Ghana's Health Insurance Scheme Research Articles

Effect of social capital on enrolment of informal sector occupational groups in the national health insurance scheme in Ghana: a cross-sectional survey

BackgroundEnrolment of informal sector workers in Ghana’s National Health Insurance Scheme (NHIS) is critical to achieving increased risk-pooling and attainment of Universal Health Coverage. However, the NHIS has struggled over the years to improve enrolment of this subpopulation. This study analysed effect of social capital on enrolment of informal sector workers in the NHIS.MethodsA cross-sectional survey was conducted among 528 members of hairdressers and beauticians, farmers, and commercial road transport drivers’ groups. Descriptive statistics, principal component analysis, and multinomial logit regression model were used to analyse the data.ResultsSocial capital including membership in occupational group, trust, and collective action were significantly associated with enrolment in the NHIS, overall. Other factors such as household size, education, ethnicity, and usual source of health care were, however, correlated with both enrolment and dropout. Notwithstanding these factors, the chance of enrolling in the NHIS and staying active was 44.6% higher for the hairdressers and beauticians; the probability of dropping out of the scheme was 62.9% higher for the farmers; and the chance of never enrolling in the scheme was 22.3% higher for the commercial road transport drivers.ConclusionsSocial capital particularly collective action and predominantly female occupational groups are key determinants of informal sector workers’ participation in the NHIS. Policy interventions to improve enrolment of this subpopulation should consider group enrolment, targeting female dominated informal sector occupational groups. Further studies should consider inclusion of mediating and moderating variables to provide a clearer picture of the relationship between occupational group social capital and enrolment in health insurance schemes.

Does mobile renewal make health insurance more responsive to clients? A case study of the National Health Insurance Scheme in Ghana

BackgroundIn 2018, Ghana’s National Health Insurance Authority (NHIA) introduced a mobile strategy to enhance re-enrolment and improve client knowledge of their entitlements. This study investigated how Ghana’s mobile strategy has...

Effect of mobile phone-based health insurance contribution payment system on retention of coverage in the National Health Insurance Scheme in Ghana: an evaluation study

BackgroundGhana introduced a mobile phone-based contribution payment system in its national health insurance scheme (NHIS) in December 2018 to improve the process of enrolment. We evaluated the effect of this digital health intervention on retention of coverage in the Scheme, one year after its implementation.MethodsWe used NHIS enrolment data for the period, 1 December 2018–31 December 2019. Descriptive statistics and propensity-score matching method were performed to examine a sample of 57,993 members’ data.ResultsProportion of members who renewed their membership in the NHIS via the mobile phone-based contribution payment system increased from 0% to 8.5% whilst those who did so through the office-based system only grew from 4.7% to 6.4% over the study period. The chance of renewing membership was higher by 17.4 percentage points for users of the mobile phone-based contribution payment system, compared to those who used the office-based contribution payment system. The effect was greater for the informal sector workers, males and the unmarried.ConclusionsThe mobile phone-based health insurance renewal system is improving coverage in the NHIS particularly for members who hitherto were less likely to renew their membership. Policy makers need to devise an innovative way for new members and all member categories to enrol using this payment system to accelerate progress towards attainment of universal health coverage. Further study needs to be conducted using mixed-method design with inclusion of more variables.

Frontline Workers’ Use of Discretion in the Implementation of National Health Insurance Scheme in Ghana

ABSTRACT The article examines frontline workers’ use of discretion in the implementation of the National Health Insurance Scheme in Ghana. It answers two questions: 1) how does discretion affect service delivery? 2) Whose interest does discretion serve in service delivery? The article provides three contributions. First, it brings a new direction in the use of discretion in organisations in a developing world context. Second, it adds to ‘how’ and ‘why’ frontline workers use discretion. Finally, it reveals whose interest the use of discretion serves. It utilises qualitative methods to reveal both positively motivated and negatively motivated discretion relationships that exist between frontline workers and clients. Most of the negatively inclined discretion is exercised largely by frontline workers in public organisations. It concludes that most of the frontline workers’ discretion serves the interest of their clients rather than service providers’ self-interest or the interest of their organisations.

