UNIVERSITY OF GHANA   

 

 

THE SOCIO-ECONOMIC FACTORS THAT AFFECT UTILISATION OF 

HEALTH CARE SERVICES BY THE EXEMPT GROUPS UNDER THE 

NATIONAL HEALTH INSURANCE SCHEME IN GHANA 

 

 

 

 

 

 

 

BY 

 

MAXWELL YEBOAH-MENSAH 

10114986 

 

 

THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, 

LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR 

THE AWARD OF M.PHIL DEVELOPMENT STUDIES DEGREE 

 

 

 

 

JULY, 2015

 



i 

 

  

DECLARATION 

I hereby certify that this thesis is my original work and that neither part nor whole of this 

work has ever been presented in this University or in any other institution for the award 

of any academic degree. All references of others made in this work have duly been 

acknowledged. 

MAXWELL YEBOAH-MENSAH 

........................................................... 

 (Candidate) 

 

We, the undersigned supervisors, certify that this is an original work we supervised the 

candidate to produce. We are also convinced that it (the thesis) meets all required 

standards set by the University of Ghana for the award of a Master of Philosophy 

Degree. 

 

PROFESSOR FELIX A. ASANTE 

Signature............................................................... 

(Supervisor) 

 

REV. DR. YAA ADOBEA OWUSU 

.............................................................. 

(Supervisor) 

 

 



ii 

 

  

DEDICATION 

This thesis is dedicated to my lovely wife, Rebecca Baah-Ofori for the inspiration 

and encouragement when I started this programme. 

 

 

 

 

 

 

 

 

 

  

 



iii 

 

  

ACKNOWLEDGEMENT 

I am very grateful to my supervisors Professor Felix Asante and Rev. Dr. Yaa Adobea 

Owusu  for  their  guidance  and  expertise  that  have  brought  this dissertation this far. 

In spite of their extremely busy schedules, they always found time to offer guidance 

and encouragement, may God richly bless you. I am equally grateful to the immediate 

past and current Coordinators of MA/MPHIL Programmes at the Institute of Statistical, 

Social and Economic Research (ISSER), University of Ghana: Dr Ernest Appiah and Dr 

Simon Bawakyillenu for their constant reminders to work hard and their concern 

exhibited by always wanting to ascertain the state of the work. 

 
To all the people who took part in the qualitative interviews. For sharing your 

experiences and time with us, I say thank you very much. 

 
Above all, and from the bottom of my heart, I am greatly indebted to Professor. Felix 

Asante, the current ISSER Director for giving me the opportunity to pursue this 

programme and for his encouragement during and beyond this study.  May the Almighty 

God grant you good health and success in all your endeavours. 

 
I am highly indebted to Dr. Robert Afutu-Kotey, Mr. Bright Osei both of the 

University of Professional Studies, Accra (UPSA) and Dr. George Domfe of the 

Centre for Social Policy Studies (CSPS) Legon for their encouragement, guidance 

and input to this work. May God richly bless you all. 

 
My final appreciation goes to my mother Miss Hannah Aframea, siblings especially 

Mrs. Beulah Asiedu, for the tremendous support offered me during the course of my 

studies. May God richly bless you all. 

 

 



iv 

 

  

ABSTRACT  

Health financing has become a topical issue among development practitioners in most 

developing countries. This has necessitated some countries introducing social health 

insurance schemes as a way of financing health. Health insurance schemes are recognized 

as a tool to finance health care provision in developing countries including Ghana. The 

health insurance scheme was introduced in Ghana with the purpose of reducing 

catastrophic health expenditures, improving access and also ensuring equity in health 

service delivery. The beneficiaries of the NHIS include informal sector workers, Social 

Security and National Insurance Trust (SSNIT) contributors, SSNIT pensioners, children 

under 18 years, pregnant women, the aged (70 years & above) and the indigent (core 

poor).  Among these categories of people, the scheme provides exemption packages for 

some of them such as children below 18 years, pregnant women, the indigent, SSNIT 

pensioners, SSNIT contributors and older people (above 70 years). 

