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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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
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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Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
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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Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
Outline
7
• Qualitative Comparative Analysis (QCA)• The National Health Insurance Scheme, Ghana• Calibration of the conditions• Results
• Tests for necessity
• Tests for sufficiency
• Discussion
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
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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Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
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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Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
Conditions for membership in NHIS
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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)
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
Conditions for membership in NHIS
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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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
Conditions for membership in NHIS
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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)
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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Microinsurance Research Conference, Twente University, 11th April 2012
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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Microinsurance Research Conference, Twente University, 11th April 2012
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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Microinsurance Research Conference, Twente University, 11th April 2012
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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
shortdist * highinc * (highedu + trust)
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good access to services
AND
certain level of income
AND
ORunderstanding of insurance trust in scheme
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
highedu * highinc * trust
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understanding of insurance
AND
ability to pay premium
AND
trust in scheme
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
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
Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012
shortdist * highedu * (highinc + ~manychildren)
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good access to services
AND
understanding of insurance
AND
ORcertain level of income NOT high share of children in household