Supporting a review of the benefits package of the National Health Insurance Scheme in Ghana

BackgroundAlthough Ghana is lauded for its National Health Insurance Scheme (NHIS), concerns exist about the scheme’s functioning and sustainability. An often-cited issue—contributing to the scheme’s decreasing membership, long-standing financial deficit, and frequent out-of-pocket payments among members—is the large benefits package (BP). While, on paper, the BP covers over 95% of the conditions occurring in Ghana, its design was not informed by any budget analysis, nor any systematic prioritization of interventions. This paper aims to provide evidence-based input into ongoing discussions regarding a review of the NHIS benefits package.MethodsAn existing analytic framework is used to calculate net health benefit (NHB) for a range of interventions in order to assess their cost-effectiveness and enable the prioritization of ‘best buys’. The framework is expanded upon by incorporating concerns for financial protection, and practical feasibility, as well as the political economy challenges of disinvesting in currently funded activities. Five different options for the benefits package, each based on policy discourse in Ghana’s health sector, are presented and evaluated.ResultsImplementing all interventions for which data was available to 100% of the population in need was estimated to cost GH₵4323 million (US$994 million), while the available NHIS budget was only GH₵970 million (US$223 million). Options for the benefits package that focussed on cost-effectiveness and primary care provision achieved the best health outcomes, while options reflecting the status quo and allowing for co-payments included a higher number of healthcare interventions. Apart from the package option focussing on primary care, all packages were faced with physician shortages.ConclusionsCurrent funding to the NHIS is insufficient to provide the historical benefits package, which promises to cover over 95% of disease conditions occurring in Ghana, to the total population. Shifting the NHIS focus from intervention coverage to population coverage is likely to lead to better health outcomes. A primary care package may be most feasible in the short-term, though additional physicians should be trained to provide higher-level care that is highly cost-effective, such as emergency neonatal care.

Availability and Affordability of Primary Health Care Among Vulnerable Populations in Urban Kumasi Metropolis: Family Health Perspective.

Purpose:Health-related expenditures pose a significant burden on vulnerable populations. This study assessed the availability and affordability of primary health care among disadvantaged populations in urban Kumasi Metropolis, Ghana.Methods:This study was a descriptive cross-sectional study conducted among multi-level participants of vulnerable populations ≥18 years of age (n=710) constituting the older adults/aged, pregnant women, head porters, sex workers, and other vulnerable groups (people with disabilities and the homeless). Data were collected using a semistructured questionnaire. Poisson regression with robust variance was used to assess the association between vulnerability and access to health care.Results:There were significant differences in the availability and adequacy of health care among the vulnerable groups studied. Distance to the source of care was >5 km for majority of the vulnerable groups and the average expenditure on a visit to the health facility was GH¢ 27.04 (∼US$ 5.55 as at January 2019). Challenges to health care among the vulnerable groups included monetary (37.9%), stigmatization (18.6%), and staff attitude (25.9%). Head porters and other vulnerable groups were less likely to view health care as affordable compared with older adults. The difference in the perception of health care affordability was, however, explained by sociodemographic characteristic and health care-related factors.Conclusion:Despite the introduction of a National Health Insurance Scheme in Ghana, this study highlights challenges in health care access among vulnerable populations independent of the type of vulnerability. This suggests the need for stakeholders to adopt other innovative care strategies that may have broader applicability for all populations.

Spatiotemporal patterns of diarrhea incidence in Ghana and the impact of meteorological and socio-demographic factors.

Diarrhea remains a significant public health problem and poses a considerable financial burden on Ghana's health insurance scheme. In order to prioritize district-level hotspots of diarrhea incidence for effective targeted interventions, it is important to understand the potential drivers of spatiotemporal patterns of diarrhea. We aimed to identify the spatiotemporal heterogeneity of diarrhea incidence in Ghana and explore how meteorological and socio-demographic factors influence the patterns. We used monthly district-level clinically diagnosed diarrhea data between 2012 and 2018 obtained from the Centre for Health Information and Management of the Ghana Health Services. We utilized a hierarchical Bayesian spatiotemporal modeling framework to evaluate potential associations between district-level monthly diarrhea incidence and meteorological variables (mean temperature, diurnal temperature range, surface water presence) and socio-demographic factors (population density, Gini index, District League Table score) in Ghana. In addition, we investigated whether these associations were consistent across the four agro-ecological zones. There was considerable spatial heterogeneity in diarrhea patterns across the districts, with clusters of high diarrhea risk areas mostly found in the transition and savannah zones. The average monthly temporal patterns of diarrhea revealed a weak biannual seasonality with major and minor peaks in June and October, respectively, coinciding with the major and minor rainy seasons. We found a significant association between both meteorological and socio-demographic factors and diarrhea risk, but the strength and direction of associations differed across the four agro-ecological zones. Surface water presence demonstrated consistently positive, while diurnal temperature range and population density demonstrated consistently negative associations with diarrhea both overall and across the agro-ecological zones. Although overall diarrhea incidence is declining in Ghana, our results revealed high-risk districts that could benefit from district-specific tailored intervention strategies to improve control efforts. Ghana health sector policy-makers can use these results to assess the effectiveness of ongoing interventions at the district level and prioritize resource allocation for diarrhea control.

