Determinants of Nonrenewal of National Health Insurance (Nhi) Membership Cards Among Healthcare Workers in the Kintamponorth Municipality, Bono East Region of Ghana

Introduction: National Health Insurance Scheme (NHIS) was implemented in Ghana in 2004 to serve as the lifeline to realizing Universal Health Coverage (UHC). Available evidence suggests that, formal sector workers do not promptly renew their expired NHIS membership cards. This study was therefore conducted to unearth factors responsible for the failure of healthcare workers in the Kintampo North Municipality to promptly renew their health insurance membership whenever it expires. Methods: A descriptive cross-sectional approach was used to conduct this study where three hundred and ninety-seven (397) participants were recruited using a proportionate strati�ed sampling technique. All variables with a p-value <0.25 at the bivariate analysis level were selected and put into multiple logistic regression analysis models for statistical signi�cance (p-value < 0.05). Odds ratios with their corresponding 95% Con�dence Interval were reported. A p-value < 0.05 was set as level of signi�cance. Results: Almost all the respondents (94.0%) had NHIS membership cards; out of which 70.7% had valid membership cards. 40.0% did not renew their expired NHIS membership cards for more than 7 months. From the study, reasons given for health workers’ inability to promptly renew NHIS membership included: 212 (19.8%) indicated forgetfulness, busy schedules 191 (17.9%), procrastination 167 (15.6%), self-medication 170 (15.9%) and utilization of spiritual homes (4.5%). All socio-economic factors were signi�cantly associated at the bivariate level (p<0.05). However, in the multiple logistic regression model, employment status, the type of health staff and monthly salary lost their statistical signi�cance. Conclusion: NHIS subscription and membership renewals is high among healthcare works in the Kintampo North District of the Bono East Region of Ghana. However, there is the need to encourage those who do not renew their expired cards by ensuring that more NHIS cards renewal centers are established at close proximity to the health facilities. It will be prudent for NHIS to liaise with Government of Ghana (GoG) to put measures in place to facilitate automatic membership renewals for public sector workers who for some other reasons often fail to