Using secondary household data collected within the three ecological zones in Ghana as 

well as data from qualitative interviews conducted, this study investigated two categories 

of the exempt group – those below 18 years and those above 70 years, to unravel some of 

the socio-economic factors that influence utilization of health care services. The results of 

both the regression analysis and the focus group discussions suggest the toddlers (0-5 

years) and the very old (80+) utilize health care more than the other age groups. Besides, 

although these groups are exempted from paying premium, some still pay premiums and 

also make out of pocket (OOP) payments at the health facilities. The results seem to 

confirm the outcome of several studies on Ghana which identified inequality in the 

payment of premium and OOP payments. Therefore, an efficient monitoring and 

supervision on the part of NHIA of the various schemes is recommended while a critical 

examination of the extent of OOP at the  

service delivery facilities is suggested. 

 



v 

 

  

TABLE OF CONTENTS 

DECLARATION .................................................................................................................. i 

DEDICATION ..................................................................................................................... ii 

ACKNOWLEDGEMENT .................................................................................................. 3 

ABSTRACT ......................................................................................................................... 4 

TABLE OF CONTENTS .................................................................................................... 5 

LIST OF TABLES .............................................................................................................. v 

LIST OF FIGURES ........................................................................................................... vi 

LIST OF ABBREVIATIONS .......................................................................................... vii 

 

CHAPTER ONE ................................................................................................................. 1 

INTRODUCTION ............................................................................................................... 1 

1.1 Background ................................................................................................................. 1 

1.2 Problem Statement ...................................................................................................... 7 

1.3 Research Questions ................................................................................................... 10 

1.4 Objectives of the study .............................................................................................. 10 

1.5 Relevance of the study .............................................................................................. 11 

1.6 Organization of Thesis .............................................................................................. 11 

 

CHAPTER TWO .............................................................................................................. 13 

LITERATURE REVIEW ................................................................................................. 13 

2.0 Introduction ............................................................................................................... 13 

2.1 The Genesis of Global Health Care Financing ......................................................... 14 

2.2 HealthCare Financing in Africa ................................................................................ 16 

2.3 Health Care Financing in Ghana ............................................................................... 17 

2.4 Challenges of Social health Insurance in some Developing Countries .................... 22 

2.5 Challenges of the Exemptions Policy in Ghana ........................................................ 25 

2.6 Utilization of HealthCare Services – The Theoretical Framework........................... 28 

2.7 Conceptual Framework ............................................................................................. 33 

2.8 Summary and Conclusion ......................................................................................... 35 



vi 

 

  

CHAPTER THREE .......................................................................................................... 37 

STUDY AREA AND METHODOLOGY ....................................................................... 37 

3.0 Introduction ............................................................................................................... 37 

3.1 The Study Area ......................................................................................................... 37 

3.1.1 Kwaebibirm District ........................................................................................... 37 

3.1.2 Asutifi District .................................................................................................... 40 

3.1.3 Savelugu-Nanton District ................................................................................... 43 

3.2 Methodology ............................................................................................................. 46 

3.2.1 Sampling Technique........................................................................................... 46 

3.2.2 Quantitative Data Collection .............................................................................. 50 

3.2.3 Primary Data collection Tool ............................................................................. 50 

3.2.4 Quantitative Analysis ......................................................................................... 51 

3.2.5 Selected explanatory variables for the probit regression ................................... 53 

 

CHAPTER FOUR ............................................................................................................. 55 

DATA ANALYSIS AND DISCUSSIONS ....................................................................... 55 

4.0 Introduction ............................................................................................................... 55 

4.1 The Socio-Economic Characteristics ........................................................................ 55 

4.1.1 Age and Age Groups .......................................................................................... 55 

4.1.2 Education Attainment of the Exempt Group ...................................................... 58 

4.1.3 Main Occupation ................................................................................................ 61 

4.1.4 Religion .............................................................................................................. 63 

4.1.5 Marital characteristics ........................................................................................ 65 

4.2 Health Seeking Behaviour of the Exempt Group ...................................................... 70 

4.2.1 Hospitalization ................................................................................................... 71 

4.2.2 Knowledge of health problems / conditions ...................................................... 72 

4.2.3 Current Health Status of Respondents ............................................................... 73 

4.2.4 Types of illness .................................................................................................. 75 

4.2.5 Sources of Seeking Treatment ........................................................................... 77 

4.2.6 Rationale for Choice of Facility ......................................................................... 79 

4.2.7 Perceived Delay in seeking health care .............................................................. 82 

4.3 Out of Pocket (OOPs) Payments by the Exempt Group ........................................... 84 

4.3.1 Insurance Status ................................................................................................. 84 

