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

Prevalence, perceptions and associated factors of health insurance enrollment among older persons in selected cash grant communities in Ghana: a cross-sectional mixed method

BACKGROUND

Universal Health Coverage has been openly recognized in the United Nations health-related Sustainable Development Goals by 2030, though missing under the Millennium Development Goals. Ghana implemented the National Health Insurance Scheme programme in 2004 to improve financial access to healthcare for its citizens. This programme targeting low-income individuals and households includes an Exempt policy for older persons and indigents. Despite population ageing, evidence of the participation and perceptions of older persons in the scheme in cash grant communities is unknown. Hence, this paper examined the prevalence, perceptions and factors associated with health insurance enrollment among older persons in cash grant communities in Ghana.

METHODS

Data were from a cross-sectional household survey of 400 older persons(60 + years) and eight FGDs between 2017 and 2018. For the survey, stratified and simple random sampling techniques were utilised in selecting participants. Purposive and stratified sampling techniques were employed in selecting the focus group discussion participants. Data analyses included descriptive, modified Poisson regression approach tested at a p-value of 0.05 and thematic analysis. Stata and Atlas-ti software were used in data management and analyses.

RESULTS

The mean age was 73.7 years. 59.3% were females, 56.5% resided in rural communities, while 34.5% had no formal education. Two-thirds were into agriculture. Three-fourth had non-communicable diseases. Health insurance coverage was 60%, and mainly achieved as Exempt by age. Being a female [Adjusted Prevalence Ratio (APR) 1.29, 95%CI:1.00-1.67], having self-rated health status as bad [APR = 1.34, 95%CI:1.09-1.64] and hospital healthcare utilisation [APR = 1.49, 95%CI:1.28-1.75] were positively significantly associated with health insurance enrollment respectively. Occupation in Agriculture reduced insurance enrollment by 20.0%. Cited reasons for poor perceptions of the scheme included technological challenges and unsatisfactory services.

CONCLUSION

Health insurance enrollment among older persons in cash grant communities is still not universal. Addressing identified challenges and integrating the views of older persons into the programme have positive implications for securing universal health coverage by 2030.

A scoping review of the residual barriers to skilled birth attendance in Ghana: A conceptual framework and a fish bone analysis

The achievement of the Sustainable Development Goals (SDGs) targets 3.1, 3.2 and 3.3.1 is strongly dependent on the effective utilization of skilled birth services. Despite advancements made in Skilled Birth Attendance (SBA) in Ghana, there are still instances of unassisted childbirths taking place. The aim of this study was to explore the residual barriers of SBA such as community- and health system-related factors affecting SBA in Ghana and to identify strategies for addressing them. An electronic search was done using PubMed, Popline, Science direct, BioMed Central, Scopus and Google scholar for peer reviewed articles as well as grey articles from other relevant sources, published between 200 and 2022 on community- and health system related factors influencing SBA in Ghana. Out of the 89 articles retrieved for full screening, a total of 52 peer-reviewed articles and 1 grey article were selected for the final review. The study revealed that cultural practices (community factors), low quality of service delivery due to the inappropriate behaviors, lack of competency of skilled birth attendants (SBAs) as well as the inefficient distribution of SBAs contribute to ineffective uptake of SBA (health system factors). Also, indirect costs are associated with the utilization of skilled delivery care even with the existence of 'free' delivery care policy under the national health insurance (policy factor). For Ghana to achieve the SDGs above and improve SBA, it is essential to enhance the quality of skilled delivery care by addressing the attitude and competencies of skilled birth professionals, while plans are put in place to expand and develop the Community-based Health Planning and Services (CHPS) strategy to help address the access barriers to SBA. More so, the 'free' delivery care policy should absorb all the costs associated with skilled delivery for pregnant women as it is intended for.

Does mobile renewal make health insurance more responsive to clients? A case study of the National Health Insurance Scheme in Ghana

BACKGROUND

In 2018, Ghana's National Health Insurance Authority (NHIA) introduced a mobile strategy to enhance re-enrolment and improve client knowledge of their entitlements. This study investigated how Ghana's mobile strategy has influenced the NHIA's responsiveness to clients in terms of patient rights and entitlements, equity and satisfaction with health services.

METHODS

We surveyed people (n=1700) in 6 districts who had renewed their insurance in the previous 12 months, using any strategy (mobile or manual). Multiple regression analysis examined correlation between individual characteristics and renewal modality. Policy documents on the mobile programme's design and focus group discussions (n=12) on people's experiences renewing their insurance were analysed thematically.

RESULTS

While the mobile platform was designed for mobile National Health Insurance Scheme (NHIS) renewal and to provide information about insurance entitlements, few people surveyed (20%) knew about these informational features. Among those who renewed their NHIS coverage, 58% did so on the mobile renewal platform. Mobile renewal was high among those with tertiary education and those in the higher wealth quintiles. Mobile renewal was considered convenient, but required literacy in English, a phone and a mobile money wallet. For those who lacked some or all of these prerequisites but wanted to use mobile renewal, mobile vendors emerged as valued facilitators.

CONCLUSION

The mobile platform has increased the responsiveness of Ghana's NHIS through offering clients a more convenient mechanism to renew their insurance policies. It does not, however, eliminate the one month waiting period for activating the card, does not provide prompts to reassure clients of their renewal and does not empower most clients with information on entitlements. To improve the adoption and use of the mobile renewal strategy, the NHIA should publicise the platform's information-sharing functions and explore formally engaging mobile vendors.

