National Health Insurance Scheme Enrolment Research Articles

National health insurance enrolment among elderly ghanaians: the role of food security status

Older people with food insecurity in Ghana are often exposed to poor health conditions, highlighting the importance of the National health Insurance Scheme (NHIS) enrolment for ensuring they receive necessary medical attention through access to health care services. However, we know very little about the association between food insecurity and National Health Insurance Scheme enrolment among older people in Ghana. To address this void in the literature, this study uses a representative survey of adults aged 60 or older from three regions in Ghana (i.e., Upper West, Bono, and Greater Accra regions (n = 1,073)). We find that 77% of older adults reported not being enrolled into the NHIS. Results from logistic regression analysis show that older people who experienced severe household food insecurity were less likely to enroll in the National Health Insurance Scheme than those who did not experience any food insecurity (OR = 0.48 p < 0.001). Based on these findings, we argue that in addition to the traditional socioeconomic factors, addressing severe food insecurity may improve health insurance enrolment among older adults. Additionally, policymakers should also consider older people’s socioeconomic circumstances when formulating policies for them to enrol in health insurance.

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.

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.

Health services availability and readiness moderate cash transfer impacts on health insurance enrolment: evidence from the LEAP 1000 cash transfer program in Ghana

BackgroundExpanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services.MethodsWe examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities’ service availability and readiness.ResultsWe find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points).ConclusionsWe find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors.Trial registrationThis study is registered in the International Initiative for Impact Evaluation’s (3ie) Registry for International Development Impact Evaluations (RIDIE-STUDY-ID-55942496d53af).

Comparative study of the effect of National Health Insurance Scheme on use of delivery and antenatal care services between rural and urban women in Ghana

BackgroundDespite the focus of the National Health Insurance Scheme (NHIS) to bridge healthcare utilisation gap among women in Ghana, recent evidence indicates that most maternal deaths still occur from rural Ghana. The objective of this study was to examine the rural-urban differences in the effects of NHIS enrolment on delivery care utilisation (place of delivery and assistance at delivery) and antenatal care services among Ghanaian women.MethodsA nationally representative sample of 4169 women from the 2014 Ghana Demographic and Health Survey was used. Out of this sample, 2880 women are enrolled in the NHIS with 1229 and 1651 being urban and rural dwellers, respectively. Multivariate logistic and negative binomial models were fitted as the main estimation techniques. In addition, the Propensity Score Matching technique was used to verify rural-urban differences.ResultsAt the national level, enrolment in NHIS was observed to increase delivery care utilisation and the number of ANC visits in Ghana. However, rural-urban differences in effects were pronounced: whereas rural women who are enrolled in the NHIS were more likely to utilise delivery care [delivery in a health facility (OR = 1.870; CI = 1.533–2.281) and assisted delivery by a medical professional (OR = 1.994; CI = 1.631–2.438)], and have a higher number of ANC visits (IRR = 1.158; CI = 1.110–1.208) than their counterparts who are not enrolled, urban women who are enrolled in the NHIS on the other hand, recorded statistically insignificant results compared to their counterparts not enrolled. The PSM results corroborated the rural-urban differences in effects.ConclusionThe rural-urban differences in delivery and antenatal care utilisation are in favour of rural women enrolled in the NHIS. Given that poverty is endemic in rural Ghana, this positions the NHIS as a potential social equaliser in maternal health care utilisation especially in the context of developing countries by increasing access to delivery care services and the number of ANC visits.

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.

Ghana's national health insurance, free maternal healthcare and facility‐based delivery services

AbstractGhana implemented the National Health Insurance Scheme (NHIS) in 2005 and introduced free maternal healthcare (FMH) into the scheme in 2008. These reforms aimed at improving the utilization of healthcare, especially for expectant mothers. Using data from the 2008 and 2014 Ghana Demographic and Health Surveys (GDHS) with a sample of 8,081, this study employed multivariate probit and conditional mixed process (CMP) estimators to analyze the NHIS enrolment and the use of facility‐based delivery services among expectant mothers within the context of Sustainable Development Goal 3 in Ghana. The influence of birth order on these policies has also been explored. Before and after analysis was used for the effect of the FMH on NHIS enrolment and the use of delivery services while CMP was used for the effect of NHIS on delivery services. It is concluded that higher birth order reduces the likelihood of NHIS enrolment and health facility delivery. Moreover, the FMH policy has improved both NHIS enrolment and facility‐based delivery. Finally, the NHIS policy proves to be a reliable factor to induce utilization of facility‐based delivery services. It is recommended that maternal health education at antenatal care visits should be enriched with potential consequences and complications associated with multiple births. The National Health Insurance Authority (NHIA) should provide registration desks for expectant mothers at health facilities.

Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana’s National Health Insurance Scheme

ObjectivesThe study aimed to understand the impact of integrating a fee waiver for the National Health Insurance Scheme (NHIS) with Ghana’s Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer programme...

Determinants of health insurance enrolment in Ghana: evidence from three national household surveys.

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.

Sociodemographic determinants of health insurance enrolment and dropout in urban district of Ghana: a cross-sectional study

BackgroundEarlier studies have found significant associations between sociodemographic factors and enrolment in the National Health Insurance Scheme (NHIS) in Ghana. These studies were mainly household surveys in relatively rural areas with high incidence of poverty. To expand the scope of existing evidence, this paper examines policy design factors associated with enrolment and dropout of the scheme in an urban poor district using routine secondary data.MethodsThis study is a cross-sectional quantitative analysis of 2014–2016 NHIS enrolment data of the Ashiedu Keteke district office. Descriptive and multivariate logistic regression analyses were performed to examine sociodemographic factors associated with NHIS enrolment and dropout.ResultsA total of 215,724 individuals enrolled in the NHIS over the period under study, of which 98,232 (46%) were new members. About 41% of existing members in 2014 dropped out of the NHIS in 2015 and 53% of those in 2015 dropped out in 2016. The indigents (core poor) are significantly more likely to enrol and to drop out of the NHIS. However, the males, informal sector employees, social security and national insurance trust (SSNIT) contributors, and the aged (70+ years) are significantly less likely to enrol in the NHIS but more likely to retain coverage.ConclusionsA considerable number of members are dropping out of the NHIS. The indigents in particular, are increasingly enrolling in and dropping out of the NHIS whilst the males, informal sector employees, SSNIT contributors and the aged are not enrolling as expected but increasingly retaining coverage. Policy reforms to ensuring continued growth towards realization of universal health coverage should take these factors into consideration.

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...

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.

Differences in the determinants of health insurance enrolment among working-age adults in two regions in Ghana

BackgroundGhana’s National Health Insurance Scheme (NHIS) has achieved varying levels of enrolment within the regions with different rural-urban populations with associated income inequalities. This study sought to investigate the differences in the determinants of enrolment between the Greater Accra (GAR) and Western (WR) regions of Ghana to inform the NHIS reforms.MethodData from 4214 adults, 18 years and above from a household survey conducted in the two regions was analyzed. Bivariate analysis (t-test for continuous and Pearson chi-square for categorical) was performed to examine differences in respondents characteristics (socio-economic and insurance enrolment) between the two regions for the total, urban and rural samples. Logistic regression estimation was performed to establish differences in determinant of enrolment between the regions.ResultsAge, sex, educational level, marital status, health status and travel time to nearest health facility were identified as determinants of enrolment in both regions and among the rural and urban residents within the regions. Although the rich and richest in both regions are more likely to enroll than the poor and poorest, the odds of enrolment for the urban richest in the WR is about twice that of GAR whiles the odds of enrolment for the rural richest in the GAR is also about twice that of the WR. Those who visit public facilities in the GAR are more likely to enroll than those in WR for the total and urban samples. However, those who visit private facilities in rural communities in both regions are more likely to enroll.ConclusionDifferences in the NHIS enrolment between the regions is as a result of differences in socio-economic factors that are intrinsic in the regions and impact on the inhabitants’ ability to afford insurance premium. Policymakers should determine NHIS premium differently at the district level based on socio-economic activities and income levels within the districts.

Universal health coverage in the context of population ageing: What determines health insurance enrolment in rural Ghana?

