Ghana National Health Insurance Scheme Research Articles

Heterogeneous effects of national health insurance scheme on healthcare utilisation: evidence from Ghana

PurposeThis paper aims to evaluate Ghana's National Health Insurance Scheme (NHIS) on healthcare utilisation by exploring its heterogeneous effects based on residential status and wealth.Design/methodology/approachThe study used the Ghana Socioeconomic Panel Survey (GSPS) datasets. An instrumental variable strategy, specifically the two-stage residual inclusion (2SRI), was employed to control endogenous NHIS membership.FindingsGenerally, the results show that NHIS improves healthcare utilisation (i.e. visits to a health facility and formal care). Concerning the heterogeneous effects of health insurance on healthcare utilisation, the results revealed that NHIS members are more likely to seek care, irrespective of their residence status. The results further indicate that the probability of visiting a health facility and utilising formal care increases for the poorest NHIS participants. Based on these, the authors conclude that NHIS provides equitable healthcare access and utilisation for its vulnerable populations, who are beneficiaries.Originality/valueTo the best of the authors' knowledge, this paper is the first to explore the heterogeneous effects of NHIS on healthcare utilisation across residential and income subpopulations. Splitting the dataset by residential status to examine healthcare utilisation inequality is worthwhile. In addition, analysing utilisation in terms of health care type would show whether Ghana's NHIS may be viewed as welfare-enhancing through increased formal health care utilisation.Peer reviewThe peer review history for this article is available at: https://publons.com/publon/10.1108/IJSE-05-2023-0330

Contribution of the Ghana National Health Insurance Scheme to Inequality in Healthcare Utilisation

Inequality in healthcare utilisation contributes to socio-economic disparities in health outcomes. The government of Ghana rolled out the Ghana National Health Insurance Scheme (NHIS) as a pro-poor health policy to reduce the financial barrier to accessing healthcare to increase healthcare utilisation, especially among the poor. Evidence showed a pro-rich utilisation inequality in Ghana prior to the nationwide start of the NHIS in 2005. This article applied the concentration index and decomposition methods to the round six of the Ghana Living Standard Survey data to investigate the contribution of the NHIS to utilisation inequality. The results showed the rich to benefit more than the poor from the NHIS and the NHIS contributed to about half of the pro-rich utilisation inequality. The NHIS increased utilisation but more so for the rich than the poor. A policy implication of the article is that pro-poorness of the NHIS might require separate NHIS schemes for the poor and non-poor to enable different policies implemented in the schemes to increase the distributional disparity of health subsidies in favour of the poor.

Billing the Insured: An Assessment of Out-of-Pocket Payment by Insured Patients in Ghana

The Ghana National Health Insurance Scheme was introduced in 2003 to provide financial protection to the population. While the Scheme has made strides in improving access to healthcare there have been a few challenges including out of pocket charges to insured patients with weak client power. The study investigated the catastrophic nature of the out-of-pocket charges, the factors affecting the charges and the client power. We used primary data collected in 3 administrative regions: Greater Accra, Ashanti and the Northern regions, within the period April and June 2022 to compute catastrophic expenditure of the out-of-pocket healthcare expenditure on household expenditure on food and non-food. In addition, multivariate logistic regressions and a linear regression were run to examine the incidence of the practice and client power. The results showed that on average the insured paid out-of-pocket charges with a probability of 66%. The probability was highest (80%) in the Greater Accra, followed by Ashanti region (66.6%) and (52.9%) in the Northern region. The out-of-pocket charges were found to be catastrophic with incidence rate between 48.2% and 26.1% for the 5% and 20% thresholds; the overshoots ranged between 34.1% and 26.9% for the thresholds; the poor were more disadvantaged than the rich. Patients reported the out-of-pocket charges to the NHIA with probability of 1.9%, but the NHIA did not respond to 81% of the reported cases. Knowledge of the benefit list is likely to motivate the insured to report out-of-pocket charges, while cordial relationship between the NHIA staff and the insured deters providers from charging out-of-pocket. The out-of-pocket charges occur extensively across health facilities and is impoverishing. A close collaboration between the NHIA and the insured is needed to reduce the incidence and hold providers accountable.

