Abstract
BackgroundThe National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003, enrolment is still far from the desired target of universal coverage. Low community engagement in the design and management of the system was identified as one of the main barriers. The aim of the current study was to explore the role of social capital in NHIS enrolment in two regions of Ghana, Western and Greater Accra.MethodsThe study involved a cluster-randomised controlled trial of 3246 clients of 64 healthcare facilities who completed both a baseline and a follow-up survey. Thirty-two facilities were randomly selected to receive two types of intervention. The remaining facilities served as control. The interventions were co-designed with stakeholders. Baseline and follow up surveys included measures of different types of social capital, as well as enrolment in the health insurance scheme.ResultsThe study found that the interventions encouraged NHIS enrolment (from 40.29 to 49.39% (intervention group) versus 36.49 to 36.75% (control group)). Secondly, certain types of social capital are associated with increased enrolment (log-odds ratios (p-values) of three types of vertical social capital are 0.127 (< 0.01), 0.0952 (< 0.1) and 0.15 (< 0.01)). Effectiveness of the interventions was found dependent on initial levels of social capital: respondents with lowest measured level of interpersonal trust in the intervention group were about 25% more likely to be insured than similar respondents in the control group. Among highly trusting respondents this difference was insignificant. There was however no evidence that the interventions effect social capital. Limitations of the study are discussed.ConclusionWe showed that the interventions helped to increase enrolment but that the positive effect was not realized by changes in social capital that we hypothesised based on result of the first phase of our study. Future research should aim to identify other community factors that are part of the enrolment process, whether other interventions to improve the quality of services could help to increase enrolment and, as a result, could provide community benefits in terms of social capital.Our findings can guide the NHIS in Ghana and other health organizations to enhance enrolment.Trial registrationEthical Clearance by Ghana Health Service Ethical Committee No. GHS-ERC 08.5.11.
Highlights
Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 to improve access to universal quality healthcare
This paper reports on the study on enrollment in the NHIS in Ghana, and the role of social capital therein
According to the independent t-test, the 4 percentage point higher insurance coverage of the intervention group at baseline is significant at the 5% level (ΔM = − 3.80, p = 0.029)
Summary
Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 to improve access to universal quality healthcare. It replaced a cash and carry system that required upfront payment from individuals at the point of service usage. The scheme increased the number of people with access to health insurance, but enrolment levels have stayed well below the desired universal coverage target. Communities with low levels of social trust and trust in healthcare service have been found to have below average active membership [8], suggesting that social capital may play role in NHIS enrolment in Ghana. The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003, enrolment is still far from the desired target of universal coverage. The aim of the current study was to explore the role of social capital in NHIS enrolment in two regions of Ghana, Western and Greater Accra
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