Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
International Journal for Equity in Health
Published in: International Journal for Equity in Health 1/2015

Open Access 01-12-2015 | Research

Refusal to enrol in Ghana’s National Health Insurance Scheme: is affordability the problem?

Authors: Anthony Kusi, Ulrika Enemark, Kristian S Hansen, Felix A Asante

Published in: International Journal for Equity in Health | Issue 1/2015

Login to get access

Abstract

Background

Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources.

Methods

The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified.

Results

Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS.

Conclusion

Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage.
Literature
1.
World Health Organisation. Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organisation; 2010.
2.
Wagstaff A, van Doorslaer E. Catastrophic and impoverishment in paying for health care: with applications to Vietnam, 1993–98. Health Econ. 2003;12(11):921–34.PubMedCrossRef
3.
Escobar ML, Griffin CC, Shaw RP. Why and how are we studying health insurance in the developing world? In: Escobar ML, Griffin CC, Shaw RP, editors. Impact of health insurance in low-and middle-income countries. Washington DC: Brookings Institution Press; 2010. p. 1–12.
4.
Gottret P, Scheiber G. Health financing revisited: A practitioner’s guide. Washington, DC: The World Bank; 2006.CrossRef
5.
World Health Organisation. World health report 2000. Health systems: Improving performance. Geneva: World Health Organisation; 2000. p. 2000.
6.
Acharya A, Vellakkal S, Taylor F, Masset E, Satija A, Burke M, et al. Impact of national health insurance for the poor and the informal sector in low and middle-income countries: a systematic review, Policy Research Working Paper no. WPS 6324. Washington, DC: The World Bank; 2013.CrossRef
7.
Preker AS, Carrin G, editors. Health Financing for Poor People: Resource Mobilization and Risk Sharing. Washington DC: The World Bank; 2004.
8.
Chankova S, Atim C, Hatt L. Ghana’s National Health Insurance Scheme. In: Escobar ML, Griffin CC, Shaw RP, editors. Impact of health insurance in low-and-middle income countries. Washington DC: Brookings Institution Press; 2010. p. 58–87.
9.
Soors W, Devadasan N, Durairaj V, Criel B. Community health insurance and universal coverage: multiple paths, many rivers to cross. World health report 2010 background paper no 48. Geneva: World Health Organization; 2010.
10.
National Development Planning Commission. The implementation of the Ghana shared growth and development agenda (GSGDA), 2010–2013. 2011 annual progress report. Accra, Ghana: NDPC; 2012.
11.
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
12.
Nguyen H, Knowles J. Demand for voluntary health insurance in developing countries: the case of Vietnam’s school-age children and adolescent student health insurance program. Soc Sci Med. 2010;71:2074–82.PubMedCrossRef
13.
De Allegri M, Sanon M, Sauerborn R. To enrol or not enrol’ a qualitative investigation of demand for health insurance in rural West Africa. Soc Sci Med. 2006;62:1520–7.PubMedCrossRef
14.
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;2:172–84.CrossRef
15.
Criel B, Waelkens MP. Declining subscriptions to the Maliando mutual health Organization in Guinea-Conakry (West Africa): what is going wrong? Soc Sci Med. 2003;57:1205–19.PubMedCrossRef
16.
17.
Kirigia JM, Sambo LG, Nganda B, Mwabu GM, Chatora R, Mwase T. Determinants of health insurance ownership among South African women. BMC Health Ser Res. 2005;5:17.CrossRef
18.
Hsiao WC, Shaw RP. Social health insurance for developing nations. Washington DC: The World Bank; 2007.CrossRef
19.
Asante F, Aikins M. Does the NHIS cover the poor? Accra, Ghana: DANIDA; 2008.
20.
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.PubMedCrossRef
21.
Kotoh MA. Improving health insurance coverage in Ghana. African Studies Centre, African studies collection, vol. 51. Leiden, The Netherlands: African Studies Centre; 2013.
22.
National Development Planning Commission. Citizen’s Assessment of the National Health Insurance Scheme. Accra, Ghana: NDPC; 2009.
23.
Sulzbach S, Garshong B, Owusu-Banahene G. Evaluating the effects of the national health insurance act in Ghana: Baseline report. Bethesda: AbtAssociates PHR+; 2005.
24.
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.PubMedCrossRef
25.
26.
Levy H, DeLeire T. What do people buy when they don’t buy health insurance and what does that tells us about why they are uninsured? Inquiry. 2008–2009;45(4):365–79.
27.
Bundorf MK, Pauly MV. Is health insurance affordable for the uninsured? J Health Econ. 2006;25:650–73.PubMedCrossRef
28.
29.
Muennig P, Sampat B, Tilipman N, Brown LD, Glied SA. We all want it, but we don’t know what it is: toward a standard of affordability for health insurance premiums. J Health Polit Policy Law. 2011;36(5):829–53.PubMedCrossRef
30.
Pauly, MV. Insight on demand for private voluntary health insurance in less developed countries. In: Preker AS, Scheffler RM, Bassett MC, editors. Private voluntary health insurance in development: Friend or Foe? Washington DC: World Bank; 2007. p. 25–54.