The effect of the price of time on healthcare provider choice in Ghana

The existing literature confirms that the cost of treatment affects the choice of a particular healthcare provider. The Ghana National Health Insurance Scheme was established in 2003 to reduce the cost of healthcare provision and increase access to healthcare. However, we find that that even when the price is assumed to be “zero”, there remain some economic costs for choosing a particular healthcare provider over the other. This is called the price of time or opportunity cost. The study uses data from the seventh round of the Ghana Living Standards Survey (GLSS 7) conducted in 2016/2017 and employs multinomial probit regression as the technique for the analysis. The study finds that travel time and waiting time have significant effects on the choice of healthcare provider. If travel time and waiting time increase by 1 h, it will decrease the probability of seeking healthcare by 12% and 17%, respectively. Travel cost was not found to have a significant effect. The recommendations are that policymakers should make the effort to decrease travel time and waiting time at the health facilities in the country to improve healthcare delivery.

Exploring heterogeneity of national health insurance scheme enrolment among persons in the informal sector.

The Ghanaian government began implementing the National Health Insurance Scheme (NHIS) in 2005, anchored on the universal health coverage principle. However, informal sector workers contribute to the low enrolment into the scheme. This paper examines the factors that influence enrolment status in Ghana's NHIS among individuals in the informal sector. The study employed the fixed-effects logit model, using the Ghana Socioeconomic Panel Survey datasets. The findings revealed that gender, age, education, marital status, household size, physical activity, income, savings and subjective social welfare determine enrolment decisions of persons in the informal sector. Drivers of NHIS enrolment for male and female household heads were secondary education and household size. Heterogeneously, age, Junior High School education, married, physical activity, subjective social welfare and savings influenced only male-headed households' enrolment status. The study shows differences in enrolment status among rural and urban residents, as age, education, marital status, household size, and physical activity influenced rural residents, while for urban inhabitants', savings determined their NHIS enrolment decisions. However, gender, obesity, income and subjective social welfare predicted enrolment decisions for rural and urban residents. Finally, two variables, gender (male) and physical activity predicted the NHIS enrolment decision among the poor, whereas subjective social welfare and savings influenced the wealthiest enrolment decisions. For Ghana to achieve the Sustainable Development Goals of universal health coverage, the study recommends enhanced public education on NHIS benefits among informal workers to promote enrolment.

An Analysis of Catastrophic Out-of-Pocket Health Expenditures in Ghana.

Ghana implemented a universal health coverage scheme aimed at attaining financial risk protection against catastrophic out-of-pocket health expenditures. The effort has yielded mixed benefits for the different socio-economic profiles of the population. The present study estimates the incidence of catastrophic payments among Ghanaian households. The study analyzed the round seven dataset of the Ghana Living Standards Survey collected between 2016 and 2017. We estimated the incidence and intensity of catastrophic payments for total household consumption and non-food consumption for a range of thresholds. The analysis further weighted the measures of catastrophic payments to determine the distribution sensitivity. As the threshold increased from 10 to 25% of total household consumption, the incidence of catastrophic payments dropped from 1.0 to 0.1%. At the 40% threshold of non-food consumption, the estimated incidence was 0.2%. For both total household consumption and non-food consumption, the concentration indices were negative at all the thresholds. The results were indicative of a higher concentration of financial catastrophe among the poorest households and significant inequalities in the incidence between the poorest and richest households. The study confirmed the declining trend in the general incidence of catastrophic health expenditures in Ghana. However, the incidence and risk of financial catastrophe remained disproportionately higher among the poorest households, which is instructive of gaps in financial risk protection coverage. The Ghana National Health Insurance Scheme must therefore strengthen its targeting and enrolment of this sub-population group to reduce their vulnerability to catastrophic payments.

Equity in the Perceived Quality of Care Received by Malaria Patients Under National Health Insurance Scheme in Ghana.

