Emerging Project Lessons
Certain key messages about HMI resonate better with low-income clients; pilot-testing is a good way to test and improve these messages. For example, during the field test, Freedom from Hunger observed that low-income households may place more value on the range of insurance benefits to enable them to access needed care and reduce the total costs related to illness, and place less value on insurance as a mechanism that helps prevent illness or promotes health. (Note that the NHIS covers consultations and prenatal care.) Specifically, they learned that an important message to stress to consumers is that the cost of illness includes lost opportunity to generate income.
Lessons on how insurance works must be simple and minimize the use of insurance terminology. The focus should be on general advantages one might gain from the ability to access care when needed (in this case without cash in hand) and the financial protection afforded by the HMI (such as ability to work, no need to borrow money from friends and family and financial security).
It is potentially beneficial to reinforce messages about the benefits of HMI when re-enrolment occurs. In the field test, Freedom from Hunger observed that some clients who had HMI did not use it, were not sure of its benefits, or had discontinued making annual premium payments after initially enrolling at some time in the past. Thus it was observed that there was a need to also provide education about the requirements and process to re-enrol before the re-enrolment period.
Consumer education tools must be flexible; the development process should allow for adaptation and include field-testing. Freedom from Hunger has developed consumer education materials in a number of settings, and the experience in Ghana with the NHIS product has confirmed the importance of using an iterative and structured process that incorporates a range of considerations, such as the existing knowledge base of the population, language, culture and customs. The features of the product and how it works on the ground must also be reflected. As Freedom from Hunger gained a greater understanding of the features and functioning of the NHIS, coupled with understanding of the knowledge and perceptions of prospective enrollees, it was able to refine the education tools and approach.
Insurance product enrolment, and by extension interventions such as consumer education, should be timed to coincide with availability of discretionary income. The average annual premium and fees of about $12.00 for an adult to enrol in the NHIS product, while low, is reported as a challenge for low-income persons to pay, especially when multiple family members need to be enrolled. Since many of the target clients in this region in Ghana have income-generating activities that are tied to agriculture, their total annual income varies by season, depending on cycles for planting and harvesting crops. Targeting enrolment outreach for times when cash may be more available can help, although it may not completely address the challenge of having sufficient cash on hand to enrol larger families. More flexible payment arrangements or simple financing such as small additional amounts added to MFI client business loans (“top-ups”) and savings schemes similar to “sou-sou”s (informal savings groups) are other possible ways to address this enrolment barrier.
Implementing field partners, such as MFIs, need to be carefully informed about how to participate in a randomized control study, and monitored. Because one or more managers of SAT did not understand that they should refrain from promoting NHIS enrolment until the demonstration test, and instead proceeded to encourage or even require new loan clients to enrol in the NHIS, Freedom from Hunger had to quickly react to mitigate the risk of a “contaminated sample”. Freedom from Hunger, SAT and IPA assessed the impact using group census data and determined that the study population was still suitable for the demonstration test and that no material changes to the population sample or study design would be required.
Surveys for rigorous impact studies are best implemented by an objective, trained third party. Although trained surveyors add cost to a study, it can be a worthwhile investment. Although most of the data collected for this study was done by trained surveyors working under close supervision of the research partner (IPA), Freedom from Hunger decided to ask its MFI partner to conduct post-education knowledge tests. Despite best intentions, the field support of the MFI partner to conduct the sampling and data collection according to defined rigorous standards broke down in several cases. Only 155 of 600 surveys were completed, and without adherence to the rules to maintain randomization. Finally, the field staff may inject an unintended bias to report positive change, thinking this will reflect positively on them or their clients. All of these consequences have implications on the quality of the research, and hence the confidence that can be placed in the final results for the knowledge-change information.
Date of last Learning Journey update: March 2013