Trust is key for success of Ghanaian health scheme

20 January 2015

To identify and reduce barriers perceived by people to enroll in health insurance requires a deep understanding of their perceptions on illness, care and insurance in their own socio-cultural context. This is important as trust between healthcare client, provider and insurer is key for the success of a health insurance, concluded Christine Fenenga in her PHD-thesis 'A matter of trust – Clients’ perspective on healthcare and health insurance services in Ghana'. Fenenga successfully defended her thesis in the grand hall of the Academy building of the University of Groningen in the north of the Netherlands.

Western Region health care clients. Picture: Christine Fenenga

In 2003, the Ghanaian government introduced national social health insurance called the National Health Insurance Scheme (NHIS) to promote access to affordable quality health care for the entire population, including the poor and vulnerable. The NHIS achieved an enrollment rate of 34 per cent of the population by 2011, but various challenges made it hard to retain this enrollment rate, let alone to increase active membership rates. Reason for the National Health Insurance Authority (NHIA) responsible for the overall management of the NHIS, to commission a study to find the driving factors and barriers for people to enroll and retain in the scheme.

The commissioned study consisted of three sub-studies, one of which was Fenengas research among Ghanaian communities. Her focus is on the clients’ perspective while the other two sub-studies explore the perspectives of healthcare providers and health insurer.

In her study, Fenega explores the socio-cultural dimensions in the community that influence clients’ behavior and decision making to utilise healthcare and health insurance services. Understanding people’s behavior and decision making, the researcher writes and demonstrates in her thesis, requires a deep understanding of their beliefs and values regarding illness, health seeking, health care and health insurance services, while taking into account the embedding of communities in a wider (health) system. This is explained by her conceptual framework: the Integrated Health Model. Because of the complex health insurance context and the multi stakeholder involvement, with their different needs and expectations, Fenenga uses the Participative Action Approach. Regular stakeholder meetings with clients together with their healthcare providers and the NHIS, are part of the linked trajectory of qualitative and quantitative methods. These meetings facilitate interaction and communication and foster relationships and understanding between the stakeholders (social change). By studying these processes insight was obtained in power relations that exist between stakeholders. These varied between Western Region and Greater Accra Region.

Cultural beliefs and communication

Focus group clients in Greater Accra Region. Picture: Christine Fenenga

The three different perspectives of clients, healthcare providers and NHIS combined provide a clear insight in their different ‘cultural lenses’ related to illness, choice of healthcare and health insurance services can be the cause of barriers to health insurance. A specialist doctor has a different perception of what is quality of care than a patient who lives in a rural village. Ignoring such differences can have a negative consequences for the communication between the different participants in the triangle of clients, provider and insurer, leading to misunderstanding or even mistakes in treatment and less trust. By paying more attention to these different ‘cultural lenses’, making them explicit and training staff to be aware of them, these problems can be reduced and trust build.

Social capital and trust

As part of her study, Fenenga looked at the role of social capital in people’s motives to seek health care and insurance services. A definition of social capital is the ‘networks of community relationships that facilitate trust and motivate action’ (Coleman, 1990). Her findings confirmed earlier studies concluding that people living in communities with strong social networks and mutual trust (horizontal social capital) are significantly more likely to participate in the insurance scheme than those living in communities with less social cohesion. She also found that people with higher levels of trust in the formal institutions (services providers) are more likely to enroll. A good relationship between clients, providers and NHIS (vertical social capital) is essential in establishing trust among participants. This relationship requires consistent, transparent information and reliable quality services as perceived by clients.


To build trust among stakeholders Fenenga developed the intervention MyCare as part of her research. Clients together with providers and insurer assess the healthcare and health insurance services and discuss practical solutions to improve the service delivery and make these more client-centered. Findings reveal that participation of all stakeholders in assessing the health services enhances the exchange of information between healthcare providers, NHIS and clients and improves the perceived quality of services (83 per cent). This promotes mutual trust and understanding among the stakeholders. The clients’ active role in this process stimulates awareness of their needs, interests and participation in influencing the health services. This encourages clients’ self-confidence and empowers them. At the same time, MyCare result inform healthcare providers and the NHIS how their services could be improved to better meet clients’ needs.


Source: University of Groningen