Dropout rate and associated factors of community-based health insurance beneficiaries in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Ethiopia aims to achieve universal healthcare using health insurance. To do so, it has been implementing community-based health insurance since 2011. However, the retention of members by the scheme has not yet been evaluated nationally. The systematic review and meta-analysis aimed to evaluate the dropout rate and associated factors among the scheme's beneficiaries in Ethiopia.

METHODS

On December 19, 2022, searches were conducted in Scopus, Hinari, PubMed, Semantic Scholar, and Google Scholar. Searches were also conducted on the general web and electronic repositories, including the Ethiopian Health Insurance Service, the International Institute for Primary Health Care-Ethiopia, and various higher education institutions. The Joanna Briggs Institute's tools and the "preferred reporting items for systematic reviews and meta-analyses 2020 statement" were used to evaluate bias and frame the review, respectively. Data were analyzed using Stata 17 and RevMan 5. To assess heterogeneity, we conducted subgroup analysis and used a random model to calculate odds ratios with a p value less than 0.05 and a 95% CI.

RESULTS

In total, 14 articles were included in the qualitative synthesis, of which 12 were selected for the quantitative analysis. The pooled estimate revealed that the dropout rate of beneficiaries from the scheme was 34.0% (95% CI: 23-44%), provided that the renewal rate was 66.0%, and was found to be influenced by socio-demographic, health status, length of enrolment, knowledge, attitude, the scheme, and health service-related variables. The southern and Oromia regions reported the lowest and highest dropout rates, with 27.0% (95% CI: 24-29%) and 48.0% (95% CI: 18-78%), respectively. The dropout rates increased from 12.3% in 2012-2015 to 34.4% in 2020-2021.

CONCLUSION

More than one-third of the scheme's beneficiaries were found to have dropped out, and this has been found to increase over time, dictating that a community-based strategy and intervention, from the supply, insurer, and demand sides, seem indispensable in minimizing this huge dropout rate.

Factors influencing the free maternal health care policy under the national health insurance scheme's provision for skilled delivery services in Ghana: a narrative literature review

BACKGROUND

Skilled Birth Attendance (SBA) is important in achieving the Sustainable Development Goals (SDGs) targets 3.1, 3.2 and 3.3.1. Ghana has made steady progress in SBA, yet, unsupervised deliveries still occur. The introduction of the Free Maternal Health Care Policy under the National Health Insurance Scheme (FMHCP under the NHIS) has improved the uptake of SBA but with some implementation challenges. This narrative review sought to explore the factors influencing the FMHCP under the NHIS provision for skilled delivery services in Ghana.

METHODS

Electronic searches were conducted of databases including PubMed, Popline, Science direct, BioMed Central, Scopus and Google scholar for peer reviewed articles as well as grey articles from other relevant sources, published between 2003 and 2021 on factors influencing FMHCP/NHIS provision for skilled delivery services in Ghana. Keywords used in the literature search were in various combinations for the different databases. The articles were screened to determine the inclusion and exclusion criteria and quality was assessed using a published critical appraisal checklist. A total of 516 articles were retrieved for initial screening based on their titles, of which 61 of them, were further screened by reading their abstracts and full text. Of this number, 22 peer-reviewed and 4 grey articles were selected for the final review based on their relevance.

RESULTS

The study revealed that the FMHCP under the NHIS does not cover the full costs associated with skilled delivery and low socioeconomic status of households affects SBA. Also, funding and sustainability, hinders the quality-of-service delivery offered by the policy.

CONCLUSION

For Ghana to achieve the SDGs above and further improve SBA, the cost associated with skilled delivery should be fully covered by the NHIS. Also, the government and the key stakeholders involved in the policy implementation, must put in place measures that will enhance the operation and the financial sustainability of the policy.

Assessing Client Satisfaction with Health Service Delivery under the National Health Insurance Scheme: The Case of Komfo Anokye Teaching Hospital

Background. Client satisfaction is the direct effect of service delivery and, in essence, the basis for quality improvement in any industry. In health financing, it is a significant determinant of clients’ enrolment in an insurance scheme. Objectives. This study sought to assess client satisfaction with healthcare delivery under the National Health Insurance Scheme (NHIS) at a tertiary facility in Ghana. Methods. A cross-sectional study was conducted among patients attending the outpatient department of the Komfo Anokye Teaching Hospital. Data were collected using structured questionnaires. Questionnaires were administered to 300 purposively selected patients, stratified based on their insurance status. Data obtained were then analysed using mean score ranking and an independent sample t-test. Results. The client satisfaction variable with a high level of satisfaction was observed for physical environment (πins = 3.80; πunins = 3.69). The least rated construct was responsiveness (πins = 2.59; πunins = 2.51). A statistically significant difference in the means between the insured and uninsured was observed for two of the five constructs, namely, communication (πdiff = 0.36; $p<0.05$ ) and service availability (πdiff = 0.33; $p<0.05$ ). Conclusions. This study advocates for prioritization of measures and policy initiatives aimed at improving responsiveness in healthcare delivery, as the least rated construct. It further draws health providers’ attention to modesty in communication regardless of socioeconomic or insurance status.

Community perspectives on cardiovascular disease control in rural Ghana: A qualitative study

BACKGROUND

Cardiovascular disease (CVD) prevalence is high in Ghana-but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors.

METHODS

We conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes.

RESULTS

CMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital.

CONCLUSIONS

CMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors-in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD-including its behavioral and mental health causes-in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise.

