Factors That Influence Enrolment and Retention in Ghana’ National Health Insurance Scheme

Abstract

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.

Health Insurance and Healthcare Quality: A Comparative Study between Insured and Uninsured Patients at a Teaching Hospital in Northeast Nigeria

“…Satisfaction scores with the other accessed areas were mixed: with uninsured patients expressing higher satisfaction levels with hospital accessibility, doctor's consultation, nursing care and quality of care; while NHIS enrollees expressed higher satisfaction scores with laboratory services, patient waiting time and cost of care, all without statistical significance. These findings suggest that patients generally experience varying levels of healthcare quality, which is comparable to the result of some previous studies [16][17][18] and recommends that efforts towards quality improvement and sustainable delivery of excellent health services should not be targeted towards a particular group but to all the patients.…”

“…Bauchet, et al [14] in India reported that insurance status has no influence on the quality of care received by patients. Abuosi, et al in Ghana reported that overall, there was no significant difference in perceptions of quality between insured and uninsured patients [15], while some other studies in Ghana and Haiti reported that patients (insured and uninsured) experience poor quality of care and it can deter healthcare utilization as well as affect health insurance schemes negatively by discouraging enrolment and renewal [16][17][18].…”

An Empirical Study on the Benefits Equity of the Medical Security Policy: the China Health and Nutrition Survey (CHNS)

“…Improving the assessment of the fairness of basic medical insurance would help provide reliable support for system optimization. However, in the evaluation of the institutional effect, it remains necessary to define fairness clearly and draw on the literature and main influencing factors that cause inequitable benefits of the group's basic medical insurance, including, for example, objective factors, such as individual health and age and the differences in social factors, such as risk, income, and education [17][18][19][20]; among them, the social factors are the main cause of social inequality. Therefore, the definition of fairness in this paper emphasizes the differences between income groups in basic medical insurance, that is, different income groups are not provided with the same health rights despite being provided the same health insurance.…”

“…Achieving fairness in basic medical services is a basic task in the reform of the medical and health systems in countries worldwide and has received increasing attention from the academic world. Scholars have studied the differences in the fairness of the basic medical insurance systems in typical countries and regions, such as the perspective of the relationship between national income and health inequality in different countries (or regions) [20]; the benefit of the difference between income groups was studied from the perspective of basic health service use and medical insurance compensation level [31,32].…”

Effect of informal financial support for health care on health Insurance uptake: Evidence from a mixed‐methods study in Tamale metropolis of northern Ghana

“…Substantial socioeconomic inequalities remain in NHIS enrollment, with fewer low‐income and informal sector households participating in the scheme . Previous studies have identified a wide range of factors that may be responsible for the inequities in coverage, including poverty, lack of information, poor quality of care, unaffordable premiums, and administrative bottlenecks . Most of Ghana's population work in the informal sector and are reliant of informal support arrangements to the meet their daily needs, including health care.…”