Introduction
Universal Health Coverage (UHC) through advance payment funding modality has proven to be a formidable vehicle for realizing the sustainable development goals (SDG) [1]. The National Health Insurance (NHI) was established to be the lifeline of UHC across the globe and Sub-Saharan Africa is no exception. Diverse types of Health Insurance (HI) could be identi ed in Sub-Sahara African countries such as Ghana, Nigeria, Kenya, Tanzania and Uganda [2]. According to [1,2] the National Health Insurance Scheme (NHIS) was implemented in Ghana in August, 2003 to increase access to quality healthcare services for all populations irrespective of one's social and nancial backgrounds. The National Health Insurance Fund (NHIF) receives its nancial strengths from ve main sources namely: Value-Added Tax (VAT), Social Security and National Insurance Trust (SSNIT) from the formal sector workers, proceeds from reserves of the National Health Insurance Authority (NHIA), contributions and premiums paid by the scheme subscribers. Exemptions are however, provided to the aged (70 years and above), SSNIT retirees, children who are below 18 years, pregnant women and people who are captured under Livelihood Empowerment Against Poverty (LEAP). Being a prepaid system, NHIS ensures mutual merging of risks and the redistribution of economic resources in a way that guarantees monetary security against the cost of ailments [3]. Similarly, a member of the NHIS could also enroll in a private health insurance scheme (HIS) as per Act 852 of parliament of Ghana. This same Act enjoins all employers to ensure their employees are registered under the NHIS [3].
Deprived households captured under social health insurance policies have reduced mortality and improved accessibility to health services. Also, out-of-pocket payments by well-to-do households have decreased by 64%, and has contributed to the reduction of out-of-pocket settlements by, between 16% and 18% [4]. According to a study established by [1] the NHIA has a predetermined bene t package; out of which almost 95% caters for common disorders being treated at health facilities in Ghana. Bene ts under the NHIS package include general out-patients and in-patients cares, reproductive, child and maternal cares, ophthalmic, oral and emergency care services, and a detail of essential drugs pre-quali ed by the NHIA are also paid for by the scheme. Cosmetic surgeries, dialysis and organ transplants are not paid for by the scheme.
Management of Human Immunode ciency Virus (HIV) and Acquired Immune De ciency Syndrome (AIDS), Expanded Program on Immunization (EPI) and family planning services are included in the NHIA for payments. In 2012, through an Act of Parliament of the Republic of Ghana, the membership of NHIS was made compulsory for all inhabitants of the country. Out of the 18.5 million people who subscribed to the scheme, just 10 million denoting 40% were valid; a situation that has the potential of obstructing the nation's goal of achieving 100% HI coverage for the populace by the year 2030 [5].
A study conducted by [6] established that the HI in Africa is struggling and it was predicted in 2007, that over 7 million people in Ghana had subscribed to cover 35% of the main workforce. Discovery from investigations carried out by [7] on the factors that in uence enrolment and retention in Ghana's NHIS showed that the determinants are multi-dimensional and encompass all shareholders. It further detected that subscribers register and renew their memberships with NHIS because of the bene ts and healthcare service providers' positive behaviors; limitations to enrolment and retention include but not limited to poverty, disappointments and attitudes of healthcare service providers. Again, traditional risk-sharing arrangements in uenced the renewal of membership cards because they need healthcare services. In 2014, a study conducted among 180 healthcare service providers in Lagos State, Nigeria, by[8] revealed that only 61% of the participants accepted NHIS clients and not only that but also, half of the participants were dissatis ed with the operations of the scheme. The operations of the NHIS in Ghana is endangered in terms of nances and effective operational determinants like spatial distribution of healthcare facilities and professionals, large exemption classi cations, inadequate sensitization of the public, poor quality care in NHIS approved facilities, hence, reduction in enrolments and or renewals of membership cards [9]. Enrolment and renewal of NHI memberships are recognized to have helpful effects in advancing accessibility to healthcare delivery services and produce mechanisms of preventing exorbitant healthcare expenses that have the potential of plunging low resourced households into poverty [10].
Formal sector workers are exempted from the at rate premium deductions because their premiums are deducted from their SSNIT contributions to the scheme, however, that does not qualify them to be automatic members of the scheme until they enroll with any district health insurance management scheme (DHIMS) of their choices and pay the required registration fee [10]. NHIS subscriptions have been explored by quite a number of scholars, however, these studies were carried out on the scheme managers and service providers with dearth focus directed at subscribers with little attention given to factors in uencing nonrenewal of NHIS membership cards among healthcare workers [11]. Some studies have established the factors impacting the enrollment and retention of NHIS memberships in the Ashanti, Eastern, Central and Volta Regions of Ghana [5]. Searches in relevant literature produced no results of scholarly study conducted in Kintampo North Municipality of the Bono East Region regarding factors responsible for the renewal or otherwise of health insurance membership among healthcare workers. It is in view of this that this study was carried out to determine the factors that in uence non-renewal of NHIS membership cards among healthcare providers in the Kintampo North Municipality of the Bono East Region, Ghana.

Study area
The study was conducted in the Kintampo North Municipality of the Bono East Region, Ghana West Africa.

Study Design
This was a municipality-based descriptive cross-sectional study that employed quantitative data collection methods. Participants were recruited within a duration of 12 weeks in the Kintampo North Municipality.

Study Population
The population under study comprised healthcare workers within the Kintampo North Municipality who were in active service. A total of three hundred and Ninty-Seven participants were interviewed.

Inclusion and Exclusion Criteria
All healthcare workers within the Kintampo North Municipality who were in active service were given equal opportunity to participate in the study. Healthcare workers who were on retirement, those doing their national service, students on industrial/clinical attachments were not recruited to participate in the study.
Healthcare providers who met the inclusion criteria but were unwilling to participate were excluded from the study.

Sample Size Estimation, Sampling Technique and Procedure
The sample size was estimated using Yamane's formula of sample size estimation [12], with a con dence interval of 95% and margin of error of 5%. The municipality had an estimated total healthcare providers of 1061. The nal sample size was estimated as 320 including a 10% non-response rate.
Eventually, a total of 397 healthcare workers were recruited during the data collection period using google forms from October, 2021 to December, 2021. Proportionate strati ed sampling technique was used to organize participants into two strata, Mechanized staff (849) and casual staff (212). In the second stage, portions of the sample size were allocated to the two categories based on their ratio to the total staff population (mechanized staff = 256 and casual staff = 64). In the nal stage of the technique, a link to the google form questionnaire was sent to the WhatsApp platforms of each stratum. The rst 397 entries by end of 31 st December, 2021 midnight were used for the study.

