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

Abstract

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.Electronic supplementary materialThe online version of this article (10.1186/s13561-019-0241-y) contains supplementary material, which is available to authorized users.

Structural Factors Responsible for Universal Health Coverage in Low- and Middle-Income Countries: Results From 118 Countries

“…Studies have shown that the economy would be sustainable after the guarantee of health service to all people (18,19). Poor enrollment and drop out in health insurance would significantly affect universal health coverage (20). Likewise, increasing government health expenditures would contribute to quality health service and also coverage (18,21,22).…”

Vertical equity in access to health insurance services: A qualitative analysis of perceptions and enrolment in the Jirapa Municipality, North-western Ghana

“…In the Jirapa Municipality where the majority of the population is employed in subsistence agriculture and without reliable records of their income to qualify to contribute based on income, adverse selection and moral hazards were a common means of avoiding catastrophic expenditure. The residents would often enrol or renew the membership of household members who are most likely to fall sick [3] or renew their membership only when they were sick. To achieve equity in enrolment in the NHIS would require a review of the current at rate contributions levied on subscribers outside the formal sector.…”

“…This de nition however, is shrouded in ambiguity and therefore inadequate when the focus is on implementing a speci c policy on equity in health (20,21). For example, a variety of studies that explored perceptions of equity in the NHIS have often tended to focus generally on the socioeconomic or sociodemographic factors associated with enrolment and dropout (3,(24)(25)(26). Other studies have examined the subjects of equity and affordability in the NHIS and arrived at the conclusion that the at rate payment of premiums by those in the informal sector favoured richer people, although the burden of illness was greater for lower-income groups (27)(28)(29)(30)(31).…”

“…This preference is in uenced by the seasonal nature of their main livelihood activities. [3] Thus, the best time to collect contributions is when the residents are harvesting farm produce and may have surplus to sell to raise funds to pay premiums. A subsistence crop farmer in Tuggo decried that: "It is not possible for us to keep some money from the sale of farm produce and pay for health insurance any time of the year.…”

“…Same is true for minority ethnic groups and indigenous peoples, and in some cases gaps in illhealth have increased (1). The National Health Insurance Scheme in Ghana (NHIS) has made signi cant progress in terms of enrolment of members, which has had a commensurate increase in the utilization of health care services (2)(3)(4), yet questions are raised about progress towards achieving its equity objectives.…”