Community perceptions of enrolment of indigents into the National Health Insurance Scheme in Ghana: a case study of the Livelihood Empowerment against Poverty Programme

BackgroundThe Livelihood Empowerment against Poverty (LEAP) programme in Ghana as part of its beneficiary programme, identifies the poor/indigents for exemptions from premium payments in the National Health Insurance Scheme (NHIS). This paper sought to understand community perceptions of enrolling the poor in the NHIS through LEAP in order to inform policy.MethodsThe study adopted a descriptive cross-sectional study design by using a qualitative approach. The study was conducted in three geographical regions of Ghana: Greater Accra, Brong-Ahafo and Northern region representing the three ecological zones of Ghana between October 2017 and February 2018. The study population included community members, health workers, NHIS staff and social welfare officers/social development officers. Eighty-one in-depth interviews and 23 Focus Group Discussions were conducted across the three regions. Data were analysed thematically and verbatim quotes from participants were used to support the views of participants.ResultsThe study shows that participants were aware of the existence of LEAP and its benefits. There was, however, a general belief that the process of LEAP had been politicized and therefore favours only people who were sympathizers of the ruling government as they got enrolled into the NHIS. Participants held the view that the process of selecting beneficiaries lacked transparency, thus, they were not satisfied with the selection process. However, the study shows the ability of the community to identify the poor. The study reports varying concepts of poverty and its identification across the three ecological zones of Ghana.ConclusionThere is a general perception of politicization and lack of transparency of the selection of the poor into the NHIS through the LEAP programme in Ghana. Community-based approaches in the selection of the indigent are recommended to safeguard the NHIS-LEAP beneficiary process.

Examining the Benefits and Challenges Associated with the Use of the Mobile Renewal Service in Ghana

This paper presents the findings of a study that examined the benefits and problems related with subscribers’ use of the Mobile Renewal Service (MRS) technology launched by the National Health Insurance Scheme in Ghana. The study adopted a descriptive survey method where questionnaires were administered to 500 respondents in 11 Districts of the Northern Region of Ghana. The study reveals the benefits associated with the use of the Mobile Renewal Service as: significant reduction in the time for renewal, which respondents agreed that NHIS members are able to renew without incurring travel costs and that this directly translates into monetary savings as a result of the implementation of the mobile renewal service. The study further revealed: Lack of user understanding of steps involved in using MRS; Mobile network challenges in renewing premium; Subscriber resistance to switch from manual renewal method to mobile renewal service mode; and Lack of knowledge and skills on how to use MRS as challenges Subscribers face in using the Mobile Renewal Service.

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.

Factors Influencing Subscribers’ Use and Adoption of the NHIS Mobile Renewal Service

This paper reports a research work that examined the applicability of the Technology Acceptance Model (TAM) in explaining clients’ decisions to accept the Mobile Renewal Service (MRS) technology introduced by the National Health Insurance Scheme in Ghana. The model’s overall fit, explanatory power, and the individual causal links that it postulates were evaluated by examining the adoption and usage of the Mobile Renewal Service technology among clients in the Northern Region of Ghana. Results of the study suggested that Technology Acceptance Model (TAM) was able to provide a reasonable depiction of clients’ adoption and usage of the Mobile Renewal Service. The study reports 0.762 R2 (with T statistics greater than 1.96 and P value less than 0.05) indicating that the independent variables, namely System Quality, Transaction Cost, Accessibility, Perceived Ease of Use and Perceived Usefulness, all together explain about 76.2 percent changes in intention to use mobile renewal services. Accessibility and perceived ease of use are both capable of influencing perceived usefulness positively. It can be established that accessibility facilitates subscriber intention to use the mobile renewal service. The study also concludes that system quality is able to influence user’s desire to use the service. The findings in this regard suggest that the underlying variables explained the substantial variance in the subscribers’ intention to use mobile renewal services of the NHIS.

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.