The Ghana National Health Insurance Scheme (NHIS) seeks to provide access to quality healthcare to its members regardless of the health facility in which they receive care. However, it is unclear if all members of the Scheme receive quality care. The objective of the study is to examine the equity of perceived healthcare quality received by NHIS members depending on the type of facility in which care was provided. The study purposively sampled 2000 NHIS members who sought malaria treatment in the study areas. Only patients who had visited the health facilities at least twice not more than 12 months, before the data collection, were sampled. The SERVQUAL model was used to examine perceived quality of healthcare services in 5 quality dimensions: Reliability, Assurance, Tangibility, Empathy, and Responsiveness. These quality dimensions were compared in health facilities according to ownership (public, private, and faith-based facilities), capacity (hospital vs health centers), and finally location (urban vs rural health facilities). Instrumental variable estimation method was used to analyze data to address health facility selection bias problem. The results showed that faith-based health facilities scored the highest in all 5 perceived quality dimensions followed by public and private. Hospitals had higher score in perceived quality than health centers just as urban facilities scored higher in quality than rural facilities. These results represent high inequality in the perceived quality of care received by NHIS members.

Is value-based payment for healthcare feasible under Ghana\u2019s National Health Insurance Scheme?

BackgroundEffective payment mechanisms for healthcare are critical to the quality of care and the efficiency and responsiveness of health systems to meet specific population health needs. Since its inception, Ghana’s National Health Insurance Scheme (NHIS) has adopted fee-for-service, diagnostic-related groups and capitation methods, which have contributed to provider reimbursement delays, rising costs and poor quality of care rendered to the scheme’s clients. The aim of this study was to explore stakeholder perceptions of the feasibility of value-based payment (VBP) for healthcare in Ghana. Value-based payment refers to a system whereby healthcare providers are paid for the value of services rendered to patients instead of the volume of services.MethodsThis study employed a cross-sectional qualitative design. National-level stakeholders were purposively selected for in-depth interviews. The participants included policy-makers (n = 4), implementers (n = 5), public health insurers (n = 3), public and private healthcare providers (n = 7) and civil society organization officers (n = 1). Interviews were audio-recorded and transcribed. Data analysis was performed using both deductive and inductive thematic analysis. The data were analysed using QSR NVivo 12 software.ResultsGenerally, participants perceived VBP to be feasible if certain supporting systems were in place and potential implementation constraints were addressed. Although the concept of VBP was widely accepted, study participants reported that efficient resource management, provider motivation incentives and community empowerment were required to align VBP to the Ghanaian context. Weak electronic information systems and underdeveloped healthcare infrastructure were seen as challenges to the integration of VBP into the Ghanaian health system. Therefore, improvement of existing systems beyond healthcare, including public education, politics, data, finance, regulation, planning, infrastructure and stakeholder attitudes towards VBP, will affect the overall feasibility of VBP in Ghana.ConclusionValue-based payment could be a feasible policy option for the NHIS in Ghana if potential implementation challenges such as limited financial and human resources and underdeveloped health system infrastructure are addressed. Governmental support and provider capacity-building are therefore essential for VBP implementation in Ghana. Future feasibility and acceptability studies will need to consider community and patient perspectives.

Political economy and the pursuit of universal health coverage in Ghana: a case study of the National Health Insurance Scheme.

The road to universal health coverage depends on resources committed to the health sector. In many cases, the political structure and strength of advocacy play an important role in setting budgets for health. However, this has, until recently, not been of interest to health system researchers and policymakers. In this study, we document the political path to the establishment of the Ghana National Health Insurance Scheme (NHIS) as well as continuous political interest in the scheme. To achieve our objectives, we used qualitative data from interviews with key stakeholders. These include stakeholders instrumental in the design and establishment of the NHIS. We also reviewed party manifestoes from the two main political parties in the country. Promises relating to the NHIS were extracted from the various manifestos and analysed. Other documents that account for the design and implementation of the scheme were reviewed. We found that the establishment of the NHIS was down to political commitment and effective engagement with relevant stakeholders. It was considered a solution to the political promise to remove user fees and make healthcare accessible to all. A review of the manifestos shows that in almost every election year after the NHIS was established, there has been some promise related to improving the scheme. There were several policy propositions repeated in different election years. The findings imply that advocacy to get health financing on the political agenda is crucial. This should start from the development of party manifestos. It is important to also ensure that proposed party policies are consistent with national priorities in the medium to long term.