31.
Dong H, De Allegri M, Gnawali D, Souares A, Sauerborn R. Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso. Health Policy. 2009;92(2–3):174–9.PubMedCrossRef
32.
Diop F. Determinants of financial stability of mutual health organizations in the Thies Region of Senegal: household survey component. Bethesda, MD: Partners for Health Reformplus Project, Abt Associates Inc.; 2005.
33.
Franco LM, Simpara CHT, Sidibé O, Kelley AG, Diop FP, Makinen M, et al. Equity Initiative in Mali: Evaluation of the impact of mutual health organizations on utilization of high impact services in Bla and Sikasso Districts in Mali. Bethesda, MD: Partners for Health Reformplus Project, Abt Associates Inc.; 2006.
34.
35.
Amporfu E. Equity of the premium of the Ghanaian national health insurance scheme and the implications for achieving universal coverage. Int J Equity Health. 2013;12:4.PubMedCentralPubMedCrossRef
36.
World Health Organisation. Reasearch for universal health coverage. Geneva: World Health Organisation; 2013.
37.
Republic of Ghana. National Health Insurance Act, 2012. Act 650. Accra, Ghana: NHIA; 2012.
38.
National Health Insurance Authority. Annual Report 2010. Accra, Ghana: NHIA; 2011.
39.
40.
Ghana Statistical Service. Ghana Living Standard Survey (GLSS 5). Accra, Ghana: GSS; 2008.
41.
Ghana Statistical Service, Ghana Health Service, ICF Macro. Ghana Demographic and Health Survey 2008. Ghana: GSS, GHS and ICF Macro; 2009.
42.
Oduro DA, Boakye-Yiadom L, Baah-Boateng W. Asset ownership and egalitarian decision-making among couples: some evidence from Ghana. The Gender asset gap project. Working Paper Series: No. 14. Bangalore, India: Indian Institute of Management; 2012.
43.
Glied S. Mandates and affordability of health care. Inquiry. 2009;46:203–14.PubMed
44.
O’Donnell O, van Doorslaer E, Wagstaff A, Lindelow M. Analyzing health equity using household survey data: a guide to techniques and their implementation. Washington DC: The World Bank; 2008.
45.
Ghana Statistical Service. Report of the Ghana Living Standards Survey. Accra, Ghana: GSS; 2007. p. 2007.
46.
Xu K. Distribution of health payments and catastrophic expenditures: methodology. Discussion paper no.2. Geneva: World Health Organisation; 2005.
47.
Deaton A, Zaidi S. Guidelines for constructing consumption aggregates for welfare analysis, LSMS Working Paper No. 135. The World Bank: Washington, DC; 2002.
48.
Akazili J, Garshong B, Aikins M, Gyapong J, McIntyre D. Progressivity of health care financing and incidence of service benefits in Ghana. Health Policy Plan. 2012;27 Suppl 1:i13–22.PubMedCrossRef
49.
Durairaj V, D’Almeida S, Kirigia J. Ghana’s approach to social health protection. World Health Report 2010, background paper, no.2. Geneva: World Health Organization; 2010.
50.
Jehu-Appiah C, Aryeetey G, Agyepong I, Spaan E, Baltussen R. Household perceptions and their implications for enrolment in the National Health Insurance Scheme in Ghana. Health Policy Plan. 2012;27:222–33.PubMedCrossRef
51.
Schieber G, Cheryl C, Karima S, Rouselle L. Health Financing in Ghana. Washington, DC: The World Bank; 2012. p. 2012.
52.
Schneider P. Why should the poor insure? Theories of decision-making in the context of health insurance. Health Policy and Planning. 2004;19(6):349–55.PubMedCrossRef
53.
Nyman JA. The value of health insurance: the access motive. J Health Econ. 1999;1999(18):141–52.CrossRef
54.
Pauly MV. The Demand for Health Insurance: Insights from theory and voluntary markets in Less-Developed countries. 2004.
55.
Gobah FFK, Liang Z. The National Health Insurance Scheme in Ghana: prospects and challenges: a cross-sectional evidence. Glob J Health Sci. 2011;3(2):90–101.
56.
SEND-Ghana. Balancing access with quality health care: An assessment of the NHIS in Ghana (2004–2008). Accra, Ghana: SEND; 2010.
Metadata
Title
Refusal to enrol in Ghana’s National Health Insurance Scheme: is affordability the problem?
Authors
Anthony Kusi
Ulrika Enemark
Kristian S Hansen
Felix A Asante
Publication date
01-12-2015
Publisher
BioMed Central
Published in
International Journal for Equity in Health / Issue 1/2015
Electronic ISSN: 1475-9276
DOI
https://doi.org/10.1186/s12939-014-0130-2

Other articles of this Issue 1/2015

International Journal for Equity in Health 1/2015 Go to the issue

Research

Addressing unresolved tensions to build effective partnerships: lessons from an Aboriginal cancer support network

Research

Social inequalities in patient-reported outcomes among older multimorbid patients – results of the MultiCare cohort study

Research

Equity of access under Korean national long-term care insurance: implications for long-term care reform

Research

Catastrophic health expenditure and its determinants in Kenya slum communities

Review

The old age health security in rural China: where to go?

Research

Health care utilization and costs among medical-aid enrollees, the poor not enrolled in medical-aid, and the near poor in South Korea