Factors contributing to low uptake and renewal of health insurance: a qualitative study in Ghana

Abstract

BackgroundThe effort to expand access to healthcare and reduce health inequalities in many low income countries have meant that many have adopted different levels of social health protection mechanisms. Ghana introduced a National Health Insurance Scheme (NHIS) in 2005 with the aim of removing previous barriers created by the user fees financing system. Although the NHIS has made health accessible to some category of people, the majority of Ghanaians (60 %) are not enroled on the scheme. Earlier studies have looked at various factors that account for this low uptake. However, we recognise that this qualitative study will nuance the depth of these barriers to enrolment.MethodsMinimally structured, qualitative interviews were conducted with key stakeholders at the district, regional and national levels. Focus group discussions were also undertaken at the community level. Using an inductive and content analytic approach, the transcripts were analyzed to identify and define categories that explain low uptake of health insurance.ResultsThe results are presented under two broad themes: sociocultural and systemic factors. Sociocultural factors identified were 1) vulnerability within certain groups such as the aged and the disabled groups which impeded access to the NHIS 2) cultural and religious norms which discouraged enrolment into the scheme. System-wide factors were 1) inadequate distribution of social infrastructure such as healthcare facilities, 2) weak administrative processes within the NHIS, and 3) poor quality of care.ConclusionsMapping the interplay of these dynamic relations between the NHIS, its clients and service providers, the study identifies critical factors at the policy-making level, service provider level, and client level (reflective in household and community level institutional arrangements) that affect enrolment in the scheme. Our findings inform a number of potential reforms in the area of distribution of health resources and cost containment to expand coverage, increase choices and meeting the needs of the end user.

Cost of malaria treatment and health seeking behaviour of children under-five years in the Upper West Region of Ghana

“…Our study findings of less expenditure on the insured compared to the uninsured is consistent with findings of some studies conducted in Ghana where the uninsured paid more for malaria care than the insured [ 14 , 38 , 39 ]. However, enrolment of households into the NHIS is not encouraging given that as at 2016, only 40% of Ghanaians were enrolled into the scheme with valid membership cards [ 40 ]. It has been reported that the main reason for low enrolment into the NHIS is affordability of the premium and poor households are less covered [ 30 , 41 – 45 ].Therefore, innovative methods are required to improve enrolment into the NHIS, especially the poor and vulnerable.…”

Determinants of enrolment in the NHIS for women in Ghana – a cross sectional study

“…Perception of the quality of care at health facilities and perception of the NHIS are significant factors to enrolment. Some insured patients, do complain of poor quality of health services provided at the health facilities which include long waiting times, bad attitude by health facility staff, and drug shortages [31, 49,50].…”

Trends and characteristics of enrolment in the National Health Insurance Scheme in Ghana: a quantitative analysis of longitudinal data

“…The coverage ratio measures proportion of the target population participating in the programme, serving as a key indicator of marketing effectiveness and programme’s success [ 33 ]. The marketing effectiveness, however depends largely on client’s satisfaction with the services and the perceived value of the programme [ 30 , 33 – 36 ]. Voluntary enrolment of large proportion of the target population, particularly in SHI programmes, gives an indication of acceptance of the risk-pooling concept and understanding of the programme including how to access the benefits.…”