Background: The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2004 with the goal of achieving universal coverage within 5 years. Evidence, however, shows that expanding NHIS coverage and especially retaining members have remained a challenge. A multilevel perspective was employed as a conceptual framework and methodological tool to examine why enrolment and retention in the NHIS remains low. Methods: A household survey was conducted after 20 months educational and promotional activities aimed at improving enrolment and retention rates in 15 communities in the Central and Eastern Regions (ERs) of Ghana. Observation, indepth interviews and informal conversations were used to collect qualitative data. Forty key informants (community members, health providers and district health insurance schemes’ [DHISs] staff) purposely selected from two casestudy communities in the Central Region (CR) were interviewed. Several community members, health providers and DHISs’ staff were also engaged in informal conversations in the other five communities in the region. Also, four staff of the Ministry of Health (MoH), Ghana Health Service (GHS) and National Health Insurance Authority (NHIA) were engaged in in-depth interviews. Descriptive statistics was used to analyse quantitative data. Qualitative data was analysed using thematic content analysis. Results: The results show that factors that influence enrolment and retention in the NHIS are multi-dimensional and cut across all stakeholders. People enrolled and renewed their membership because of NHIS’ benefits and health providers’ positive behaviour. Barriers to enrolment and retention included: poverty, traditional risk-sharing arrangements influence people to enrol or renew their membership only when they need healthcare, dissatisfaction about health providers’ behaviour and service delivery challenges. Conclusion: Given the multi-dimensional nature of barriers to enrolment and retention, we suggest that the NHIA should engage DHISs, health providers and other stakeholders to develop and implement intervention activities to eliminate corruption, shortage of drugs in health facilities and enforce the compulsory enrolment stated in the NHIS policy to move the scheme towards universal coverage.

BackgroundThe 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.MethodsFifteen 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.ResultsThe 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.ConclusionInequity 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.

Background Attending antenatal care (ANC) early contribute to better birth outcomes. Studies have shown that many pregnant women in Sub-Saharan Africa do not initiate ANC early (i.e. in the first trimester). This study determined the gestational age of pregnancy at first ANC attendance. It also explored factors that influence initiation of ANC. Methods This cross-sectional study, conducted in Ghana, used mixed methods to collect data from women aged 15–45 years who delivered 6 months prior to the study. Crosstabs, chi-square test and logistic regression were used to analyse quantitative data. Also, 33 participants were engaged in focus group discussions (FGDs). Thematic content analysis was used to develop themes from the data. Results Of the 431 participants, 8.9, 8, 25.4, 45.3 and 10.7% started ANC in the first, second, third, fourth and fifth months of pregnancy respectively. Formal education, employment and number of living children were predictors of initiating ANC early; by 12 weeks of gestation. Women who attained primary, junior high, secondary education and above had 5.6, 57.5 and 163.2 higher odds respectively of initiating ANC in the first trimester compared to women with no education ( p ≤ 0.05). Women with two, three and four to nine living children were 4.1, 3 and 3.5 times respectively more likely to access ANC early compared to primigravidae women. However, women with five or more children and primigravidae women are more likely to initiate ANC late; after 12 weeks gestation. The FGD data also show that most of the participants initiated ANC late. Two themes: visible signs of pregnancy and or sickness influence ANC attendance in the first trimester. The themes that explain late initiation of ANC are: healthy, do not value the benefits of early ANC attendance, desire to avoid embarrassment associated with the pregnancy, unplanned pregnancy, indirect cost of accessing ANC and traditional rites and practices. Conclusion Contextual factors influence ANC initiation. Investment in female education, intensification of health promotion activities by health workers, non-governmental organisations, community and religious leaders to sensitise communities on the benefits of initiating ANC at the onset of pregnancy is needed to improve first trimester attendance. Electronic supplementary material The online version of this article (10.1186/s12889-019-7400-2) contains supplementary material, which is available to authorized users.

BackgroundPoverty is multi dimensional. Beyond the quantitative and tangible issues related to inadequate income it also has equally important social, more intangible and difficult if not impossible to quantify dimensions. In 2009, we explored these social and relativist dimension of poverty in five communities in the South of Ghana with differing socio economic characteristics to inform the development and implementation of policies and programs to identify and target the poor for premium exemptions under Ghana’s National Health Insurance Scheme.MethodsWe employed participatory wealth ranking (PWR) a qualitative tool for the exploration of community concepts, identification and ranking of households into socioeconomic groups. Key informants within the community ranked households into wealth categories after discussing in detail concepts and indicators of poverty.ResultsCommunity defined indicators of poverty covered themes related to type of employment, educational attainment of children, food availability, physical appearance, housing conditions, asset ownership, health seeking behavior, social exclusion and marginalization. The poverty indicators discussed shared commonalities but contrasted in the patterns of ranking per community.ConclusionThe in-depth nature of the PWR process precludes it from being used for identification of the poor on a large national scale in a program such as the NHIS. However, PWR can provide valuable qualitative input to enrich discussions, development and implementation of policies, programs and tools for large scale interventions and targeting of the poor for social welfare programs such as premium exemption for health care.