1. 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 11 th 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.

2. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 Outline 2 Qualitative Comparative Analysis (QCA) The National Health Insurance Scheme, Ghana Calibration of the conditions Results Tests for necessity Tests for sufficiency Discussion

3. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 Basic features of Qualitative Comparative Analysis (QCA) QCA is based on set-relations QCA is case-oriented rather than variable-oriented QCA uses Boolean Algebra (binary data) QCA assumes asymmetric causality (necessary and sufficient causes): instead of correlational patterns 3

4. 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) 4

5. 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 5 ABCOutcome 1001 1101 0111 0100 0010 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

6. 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)  three qualitative anchors (1, 0.5, 0) 6

7. 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

8. 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 8

9. 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 9

10. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 Conditions for membership in NHIS 10 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

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

12. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 Conditions for membership in NHIS 12 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

13. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 Conditions for membership in NHIS 13 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

14. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Microinsurance Research Conference, Twente University, 11th April 2012 Calibration of conditions 14 Condition or outcomeBreakpoint for 1Breakpoint at 0.5Breakpoint for 0 insured household (insuredhh) 85% 59%30% short distance to hospital (shortdist) 10 km24.9 km40 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)

15. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 Outline 15 Qualitative Comparative Analysis (QCA) The National Health Insurance Scheme, Ghana Calibration of the conditions Results Tests for necessity Tests for sufficiency Discussion

16. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Microinsurance Research Conference, Twente University, 11th April 2012 Test for necessity ConditionConsistency level trust0.819019 short distance0.725273 many children0.644770 relatively high income0.577378 relatively high education0.524714 ~relatively high income0.446789 16  no deterministic systematic exclusion of households from NHIS

17. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Microinsurance Research Conference, Twente University, 11th April 2012 Test for sufficiency – minimized truth table shortdisthigheduhighincmanychildrentrustcasesinsuredhhconsistency 111011710.905 111113210.903 101112910.859 11001810.856 111001010.842 11110910.839 11011910.829 101011110.823 011111210.818 01101510.815 100113710.802 11000110.800 17

18. 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 * highedu0.2301030.0314670.899846 shortdist * highedu * highinc0.3298370.0265290.913902 shortdist * manychildrenhh * trust0.4148410.1284900.874839 shortdist * highinc * trust0.3811890.0284510.895483 highedu * highinc * trust0.3356930.0612730.891481 18  equifinality  absence of certain conditions can be compensated by others solution coverage 0.67, solution consistency 0.87

19. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 Sufficient configurations of conditions 19 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

20. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 shortdist * trust * (highinc + manychildren) 20 good access to services AND trust in scheme AND OR certain level of income high share of children in household

21. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 shortdist * highinc * (highedu + trust) 21 good access to services AND certain level of income AND OR understanding of insurancetrust in scheme

22. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 highedu * highinc * trust 22 understanding of insurance AND ability to pay premium AND trust in scheme

23. 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 23

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

25. Degens, May: Analysing Membership in the NHIS, Ghana – applying QCA Research Conference on Microinsurance, Twente University, 11th April 2012 shortdist * highedu * (highinc + ~manychildren) 25 good access to services AND understanding of insurance AND OR certain level of incomeNOT high share of children in household