4.3.2 Last Premium Paid ............................................................................................. 90 



vii 

 

  

4.3.3 Medical Expenses paid at the Facility (OPD) by the Exempt Group ................ 93 

4.3.4 Impact of the NHIS ............................................................................................ 95 

4.4 Conclusion ................................................................................................................ 96 

 

CHAPTER FIVE ............................................................................................................... 98 

SUMMARY, CONCLUSION AND RECOMMENDATIONS ..................................... 98 

5.1 Summary ................................................................................................................... 98 

5.2 Socio-economic Factors ............................................................................................ 99 

5.2.2 The Health Seeking Behaviour of the Exempt Group ..................................... 100 

5.2.3 OOP Payment made by the exempt Group ...................................................... 100 

5.3 Conclusion .............................................................................................................. 101 

5.3.1 The Socio-economic factors ............................................................................. 102 

5.3.2 Health seeking behaviour among the Exempt Group ...................................... 102 

5.3.3 Out of Pocket Payment by the Exempt Group ................................................. 103 

5.4 Policy Recommendations ........................................................................................ 103 

5.5 Recommendations for Further Research ................................................................. 105 

 

REFERENCES ................................................................................................................ 106 

APPENDIX ...................................................................................................................... 115 

 

 

  

 



v 

 

  

LIST OF TABLES 

Table 1.1: Aggregate NHIS Subscribers Ever Registered, 2008 – 2010 .............................. 4 

Table 4.1: Age Group according to the Study Districts ...................................................... 58 

Table 4.2:  Educational Attainment of the Exempt Group by the Study Districts .............. 60 

Table 4.3: Main Occupation in the last 12 months by Age Group ..................................... 62 

Table 4.4: Main Occupation of the Exempt Group by the Study Districts ......................... 63 

Table 4.5: Religion of the Exempt Group by Study Districts ............................................. 64 

Table 4.6: Marital Characteristics of the Exempt Group by the Study Districts ................ 66 

Table 4.7: Socioeconomic Factors Influencing Utilization of Health care among the 

Exempt Group..................................................................................................... 68 

Table 4.8: Knowledge of Health Conditions among the Exempt by Study Districts ......... 73 

Table 4.9: Types of Illness/Injuries Experienced by the Exempt ....................................... 76 

Table 4.10: Sources of Treatment of the Exempt Group by the Study Districts ................ 78 

Table 4.11: Rationale for Choice of Health Facility ........................................................... 80 

Table 4. 12: Reasons for Perceived Delay .......................................................................... 83 

Table 4. 13: NHIS status among the Exempt Group ........................................................... 85 

Table 4.14: Insurance Status of the Exempt Group by the Study Districts ........................ 86 

Table 4.15: Reasons for Non-Membership of NHIS among the Exempt Group ................ 88 

Table 4.16: Reasons for Non-Membership by the Exempt Group according to the Study 

Districts ............................................................................................................... 89 

Table 4.17: Medical Expenses at OPD by the Exempt Group according to the Study 

Districts ............................................................................................................... 93 

 

 

 



vi 

 

  

LIST OF FIGURES 

Figure 1.1: NHIS Active Membership in 2011 ..................................................................... 5 

Figure 2. 1 Suchman‟s Stages of Illness and Medical Care (1965) .................................... 30 

Figure 2.2: Andersen‟s Health Utilization Model ............................................................... 32 

Figure 2.3: Determinants of Healthcare Utilization ............................................................ 34 

Figure 4.1: Proportion of the exempt by age category ........................................................ 56 

Figure 4.2: Distribution by Age Groups ............................................................................. 57 

Figure 4.3: Educational Attainment of the exempt group ................................................... 59 

Figure 4.4: Religious Affiliation ......................................................................................... 64 

Figure 4.5: Marital Characteristics of the Exempt Group ................................................... 65 

Figure 4.6: Hospitalization among the Exempt Groups ...................................................... 72 

Figure 4.7: Health Status of Respondents ........................................................................... 74 

Figure 4.8: Paid Premium by the Exempt according to the Districts .................................. 91 

Figure 4.9: Medical Expenses by Age the Exempt Group .................................................. 94 

 

 

 

 

 

 

  



vii 

 

  

