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International Journal for Equity in Health
Published in: International Journal for Equity in Health 1/2016

Open Access 01-12-2016 | Research

Why are the poor less covered in Ghana’s national health insurance? A critical analysis of policy and practice

Authors: Agnes Millicent Kotoh, Sjaak Van der Geest

Published in: International Journal for Equity in Health | Issue 1/2016

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Abstract

Background

The National Health Insurance Scheme (NHIS) was introduced in Ghana to ensure equity in healthcare access. Presently, some low and middle income countries including Ghana are using social health insurance schemes to reduce inequity in access to healthcare. In Ghana, the NHIS was introduced to address the problem of inequity in healthcare access in a period that was characterised by user-fee regimes. The premium is heavily subsidised and exemption provided for the poorest, yet studies reveal that they are least enrolled in the scheme. We used a multi-level perspective as conceptual and methodological tool to examine why the NHIS is not reaching the poor as envisaged.

Methods

Fifteen communities in the Central and Eastern Regions of Ghana were surveyed after implementing a 20 months intervention programme aimed at ensuring that community members have adequate knowledge of the NHIS’ principles and benefits and improve enrolment and retention rates. Observation and in-depth interviews were used to gather information about the effects of the intervention in seven selected communities, health facilities and District Health Insurance Schemes in the Central Region.

Results

The results showed a distinct rise in the NHIS’ enrolment among the general population but the poor were less covered. Of the 6790 individuals covered in the survey, less than half (40.3 %) of the population were currently insured in the NHIS and 22.4 % were previously insured. The poorest had the lowest enrolment rate: poorest 17.6 %, poor 31.3 %, rich 46.4 % and richest 44.4 % (p = 0.000). Previous enrolment rates were: poorest (15.4 %) and richest (23.8 %), (p = 0.000). Ironically, the poor’s low enrolment was widely attributed to their poverty. The underlying structural cause, however, was policy makers’ and implementers’ lack of commitment to pursue NHIS’ equity goal.

Conclusion

Inequity in healthcare access persists because of the social and institutional environment in which the NHIS operates. There is a need to effectively engage stakeholders to develop interventions to ensure that the poor are included in the NHIS.
Footnotes
1
User-fees refer to out-of-pocket payments for some healthcare services at the point of utilisation.
 
2
Fee-free refers to free access to healthcare for all residents in Ghana at public facilities.
 
3
Cash and carry was a WHO and UNICEF initiative adopted by African Health Ministers in Bamako, Mali, in 1987. The policy aimed at improving drug supplies in public health facilities and led to out-of-pocket payment for full cost of drugs in public health facilities.
 
4
The Social Security and National Insurance Trust (SSNIT) is a government pension scheme in Ghana that most formal sector workers and their employers contribute to.
 
5
The Livelihood Empowerment against Poverty (LEAP) Programme started in March 2008 and expanded in 2009 and 2010 as a social cash transfer programme which provides cash and health insurance to extremely poor households across Ghana. It is funded by the Government of Ghana (50 %), donations from the Department for International Development and a loan from the World Bank and implemented by the Department of Social Welfare in the Ministry of Gender, Children and Social Protection.
 
