of the transaction being made and mobile wallet users tend to be wealthier and more educated.37 40 Close to a third of the adult population in Ghana is not literate, and thus unable to independently navigate mobile renewal and mobile wallets.23 The language used in the mobile application and the literacy level required to understand the instructions can impact clients’ ability to complete the renewal process accurately.41 Illiterate, non-English speakers, and those without a mobile wallet who use mobile renewal are more likely to need someone’s help, which opens them up to possible financial exploitation. Clients with higher levels of digital literacy are more likely to successfully complete the renewal process without assistance.42 Also, younger generations who are more accustomed to using mobile technology may find mobile renewal easier than older generations who might be less familiar with digital interfaces.43 The socio-economic disparities and financial constraints might impact clients’ ability to afford smartphones or data plans required for mobile renewal.22 Similarly, access to reliable mobile networks varies by location. Rural areas or areas with poor network coverage might limit the effectiveness of mobile renewal systems.44 Thus, these contextual factors and content of the mobile renewal strategy interact to undermine the responsiveness of the mobile platform.
The mobile renewal platform could be further strengthened to enhance the NHIS’s responsiveness through several strategies. First, greater publicity about the existence of the platform and its range of features would increase client awareness of this tool as well as its use and associated rights and entitlements. Increasing population awareness and knowledge of advanced technologies enhances their adoption and usage.45–47 Second, mobile money vendors could be more formally engaged as platform ambassadors. We found that mobile money vendors have become intermediaries in renewing for clients who are not familiar with the platform and are not technologically inclined. Formalising this organic adaptation could increase the reach and equity of mobile renewal, and potentially assuage concern about sharing mobile money codes and making them accountable to clients who renew with them. Finally, an alert system to confirm that the transaction and renewal process is successful will make people more confident that the renewal ‘worked’.
Conclusion
The mobile renewal platform has increased the responsiveness of Ghana’s NHIS through offering clients a more convenient mechanism to renew their insurance policies. It however does not eliminate the 1 month waiting period for activating the card, does not provide prompts to reassure clients of their membership renewal and does not empower the clients with knowledge of the functions of the platform and information on benefits of the scheme. To improve the adoption and use of the mobile renewal strategy, the NHIA should do better at informing clients about the platform, highlighting its information-sharing functions as well as the mobile renewal function. The NHIA could also develop targeted support strategies for those with lower literacy or without mobile wallet accounts by engaging mobile money vendors.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study was approved by Ghana Health Services Ethics Review Committee (GHS-ERC 001/10/19). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We are grateful for the financial support from WHO Alliance for Health Policy and Systems Research. The manuscript is part of the research project ‘on making health insurance responsive to citizens’. We acknowledge the technical and scientific guidance of Zubin Shroff and Manuela De Allegri. We are grateful to Kerry Scott for the critical comments and reviews for the manuscript. We thank all the research participants from the Greater Accra and Volta Regions and research assistants who collected the data.
References
Footnotes
Handling editor Seye Abimbola
Twitter @dgadeka
Contributors conceived the study, analysed data and drafted the manuscript. DDG, GA, JS. JMKA and MA participated in the design and analysis and helped to draft the manuscript. All the authors read and approved the manuscript. PA accepts full reponsibility for the conduct of the study, had access to the data, and controlled the decision to publish.
Funding This study funded by WHO Alliance for Health Policy and Systems Research under the ‘on making health insurance responsive to citizens’ project.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.