Refusal to enrol in Ghana’s National Health Insurance Scheme: is affordability the problemReport as inadecuate

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International Journal for Equity in Health

, 14:2

First Online: 17 January 2015Received: 18 January 2014Accepted: 10 December 2014DOI: 10.1186-s12939-014-0130-2

Cite this article as: Kusi, A., Enemark, U., Hansen, K.S. et al. Int J Equity Health 2015 14: 2. doi:10.1186-s12939-014-0130-2


BackgroundAccess 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.

MethodsThe 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.

ResultsResults 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.

ConclusionAffordability 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.

KeywordsVoluntary health insurance Universal coverage Enrolment Premium Affordability Ghana AbbreviationsCHICommunity health insurance

DMHISDistrict mutual health insurance schemes

IRBInstitutional Review Board

LMICLow-and middle-income countries

NHINational Health Insurance

NHIANational Health Insurance Authority

NHIFNational Health Insurance Fund

NHISNational Health Insurance Scheme

NMIMRNoguchi Memorial Institute for Medical Research

SSNITSocial Security and National Insurance Trust

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Author: Anthony Kusi - Ulrika Enemark - Kristian S Hansen - Felix A Asante


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