Quality healthcare services under National Health Insurance Scheme in Ghana: perspectives from health policy implementers and beneficiaries

PurposeThis paper aims to examine the factors that affect the quality of healthcare services in the implementation of the National Health Insurance Scheme (NHIS) at the local level in Ghana from the perspectives of health policy implementers and beneficiaries in public-private organisations.Design/methodology/approachThis paper has adopted a mixed research method with both qualitative and quantitative data, with in-depth interviews, document analysis and focus groups discussions. A total of 107 participants took part in the interviews and the questionnaire survey.FindingsThe study found that these factors greatly affect the quality of healthcare services from the implementers’ perspectives — referrals, effectiveness in monitoring, timeliness, efficiency, reimbursement, compliance with standard guidelines of Ghana Health Service (GHS) and accreditation process. For the beneficiaries, three healthcare services factors are important, including medical consultations, diagnostic services and the supply of drugs and medicines. Some other factors are found to be the least prioritized healthcare services, namely the issuance of prescription forms, verification of identification (ID) cards and staff attitude. However, the study found that implementers and beneficiaries exhibited a mixed reaction (perspectives) on accessing some healthcare services. In some healthcare services where the implementers perceived that beneficiaries have more access to such services, the beneficiaries think otherwise, an irony in the perspectives of the two actors.Originality/valueThis paper adds to the extant literature on the perspectives of policy implementers and beneficiaries on factors that affect the quality of healthcare services in general and specifically on the implementation of NHIS in Ghana with the public-private dimension.

Effect of the Ghana National Health Insurance Scheme on exit time from catastrophic healthcare expenditure

AbstractCatastrophic healthcare expenditure (CHE) can plunge households into poverty. Faced with CHE, the question that becomes relevant is how long it will take the household to exit CHE. This paper examines the effect of the Ghana National Health Insurance Scheme (NHIS) on exit time from CHE. The paper uses the Cox proportional hazard model for the analysis, with data sourced from round six of the Ghana Living Standard Survey and World Development Indicators. The results show that households that spend 40% (20%) of their non‐food incomes on healthcare, on average, exit CHE after 10 months and 4 days (13 months and 24 days) being in CHE and those with NHIS coverage exit CHE 19 days (30 days) earlier than those without NHIS coverage. Policy implications arising from this paper include the need to expand NHIS enrolment to mitigate impoverishment due to out‐of‐pocket healthcare payments. Households with higher risks of severe CHE and longer exit time from CHE should be identified and provided with comprehensive NHIS coverage than those with lower risks.

Access Differentials in Primary Healthcare among Vulnerable Populations in a Health Insurance Setting in Kumasi Metropolis, Ghana: A Cross-Sectional Study

Background. Access to healthcare remains a challenge towards the achievement of the Sustainable Development Goals in Ghana. There still remain inequalities in the distribution of health services especially among vulnerable groups despite sustained efforts to strengthen the health system. This study was conducted to analyze access differentials among different vulnerable groups in the context of primary healthcare under a National Health Insurance Scheme (NHIS) in Ghana. Methods. This study was a descriptive cross-sectional study conducted among multilevel participants of vulnerable groups in Kumasi Metropolis: 710 vulnerable people constituting elderly/aged (n = 359), pregnant women (n = 117), head poters (teenage girls who migrated from the northern Ghana mainly to the capital cities of the Ashanti and Greater Accra region to help in carrying of goods for their livelihood) (n = 86), sex workers (n = 75), and other vulnerable groups (people with disabilities and street participants) (n = 73). Data were collected using a semistructured questionnaire. Poisson regression with robust variance was used to access the association between vulnerability and access to healthcare. Results. Close to a fifth, 18.5% of the study respondents were unable to access care at any point in time during the last 12 months. Reasons for the inability to access healthcare included limited funding (69.7%), poor attitude of service providers (7.6%), distance to health centers (8.3%), and religious reasons (6.2%). More than 95% of respondents were insured under the NHIS, but acceptability of service provision under the NHIS was low among the vulnerable groups. In the crude models, pregnant women had lower prevalence of access to medications as compared to the elderly (prevalence ratio (PR): 0.88; 95% CI: 0.80–0.98). Head poters and other vulnerable groups were also less likely to view healthcare as affordable as compared to the elderly. The differences in healthcare access observed were attenuated after adjustment for sociodemographic characteristics and healthcare-related factors. Conclusions. Despite the introduction of a NHIS in Ghana, this study highlights challenges in healthcare access among vulnerable populations independent of the type of vulnerability. This suggests the need for stakeholders to work to address access differentials in the NHIS and adopt other innovative care strategies that may have broader applicability for all populations.