Data Collection Tools and Procedures
The data was gathered using a structured questionnaire. The questionnaire was designed based on the objectives of the study to elicit information from the participants. The questionnaire was segmented into sections A and B. Whilst the Section A composed of the socio-economic and demographic characteristics of respondents, Section B consisted of the proportion of respondents with valid NHIS membership cards. The questionnaire was piloted among 15 healthcare workers in the Kintampo South District which shares geological boundary with the study setting and has similar socio-economic and demographic characteristics as those in the study setting. This was to ensure the reliability and consistency of the instrument. The appropriate corrections were effected before the actual data collection was carried out on the study participants. The questionnaire was digitized and shared on WhatsApp platforms made of only the study participants (healthcare workers in the Kintampo North Municipality). The digitized questionnaire was restricted in such a way that multiple responses from the same device were not allowed.

Statistical Analysis
Data was entered, cleaned and managed using Microsoft excel version 16. The data was later exported to Stata version 15 and analyzed. Gender, religion, marital status, educational level were coded as categorical variables. Age was collected as continuous variable and categorized during analysis.
Descriptive statistics were used to present the proportions on background characteristics of the respondents at the univariate level. Binary and multiple logistic analysis were performed to establish the strength of associations between socio-demographic and socio-economic factors in uencing the nonrenewal of NHIS membership. All variables with p-value <0.25 at the bivariate analysis level were selected and put into a multiple logistic regression analysis model for statistical signi cance (p-value < 0.05). Odds ratio with their corresponding 95% Con dence Interval were reported. A p-value < 0.05 was set as level of signi cance.

Ethical Clearance
The study was carried out in strict adherence to the 1964 Helsinki declaration as revised in 2013 [13]. Ethical clearance was sought and obtained from the Kintampo Municipal Hospital Institutional Review Committee (KMH-IRC023/09/21) before data was collected. Verbal and written consents were obtained from the participants before they were allowed to participate in the study. Adequate information about the study was provided to the participants regarding the aim of the study. Participants were assured and guaranteed of anonymity, privacy and con dentiality. Furthermore, they were guaranteed of data safety and appropriate data usage and storage on the digitized questionnaire. Only participants who consented were recruited into the study. All participants' personal identi ers were deleted from the summarised data, ensuring con dentiality.

Demographic Characteristics of Respondents
The study surveyed 397 healthcare workers in the Kintampo North Municipality to assess the determinants of nonrenewal of the National Health Insurance Membership card. The demographic characteristics are presented in Table 1. The minimum age of the respondents was 20 years whiles the maximum age was 48years. The mean age of the healthcare workers was 31.3 ± 4.7 years. The median age of these healthcare workers in the study was 30 years. Majority of the healthcare workers (51.9) were in age group 30-39 years, 42.1% were in age group 20-29 years while 6.0% were in age group 40-49 years. In terms of sex, the healthcare workers were approximately equally distributed with the females (52.1%) slightly edging out the men (47.9%). More than half of the healthcare workers (75.3%) were Christians. Majority of the healthcare workers (98.5%) reported having attended school before. The healthcare workers were of varying educational levels. Only 1.5% of the healthcare workers had no formal education. Majority of them (96.0%) had tertiary education. More than half of the healthcare workers (48.9%) were married while 1.5% were divorced (Table 1).  Proportion of respondents with valid NHIS membership cards The proportion of respondents who were willing to renew their NHIS membership upon expiration was 81.9% [(95%CI = 77.5-85.1)] (Fig. 1).
Most healthcare workers in this study 94.0% had NHIS membership card. Out of these, majority 70.7% had a valid NHIS membership card. Most of the healthcare workers (40.0%) with expired NHIS membership card did not renew their membership for at least 7 months while 24.4% of them had their cards expired between 0-3 months and 4-6 months respectively (Table 3).  Fig. 2.

Motivators for the renewal of NHIS membership
When quizzed about what should be done to encourage healthcare workers to renew their NHIS membership cards on time, it was observed that 271 (29.0%) expressed that strict measures should be put in place to stop self-medication. About a quarter of the healthcare workers were of the opinion that more institutional NHIS o ces should be created so that members can easily renew their membership when it expires. Some of the healthcare (8.7%) workers were of the view that membership renewal should be deducted at source (Fig. 3).

