Abstract
In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) to move towards Universal Health Coverage. NHIS enrolment is mandatory for all Ghanaians, but the most recent estimates show that coverage stands under 40%. The evidence on the relationship between socio-economic characteristics and NHIS enrolment is mixed, and comes mainly from studies conducted in a few areas. Therefore, in this study we investigate the socio-economic determinants of NHIS enrolment using three recent national household surveys. We used data from the Ghanaian Demographic and Health Survey conducted in 2014, the Multiple Indicator Cluster Survey conducted in 2011 and the sixth wave of the Ghana Living Standard Survey conducted in 2012–13. Given the multilevel nature of the three databases, we use multilevel logistic regression models to estimate the probability of enrolment for women and men separately. We used three levels of analysis: geographical clusters, household and individual units. We found that education, wealth, marital status—and to some extent—age were positively associated with enrolment. Furthermore, we found that enrolment was correlated with the type of occupation. The analyses of three national household surveys highlight the challenges of understanding the complex dynamics of factors contributing to low NHIS enrolment rates. The results indicate that current policies aimed at identifying and subsidizing underprivileged population groups might insufficiently encourage health insurance enrolment.
Highlights
In low- and middle-income countries (LMIC) one of the obstacles for Universal Health Coverage (UHC) is including vulnerable populations in social health protection schemes such as social health insurance (WHO, 2010, 2013)
National Health Insurance Scheme (NHIS) enrolment is mandatory for all Ghanaians, but the most recent estimates show that coverage stands under 40%
The three surveys included three different possible answers to the question regarding enrolment in the NHIS: ‘no’, ‘yes card seen’ in case the person was able to show a valid card during the interview and ‘yes, card not seen’ when the person was not able to show the card to the enumerator
Summary
In low- and middle-income countries (LMIC) one of the obstacles for Universal Health Coverage (UHC) is including vulnerable populations in social health protection schemes such as social health insurance (WHO, 2010, 2013). In 2003, the government of Ghana implemented a single National Health Insurance Scheme (NHIS) that requires all Ghanaians to enrol either into the NHIS, or into one of the private health insurance schemes. Each of these schemes are required to provide basic health care benefits as delineated by the National Health Insurance Authority. The NHIS yearly premium ranges from GHS 7.20 (USD 1.60) to GHS 48.00 (USD 10.60) per person, depending on the region of residence (http://www.nhis.gov.gh/faqs.aspx). All members must pay an initial membership card processing fee of GHS 8.00 (USD 1.82) and GHS 5.00 (USD 1.14) for yearly renewal
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