Prevalence and quality of antihypertensive therapy among hypertension patients enrolled in the Ghana National Health Insurance Scheme

Hypertension is a leading cause of morbidity in Ghana. However, there is insufficient data on the prevalence and quality of antihypertensive therapy. To describe the prevalence of use and quality of antihypertensive therapy. A cross-sectional study design was used to analyze the 2015 Ghana National Health Insurance Scheme (NHIS) electronic claims data. Hypertension diagnosis was defined using ICD-10 codes. The primary outcomes assessed were the prevalence of use and quality of antihypertensive therapy. Quality of antihypertensive therapy was defined as the use of antihypertensive agents recommended for treating hypertension patients with comorbid heart failure, myocardial Infarction/Coronary Artery Disease, diabetes, chronic kidney disease or stroke. We used multivariable logistic regression models to identify predictors of antihypertensive use and quality of therapy. Antihypertensive medication use was very high (86%) among the 161 873 hypertension patients covered under the Ghana NHIS. Only a third (32%) of hypertension patients received guideline-concordant therapy. Angiotensin receptor blockers were consumed at the highest dosages of 120 (Interquartile Range [IQR]: 60, 180) daily defined doses over a year. Males (odds ratio [OR]=0.60; 95% Confidence Interval [CI]:0.58, 0.61) and those with comorbid stroke (OR=0.91, 95% CI:0.84, 0.99), diabetes (OR=0.72; 95% CI:0.69, 0.74) and stroke (OR=0.74, 95%CI:0.68, 0.80) were less likely to use antihypertensives, all other predictors were associated with higher use. Antihypertensive medication use was very high among hypertension patients covered under the Ghana NHIS. However, there was indication of suboptimal quality of the antihypertensive therapy provided.

Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children.

IntroductionGhana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana.MethodsWe performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE.ResultsOf the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08–0.55).ConclusionsNHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children.

Implementation of the National Health Insurance Scheme (NHIS) in Ghana: Lessons for South Africa and Low- and Middle-Income Countries.

BackgroundSouth Africa is having difficulties in rolling out the National Health Insurance(NHI) policy. There are ongoing arguments on whether the NHI will provide access to quality and equitable healthcare it is intended to and whether South Africa is ready to implement the policy. Many stakeholders believe the country needs more preparation if the policy will be successful. Ghana, on the other hand, has successfully implemented the National Health Insurance Scheme(NHIS) for over 15 years.ObjectiveThis paper sought to explore the implementation of the NHIS in Ghana and the lessons South Africa and other low- and middle-income countries can learn from such a process.MethodsA scoping review was conducted using the Joanna Brigs Institute’s System for the Unified Management, Assessment and Review of Information (SUMARI) and Mendeley reference manager to manage the review process. Journal articles published on the NHIS in Ghana from January 2003 to December 2018 were searched from Science Direct, PubMed, Scopus, CINAHL, and Medline using the keywords: Ghana, Health, and Insurance.ResultsThe implementation of the NHIS has provided access to healthcare for the Ghanaian population, especially to poor and vulnerable . Despite the successful implementation of the NHIS in Ghana, the scheme is challenged with poor coverage; poor quality of care; corruption and ineffective governance; poor stakeholder participation; lack of clarity on concepts in the policy; intense political influence; and poor financing.ConclusionThe marked inequity in the South African health system makes the implementation of the NHI inevitable. The challenges experienced in the implementation of the NHIS in Ghana are not new to the South African healthcare system. South Africa must learn from the experiences of Ghana,a context that shares common socio-cultural and economic factors and disease burden,in order to successfully implement the NHI.

Ghana's Journey towards Universal Health Coverage: The Role of the National Health Insurance Scheme.

