Factors contributing to low uptake and renewal of health insurance: a qualitative study in Ghana
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Date
2016
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Abstract
Background: The effort to expand access to healthcare and reduce health inequalities in many low income
countries have meant that many have adopted different levels of social health protection mechanisms. Ghana
introduced a National Health Insurance Scheme (NHIS) in 2005 with the aim of removing previous barriers created
by the user fees financing system. Although the NHIS has made health accessible to some category of people, the
majority of Ghanaians (60 %) are not enroled on the scheme. Earlier studies have looked at various factors that
account for this low uptake. However, we recognise that this qualitative study will nuance the depth of these
barriers to enrolment.
Methods: Minimally structured, qualitative interviews were conducted with key stakeholders at the district, regional
and national levels. Focus group discussions were also undertaken at the community level. Using an inductive and
content analytic approach, the transcripts were analyzed to identify and define categories that explain low uptake
of health insurance.
Results: The results are presented under two broad themes: sociocultural and systemic factors. Sociocultural factors
identified were 1) vulnerability within certain groups such as the aged and the disabled groups which impeded
access to the NHIS 2) cultural and religious norms which discouraged enrolment into the scheme. System-wide
factors were 1) inadequate distribution of social infrastructure such as healthcare facilities, 2) weak administrative
processes within the NHIS, and 3) poor quality of care.
Conclusions: Mapping the interplay of these dynamic relations between the NHIS, its clients and service providers,
the study identifies critical factors at the policy-making level, service provider level, and client level (reflective in
household and community level institutional arrangements) that affect enrolment in the scheme. Our findings
inform a number of potential reforms in the area of distribution of health resources and cost containment to
expand coverage, increase choices and meeting the needs of the end user.
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Keywords
National Health Insurance, Sociocultural, Barriers to health care, Qualitative study