LIST OF ABBREVIATIONS 

AMA  Accra Metropolitan Assembly 

CHBIs Community-Based Insurance Schemes 

CHPS Community-Based Health Planning Services 

DMHIS District Mutual Health Insurance Schemes 

FFS Fe e for Service 

GDHS Ghana   Demographic and Health Survey 

G-DRGs  Ghana Diagnostics Related Groupings 

GHS Ghana Health Service 

GSS Ghana Statistical Service 

HIV /AIDS Human Immunodeficiency Virus /Acquired Immune 

Deficiency Syndrome   

ISSER  Institute of Statistical, Social and Economic Research 

JHS Junior High School 

LDCs Least Developed Countries 

MOH Ministry of Health 

NDPC National Development Planning Commission 

NHIA National Health Insurance Authority 

NHIL National Health Insurance Levy  

NHIS National Health Insurance Scheme 

NHS National Health Service 

OECD Organization of Economic Co-operation and 

Development 

OOP Out of Pocket Payment 

OPD Out Patients Department 

PNDC  Provisional National Defence Council 

RCH Reproductive and Child Health   

SSA Sub-Saharan Africa 

SSNIT Social Security and National Insurance Trust 

UNICEF United Nations International Children's Emergency Fund 

WB/IMF World Bank/International Monetary Fund 

WHO World Health Organization 

     



 

1 
 

CHAPTER ONE 

INTRODUCTION 

1.1 Background 

Health insurance schemes are increasingly recognized as a tool to finance health care 

provision in developing countries. Indeed, this has the potential to increase utilization and 

better protect people against health expenses (catastrophic) and also address issues of 

equity (WHO, 2000). Health insurance according to the World Health Organization is 

undeniably one of the avenues by which developing and middle income countries can 

achieve universal coverage in health care (WHO, 2010). Yet, health care financing 

continues to stir debates around the world. Many low and middle income countries 

particularly, keep on exploring diverse ways of financing their health systems. This is due 

to the constant and persistent under-funding confronting the health systems (Dalinjong & 

Laar, 2012). 

 

 Poor households in developing countries have reckoned health insurance as an essential 

intervention which provides relief to their healthcare expenditures. However, the 

overwhelming evidence suggests that user fees constitute a strong barrier to the utilization 

of healthcare services, as well as preventing adherence to long term treatment among poor 

and vulnerable groups (Palmer et al., 2004). 

In Sub-Saharan Africa, Ghana is among the first countries to introduce and implement the 

National Health Insurance Scheme (NHIS). The health insurance scheme appears to 

provide a solution to the long standing healthcare financing problem which has been a 

considerable constraint to the accessibility of healthcare, especially by the poor and the 

vulnerable (Osei-Akoto & Adamba, 2011; Aryeteey, 2012).  



 

2 
 

Healthcare financing in Ghana has witnessed a number of reforms over the years.  Firstly, 

during the pre-independence era, financing of health care was mainly out-of-pocket (OOP) 

payments at service points (Arhinful, 2003).  Following the introduction of cost sharing as 

part of health sector reforms in Ghana, user fee exemptions were introduced for poor and 

vulnerable groups as part of an overall effort to address equity in public healthcare 

delivery (Derbile & Geest, 2012).  

Since parliamentary enactment of the Hospital Fees Act 1971 which introduced user 

charges (Shaw & Griffin 1995; Coleman, 1997), exemptions have been part of Ghana‟s 

health care system and have changed in various forms through successive governments. 

However, the history of exemptions date back to the 1960s under Nkrumah‟s Socialist 

Government that sought to provide free health care to the populace after independence 

(Senah, 1989). After independence, the National Health Service (NHS) was established 

and the state was the sole financier of healthcare. This was known as the “free health for 

all” and the source of funding was largely tax-based. The NHS provided health services to 

everybody without any cost and protected poor people in the event of financial shocks. In 

fact, existing user charges in public health facilities were totally abolished (Nyonator & 

Kutzin, 1999; Owusu et al., 2008; Ghana Health Service & Abt Associates Inc., 2009; 

Adamba, 2011; Rosner et al., 2012). 

