In December 2018, the Ghanaian National Health Insurance Scheme (NHIS) introduced an innovative method of membership renewal and premium payment through the mobile phone. The new system uses the mobile money banking system to allow members to renew their membership on any of the mobile money platforms [
1]. This initiative is part of the effort of the NHIS to totally digitize enrollment and renewal [
1]. With this method, members can receive alert when their membership is due for renewal. It is thus expected to increase enrollment on the NHIS.
The NHIS was introduced in Ghana in 2003 to replace the existing out-of-pocket fee-paying system locally known as Cash and Carry. Under the Cash and Carry system, patients paid for healthcare provided at the point of purchase. While the Cash and Carry might have provided the much-needed revenue to run health facilities in the health sector, it imposed a financial burden on the poor with the accompanied negative impact on health due to underutilization of care [
2]. Under the NHIS, members do not make copayment and so the Scheme provides financial risk protection to its members. However, enrollment on the NHIS has been slower than expected, with the current coverage being about 40% of the population, implying that the NHIS does not even cover half of the population.
Currently, registration and renewal of membership involve travelling to the NHIS designated areas for the service and this may impose a high travel cost on members in terms of money, time, and the inconvenience. There have been many studies on the factors affecting enrolment on the NHIS. Some of the factors identified as impeding growth in enrollment include poverty, quality of care in NHIS accredited facilities, culture, inadequate distribution of social infrastructure, religion, among others [
3,
4]. None of these studies however included transportation and time cost for renewal or registration of the insurance as factors. According to the NHIS, the introduction of membership renewal by mobile phone was to relieve the NHIS members of the stress of spending long period at NHIS offices for registration and renewal [
5]. The use of mobile phone for membership renewal and premium payment is expected to ease membership renewal and improve enrollment as well as retention of membership. The electronic renewal system was piloted in a district each in the Northern and Eastern regions [
1]. The policy raises a lot of questions including factors that ensure its success. The purpose of this study is to find the determinants of NHIS members’ patronage of the electronic renewal of their membership via mobile phones in the Ashanti region of Ghana.
The NHIS in Ghana
The membership of the NHIS is categorized into eight: those in the informal sector, those under 18 years old, the 70-year old and older, Social National Insurance Trust (SNNIT) contributors, SNNIT pensioners, pregnant women, indigents, and members under the Livelihood Empowerment Against Poverty (LEAP). With the exception of those in the informal sector, none of the members pay premium. However, all need to register for membership and renew their membership every year. Under the initiative, all categories can renew their membership by mobile phone, while those in the informal sector also renew their membership and make payment of premium by mobile money [
1].
Ghana’s vision to alleviate the burden of healthcare cost of its citizens was realized in 2003 when the NHIS was introduced. The core objective of the Scheme is to provide equity in the health sector as well as ensure affordable healthcare for the poor [
6], an objective which is consistent with the universal health coverage (UHC). The NHIS is then an instrument for the achievement of UHC in Ghana [
6]. The Sustainable Development Goal 3.8 is the achievement of UHC with financial risk protection and access to quality essential health services as well as medicines and vaccines. It is important for the NHIS to expand both enrollment and retention rates of membership in order to provide the needed financial risk protection to all because the annual growth rate of enrollment on NHIS is only about 1% [
7,
8].
Some studies done on the NHIS reveal that the insurance premium may not be affordable to some members in the informal sector under the current payment system due to irregularity in their income streams [
9,
10]. The pre-mobile phone payment system (MPPS) is characterized by non-flexibility in insurance payment, transportation time and cost, long waiting time in queues at the NHIS offices. These problems arising from such payment method could explain why enrollment and retention onto the scheme are low for people in the informal sector. For the NHIS members in the informal category, membership is a function of premium, therefore, affordability of the premium can predict the enrollment or retention rates on the insurance scheme. One of the potential advantages of paying premium by mobile phone is that it is possible to introduce flexibility in payment to allow those who would normally not afford to pay their premium up front to make gradual payments for membership on the NHIS. It is therefore important to identify the factors that determine the success of the mobile phone renewal and payment system to ensure its success. Previous studies on factors affecting enrollment on the NHIS identified age, gender, health status, income status, availability of health facility, marital status, culture, and religion among others [
3,
4]. It is important to find out the extent to which these factors could also affect the patronage of the mobile phone renewal membership and payment of premium.