Insured clients out-of-pocket payments for health care under the national health insurance scheme in Ghana

BackgroundIn 2003, Ghana implemented a National Health Insurance Scheme (NHIS) designed to promote universal health coverage and equitable access to health care. The scheme has largely been successful, yet it is confronted with many challenges threatening its sustainability. Out-of-pocket payments (OOP) by insured clients is one of such challenges of the scheme. This study sought to examine the types of services OOP charges are made for by insured clients and how much insured clients pay out-of-pocket.MethodsThis was a descriptive cross-sectional health facility survey. A total of 2066 respondents were interviewed using structured questionnaires at the point of health care exit in the Ashanti, Northern and Central regions of Ghana. Health facilities of different levels were selected from 3 districts in each of the three regions. Data were collected between April and June 2018. Using Epidata and STATA Version 13.1 data analyses were done using multiple logistic regression and simple descriptive statistics and the results presented as proportions and means.ResultsOf all the survey respondents 49.7% reported paying out-of-pocket for out-patient care while 46.9% of the insured clients paid out-of-pocket. Forty-two percent of the insured poorest quintile also paid out-of-pocket. Insured clients paid for consultation (75%) and drugs (63.2%) while 34.9% purchased drugs outside the health facility they visited. The unavailability of drugs (67.9%) and drugs not covered by the NHIS (20.8%) at the health facility led to out-of-pocket payments. On average, patients paid GHS33.00 (USD6.6) out-of-pocket. Compared to the Ashanti region, patients living in the Northern region were 74% less at odds to pay out-of-pocket for health care.Conclusion and recommendationInsured clients of Ghana’s NHIS seeking health care in accredited health facilities make out-of-pocket payments for consultation and drugs that are covered by the scheme. The out-of-pocket payments are largely attributed to unavailability of drugs at the facilities while the consultation fees are charged to meet the administrative costs of services. These charges occur in disadvantaged regions and in all health facilities. The high reliance on out-of-pocket payments can impede Ghana’s progress towards achieving Universal Health Coverage and the Sustainable Development Goal 3, seeking to end poverty and reduce inequalities. In order to build trust and confidence in the NHIS there is the need to eliminate out-of-pocket payments for consultation and medicines by insured clients.

Socioeconomic and demographic correlates of nonenrolment onto the national health insurance scheme among children in Ghana: Insight from the 2017/18 Multiple Indicator Cluster Survey.

The goal of Ghana's health insurance scheme is to achieve universal coverage. Despite NHIS' benefits to children, not all children in Ghana are covered. This study investigates the sociodemographic covariates of nonenrolment onto the national health insurance scheme among children in Ghana. We used the child dataset of the 2017/18 Ghana Multiple Indicator Cluster Survey (G-MICS). We used STATA version 14 for the data analyses. We described each study variable using frequency and percentages. We used Poisson regression to estimate crude and adjusted prevalence ratios of the relationship between the covariates and the outcome variable. Approximately 57% of children were covered with health insurance in Ghana. In the adjusted multivariable model, male children, children within the ages of 10-14 or 15-17years, and children who have some form of functional disability and those with no information on their functional disability status, children of mothers with lower than post-secondary education, and children residing in households of less than the fifth quantile on the household wealth index were associated with a higher likelihood of nonenrolment onto the national health insurance scheme. Finally, compared to the children in greater Accra, children in the other nine regions were associated with a lower likelihood of nonenrolment onto the national health insurance scheme. Given the results, improvement in health insurance coverage should be done, taking into consideration variations across the socio-demographic characteristics of the child, mother, and households.

How does it affect service delivery under the National Health Insurance Scheme in Ghana? Health providers and insurance managers perspective on submission and reimbursement of claims.

IntroductionIn 2003, the Government of Ghana launched the National Health Insurance Scheme (NHIS) to enable all Ghanaian residents to have access to health services at the point of care without financial difficulty. However, the system has faced a number of challenges relating to delays in submission and reimbursement of claims. This study assessed views of stakeholders on claims submission, processing and re-imbursement under the NHIS and how that affected health service delivery in Ghana.MethodsThe study employed qualitative methods where in-depth interviews were conducted with stakeholders in three administrative regions in Ghana. Purposive sampling method was used to select health facilities and study participants for the interviews. QSR Nvivo 12 software was used to code the data into themes for thematic analysis.ResultsThe results point to key barriers such as lack of qualified staff to process claims, unclear vetting procedure and the failure of National Health Insurance Scheme officers to draw the attention of health facility staff to resolve discrepancies on time. Participants perceived that lack of clarity, inaccurate data and the use of non-professional staff for NHIS claims vetting prolonged reimbursement of claims. This affected operations of credentialed health facilities including the provision of health services. It is perceived that unavailability of funds led to re-use of disposable medical supplies in health service delivery in credentialed health facilities. Stakeholders suggested that submission of genuine claims by health providers and regular monitoring of health facilities reduces errors on claims reports and delays in reimbursement of claims.ConclusionLong delays in claims reimbursement, perceived vetting discrepancies affect health service delivery. Thus, effective collaboration of all stakeholders is necessary in order to develop a long-term strategy to address the issue under the NHIS to improve health service delivery.