Literature
1.
Nyonator F, Kutzin J. Health for some: the effect of user-fee in Volta Region of Ghana. Health Policy Plan. 1999;14(4):329–41.CrossRefPubMed
2.
Asenso-Okyere WK, Anum A, Osei-Akoto I, Adukonu A. Cost recovery in Ghana: are there any changes in healthcare seeking behaviour? Health Policy Plan. 1998;13(2):181–811.CrossRefPubMed
3.
Waddington CJ, Enyimayew KA. A price to pay. Part 1: The impact of user charges in the Ashanti-Akim district, Ghana. Int J Health Plann Manage. 1989;4(1):17–47.CrossRef
4.
Waddington CJ, Enyimayew KA. A price to pay. Part 2: The impact of user charges in the Volta Region of Ghana. Int J Health Plann Manage. 1990;5(4):287–312.CrossRef
5.
Hutchful E. Ghana adjustment experience: The paradox of reform. Geneva: United Nations Research Institute for Social Development; 2002.
6.
Turshen M. Privatising Health Services in Africa. New Brunswick. New .Jersey, London: Rutgers University Press; 1999.
7.
World Health Organisation. World Health Report 2000: Health Systems: Improving performance. Geneva: World Health Organisation; 2000.
8.
Mensah J, Oppong JR, Schmidt CM. Ghana’s National Health Insurance Scheme in the context of the health MDGS: an empirical evaluation using propensity score matching. Health Econ. 2010;19:95–106.CrossRefPubMed
9.
Durairaj V, D’ameida Kirigia S, Kirigia J. Ghana’s approach to social health protection. World Health Report Background Paper No. 2. Geneva: WHO; 2010.
10.
Amporfu E. Private hospital accreditation and inducement of care under the Ghanaian National Insurance Scheme. Health Econ Rev. 2011;1(13):1–9.
11.
Asante F, Aikins M. Does the NHIS cover the poor? Ghana: DANIDA Health Sector Support Office; 2008.
12.
Sarpong N, Loag W, Fobil J, Meyer CG, Adu-Sarkodie Y, May J, et al. National health insurance coverage and socio-economic status in a rural district of Ghana. Trop Med Int Health. 2010;15(2):191–7.CrossRefPubMed
13.
Goodman H, Waddington C. Financing healthcare. Oxford: Oxfam UK and Ireland; 1993.CrossRef
14.
Ministry of Health. Policy framework for the establishment of health insurance in Ghana. Revised Edition. Accra: Ministry of Health; 2002.
15.
Ministry of Health. National Health Insurance Policy Framework for Ghana. Revised Edition. Accra: Ministry of Health; 2004.
16.
Republic of Ghana. Hospital Fees Regulation Legislative Instrument 1313. Accra: Government of Ghana; 1985.
17.
Anyiman C. The social cost of the IMF’s adjustment programmes for poverty: the case of healthcare in Ghana. Int J Health Serv. 1989;19:531–47.CrossRef
18.
Arhinful DK. The solidarity of self-interest: Social and cultural feasibility of rural health insurance in Ghana. Leiden: African Studies Centre; 2003.
19.
Agyepong IA, Adjei S. Public social policy development and implementation: a case study of the Ghana National Health Insurance Scheme. Health Policy Plan. 2008;23(2):150–60.CrossRefPubMed
20.
Government of Ghana. The National Health Insurance Act: Act 650. Accra: Ghana Government; 2003.
21.
Baer H, Singer M, Johnson J. Towards a critical medical anthropology. Soc Sci Med. 1986;23(2):95–8.CrossRefPubMed
22.
23.
Scheper-Hughes N. Death without weeping: The violence of everyday life in Brazil. Los Angeles/London: University of California Press; 1992.
24.
Van der Geest S, Speckmann JD, Streefland P. Primary Health Care in a multilevel perspective: towards a research agenda. Soc Sci Med. 1990;30(9):1025–34.CrossRefPubMed
25.
Press I. Levels of explanation and cautions for a critical clinical anthropology. Soc Sci Med. 1990;30(9):1001–9.CrossRefPubMed
26.
Ghana Statistical Service. Trends and patterns of poverty in Ghana 1990-2005: Report of Ghana Living Standards Survey. Accra: Ghana Statistical Service; 2007.
27.
Kotoh AM. Improving health insurance coverage in Ghana: A case study. Leiden: African Studies Centre; 2013.
28.
Aryeetey GC, Jehu-Appiah C, Spaan E, D’exelle B, Agyepong I, Baltussen R. Identification of poor households for premium exemptions in Ghana’s Health Insurance Scheme: empirical analysis of three strategies. Trop Med Int Health. 2010;15(12):1544–52.CrossRefPubMed
29.
Jehu-Appiah C, Aryeetey GC, Spaan E, De Hoop T, Agyepong I, Baltussen R. Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling, who is not and why? Soc Sci Med. 2011;72:157–65.CrossRefPubMed
30.
Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105–12.CrossRefPubMed
31.
Con CP, Walford V. An introduction: Designing and implementing pro-poor policies. London: Department for International Development, Health Systems Resources Centre; 1998.CrossRef
32.
Badasu DM. Implementation of Ghana’s health user fee policy and the exemption of the poor: Problems and prospects. Afr Popul Stud Suppl A. 2004;19:285-302.
33.
Aikins M, Arhinful D. Review of exemption policy: A report on the annual health sector review 2005. Ghana: Ministry of Health; 2006.
34.
Kamuzora P, Gilson L. Factors influencing implementation of the Community Health Fund in Tanzania. Health Policy Plan. 2007;22(2):95–102.CrossRefPubMed
35.
Basaza R, Criel B, Van Der Stuyft P. Community health insurance in Uganda: Why does enrolment remain low? A view from beneath. Health Policy. 2008;87(2):172–84.CrossRefPubMed
36.
37.
Derbile EK, Van der Geest S. Repackaging exemptions under National Health Insurance in Ghana: How can access to care for the poor be improved? Health Policy Plan. 2013;28(6):586–95.CrossRef
38.
39.
Tipple G, Speak S. Definitions of homelessness in developing countries. Habitat Int. 2003;29(2005):337–52.
40.
Aryeetey GC. Targeting the poor in Ghana’s National Health Insurance Scheme and benefits of enrolment. PhD Dissertation. Nijmegen: Radboud University; 2012.
41.
Criel B. District-based health insurance in Sub-Sahara Africa Part I: From theory to practice. Antwerp: IGT Press; 1999.
42.
Ghana Statistical Service, Ghana Statistical Service, Noguchi Memorial Institute for Medical Research, ORC Macro. Ghana Demographic and Health Survey 2003. Calverton, Maryland: GSS, NMIMR and ORC Macro; 2004.
43.
Ghana Statistical Service. 2000 Population and housing census. Summary report of final results. Accra: Ghana Statistical Service; 2002.
44.
Ghana Statistical Service. 2010 Population and Housing Census: National Analytical Report. Accra: Ghana Statistical Service; 2013.
45.
Rajkotia Y. The political development of the Ghanaian National Health Insurance System: Lessons in health governance. Bethesda, MD: Health Systems 20/20 project. Abt Associates Inc; 2007.
46.
Agyepong IA, Nagai RA. “We charge them; otherwise we cannot run the hospital”. Frontline workers, clients and health financing policy implementation gaps in Ghana. Health Policy. 2011;99(3):226–33.CrossRefPubMed
47.
Lipsky M. Street-level Bureaucracy: Dilemmas of the individual in public services. New York: Russel Sage Foundation; 1980.
48.
Mclntyre D, Doherty J, Gilson L. A tale of two visions: the changing fortunes of social health insurance in South Africa. Health Policy Plan. 2003;18(1):47–58.CrossRef
49.
50.
Sudhanshu H. Livelihood empowerment against poverty programme Ghana Baseline Report. Carolina Population Centre: University of North Carolina; 2012.
Metadata
Title
Why are the poor less covered in Ghana’s national health insurance? A critical analysis of policy and practice
Authors
Agnes Millicent Kotoh
Sjaak Van der Geest
Publication date
01-12-2016
Publisher
BioMed Central
Published in
International Journal for Equity in Health / Issue 1/2016
Electronic ISSN: 1475-9276
DOI
https://doi.org/10.1186/s12939-016-0320-1

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