philipp p. degens and christina may department for co-operative studies, university of cologne

Analysing Membership in the National Health Insurance Scheme in Ghana - Applying Qualitative Comparative Analysis

Philipp P. Degens and Christina May

Department for Co-operative Studies, University of Cologne

Research Conference on Microinsurance, University of Twente, April 11th 2012

Pro MHI Africa – EU-African university network to strengthen community-based micro health insurance

Pro MHI Africa is kindly funded by the ACP-EU Cooperation Programme in Higher Education (EDULINK). A programme of the ACP Group of States with the financial assistance of the European Union. This document has been produced with the financial assistance of the European Union. The contents of this document are the sole responsibility of the University of Cologne and can under no circumstances be regarded as reflecting the position of the European Union.

Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012

Outline

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• Qualitative Comparative Analysis (QCA)• The National Health Insurance Scheme, Ghana• Calibration of the conditions• Results

• Tests for necessity

• Tests for sufficiency

• Discussion


Why QCA?

Compared to other frequently used methods, e.g. regression analysis, QCA has several distinct properties as it is able

•to identify necessary and sufficient conditions for an outcome,

•to display conjunctional causality (i.e. cases where single conditions are neither necessary nor sufficient, but configurations of conditions are),

•to display equifinality (i.e. different combinations of conditions leading to the same outcome)

(cf Schneider 2007)

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Truth table minimization and solution paths

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A B C Outcome

1 0 0 1

1 1 0 1

0 1 1 1

0 1 0 0

0 0 1 0

A: sufficient condition

B, C: insufficient but necessary parts of causal recipes wich are themselves unnecessary but sufficient (INUS)

A + A*B + B*C O

A + B*C O


Why fuzzy sets?

• Crisp sets differ in kind (0 or 1)

• Fuzzy sets: differ in kind and in degree of membership between 0 and 1

• fully in the set (1)

• fully out of a set (0)

• more in than out (>0.5; <1)

• more out than in (<0.5; >0)

• three qualitative anchors (1, 0.5, 0)

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Outline

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• Discussion


Aim of the analysis and data

• Identify relevant factors for enrolment decision in NHIS on basis of set relations

Are there conditions (conjunctions) necessary for enrolment? Which conjunctions of conditions explain membership [i.e.

search for INUS conditions]?

• Data source: Household Survey conducted in 2009: 299 hh (192 insured) in

West Gonja District

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Defining the outcome

• Enrolment in NHIS (West Gonja District) on household level Is the household enrolled in NHIS?

• Calibration of outcome: >=85% insured = fully in the set of insured hh <=30% insured = fully out of the set of insured hh Breakpoint at 59%: neither in nor out of the set of insured hh

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Conditions for membership in NHIS

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• short distance to hospital good physical access to healthcare provider as reason for

joining proven for NHIS: Witter and Garshong (2009), Sarpong et al.

(2010), Nketiah-Amponsah (2009)

• relatively high education better level of understanding of insurance principles and

benefits proven for NHIS: Jehu-Appiah, Aryeetey, Spaan et al. (2011) ,

Gobah and Zhang (2011), contradicting: Nketiah-Amponsah (2009), but only female respondents



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• relatively high income high socio-economic status increases ability to pay for product,

but also reduces need exemption policies in Ghana not well established: socio-

economic status still has an effect proven for NHIS: Jehu-Appiah, Aryeetey, Spaan, et al. (2011);

Nketiah-Amponsah (2009); Asante and Aikins (2008); Sarpong et al. (2010); Gobah and Zhang (2011)



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• relatively many children free enrolment of children whose parents are insured for the same amount of premium, more people are covered

and more expected expenditure is transferred to the insurance scheme studies in Ghana: not considered yet



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• trust in West Gonja scheme important role in insurance: leap of faith from part of insured

individual underlying process is unclear: does enrolment increase trust or

trust increase enrolment? strong causal link expected: positive experience increases trust

among insured; members lacking trust in the scheme are more likely to drop out studies on Ghana: trust is not considered

Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Microinsurance Research Conference, Twente University, 11th April 2012

Calibration of conditions

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Condition or outcome Breakpoint for 1 Breakpoint at 0.5 Breakpoint for 0

insured household

(insuredhh)

85% 59% 30%

short distance to hospital

(shortdist)

10 km 24.9 km 40 km

relatively high education

(highedu)

Junior secondary and higher

More than primary education

No formal education

relatively high income

(highinc)

195 ₵ 99 ₵ 31 ₵

many children

(manychildrenhh)

65% 49% 20%

trust in West Gonja scheme

(trust)


Outline

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• Discussion


Test for necessity

Condition Consistency level

trust 0.819019

short distance 0.725273

many children 0.644770

relatively high income 0.577378

relatively high education 0.524714

~relatively high income 0.446789

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no deterministic systematic exclusion of households from NHIS


Test for sufficiency – minimized truth table

shortdist highedu highinc manychildren trust cases insuredhh consistency

1 1 1 0 1 17 1 0.905

1 1 1 1 1 32 1 0.903

1 0 1 1 1 29 1 0.859

1 1 0 0 1 8 1 0.856

1 1 1 0 0 10 1 0.842

1 1 1 1 0 9 1 0.839

1 1 0 1 1 9 1 0.829

1 0 1 0 1 11 1 0.823

0 1 1 1 1 12 1 0.818

0 1 1 0 1 5 1 0.815

1 0 0 1 1 37 1 0.802

1 1 0 0 0 1 1 0.80017


Sufficient configurations of conditions

raw

coverage

unique

coverage

consistency

shortdist * ~manychildrenhh * highedu 0.230103 0.031467 0.899846

shortdist * highedu * highinc 0.329837 0.026529 0.913902

shortdist * manychildrenhh * trust 0.414841 0.128490 0.874839

shortdist * highinc * trust 0.381189 0.028451 0.895483

highedu * highinc * trust 0.335693 0.061273 0.891481

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equifinality absence of certain conditions can be compensated by others

solution coverage 0.67, solution consistency 0.87


Sufficient configurations of conditions

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•shortdist * trust * (highinc + manychildren)¹ → insuredhh

•shortdist * highinc * (highedu + trust) → insuredhh

•highedu * highinc * trust → insuredhh

•shortdist * highedu * (highinc + ~manychildren) → insuredhh

¹in Boolean algebra, * denotes AND and + OR


shortdist * trust * (highinc + manychildren)

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good access to services

AND

trust in scheme

AND

ORcertain level of income high share of children in household


shortdist * highinc * (highedu + trust)

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AND

certain level of income

AND

ORunderstanding of insurance trust in scheme


highedu * highinc * trust

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understanding of insurance

AND

ability to pay premium

AND

trust in scheme


Conclusion and outlook

• NHIS (West Gonja)• no deterministic systematic exclusion of certain population groups within NHIS

• high level of equifinality rather diverse household types enrolled

• certain amount of income/ressources important for enrolment (=indigent policy insufficient), yet not necessary

• QCA• promising tool for analysis

• next steps: add further conditions and districts

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Thank you!

Pro MHI Africa – EU-African University Network to strengthen community-based Micro Health Insurance


shortdist * highedu * (highinc + ~manychildren)

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AND

understanding of insurance

AND

ORcertain level of income NOT high share of children in household

philipp p. degens and christina may department for co-operative studies, university of cologne

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