Demographic factors in uencing the nonrenewal of health insurance membership
Multiple logistic regression analysis was performed on all variables with p-value < 0.25 at 95% con dence interval. Adjusted odds ratio showed that level of education, religious a liation of healthcare workers and their marital status were signi cant predictors of nonrenewal of health insurance membership in the Kintampo North Municipality. Healthcare workers who have attained tertiary education were 5 times more likely not to renew their NHIS memberships compared to those without a formal education. Also the healthcare workers who were a liated to Christianity were 2.8 times likely not to renew their expired NHIS membership card compared to the traditional believers. Those who were divorced were 0.076 times likely not to renew their expired NHIS membership cards compared to those who were single. All other demographic characteristics were not signi cantly associated to nonrenewal of expired NHIS membership card (Table 4). controlled for, those with working experience of at least 8 years were 63.6% less likely to renew their health insurance membership compared those who have worked for less than 3 years (aOR = 0.36, 95% CI = 0.153-0.868). All other factors that were not statistically adjusted were not signi cant after adjusting (Table 5).  [14]. Also, further ndings from the study on the socio-economic characteristics of the study participants do not agree with [16,17] outcomes that suggested minimum monthly earnings of 200 Ghana Cedis and 300 Ghana Cedis respectively. These minimum monthly income earnings may be as a result of the kind of services they provide, their corresponding salaries, their market premiums and conditions of service, but, this may not translate into the real standard of living of the health workers in the municipality since the actual standard of living could be in uenced by their families, household sizes and the state of the country's economy.
Majority of the participants had some form of certi cates. This is consistent with studies by [14,18] which revealed that majority(more than 60%) and more than a third had graduated from senior high school or more respectively. Likewise, the nding in this study supports another one by [19]. However, most of the participants in this study were tertiary graduates which do not support previous ndings from studies carried out in Dormaa Municipality of Ghana[16] and [4,5,7]. Again, our nding on the level of education (tertiary) contradicts that of [20] in the Hohoe Municipality of Ghana. A similar study carried out in Nigeria discovered higher level of education being rst degree [8]. The difference in the level of education could be as result of the kind of services they provide and the certi cate requirements for that form of employment.
Almost all the respondents were NHIS subscribers and majority of them had a valid NHIS membership cards. This nding is consistent with that of [4,21] which reported higher proportions for those in the East Gonja District and patients who visited some selected healthcare delivery centers in some selected areas in Ghana. However, it is inconsistent with a similar study carried out by [22] which discovered that NHIS subscription and renewal rate were low. Again, our nding does not support the study by [23] which revealed that SSNIT contributors are unlikely to subscribe and renew their memberships with the NHIA.
This could be ascribed to the study participants' job descriptions, knowledge and experience they have gained on how to prevent diseases and not falling sick. Inferences from the study points that, most of the healthcare providers in KNM use NHIS as the key means of seeking healthcare. However, this current study discovery is about twice more than that of the 2012 and 2013 national level active NHIS membership which stands at 37% and 38% respectively [24].Similarly, this study outcome is higher than that of a study established by [25] in Barekese in the Ashanti Region of Ghana. It supports a study by [16] that revealed increment in NHIS subscriptions. Additionally, available literature from [22] indicated that majority(63.0%) had not renewed their NHIS membership cards which is in contradiction to this current study which revealed less than half of the respondents not renewing their NHIS membership cards. Majority of our study participants were however, willing to renew their NHIS memberships upon expirations. This discovery does not back previous studies ndings that revealed that less than half of the people had previously renewed their memberships with NHIS and signi cant others not willing to renew their cards upon expirations [7,[26][27][28].
A number of barriers were identi ed by the study to be responsible for the nonrenewal NHIS membership cards. These barriers included forgetfulness, busy schedules, self-medications, procrastination and the choice of spiritual homes which do not require NHIS membership cards. These challenges are in variance with studies established by [7,16,22] which reported non affordability of renewal premiums, dissatisfaction of NHIS services, the need to buy drugs outside NHIS accredited facilities, vast distances to health facilities and no transportation fares, NHIS covered drugs are of low quality and feeling being healthy. Again, this study nding is inconsistent with available literature that stated long waiting in queues to renew NHIS memberships due to administrative protocols as barriers to NHIS dropouts and non-renewals [3]. Evidence from the Hohoe Municipality of Ghana in a study carried out by [20] does not support our ndings on the barriers to the renewals of NHIS membership cards. According to another study conducted in Ghana on the informal sector workers also made discoveries that do not support our ndings [29], however, in the rural South -Western Uganda ndings from a similar study revealed high premiums as the major barrier [30]. These variations in the barriers to the renewal of NHIS membership cards may be due to differences in the geological locations of the study settings, the sector they nd themselves and the caliber of the study participants involved in the study.
Interestingly, there were a signi cant number of factors that could be used motivate healthcare workers to renew their membership cards. These reasons included: the need to put in place strict measures to curb self-medications, establishment of institutional NHIS o ces, at source deductions or deductions from the Controller and Accountant Generals Department (CAGD) for automatic renewals of NHIS membership cards, creation of renewal centers closer to health facilities and education/promotion of NHIS cards renewals. This is inconsistent with a similar study from [9] that reported on geographical accessibility of accredited health facilities in terms of expansion, stringent monitoring mechanisms on health providers and early reimbursement of health providers. Again, our ndings contradict that of another study that proposed that the introduction of instant NHIS membership cards at the point of registration and the electronic renewal methods are likely to alleviate and motivate the protracted registration and renewals process [1]. The high mobile phone penetration in Ghana gives a special chance for NHIA to apply the voice or short text messages as techniques to educate the general public about the procedures of the scheme which can also include sending reminders to NHIS customers whose memberships are nearing expiration to avoid inadvertent loss of memberships; text messages have been con rmed to stay on mobiles phones for longer periods and could remind individuals better and further [1,31]. Above that, ndings from our study on the motivators for renewals of NHIS membership cards are inconsistent with that of [7]. The variations in the motivators for the renewals of NHIS membership cards could be attributed to the fact that there are varied ways of motivating clients and they could be client speci c depending on choices coupled with individual and group interests.
It was further revealed that, educational level (tertiary), religious a liation (Christianity) and marital status (being divorced) were signi cant predictors of non-renewal of NHIS membership cards. This is consistent with previous studies carried out by [5,14]. However, it is in contrast with earlier studies by [21,24] which revealed that educational level, marital status and religious beliefs were insigni cant predicators to non-renewal of NHIS membership cards. In addition, our ndings on educational level being a signi cant predictor to NHIS nonrenewal agrees with that of [32]. Again, our ndings are inconsistent with other discoveries by [29] that suggested that educational level and religious a liation were signi cant predictors to non-renewal of NHIS membership cards. The results suggest that having a spouse/partner could be bene cial because of the nancial assistance obtained from being in a dualincome household, which increases the probability of renewing NHIS membership cards. Those who had attained tertiary education being more likely not to renew their NHIS membership cards compared to those without a formal education may be because at that level of their educational status, they might have accumulated su cient knowledge on primary prevention of diseases. Hence, no need to subscribe or renew their NHIS memberships. Furthermore, it is possible they have other alternative health insurance policies.