“It is very difficult in this business if you want to have a good conscience”: pharmaceutical governance and on-the-ground ethical labour in Ghana

The governance of pharmaceutical medicines entails complex ethical decisions that should, in theory, be the responsibility of democratically accountable government agencies. However, in many Low- and Middle-Income Countries (LMICs), regulatory and health systems constraints mean that many people still lack access to safe, appropriate and affordable medication, posing significant ethical challenges for those working on the “front line”. Drawing on 18 months of fieldwork in Ghana, we present three detailed case studies of individuals in this position: an urban retail pharmacist, a rural over-the-counter medicine retailer, and a local inspector. Through these case studies, we consider the significant burden of “ethical labour” borne by those operating “on the ground”, who navigate complex moral, legal and business imperatives in real time and with very real consequences for those they serve. The paper ends with a reflection on the tensions between abstract, generalised ethical frameworks based on high-level principles, and a pragmatic, contingent ethics-in-practice that foregrounds immediate individual needs – a tension rooted in the gap between the theory and the reality of pharmaceutical governance that shifts the burden of ethical labour downwards and perpetuates long-term public health risks.

Dam-mediated flooding impact on outpatient attendance and diarrhoea cases in northern Ghana: a mixed methods study

Background

Floods are the most frequently occurring natural disaster and constitute a significant public health risk. Several operational satellite-based flood detection systems quantify flooding extent, but it is unclear how far the choice of satellite-based flood product affects the findings of epidemiological studies of associated public health risks. Few studies of flooding’s health impacts have used mixed methods to enrich understanding of these impacts. This study therefore aims to evaluate the relationship between two satellite-derived flood products with outpatient attendance and diarrhoeal disease in northern Ghana, identifying plausible reasons for observed relationships via qualitative interviews.

Methods

A convergent parallel mixed methods design combined an ecological time series with focus group discussions and key informant interviews. Through an ecological time series component, monthly outpatient attendance and diarrhoea case counts from health facilities in two flood-prone districts for 2016–2020 were integrated with monthly flooding map layers classified via the Moderate Resolution Imaging Spectroradiometer (MODIS) and Landsat satellite sensors. The relationship between reported diarrhoea and outpatient attendance with flooding was examined using Poisson regression, controlling for seasonality and facility catchment population. Four focus group discussions with affected community members and four key informant interviews with health professionals explored flooding’s impact on healthcare delivery and access.

Results

Flooding detected via Landsat better predicted outpatient attendance and diarrhoea than flooding via MODIS. Outpatient attendance significantly reduced as LandSat-derived flood area per facility catchment increased (adjusted Incidence Rate Ratio = 0.78, 95% CI: 0.61–0.99, p < 0.05), whilst reported diarrhoea significantly increased with flood area per facility catchment (adjusted Incidence Rate Ratio = 4.27, 95% CI: 2.74—6.63, p < 0.001). Key informants noted how flooding affected access to health services as patients and health professionals could not reach the health facility and emergency referrals were unable to travel.

Conclusions

The significant reduction in outpatient attendance during flooding suggests that flooding impairs healthcare delivery. The relationship is sensitive to the choice of satellite-derived flood product, so future studies should consider integrating multiple sources of satellite imagery for more robust exposure assessment. Health teams and communities should plan spatially targeted flood mitigation and health system adaptation strategies that explicitly address population and workforce mobility issues.

Successes and obstacles in implementing social health insurance in developing and middle-income countries: A scoping review of 5-year recent literatures

Social health insurance (SHI) is a form of health finance mechanism that had been implemented in many countries to achieve universal health care (UHC). To emulate the successes of SHI in many developed countries, many developing and middle-income countries (MICs) have attempted to follow suit. However, the SHI implementation has problems and obstacles. Many more obstacles were observed despite some successes. This scoping review aimed to study the various developments of SHI globally in its uses, implementation, successes, and obstacles within the last 5 years from 2017 to 2021. Using three databases (i.e., PubMed, EBSCO, and Google Scholar), we reviewed all forms of articles on SHI, including gray literature. The PRISMA-ScR protocol was adapted as the guideline. We used the following search terms: social health insurance, national health insurance, and community health insurance. A total of 57,686 articles were screened, and subsequently, 46 articles were included in the final review. Results showed that the majority of SHI studies were in China and African countries, both of which were actively pursuing SHI programs to achieve UHC. China was still regarded as a developing country. There were also recent experiences from other Asian countries, but only a few from South America. Implementing SHI to achieve UHC was desirable but will need to consider several factors and issues. This was especially the case in developing and MICs. Eventually, full UHC would only be possible with a combination of general taxation and SHI.

Acceptability of prepayment, social solidarity and cross-subsidies in national health insurance: A mixed methods study in Western Kenya

Introduction

Many low- and middle-income countries are attempting to finance healthcare through voluntary membership of insurance schemes. This study examined willingness to prepay for health care, social solidarity as well as the acceptability of subsidies for the poor as factors that determine enrolment in western Kenya.

Methods

This study employed a sequential mixed method design. We conducted a cross-sectional household survey (n = 1,746), in-depth household interviews (n = 36), 6 FGDs with community stakeholders and key informant interviews (n = 11) with policy makers and implementers in a single county in western Kenya. Social solidarity was defined by willingness to make contributions that would benefit people who were sicker ("risk cross-subsidization") and poorer ("income cross-subsidization"). We also explored participants' preferences related to contribution cost structure - e.g., flat, proportional, progressive, and exemptions for the poor.