As part of health sector financing reforms, the Government of Ghana passed the National 

Health Insurance Law in 2003. The rationale behind this was to eliminate the financial 

barriers posed by the user fees (cash and carry) at the point of service and then limit the 

out of pocket cash payment to enhance access and improve quality healthcare services in 

Ghana (NHIS Act 650, 2003; Derbile & Geest, 2012). The policy objective for 

establishing the NHIS in Ghana as cited in Aryeetey (2012 p.10) states that: 



 

3 
 

 “Ultimately, the vision of the government in instituting a health insurance scheme... is to 

assure equitable and universal access for all residents of Ghana to an acceptable quality 

package of essential healthcare. The policy objective is that “within the next five years, 

every resident of Ghana shall belong to a health insurance scheme that adequately covers 

him / her against the need to pay out of pocket at the point of service use in order to obtain 

access to a defined package of acceptable quality of health service”. 

At the beginning of the year 2000, the share of households out of pocket (OOP) payment 

to total health expenditure in Ghana was considerably higher than the regional average for 

Sub-Saharan Africa (50 percent versus 39 percent respectively in 2006) according to 

WHO (2010). 

Over the past 10 years, the Government of Ghana has been implementing the NHIS as a 

replacement to the user fee system; yet, the scheme is still bedevilled with the problem of 

exemption for the poor and vulnerable (Aryteetey, 2012). This gave rise to a new era of 

exemptions where the poor and vulnerable were to be enrolled into the scheme without 

paying premium. This new policy shift according to Derbile and Geest (2012), was not 

preceded by adequate conceptualization of how to deal with exemptions for vulnerable 

groups and the poor under the National Health Insurance Scheme (NHIS). Due to this 

inadequacy, there was a risk that the poor would be excluded from voluntary social 

insurance (Kunfaa, 1996; Arhinful, 2003). Thus, the shift in policy to an “insurance-based 

system of exemptions” gives rise to outstanding questions on how to address equity 

concerns that the former exemption regimes failed to adequately deal with (Derbile &  

Geest, 2012). 

Concerning benefits, the National Health Insurance Authority (NHIA) mandates a pre-

defined benefits package that covers 95% of the disease burden in Ghana. Services 



 

4 
 

covered include outpatient consultations, essential drugs, inpatient care and shared 

accommodation, maternity care (normal and caesarean delivery), eye care, dental care and 

emergency care. Currently, the NHIS reimburses providers based on the Ghana Diagnostic 

Related Groupings (G-DRGs) and fee for-service (FFS) for medicines using a medicines 

tariff list (Ministry of Health, 2009).  

The members or beneficiaries of the NHIS comprise informal sector workers, that is, those 

who are not Social Security and National Insurance Trust (SSNIT) contributors; SSNIT 

contributors who are mainly formal sector workers; SSNIT pensioners; children under 18 

years; pregnant women; people who are 70 years and above and lastly the indigents 

(National Development Planning Commission, 2008; 2009; 2010 and 2011). The number 

of registered subscribers has increased over time as illustrated in Table 1.1 

Table 1.1: Aggregate NHIS Subscribers Ever Registered, 2008 – 2010 

Category No. 

Registered 

as at Dec. 

2008 

% of total 

Pop.  in 

2008 

No. 

Registered 

as at Dec. 

2009 

% of total 

Pop.  in 

2009 

No. 

Registered 

as at Dec. 

2010 

% of total 

Pop.  in 

2010 

Informal  3,725,965 29.76 4,266,051 29.40 5,282,258 29.3 

SSNIT 

Cont. 

798,573 

6.38 884,666 6.10 

1,036,883 5.8 

SSNIT 

Pensioners. 

65,653 

0.52 76,974 0.53 

89,639 0.5 

Under 18 

years 

6,324,487 

50.52 7,175,085 49.44 

8,709,389 48.3 

Pregnant 

women 

881,725 

7.04 967,401 6.67 

1,394,445 7.7 

70 years 

and above 

300,923 

2.40 337,150 2.32 

1,140,549 6.3 

Indigent 421,234 3.36 804,450 5.54 378,204 2.1 

Total 12,518,560 54.66 14,511,777 61.97 18,031,366 74.5 

Source: Annual Progress Reports National Development Planning Commission, 2009 and 2011 



 

5 
 

Table 1.1 points out to the trend of membership of the NHIS between 2008 and 2010. The 

data shows that the population of the ever registered has been going up since 2008 and out 

of the total population ever registered, the exempt group (children below 18 years, adults 

70 years and above, SSNIT contributors, SSNIT pensioners, pregnant women and the 

indigents) consist of about 65 percent. 