Background: the main aim of the study is to find if the National Health Insurance Scheme (NHIS) in Ghana is achieving universal health coverage (UHC) or not. The study gives the trajectories of health policies in Ghana and their implications on long term health financing. NHIS in Ghana was implemented in 2004, with the aim of increasing subscribers’ access to health care services and reduce financial barriers to health care. On equity access to healthcare, it addresses two core concerns: (1) enrolling particular groups (persons exempted from annual premium payments) and (2) achieving UHC for all citizens and persons with legal residence. It utilizes a multifactor approach to the conceptualization of UHC. The research question: Is Ghana’s NHIS on course to deliver or achieve universal health coverage? Methods: we used qualitative methods. In doing so, the study engaged participants in in-depth interviews, focus group discussions and direct observations of participants in their natural settings, like hospitals, clinics, offices and homes, with purposive and snowball techniques. This data triangulation approach aims to increase the reliability and validity of findings. Results: the empirical evidence shows NHIS performed relatively well in enrolling more exempt groups (particular groups) than enrolling all persons in Ghana (UHC). The biggest challenge for the implementation of NHIS from the perspectives of health insurance officials is inadequate funding. The health insurance beneficiaries complained of delays during registrations and renewals. They also complained of poor attitude of some health insurance officials and health workers at facilities. Conclusions: both health insurance officials and beneficiaries emphasized the need for increased public education and for implementers to adopt a friendly attitude towards clients. To move towards achieving UHC, there is a need to redesign the policy, to move it from current voluntary contributions, to adopt a broad tax-based approach to cover all citizens and persons with legal residence in Ghana. Also, to adopt a flexible premium payment system (specifically ‘payments by installation’ or ‘part payments’) and widen the scope of exempt groups as a way of enrolling more into the NHIS.

Is enrolment in the national health insurance scheme in Ghana pro-poor? Evidence from the Ghana Living Standards Survey

ObjectivesThis article examines equity in enrolment in the Ghana National Health Insurance Scheme (NHIS) to inform policy decisions on progress towards realisation of universal health coverage (UHC).DesignSecondary analysis of data...

Could cost sharing sustain the Ghana National Health Insurance Scheme?

ABSTRACT This paper estimates the effect of cost sharing on the sustainability of the Ghana National Health Insurance Scheme (NHIS) from the point of view of enrollment, utilization, and financing. We use data from a nationwide survey to estimate the retention of subscribers and propensity to utilize the scheme's benefit package under a cost sharing policy. The estimates from the survey are used together with data on the Ghana NHIS, to estimate the patronage, and financial status of the Ghana NHIS had cost sharing been introduced. The result indicates that a 5% cost sharing rate would have kept the scheme in surplus between 2007 and 2015. In addition, the 5% cost sharing rate would have led to virtually no change in enrollment and would have reduced utilization rate by about 15%. It is also found that women have higher enrollment and utilization of health insurance than men under cost sharing.

Is Enrolment in the National Health Insurance Scheme in Ghana Pro-Poor? Evidence from the Ghana Living Standard Survey

Background: Earlier studies have found enrolment in the Ghana National Health Insurance Scheme (NHIS) as pro-rich. In recent years, the NHIS has embarked on aggressive enrolment of the poor and vulnerable to reverse the trend. This article examines equity in enrolment in the NHIS to inform policy decisions on progress towards realisation of universal health coverage (UHC). Methods: Secondary analysis of data from the sixth round of the Ghana Living Standards Survey (GLSS 6). The survey was conducted between 18 October 2012 and 17 October 2013 with 16,774 household heads. Equity in enrolment was assessed using concentration curves and bivariate and multivariate analyses to determine associated factors. Findings: Survey participants had a mean age of 46 years and mean household size of four persons. About 71% of households interviewed had at least one person enrolled in the NHIS. Households in the poorest wealth quintile (73%) had enrolled significantly (p<0.001) more than those in the richest quintile (67%). The concentration curves further showed that enrolment was slightly disproportionally concentrated among poor households, particularly those headed by males. However, multivariate logistic analyses showed that the likelihood of NHIS enrolment increased from poorer to richest quintile and from low to high level of education. Other factors including age, sex, household size, household setting, and geographic region were significantly associated with enrolment. Interpretations: From 2012-2013 enrolment in the NHIS was higher among poor households, particularly male-headed households, although multivariate analyses demonstrated that the likelihood of NHIS enrolment increased from poorer to richest quintile and from low to high level of education. Policy makers need to ensure equity within and across gender as they strive to achieve UHC. Funding Statement: The authors declare: None. Declaration of Interests: ENB is an employee of the National Health Insurance Authority, however his affiliation did not influence findings of this study. JPR and JN declare no competing interests. Ethics Approval Statement: Not Required.

Health insurance and social capital in Ghana: a cluster randomised controlled trial

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.