Results

Our study found high willingness to prepay for healthcare among those without insurance (87.1%) with competing priorities, low incomes, poor access, and quality of health services, lack of awareness of flexible payment options cited as barriers to enrolment. More than half of respondents expressed willingness to tolerate risk and income cross-subsidization suggesting strong social solidarity, which increased with socio-economic status (SES). Higher SES was also associated with preference for a proportional payment while lower SES with a progressive payment. Few participants, even the poor themselves, felt the poor should be exempt from any payment, due to stigma (being accused of laziness) and fear of losing power in the process of receiving care (having the right to demand care).

Conclusion

Although there was a high willingness to prepay for healthcare, numerous barriers hindered voluntary health insurance enrolment in Kenya. Our findings highlight the importance of fostering and leveraging existing social solidarity to move away from flat rate contributions to allow for fairer risk and income cross-subsidization. Finally, governments should invest in robust strategies to effectively identify subsidy beneficiaries.

Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana

Ghana is positioned to become the first country in sub-Saharan Africa to implement universal health coverage based on nationwide expansion of geographic access through the Community-based Health Planning and Services initiative. This achievement is the outcome of 3 decades of implementation research that health authorities have used for guiding the development of its primary health care program. This implementation research process has comprised Ghana's official endorsement of the 1978 Alma Ata Declaration, leading to the institutionalization of evidence relevant to the strategic design of primary health care and national health insurance policies and services. Rather than relying solely upon the dissemination of project results, Ghana has embraced a continuous and systemic process of knowledge capture, curation, and utilization of evidence in expanding geographic access by a massive expansion in the number of community health service points that has taken decades. A multisectoral approach has been pursued that has involved the creation of systematic partnerships that included all levels of the political system, local development officials, community groups and social networks, multiple university-based disciplines, external development partners, and donors. However, efforts to achieve high levels of financial access through the roll-out of the National Health Insurance Scheme have proceeded at a less consistent pace and been fraught with many challenges. As a result, financial access has been less comprehensive than geographical access despite sequential reforms having been made to both programs. The legacy of activities and current research on primary health care and national health insurance are reviewed together with unaddressed priorities that merit attention in the future. Factors that have facilitated or impeded progress with research utilization are reviewed and implications for health systems strengthening in Ghana and elsewhere in Africa and globally are discussed.

Health services availability and readiness moderate cash transfer impacts on health insurance enrolment: evidence from the LEAP 1000 cash transfer program in Ghana

BACKGROUND

Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services.

METHODS

We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities' service availability and readiness.

RESULTS

We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points).

CONCLUSIONS

We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors.

TRIAL REGISTRATION

This study is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations ( RIDIE-STUDY-ID-55942496d53af ).

Factors associated with health insurance enrolment among ghanaian children under the five years. Analysis of secondary data from a national survey

Background

Health insurance enrolment provides financial access to health care and reduces the risk of catastrophic healthcare expenditure. Therefore, the objective of this study was to assess the prevalence and correlates of health insurance enrolment among Ghanaian children under five years.

Methods

We analysed secondary data from the 2017/18 Ghana Multiple Indicator Cluster Survey. The survey was a nationally representative weighted sample comprising 8,874 children under five years and employed Computer Assisted Personal Interviewing to collect data from the participants. In addition, Chi-square and Logistic Regression analyses were conducted to determine factors associated with health insurance enrolment.

Results

The results showed that a majority (58.4%) of the participants were insured. Health insurance enrollment was associated with child age, maternal educational status, wealth index, place of residence and geographical region (p < 0.05). Children born to mothers with higher educational status (AOR = 2.14; 95% CI: 1.39–3.30) and mothers in the richest wealth quintile (AOR = 2.82; 95% CI: 2.00–3.98) had a higher likelihood of being insured compared with their counterparts. Also, children residing in rural areas (AOR = 0.75; 95% CI: 0.61–0.91) were less likely to be insured than children in urban areas.

Conclusion

This study revealed that more than half of the participants were insured. Health insurance enrolment was influenced by the child's age, mother's educational status, wealth index, residence, ethnicity and geographical region. Therefore, interventions aimed at increasing health insurance coverage among children should focus on children from low socio-economic backgrounds. Stakeholders can leverage these findings to help improve health insurance coverage among Ghanaian children under five years.

Continued adherence to community-based health insurance scheme in two districts of northeast Ethiopia: application of accelerated failure time shared frailty models

Background

The sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. In low- and middle-income countries, high rate of member dropout has been a great concern for such schemes. Although several studies have investigated the factors influencing dropout decisions, none of these looked into how long and why members adhere to the scheme. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables.

Methods

A community-based cross-sectional study was conducted among 1232 rural households who have ever been enrolled in two community-based health insurance schemes. Data were collected using an interviewer-administered questionnaire via a mobile data collection platform. The Kaplan–Meier estimates were used to compare the time to drop out among subgroups. To identify predictors of time to drop out, a multivariable analysis was done using the accelerated failure time shared frailty models. The degree of association was assessed using the acceleration factor (δ) and statistical significance was determined at 95% confidence interval.

Results

Results of the multivariable analysis revealed that marital status of the respondents (δ = 1.610; 95% CI: 1.216, 2.130), household size (δ = 1.168; 95% CI: 1.013, 1.346), presence of chronic illness (δ = 1.424; 95% CI: 1.165, 1.740), hospitalization history (δ = 1.306; 95% CI: 1.118, 1.527), higher perceived quality of care (δ = 1.322; 95% CI: 1.100, 1.587), perceived risk protection (δ = 1.218; 95% CI: 1.027, 1.444), and higher trust in the scheme (δ = 1.731; 95% CI: 1.428, 2.098) were significant predictors of time to drop out. Contrary to the literature, wealth status did not show a significant correlation with the time to drop out.