Knowledge, Attitudes and Socio-Demographic Factors Associated with Malesâ Involvement in Fertility Treatment in Ghana

Background: Infertility in developing countries often raises distinct and complex issues as compared to developed countries. Infertility affects an estimated 15% of couples globally with several socio-cultural implications. Many studies have reported that, males have poor health seeking behaviour when it comes to infertility treatment as they do not involvement themselves strongly due to varied factors. Therefore, this paper sets the pace by exploring how knowledge level, attitudes of men and their socio-demographic backgrounds influence their involvement in infertility treatment in Ghana. The paper was underpinned by the ancient Social Learning Theory which is still instrumental in modern social science research. Methods: The study adopted a quantitative approach using a cross-sectional study design. The study population was married men selected using a simple random sampling technique from 8 clustered demarcation to obtain 423 respondents using the formula N=z2pq/d2. A structured questionnaire was administered and data were analysed using STATA 15. Statistical significance for all testing was set as p<0.05 with 95CI. Result: The study found that, the mean age for the participants was 38.35 ± 0.48 and 92.67% were involved in monogamous marriage. Again, 57.45% had secondary/vocational education, 97.40% active employment with greater number of them earning less than GHC 600. It was noted that 84.16% of respondents agreed that, female partners are always the cause of childlessness in an infertile relationship. Misconceptions on infertility being caused by witchcraft, curses, or other supernatural powers were also noted (58.39%). It was also found that, married men in polygamous marriages were 6 times more likely to be involved in a fertility treatment than married men in monogamous marriages (Adjusted OR=6.210, 95%CI=3.153-7.232). Moreover, married men with primary and tertiary education were 0.517 less likely (Adjusted OR=0.517, 95%CI=0.319-0.819) and 0.597 less likely (Adjusted OR=0.597, 95%CI=0.153-0.732) to be involved in fertility treatment respectively as compared to those with secondary education. Again, married men who were employed were 3 times more likely (Adjusted OR=3.331, 95%CI=2.193-3.304) to be involved in infertility treatment as compared with those who are self-employed. Moslems were 4 times more likely (Adjusted OR=4.036, 95%CI=1.420-4.304) to be involved in infertility treatment as compared to Christians. Finally, traditionalists were 0.331 less likely (Adjusted OR=0.331, 95%CI=0.193-0.364) to be involved in infertility treatment as compared to Christians. Conclusion: The study concludes that, fertility declines with age coupled with factors such as the consumption of excessive alcohol, use of anabolic steroids, untreated sexually transmitted diseases, excessive stress, and among others. Also, the general attitudes of men towards infertility treatment were good as majority of them perceive infertility treatment to be the responsibility of both couples. However, the ability to achieve this orientation is positively influenced by the males’ socio-demographic factors such as marriage type, level of education, employment status and religious inclinations towards infertility issues. Recommendation: The study recommends that, men should seek for infertility treatment together with their wives so that it can be wholly managed for the couples. Again, the National Health Insurance Scheme in Ghana (NHIS) should cover infertility treatment and the charges of Private Fertility Treatment Centres should be regulated to prevent them from charging exorbitant fees. Moreover, educational forum on issues related to infertility and fertility should be undertaken by the community health unit of District Hospitals to sensitize the public.

A Multifactor Authentication Framework for the National Health Insurance Scheme in Ghana using Machine Learning

The creation of the National Health Insurance Scheme (NHIS) in 2005 to replace the traditional “cash and carry” healthcare financial model, was anticipated to offer a safe, reliable, affordable and national coverage healthcare system for the Ghanaian populace. The scheme has recorded several challenges; as a result, policymakers and donor agencies are reconsidering the current NHIS model and are thinking of crafting a better alternate and sustainable financial model for the NHIS. This study seeks to propose a multifactor authentication framework for the national health insurance scheme in Ghana using soft-computing machine learning techniques to minimize the current challenges. It was observed that the proposed system used 1.02 sec to vet 25 claim forms, while the human professional used 120 sec for a single document. The accuracy (91.50%) and F1 (88.52) score measure obtained shows a higher rate of the vetting process by the proposed system.