Mobile phone utilization
There has been a rapid increase in mobile phone penetration globally particularly in the Asia Pacific region, with 90% of the global and 80% of the rural population having access to a mobile network in 2010 [
11]. In that same year, the number of subscriptions reached 5.3 billion following earlier study in 2006 that reported an estimated subscription of 2 billion [
12]. This represents 76.2% global penetration rate. In Africa, the demand for mobile phones is huge and rapidly increases having recorded 50milliion subscribers in the past decade [
13]. This represents 7% of the continent’s population. With an annual growth rate of 35% according to Scott et al., [
13], it is expected that the current figure will overwhelmingly increase after 10 years.
The consideration of mobile phone for NHIS membership renewal in Ghana is as a result of extensive use of mobile phones in Ghana. Available statistics by Ghana’s National Communication Authority (NCA) indicate that the number of registered active mobile phone chips in Ghana as of December 2017 stands at 36.75 million. With a population of about 28.83 million in 2017 this is an indication that on the average, each Ghanaian has 1.27 mobile phones. Mobile phones are extensively utilized by the population in both the formal and informal sectors, and the utilization is expected to increase. The number of registered active mobile phone is projected to increase to 40 million while population is projected at 31 million in 2020 [
14].
The use of mobile phones in the health sector is not new but not much studies have been done to identify the factors affecting their success. Earlier studies have shown how mobile phones have played remarkable roles in healthcare delivery. For instance, text messaging interventions have been adopted to improve compliance to medication and to clinical appointments [
15‐
18]. The NHS Direct which is a nurse-led telephone service provides basic medical advice to callers 24 h a day, 7 days a week in the UK [
19]. Analysis of the calls showed that the service was patronized by male callers between 16 and 44 years [
19], implying that age and gender play an important role in the success of the program. A study that reviewed the literature on the use of mobile phone messaging interventions to support and improve preventive healthcare, health status and health behavior outcomes showed that only some selected interventions were successful [
20]. Information on users’ satisfaction which is an important determinant of the success of the intervention is unknown, A similar study also reports limited evidence that mobile phone messaging interventions are likely to provide benefit in supporting the self-management of long-term illnesses [
11]. The intervention involves the use of Short Message Service (SMS) and Multimedia Message Service (MMS) to improve patients’ self-efficacy skills through medication reminders and therapy adjustments or supportive messages [
11]. In Malawi, HIV and AIDS patients receive text messages daily to remind them about their medication schedule [
21]. Again, there is little evidence of the acceptability of the interventions. Furthermore, mobile phones have also been employed through SMS to support college students to quit smoking, but studies show that further research is needed to determine its success [
22].
None of the above interventions involved the use of mobile phone for healthcare financing. Ghana is however not the first to use mobile phone for health insurance membership renewal. Kenya has made a bold step by launching a mobile phone platform called “M-Pesa” (Mobile Money Payment System) for paying the health insurance premium on a monthly basis [
23]. The method of payment has become increasing popular among members of Kenya’s National Health Insurance [
23]. However, no study has been done on its patronage. In the case of Ghana, it is only now that the mobile money system is considered an avenue to pay for health care bills in some health facilities especially in private health care providers.
As already mentioned, there has been no study on the factors that determine the patronage in the use of mobile phone for renewal of membership and payment of premium of insurance. Just as characteristics of members were identified as being important in affecting the enrolment on the NHIS, the current study expects members’ characteristics to be important determinants of the patronage of the innovation. In accordance with the previous studies, factors to be examined include age, gender, education level, employment status, marital status, area of residence, and distance between residence and NHIS office. Previous studies [
3] have shown that females, older adults, the employed, married, and urban dwellers are likely to enroll on the NHIS. However, de Jongh et al., [
11] has shown that young males are likely to patronize services that require the use of mobile phone. The current study then examines the role of these characteristics in affecting the patronage of the mobile phone payment method and hence effect on enrolment on the NHIS.