Conclusions

The fact that larger households and those with chronic illness remained longer in the scheme is suggestive of adverse selection. It is needed to reconsider the premium level in line with household size to attract small size households. Resolving problems related to the quality of health care can be a cross-cutting area of ​​intervention to retain members by building trust in the scheme and enhancing the risk protection ability of the schemes.

Physician Experiences and Perceived Barriers to Providing Quality Infertility Care in the Greater Accra Region of Ghana

High-quality, patient-centered care is essential to achieving equity and dignity for individuals with infertility, yet few studies have explored quality of infertility care in sub-Saharan Africa. We interviewed 13 non-specialist physicians and 2 medical school faculty to explore experiences in and perceptions of providing infertility care in Greater Accra, Ghana. We used a patient-centered infertility care model to inform our analysis and results. Individualized care and taking time to counsel and emotionally support patients were perceived as the most important things a physician can do to provide quality infertility care. Financial costs and lack of infertility services within a single facility were the most common barriers reported to providing quality infertility care. To the best of our knowledge, our study is the first to explore quality of infertility care provided by physicians in public sector facilities in Ghana, shedding light on existing barriers and identifying strategies for improvement.

TRAINING NEEDS ASSESSMENT OF STAKEHOLDERS IN THE HEALTH INSURANCE INDUSTRY IN SOUTHWEST REGION OF NIGERIA: IMPLICATIONS FOR UNIVERSAL HEALTH COVERAGE

BACKGROUND

The coverage of the social health insurance scheme in Nigeria has been low. The scheme may benefit from personnel training which has been shown to improve organisational performance.

OBJECTIVE

This study, therefore, aimed to assess the training needs of personnel in the health insurance industry in Southwest Nigeria.

METHODS

This was a cross-sectional survey conducted among personnel of the health insurance industry in Southwest of Nigeria. The survey tool adapted was the Hennessy-Hicks Training Needs Analysis Questionnaire. The tool has been psychometrically tested for validity and reliability. Originally, the tool has 30 items with an allowance for modification without compromising its psychometric properties. The 30 items were grouped into six superordinate categories; management/supervisory, administration, clinical/service delivery assessment, communication/ teamwork, facility financial audit/assessment, and facility infrastructure assessments. Respondents rated each item along two seven-point scales. In the first scale, respondents rated how important (importance rating) the item is to their job while in the second scale, respondents self-rated their current performance level of the item (performance rating). A training need index was generated by subtracting performance rating from the importance rating for each of the six superordinate categories.

RESULTS

Training needs for each of the six subcategories ranked by the magnitude of the derived training need index (from highest to lowest) were; clinical/service delivery, facility infrastructure, facility financial audit, management/supervisory skills, communication, and teamwork, and administration.

CONCLUSION

Training need was demonstrated in all six subcategories. Emphasis on the relevant training need of personnel in the health insurance industry in Nigeria is important to improve efficiency and performance.

Global geographic differences in healthcare utilization for sickle cell disease pain crises in the CASiRe cohort

BACKGROUND

Sickle cell disease (SCD) is characterized by frequent, unpredictable pain episodes and other vaso-occlusive crises (VOCs) leading to significant healthcare utilization. VOC frequency is often an endpoint in clinical trials investigating novel therapies for this devastating disease.

PROCEDURE

The Consortium for the Advancement of Sickle Cell Research (CASiRe) is an international collaboration investigating clinical severity in SCD using a validated questionnaire and medical chart review standardized across four countries (United States, United Kingdom, Italy and Ghana).

RESULTS

This study, focused on pain crisis incidence and healthcare utilization, included 868 patients, equally represented according to age and gender. HgbSS was the most common genotype. Patients from Ghana used the Emergency Room/Day Hospital for pain more frequently (annualized mean 2.01) than patients from other regions (annualized mean 1.56 U.S.; 1.09 U.K.; 0.02 Italy), while U.K. patients were hospitalized for pain more often (annualized mean: U.K. 2.98) than patients in other regions (annualized mean 1.98 U.S.; 1.18 Ghana; Italy 0.54). Italy's hospitalization rate for pain (annualized mean: 0.57) was nearly 20 times greater than its emergency room/day hospital only visits for pain (annualized mean: 0.03). When categorized by genotype and age, similar results were seen.

CONCLUSIONS

Geographic differences in pain crisis frequency and healthcare utilization may correlate with variable organization of healthcare systems among countries and should be considered regarding trial design, endpoints, and analysis of results when investigating novel agents for clinical benefit.

The Cost-Effectiveness of Adjuvant Tamoxifen Treatment of Hormone Receptor-Positive Early Breast Cancer Among Premenopausal and Perimenopausal Ghanaian Women

OBJECTIVES

Most breast cancer cases in Ghana occur in premenopausal and perimenopausal (PPM) women. This study evaluated the cost-effectiveness of tamoxifen compared with no tamoxifen for the adjuvant treatment of hormone receptor-positive (HR+) early breast cancer (EBC) among PPM Ghanaian women.

METHODS

A Markov model was constructed to synthesize data on the effectiveness, costs, and health benefits of tamoxifen. Effectiveness and utility data were sourced from a literature review. Resource use and healthcare costs were estimated from Ghanaian sources. The evaluation was conducted in 2017 from the perspective of the health system over a 15-year time horizon. The financial impact of funding tamoxifen on Ghana's National Health Insurance Scheme (NHIS) was also estimated.

