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

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.

Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana

“…The findings of this study have implications for reducing inequity in access to healthcare, especially in light of the ongoing challenges to improve NHIS coverage [23,45] and efforts to achieve Universal Health Coverage. The results suggest that enabling factors (wealth) were a strong predictor for the use of both public and private health facilities.…”

“…However, it has also been reported that the NHIS contribution from the formal employment sector is very regressive, in that people with lower income contribute a higher share of their income than do people with higher income [21]. Coverage also remains low, with only 34% of people being active members (valid cardholder members) of the NHIS [23]. Furthermore, it is mainly public and mission-based healthcare facilities which provide healthcare through the NHIS; most private for-profit facilities require payment at the point of use.…”

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

“…A number of authors have attributed the low coverage of the scheme to unaffordable premium, perceived poor quality of health services, lack of trust, and confusion over basic details of the scheme, among others [8][9][10]. It has been found that certain groups of persons, especially the poor are systematically excluded from the NHIS [11][12][13][14].…”

Trends and projections of universal health coverage indicators in Ghana, 1995-2030: A national and subnational study

“…Insurance premiums and registration fees remain as obstacles to enrolment for the poor, many are simply left unattended without any form of protection [27]. For people in the poorest quintile, premium imposes a heavy burden as it takes up 11.4% of their non-food expenditure while it only takes up 5.9% for general households [28]. A recent study done in Ghana revealed that as share of OOP payment for healthcare in total household expenditure increases, impoverishment deepens [37].…”