Nonetheless in order to discontinue the cumulative approach of calculating the 

membership, the National Health Insurance Authority (NHIA) in 2011 decided to consider 

active membership. 

Figure 1.1: NHIS Active Membership in 2011 

 

 

Source: Annual Progress Report NDPC, 2012. 

In defining active membership, the NHIA considered those with valid I.D cards (that is 

newly registered and renewals). This was to forestall the cumulative process of counting 

membership in order to achieve a credible membership data base. In this regard, active 

membership constituted about 34 percent of the country‟s population in 2011 (NDPC, 

2012). Active membership went up to 10.2 million subscribers representing 38 percent of 

the national population in 2011 (NHIA, 2014; NDPC, 2013). Among the active 



 

6 
 

membership of NHIA subscribers in 2013,  62 percent were exempted from paying 

premiums (i.e. children under 18 years, persons 70 years and older, and indigents), Social 

Security and National Insurance Trust (SSNIT) contributors and SSNIT Pensioners 

constituted 4.0% and 0.24% of membership, respectively and the Military, Police and 

other Security Services constituted 0.243% of membership (NDPC, 2013). 

As a departure from a normal insurance system, increase in membership does not 

necessarily produce increased income from premium to the scheme. The income from the 

National Health Insurance Levy (NHIL) is by far the largest source of income (70%), 

followed by Social Security taxes (23%), premiums (5%) and other sources (2%) 

(Blanchet, Fink & Osei-Akoto, 2012). Therefore, the bulk of income to the NHIS will 

grow with national income rather than growth in membership (Witter & Garshong, 2009).  

Exemptions can however make up for the equity related limitations of the NHIS. Yet, 

based on empirical evidence, community health insurance has been less effective in 

achieving equity (Jütting, 2004). Nevertheless in Nigeria, there is a similar advocacy for 

subsidies and exemptions to improve healthcare for the poorest under community-based 

health insurance schemes (CBHIs) (Onwujekwe et. al., 2010). However,  by taking out 

financial blockades at the points of service through resource and risk sharing, health 

insurance‟s purpose to overcome inequalities associated with access to healthcare by the 

poor can be achieved (Preker & Carrin, 2004).  

Suffice  to say that while health insurance can facilitate utilization and offer financial 

protection regarding the cost of illness (Aryeetey et al., 2012), evidence indicates that 

health insurance has been less effective in achieving this core purpose of equity (Jütting, 

2004; Sulzbach, Garshong, & Owusu-Banahene, 2005; De Allegri et al., 2006). However, 

literature suggests the poor and indigent who should be exempted as a form of greater 

protection against catastrophic health expenditures are reluctant to enrol in such schemes 



 

7 
 

in most African countries with the exception of Rwanda, (Arhin-Tenkorang, 1994; Criel & 

Waelkens, 2003; Jütting, 2004; Jehu-Appiah et al., 2011). 

 

1.2 Problem Statement 

User fee exemptions have been part of various packages for promoting equity in Ghana‟s 

health delivery system since the 1960s. To underscore this, four distinctive periods of 

exemptions have evolved. The initial concession on exemptions was an almost free health 

care policy granted to a major percentage of the populace under Nkrumah‟s government 

(Senah, 1989). The second era of exemptions came under the 1971 Legislative Instrument 

(LI) 701 where Busia‟s government exempted clients who attended rural health centres 

and health posts from the payment of user fees (Adamba, 2011).  

The third era of exemptions was introduced by the Provisional National Defence Council 

(PNDC) government in 1985 under LI 1313 of the 1985 Hospital Fees Regulation. Under 

this, two categories of exemptions were promulgated with the first being patients suffering 

from leprosy or tuberculosis and other special diseases. Such patients were exempted from 

the payment of all fees. The second type came into being in 1997 when the Government of 

Ghana in a renewed effort extended the exemption policy as stated in LI 1313 to include 

antenatal care, those aged 70 years and above, children under 5 years and later the poor 

(Government of Ghana, 1999). To do away with the user fee or cash and carry system, the 

NHIS was instituted in 2003 as the new policy framework for health financing in Ghana 

setting out the fourth era of exemptions.  