RESULTS

Adjuvant tamoxifen treatment for women with HR+ EBC was more effective and more costly than no-tamoxifen therapy. The incremental benefit and costs were estimated to be 1.38 quality-adjusted life-years gained and Ghana cedis (GHC) 2338 ($520), respectively. The incremental cost-effectiveness ratio was estimated to be GHC 1694 ($376). The model was sensitive to the cost of tamoxifen and utility values. The cost of tamoxifen for the treatment of HR+ EBC represents less than 0.01% GHC 96 960 ($21 547) of the current NHIS total claims expenditure.

CONCLUSIONS

Tamoxifen provides additional benefits to PPM Ghanaian women with HR+ EBC and is cost-effective compared with no tamoxifen. These results support the public funding of tamoxifen under the NHIS and provide Ghanaian policy makers with vital information for future budgetary planning.

Health systems, population and patient challenges for achieving universal health coverage for hypertension in Ghana

Ghana has signed on to the United Nations Sustainable Development Goal to achieve universal health coverage (UHC), ensuring that all individuals receive the health care they require without financial hardship. Achieving that goal is a difficult task in any setting. The challenges are further exacerbated by a changing disease landscape, as the burden of non-communicable diseases (NCDs) is increasing and creating a dual burden along with infectious diseases. This study explores the existing health system for delivering hypertension care and the challenges of delivering UHC for hypertension in Ghana. Document analysis of national health reports, policies and legislations along with a review of research articles was conducted to explore the challenges of delivering UHC for NCDs in Ghana, and hypertension in particular. The main themes and indicators related to the challenges of delivering UHC for hypertension were mapped and analysed. The main challenges to delivering UHC for hypertension can be grouped into population and patient, on the one hand, and health system factors, on the other. Population and patient factors include (1) unhealthy lifestyles overburdening the health system, (2) poor health-seeking behaviour and (3) poor adherence to medication, which has led to uncontrolled cases and poor clinical outcomes even among treated patients with hypertension. Health system factors include (1) inadequate health system capacity for early diagnosis due to an increasing number of patients, (2) inequitable distribution of health care facilities affecting access, (3) financial sustainability of the National Health Insurance Scheme and delays in reimbursement of claims to facilities that affect the health system's ability to provide timely management of hypertension and (4) health care facilities and practitioners' use of non-standardized and uncalibrated blood pressure measuring equipment. Ghana therefore will need to make important decisions to overcome operational and financial challenges on its path to UHC.

The 6-star doctor? Physicians' communication of poor prognosis to patients and their families in Cape Coast, Ghana

INTRODUCTION

Communication is considered a key skill for physicians globally and has formed a central part of medical curricula since the WHO identified it as a key attribute of the '5-star doctor'. Communication of poor prognosis to patients and caregivers is particularly challenging, yet an important example of physicians' clinical communication, and a priority within palliative care research. Knowledge is scarce regarding the different positions physicians adopt during poor prognosis communication, especially in sub-Saharan countries.

METHODS

This qualitative study took place at the Cape Coast Teaching Hospital in Ghana's Central Region. Physicians in the internal medicine department, with experience in communicating poor prognosis to patients and families on a weekly basis were purposively sampled. Based on the concept of information power, a maximum variation of participants, in terms of age, sex, seniority and experience was achieved after conducting 10 semistructured interviews in March 2019. Positioning theory was used as a theoretical lens to inform study design. The data were analysed through a constructivist thematic analysis approach.

RESULTS

Physicians adopted six positions, considered as six different themes, during their communication of poor prognosis: clinical expert, educator, counsellor, communicator, protector and mentor. Physicians' choice of position was fluid, guided by local context and wider health system factors. Physicians' desire to communicate with patients and families in a way that met their needs highlighted three key challenges for communication of poor prognosis: linguistic difficulties, pluralistic health beliefs and the role of family. These challenges presented ethical complexities in relation to autonomy and non-maleficence.

CONCLUSION

Context is key to physicians' communication of poor prognosis. Communication of poor prognosis is multifaceted, complex and unpredictable. Physicians' communication training should be developed to emphasise contextual circumstances and physician support, and international policy models on physicians' roles developed to include a greater focus on social accountability.

Adopting localised health financing models for universal health coverage in Low and middle-income countries: lessons from the National Health lnsurance Scheme in Ghana

The health-related Sustainable Development Goals (SDGs) and the Coronavirus Pandemic (COVID-19) have recently increased awareness of the need for countries to increase fiscal space for health. Prior to these, many Low and Middle-Income Countries (LMICs) had embraced the concept of Universal Health Coverage (UHC) and have either commenced or are in the process of implementing various models of health insurance in order to provide financial access to health care to their populations. While evidence of a relationship between experimentation with UHC and increased access to and utilisation of health care in LMICs is common, there is inadequate research evidence on the specific health financing model that is most appropriate for pursuing the objectives of UHC in these settings. Drawing on a synthesis of empirical and theoretical discourses on the feasibility of UHC in LMICs, this paper argues that the journey towards UHC is not a 'one size fits all' process, but a long-term policy engagement that requires adaptation to the specific socio-cultural and political economy contexts of implementing countries. The study draws on the WHO's framework for tracking progress towards UHC using the implementation of a mildly progressive pluralistic health financing model in Ghana and advocates a comprehensive discourse on the potential for LMICs to build resilient and responsive health systems to facilitate a gradual transition towards UHC.

Insured clients out-of-pocket payments for health care under the national health insurance scheme in Ghana

BACKGROUND

In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) designed to promote universal health coverage and equitable access to health care. The scheme has largely been successful, yet it is confronted with many challenges threatening its sustainability. Out-of-pocket payments (OOP) by insured clients is one of such challenges of the scheme. This study sought to examine the types of services OOP charges are made for by insured clients and how much insured clients pay out-of-pocket.