BackgroundPopulation ageing presents considerable challenges for the attainment of universal health coverage (UHC), especially in countries where such coverage is still in its infancy. Ghana presents an important case study on the effectiveness of policies aimed at achieving UHC in the context of population ageing in low and middle-income countries. It has witnessed a profound recent demographic transition, including a large increase in the number of older adults, which coincided with the development and implementation of a National Health Insurance Scheme (NHIS), designed to help achieve UHC. The objective of this paper is to examine the community, household and individual level determinants of NHIS enrolment among older adults aged 50–69 and 70 plus. The latter are exempt from NHIS premium payments.MethodsUsing the Ghanaian Living Standards Survey from 2012 to 2013, determinants of NHIS enrolment for individuals aged 50–69 and 70 plus living in rural Ghana are examined through the application of multilevel regression analysis.ResultsPrevious studies have mainly focused on the enrolment of young and middle aged adults and considered mainly demographic and socio-economic factors. The novel inclusion of spatial barriers within this analysis demonstrates that levels of NHIS enrolment are determined in part by the community provision of healthcare facilities. In addition, the findings imply that insurance enrolment increases with household expenditure even for those aged 70 plus who are exempt from the NHIS premium payment.ConclusionAdequate and appropriate infrastructure as well as health insurance is vital to ensure movement to UHC in low and middle income countries. Overall, the results confirm that there remain significant inequalities in enrolment by expenditure quintile that future policy reform will need to address.

Examining the association between exposure to mass media and health insurance enrolment in Ghana.

Although previous studies have explored the National Health Insurance Scheme (NHIS) in Ghana, very little attention is paid to the influence of mass media exposure on NHIS enrolment. Yet, understanding this linkage is important, particularly due to the critical role of mass media in disseminating health information and shaping people's health perceptions and choices. Using data from the 2014 Ghana Demographic and Health Survey, we employed logistic regression analysis to understand the relationship between NHIS enrolment and exposure to print media, radio, and television. Our findings indicate that women with more exposure to radio (OR=1.23, P<0.01) and television (OR=1.24, P<0.01) were more likely to enroll in the NHIS than those with no exposure. For men, more exposure to print media was associated with higher odds of enrolling in the NHIS (OR=1.41, P<0.01). In conclusion, all 3 types of media may be helpful in promoting NHIS enrolment in Ghana. However, given that the relationship between media exposure and enrolment in the NHIS was gendered, we recommend that policymakers should pay attention to these dynamics to ensure effective targeting in NHIS media campaigns for increased enrolment into the scheme.

Migrant female head porters\u2019 enrolment in and utilisation and renewal of the National Health Insurance Scheme in Kumasi, Ghana

PurposeAs a social protection policy, Ghana’s National Health Insurance Scheme (NHIS) aims to improve access to healthcare, especially for the vulnerable. Migrant female head porters (kayayoo), who are part of the informal economic workforce, are underscored as an ethnic minority and vulnerable group in Ghana. This study aimed to analyse the factors associated with enrolment in and renewal and utilisation of the NHIS among migrant female head porters in the Kumasi Metropolis.MethodWe purposively sampled 392 migrant female head porters in the Kejetia, Asafo and Bantama markets. We used a binary logit regression model to estimate associations among baseline characteristics, convenience and benefit factors and enrolment in and renewal and utilisation of the NHIS.ResultAge and income significantly increased the probability of NHIS enrolment, renewal and utilisation. Long waiting times at NHIS offices significantly reduced the likelihood of renewal, while provision of drugs highly significantly increased the tendency for migrant female head porters to enrol in, renew and use the NHIS. Consulting and surgery also significantly increased renewal and utilisation of the NHIS.ConclusionPolitical commitment is imperative for effective implementation of the decentralisation policy of the NHIS through the National Health Insurance Authority in Kumasi. We argue that retail offices should be well equipped with logistic facilities to ensure convenience in NHIS initial enrolment and renewal processes by citizenry, and by vulnerable groups in particular.

National health insurance scheme enrolment and antenatal care among women in Ghana: is there any relationship?

The objective of this study was to examine whether enrolment in the National Health Insurance Scheme (NHIS) affects the likelihood and timing of utilising antenatal care among women in Ghana. Data were drawn from the Ghana Demographic and Health Survey, a nationally representative survey collected in 2008. The study used a cross-sectional design to examine the independent effects of NHIS enrolment on two dependent variables (frequency and timing of antenatal visits) among 1610 Ghanaian women. Negative binomial and logit models were fitted given that count and categorical variables were employed as outcome measures, respectively. Regardless of socio-economic and demographic factors, women enrolled in the NHIS make more antenatal visits compared with those not enrolled; however, there was no statistical association with the timing of the crucial first visit. Women who are educated, living in urban areas and are wealthy were more likely to attend antenatal care than those living in rural areas, uneducated and from poorer households. The NHIS should be strengthened and resourced as it may act as an important tool for increasing antenatal care attendance among women in Ghana.