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Philipp P. Degens and Christina May Department for Co-operative Studies, University of Cologne

Philipp P. Degens and Christina May Department for Co-operative Studies, University of Cologne Research Conference on Microinsurance, University of Twente, April 11 th 2012. Pro MHI Africa – EU-African university network to strengthen community-based micro health insurance.

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Philipp P. Degens and Christina May Department for Co-operative Studies, University of Cologne

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

  2. Outline • Qualitative Comparative Analysis (QCA) • The National Health Insurance Scheme, Ghana • Calibration of the conditions • Results • Tests for necessity • Tests for sufficiency • Discussion

  3. Why QCA? Compared to other frequently used methods, e.g. regression analysis, QCA has several distinctpropertiesasitisable • 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)

  4. Truth table minimization and solution paths A: sufficientcondition B, C: insufficient but necessarypartsofcausalrecipes wich arethemselvesunnecessary but sufficient (INUS) A + A*B + B*C  O A + B*C  O

  5. 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)

  6. Outline • Qualitative Comparative Analysis (QCA) • The National Health Insurance Scheme, Ghana • Calibration of the conditions • Results • Tests for necessity • Tests for sufficiency • Discussion

  7. 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

  8. 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

  9. Conditions for membership in NHIS • 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

  10. Conditions for membership in NHIS • 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)

  11. Conditions for membership in NHIS • 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

  12. Conditions for membership in NHIS • 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

  13. Calibration of conditions

  14. Outline • Qualitative Comparative Analysis (QCA) • The National Health Insurance Scheme, Ghana • Calibration of the conditions • Results • Tests for necessity • Tests for sufficiency • Discussion

  15. Test for necessity  nodeterministicsystematicexclusionofhouseholdsfrom NHIS

  16. Test for sufficiency – minimized truth table

  17. Sufficient configurations of conditions solution coverage 0.67, solution consistency 0.87  equifinality  absence of certain conditions can be compensated by others

  18. Sufficient configurations of conditions • 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

  19. shortdist * trust * (highinc + manychildren) good access to services AND trust in scheme AND OR certain level of income high share of children in household

  20. shortdist * highinc * (highedu + trust) good access to services AND certainlevelofincome AND OR understanding of insurance trust in scheme

  21. highedu * highinc * trust understanding of insurance AND ability to pay premium AND trust in scheme

  22. 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

  23. Pro MHI Africa – EU-African University Network to strengthen community-based Micro Health Insurance Thank you!

  24. shortdist * highedu * (highinc + ~manychildren) good access to services AND understanding of insurance AND OR certain level of income NOT high share of children in household

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