Conclusion
The study discovered that almost all the healthcare workers in the KNM had subscribed to NHIS and majority had their membership cards valid. However, signi cant number of them whose NHIS cards had expired had not renewed them for the past seven months, a situation that calls for practical efforts to sensitize people on the need to promptly renew their memberships with NHIA.
Conscious efforts should be made by the NHIA and its accredited facilities to reduce NHIS card waiting time and bureaucracies in accessing healthcare with the NHIS; this will encourage more people to subscribe or renew their memberships. This could be in the form creating more NHIA o ces/ renewal centers closer to health facilities.
Above that, policymakers must apply the compulsory subscription provision in the rules governing the set-ups of the scheme. This could be realized by ensuring that subscription and renewals of NHIS membership cards are requirements for accessing certain services in both public and private institutions such as securing passports, driving licenses and gaining admissions to schools.
Eventually, pragmatic measures ought to be implemented by stakeholders and policymakers, the Municipal Health Directorate (MHD), Regional Health Directorate (RHD), the Municipal Health Insurance Authority (MHIA), Ministry of Health and its agencies to intensify education and promotion of NHIS membership renewals; attention should be paid to measures that could NHIS membership subscriptions and prompt renewals of expired membership cards.

Limitations
As with self-reported surveys, there was recall bias among some of the study participants in determining exactly when their NHIS membership cards expired. It is a cross sectional study, hence causality cannot be established. The sample size wasn't large enough for some factors that were statistically signi cant, as such they had wider con dence interval.

Declarations
Ethics approval and consent to participate Ethical clearance was sought and obtained from the Kintampo Municipal Hospital Institutional Review Committee before data was collected. The ethics application was approved on the 10 th September 2021. The clearance certi cate number is KMH-IRC023/09/21.

Consent for publication
Not applicable Availability of data and material All data generated or analyzed are available on request

Competing interests
Mustapha Hallidu conceptualized the topic, drafted the manuscript and collected the data.
Issah Sumaila analyzed the data. Both authors reviewed the manuscript before submitting it for publication.

Figure 1
Proportion of respondents willing to renew their NHIS card What should be done to encourage healthcare workers to renew their NHIS membership cards on time