Health Insurance Provision and Women's Healthcare Utilization: Evidence from the National Health Insurance Scheme in Ghana

We use the Demographic and Health Survey to study the healthcare utilization effects of Ghana’s 2004 adoption of a national health insurance scheme (NHIS), covering over 95% of medical expenditures. First, we find that self-reported participation in the NHIS increases twelve-month healthcare visits by 32 percentage points using the timing of the rollouts across districts as an instrument. We also show that the positive effect is larger for less-educated, poor, and rural women. Second, we find that the NHIS increases deliveries in health facilities and prenatal care visits by 6 and 7 percentage points, respectively, using a difference-in-differences strategy and women from rural Nigeria as the control group. Together, these findings are consistent with evidence from similar programs in developed countries despite numerous implementation challenges and relatively low take-up of the NHIS.

Health insurance coverage, type of payment for health insurance, and reasons for not being insured under the National Health Insurance Scheme in Ghana

BackgroundGhana’s National Health Insurance Scheme has improved access to care, although equity and sustainability issues remain. This study examined health insurance coverage, type of payment for health insurance and reasons for being uninsured under the National Health Insurance Scheme in Ghana.MethodsThe 2014 Ghana Demographic Health Survey datasets with information for 9396 women and 3855 men were analyzed. The study employed cross-sectional national representative data. The frequency distribution of socio-demographics and health insurance coverage differentials among men and women is first presented. Further statistical analysis applies a two-stage probit Hackman selection model to determine socio-demographic factors associated with type of payment for insurance and reasons for not insured among men and women under the National Health insurance Scheme in Ghana. The selection equation in the Hackman selection model also shows the association between insurance status and socio-demographic factors.ResultsAbout 66.0% of women and 52.6% of men were covered by health insurance. Wealth status determined insurance status, with poorest, poorer and middle-income groups being less likely to pay themselves for insurance. Women never in union and widowed women were less likely to be covered relative to married women although this group was more likely to pay NHIS premiums themselves. Wealth status (poorest, poorer and middle-income) was associated with non-affordability as a reason for being not insured. Geographic disparities were also found. Rural men and nulliparous women were also more likely to mention no need of insurance as a reason of being uninsured.ConclusionTailored policies to reduce delays in membership enrolment, improve positive perceptions and awareness of National Health Insurance Scheme in reducing catastrophic spending and addressing financial barriers for enrolment among some groups can be positive precursors to improve trust and enrolments and address broad equity concerns regarding the National Health Insurance Scheme.

The Impact of Ghana's National Health Insurance on Psychological Distress.

Poor mental health is among the growing number of noncommunicable diseases in low- and middle-income countries. Despite poor mental health accounting for an already considerable and growing burden of disease in many low- and middle-income countries, policy action to confront the challenge has been limited, at both international and national levels. Recently, several low- and middle-income countries have embarked on the journey toward universal health coverage by expanding their public health insurance provision, with the ultimate objective of improving population health, in addition to other health system objectives. Mental health interventions typically may not have been specifically covered in the publicly funded benefit package, and this raises the question of whether, and if so, by how much, the expansion of public health insurance may have directly or indirectly contributed to improved mental health. We assessed the impact of Ghana's implementation of national health insurance on psychological distress. Our study used the first wave of the 2009-2010 Ghana Social Economic Panel survey, including 10,007 respondents. We employed instrumental variable and propensity score matching methods to estimate the causal impact of health insurance on psychological distress, measured by the Kessler Psychological Distress Scale (K10). Higher K10 values indicate greater psychological distress. The median K10 score in Ghana was 16 (P < 0.001), with a minimum of 10 (P < 0.001) and a maximum of 45 (P < 0.001). The results from the instrumental variable estimations, without matching, indicated that the K10 score for the insured was 11.8% lower (P < 0.001) than that of the uninsured. After running the instrumental variable regression on the matched sample, the K10 score for the insured was 10.6% (P < 0.001) lower than that of the uninsured. Similarly, the estimates based on propensity score matching indicated that the insured had a lower K10 score (-0.023; P < 0.05). Furthermore, the beneficial impact of health insurance on psychological distress is larger for wealthier than poorer insurance members and varies across regions in Ghana. The findings were robust to the various estimation methods. This study suggests that having health insurance is associated with reduced psychological distress and hence improved mental health, even though mental illness treatment or prevention were at best only partially covered by the National Health Insurance Scheme in Ghana.