METHODS

This was a descriptive cross-sectional health facility survey. A total of 2066 respondents were interviewed using structured questionnaires at the point of health care exit in the Ashanti, Northern and Central regions of Ghana. Health facilities of different levels were selected from 3 districts in each of the three regions. Data were collected between April and June 2018. Using Epidata and STATA Version 13.1 data analyses were done using multiple logistic regression and simple descriptive statistics and the results presented as proportions and means.

RESULTS

Of all the survey respondents 49.7% reported paying out-of-pocket for out-patient care while 46.9% of the insured clients paid out-of-pocket. Forty-two percent of the insured poorest quintile also paid out-of-pocket. Insured clients paid for consultation (75%) and drugs (63.2%) while 34.9% purchased drugs outside the health facility they visited. The unavailability of drugs (67.9%) and drugs not covered by the NHIS (20.8%) at the health facility led to out-of-pocket payments. On average, patients paid GHS33.00 (USD6.6) out-of-pocket. Compared to the Ashanti region, patients living in the Northern region were 74% less at odds to pay out-of-pocket for health care.

CONCLUSION AND RECOMMENDATION

Insured clients of Ghana's NHIS seeking health care in accredited health facilities make out-of-pocket payments for consultation and drugs that are covered by the scheme. The out-of-pocket payments are largely attributed to unavailability of drugs at the facilities while the consultation fees are charged to meet the administrative costs of services. These charges occur in disadvantaged regions and in all health facilities. The high reliance on out-of-pocket payments can impede Ghana's progress towards achieving Universal Health Coverage and the Sustainable Development Goal 3, seeking to end poverty and reduce inequalities. In order to build trust and confidence in the NHIS there is the need to eliminate out-of-pocket payments for consultation and medicines by insured clients.

Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children

Introduction

Ghana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana.

Methods

We performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE.

Results

Of the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08–0.55).

Conclusions

NHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children.

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Despite strides toward universal health coverage with the National Health Insurance Scheme (NHIS) in Ghana, one third of injured children did not have insurance.

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Families on uninsured injured children pay markedly more out-of-pocket costs than families of insured children.

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Although families of uninsured children were more likely to experience catastrophic health expenditure (CHE), CHE was commonly experienced regardless of insurance.

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These findings have useful implications for NHIS, agencies working toward universal health coverage, and trauma systems generally.

Employment based health financing does not support gender equity in universal health coverage

Health financing and entitlement systems linked to employment can disadvantage women, argue Lavanya Vijayasingham and colleagues

Implementation of the National Health Insurance Scheme (NHIS) in Ghana: Lessons for South Africa and Low- and Middle-Income Countries

BACKGROUND

South Africa is having difficulties in rolling out the National Health Insurance(NHI) policy. There are ongoing arguments on whether the NHI will provide access to quality and equitable healthcare it is intended to and whether South Africa is ready to implement the policy. Many stakeholders believe the country needs more preparation if the policy will be successful. Ghana, on the other hand, has successfully implemented the National Health Insurance Scheme(NHIS) for over 15 years.

OBJECTIVE

This paper sought to explore the implementation of the NHIS in Ghana and the lessons South Africa and other low- and middle-income countries can learn from such a process.

METHODS

A scoping review was conducted using the Joanna Brigs Institute's System for the Unified Management, Assessment and Review of Information (SUMARI) and Mendeley reference manager to manage the review process. Journal articles published on the NHIS in Ghana from January 2003 to December 2018 were searched from Science Direct, PubMed, Scopus, CINAHL, and Medline using the keywords: Ghana, Health, and Insurance.

RESULTS

The implementation of the NHIS has provided access to healthcare for the Ghanaian population, especially to poor and vulnerable . Despite the successful implementation of the NHIS in Ghana, the scheme is challenged with poor coverage; poor quality of care; corruption and ineffective governance; poor stakeholder participation; lack of clarity on concepts in the policy; intense political influence; and poor financing.

CONCLUSION

The marked inequity in the South African health system makes the implementation of the NHI inevitable. The challenges experienced in the implementation of the NHIS in Ghana are not new to the South African healthcare system. South Africa must learn from the experiences of Ghana,a context that shares common socio-cultural and economic factors and disease burden,in order to successfully implement the NHI.

The Impact of Ghana's National Health Insurance on Psychological Distress

BACKGROUND

Poor mental health is among the growing number of noncommunicable diseases in low- and middle-income countries. Despite poor mental health accounting for an already considerable and growing burden of disease in many low- and middle-income countries, policy action to confront the challenge has been limited, at both international and national levels. Recently, several low- and middle-income countries have embarked on the journey toward universal health coverage by expanding their public health insurance provision, with the ultimate objective of improving population health, in addition to other health system objectives. Mental health interventions typically may not have been specifically covered in the publicly funded benefit package, and this raises the question of whether, and if so, by how much, the expansion of public health insurance may have directly or indirectly contributed to improved mental health.

OBJECTIVE

We assessed the impact of Ghana's implementation of national health insurance on psychological distress.

METHODS

Our study used the first wave of the 2009-2010 Ghana Social Economic Panel survey, including 10,007 respondents. We employed instrumental variable and propensity score matching methods to estimate the causal impact of health insurance on psychological distress, measured by the Kessler Psychological Distress Scale (K10). Higher K10 values indicate greater psychological distress.

