An analysis of Ghana’s 2003 National Health Insurance Scheme reform

Background: Despite long debates, a National Health Insurance Scheme was instituted in Ghana in 2003, as a promise to improve affordability and access and consequently improve health outcomes. Given the reform design, the aim of this study consists in analysing the relationship between the NHIS coverage and the characteristics of a Ghanaian woman’s demographic, socio-economic, pregnancy and self-determination factors. Data and Methods: The analysis is based on the nationally-representative Ghana Demographic and Health Survey data for the year 2008, including information on the situation of the population and health of a sample of 4916 women aged 15-49. Using a binary logit model including both individual and household characteristics, we measure the probability of a Ghanaian woman’s ownership of the NHIS coverage. Results: Although problems of distance negatively influence the likelihood of uptake mainly in rural locations, rural residents are more likely to enrol compared with their urban counterpart. The region of residence, however, strongly influences a woman’s probability of being enrolled as Brong-Ahafo and Northern regions are more likely to have their female residents enrolled compared with their Southern counterpart. Poorer and lower educated women, women belonging to ethnic minorities as well as women employed either in agriculture or as unskilled manual workers, have lower probability of enrolment. Living in households headed by females and having problems with getting permission to reach healthcare facilities negatively influence a woman’s likelihood of coverage. According to premium exemption policies, pregnant and married women are more likely to enrol; on the same line a greater number of sons living within the household, as well as a greater number of births during the year before the interview, increase the probability of being enrolled. Conclusions: Evident regional and socio-economic differences suggest the chance to reconsider the design of premium exemption policies applying to the indigents as possible attempts. At the same time a brighter light on Southern and urbanized regions might help improving the achievement of a comprehensive coverage across the population and particularly among women. Despite the success in enrolling married women and either women with children or currently pregnant women, exemption rules applying to children under 18 suggest an attempt to design children’s entitlements regardless of their parents’ enrolment status.