The state of enrollment on the National Health Insurance Scheme in rural Ghana after eight years of implementation

Abstract

BackgroundIn 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations.MethodsA cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES.ResultsApproximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme.ConclusionsDespite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.

Mixed effects analysis of factors associated with health insurance coverage among women in sub-Saharan Africa

“…In the pursuit of achieving the SDG target of UHC, many countries in sub-Saharan Africa (SSA) have implemented health insurance policies over the last two decades [4]. Many of the schemes currently cover public servants at both central and local government levels together with their family members while others cover the entire population [5][6][7][8][9][10][11][12][13][14]. The health insurance schemes in SSA have been introduced to largely replace the existing health financing systems which are dominated by out-of-pocket payments.…”

Prevalence of health insurance enrolment and associated factors among persons with disabilities in Ghana

“…The exempt group of the NHIS which includes Social Security and National Insurance Trust (SSNIT) pensioners, people over 70 years, pregnant women, children under 18 and paupers (NHIS, 2018a). Even though the SSNIT beneficiaries are excluded from paying the premium, they are required to pay a registration fees for NHIS card to access healthcare services under NHIS (Kwarteng et al, 2020).…”

“…Treatments such as dialysis for chronic rental failure, treatments for cancer (except cervical and breast cancers), organ transplants and cosmetic surgery which are considered expensive are not covered under the NHIS. Further, treatment for Human Immuno-Deficiency Virus/Acquired Immuno Deficiency Syndrome, immunization and family planning services are excluded under the scheme but provided for under other government vertical programmes (Kwarteng et al, 2020). The funding sources include a 2.5% value added tax levied on selected goods and services consumed in Ghana, 2.5% of employees' SSNIT pension fund deductible at source, annual premium and registration fees, returns on investments and support from international donors (Kwarteng et al, 2020).…”

A Collaborative Health Promotion Approach to Improve Rural Health Delivery and Health Outcomes in Ghana: A Case Example of a Community-Based Health Planning and Services (CHPS) Strategy

“…In their study, Kwarteng and colleagues have also highlighted the low enrolment and coverage of rural residents by the NHIS that aims at protecting the vulnerable and poor from catastrophic health expenditure. They highlighted "the great disparities in NHIS enrolment against members of the poorest households, those without formal education and living in rural areas" [38]. Similarly, other researchers have demonstrated in a study spanning seven districts of the Upper East region that women of lower Socio-Economic Status, living in rural settings with no formal education among other conditions were less likely to register with the scheme [38,39].…”

“…They highlighted "the great disparities in NHIS enrolment against members of the poorest households, those without formal education and living in rural areas" [38]. Similarly, other researchers have demonstrated in a study spanning seven districts of the Upper East region that women of lower Socio-Economic Status, living in rural settings with no formal education among other conditions were less likely to register with the scheme [38,39]. The researchers identified a number of factors militating against the willingness of those in the rural areas to subscribe to the NHIS.…”