RESULTS

The median K10 score in Ghana was 16 (P < 0.001), with a minimum of 10 (P < 0.001) and a maximum of 45 (P < 0.001). The results from the instrumental variable estimations, without matching, indicated that the K10 score for the insured was 11.8% lower (P < 0.001) than that of the uninsured. After running the instrumental variable regression on the matched sample, the K10 score for the insured was 10.6% (P < 0.001) lower than that of the uninsured. Similarly, the estimates based on propensity score matching indicated that the insured had a lower K10 score (- 0.023; P < 0.05). Furthermore, the beneficial impact of health insurance on psychological distress is larger for wealthier than poorer insurance members and varies across regions in Ghana. The findings were robust to the various estimation methods.

CONCLUSION

This study suggests that having health insurance is associated with reduced psychological distress and hence improved mental health, even though mental illness treatment or prevention were at best only partially covered by the National Health Insurance Scheme in Ghana.

Does insurance protect individuals from catastrophic payments for surgical care? An analysis of Ghana's National Health Insurance Scheme at Korle-Bu teaching Hospital

BACKGROUND

According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe.

METHODS

We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017 - October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual's income.

RESULTS

Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58-87% of insured patients would face financial catastrophe, versus 83-98% of uninsured patients (all comparisons by definition were significant, p < .05).

CONCLUSION

This study-the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana-found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana's national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care.

TRIAL REGISTRATION

Registered at www.clinical trials.gov identifier NCT03604458.

The state of enrollment on the National Health Insurance Scheme in rural Ghana after eight years of implementation

Background

In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations.

Methods

A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES.

Results

Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme.

Conclusions

Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.

Predictors of enrollment in a health protection scheme among informal sector workers in Kumasi Metropolis of Ghana

Objective

Informal sector workers are exposed to occupational hazards which could escalate their healthcare expenditures. Thus, enrollment in a health protection scheme among informal sector workers is useful for reducing their catastrophic healthcare expenditures. However, there is scant information on factors predicting their enrollment in the National Health Insurance Scheme (NHIS) in Ghana, a gap this quantitative study aims to fill. A sample of 350 informal sector workers was involved in a cross-sectional survey.

Results

Approximately 17% of the participants were enrolled in NHIS. Respondents who had worked between 5 and 7 years were significantly more likely to enroll in NHIS compared with those who had worked below 2 years (AOR = 13.159, CI 1.135–152.596, p = 0.039). The study further found that apprentices (AOR = 0.72, CI 0.353–1.056, p = 0.005) were less likely to enroll in NHIS compared with their masters. Participants who were exposed to electrical hazards (AOR = 2.93, CI 1.56–5.10, p = 0.013) and suffered from occupational diseases (AOR = 2.75, CI 1.743–5.17, p = 0.001) were significantly more likely to enroll in NHIS. Also, respondents who were non-Christians were significantly less likely to enroll in NHIS compared with their respective counterparts (AOR = 0.726, CI 0.067–2.503, p = 0.011). The findings are useful for increasing the NHIS enrollment rate among informal sector workers in Ghana.

Sociodemographic determinants of health insurance enrolment and dropout in urban district of Ghana: a cross-sectional study

BACKGROUND

Earlier studies have found significant associations between sociodemographic factors and enrolment in the National Health Insurance Scheme (NHIS) in Ghana. These studies were mainly household surveys in relatively rural areas with high incidence of poverty. To expand the scope of existing evidence, this paper examines policy design factors associated with enrolment and dropout of the scheme in an urban poor district using routine secondary data.

METHODS

This study is a cross-sectional quantitative analysis of 2014-2016 NHIS enrolment data of the Ashiedu Keteke district office. Descriptive and multivariate logistic regression analyses were performed to examine sociodemographic factors associated with NHIS enrolment and dropout.

RESULTS

A total of 215,724 individuals enrolled in the NHIS over the period under study, of which 98,232 (46%) were new members. About 41% of existing members in 2014 dropped out of the NHIS in 2015 and 53% of those in 2015 dropped out in 2016. The indigents (core poor) are significantly more likely to enrol and to drop out of the NHIS. However, the males, informal sector employees, social security and national insurance trust (SSNIT) contributors, and the aged (70+ years) are significantly less likely to enrol in the NHIS but more likely to retain coverage.

CONCLUSIONS

A considerable number of members are dropping out of the NHIS. The indigents in particular, are increasingly enrolling in and dropping out of the NHIS whilst the males, informal sector employees, SSNIT contributors and the aged are not enrolling as expected but increasingly retaining coverage. Policy reforms to ensuring continued growth towards realization of universal health coverage should take these factors into consideration.

Determinants of paying national health insurance premium with mobile phone in Ghana: a cross-sectional prospective study

INTRODUCTION

In an effort to increase Ghana's National Health Insurance Scheme (NHIS) enrollment and retention rates, the NHIS introduced membership renewal and premium payment by mobile phone. The success of such an innovation dependents on many factors including personal and community characteristics of members.

OBJECTIVE

The objective of the study is to investigate the determinants of renewing membership and paying the NHIS premium through a mobile phone.

METHODOLOGY

The prospective cross-sectional survey was used to solicit the required information from about 1192 respondents living in Kumasi Metropolis, Atwima Nwabiaya and Sekyere Central Districts of Ghana. Logistic regression model was employed to estimate the determinants of paying the NHIS premium with the mobile phone.

RESULTS

The study found that factors including residing in an urban area (Kumasi metropolis), senior high education, tertiary education and informal employees are the determinants of paying the NHIS premium with the mobile phone.

CONCLUSION

It is recommended that the NHIS consider making the mobile payment as simple as possible for the less educated and the rural members to access it.