The National Health Insurance Scheme Act 650 was promulgated in 2003 with the 

primary purpose of reducing the inequalities in healthcare provision especially for the poor 

and the vulnerable. The NHIS in its design has an in-built mechanism for equity in 



 

8 
 

financial contributions with subscribers paying income-adjusted premiums. The Act 650 

mandated all district schemes to charge a minimum premium of roughly GH¢ 7.20 and a 

maximum of GH¢ 48 per adult from the informal sector based on the ability to pay and 

this was determined by the individual‟s declared income or job position. However, given 

that accurate income measures are not generally available, many District Mutual Health 

Insurance Schemes (DMHIS) have moved to charging a constant premium from all, 

typically in the range of  GH¢ 8 – GH¢10. In their paper on healthcare utilization in the 

Accra Metropolitan Area (AMA), Blanchet, Fink and Osei-Akoto (2012) observed that the 

average premium reported by respondents was GH¢ 21.  

The National Health Insurance Act 650 has made provision for certain categories of 

people to be exempted from payment of premiums. This group include children under 18 

years, the aged 70 years and above, pregnant women, SSNIT contributors, SSNIT 

pensioners and the indigents        (core poor). All these categories of people who are 

exempted are made to pay for the processing of their insurance cards except the indigent 

who do not pay anything whatsoever. In 2012, the NHIS Act 650 was repealed and 

replaced with the new National Health Insurance Act 852. This new Act mandates all 

residents in Ghana to register with the National Health Insurance Scheme (NHIS) and this 

is to help achieve the universal coverage objective of the NHIA. The Act 852 also seeks to 

harmonize the operations of the NHIA to ensure efficient and effective service delivery 

(NHIA, 2012). 

Nevertheless, the scope has been expanded further under the new NHIS Act where 

children under 18 years have been de-coupled from their parents. Additionally, the Act has 

included persons with acute mental disorder, leprosy and HIV/AIDS under the 



 

9 
 

exemptions. Although these patients were not paying for their treatment initially, they 

have now been subsumed under the NHIS.   

The numbers that are exempted from payment of premium keeps on increasing every year. 

For instance in 2011, out of the total active membership of 8.2 million, about 63 percent 

(5.2 million) were classified as part of the exempt group (NDPC, 2012) and this figure 

went up to about 68 percent in 2012 (Saleh, 2012). Various studies have shown that there 

has been an increase in the utilization of health services by means of out-patient visitations 

and reduction in out-of-pocket payments (OOP) by the insured (including exempt) as 

compared to the uninsured (Ranson, 2002; Jakab & Krishman, 2004; Diop, Sulzbach & 

Slavea, 2006; Derbile & Geest, 2012; NDPC, 2012). 

In order to access healthcare under the NHIS, the National Health Insurance Regulations, 

L.I. 1809, requires a beneficiary to first report to a primary care facility, and subsequently 

to second and third levels of care by way of referral. However, poor gate-keeping in the 

health delivery system in general has led to clients having preferences for higher level 

facilities which results in higher cost and delayed re-imbursement to the service providers 

(Ghana Health Service, 2007).   

Generally, the NHIS has improved access to and utilization of healthcare services but not 

without challenges. Anecdotal examples of poor quality of care include provider 

discrimination against insured patients, long waiting time, low likelihood of being seen by 

a doctor and the uncertainty of receiving all drugs prescribed. It has therefore been 

reported that providers commonly solicit informal payments from the patients by asking 

them to pay for drugs, which are said to be out of stock or pay for „‟better‟‟ drugs, not 

provided under the NHIS (Ministry of Health, 2009).   



 

10 
 

Majority of the membership of the NHIS (68%) are considered exempt and are mostly in 

the lower income bracket; therefore, this study tries to identify some of the socio-

economic challenges that affect the exempt groups when it comes to utilization of 

healthcare services. 

What are the real challenges that confront the exempt in their attempt at utilising 

healthcare services under the NHIS? Are these challenges the same everywhere? Or are 

some challenges specific to localities? Do these challenges vary by way of sex among the 

exempt?  

 

1.3 Research Questions 

The study seeks to explore the following questions:  

 What are some of the socio-economic factors that affect utilization of healthcare 

services by the exempt group?  

 What are the health seeking behaviours of the exempt group?   

 To what extent does the exempt group make OOPs at the point of service delivery?  

 

1.4 Objectives of the study 

The main aim of this study is to investigate the socio-economic challenges that affect the 

exempt groups in utilization of healthcare under the NHIS. Specifically the study seeks:  

 To investigate the socio-economic factors that affect utilization of healthcare services 

by the exempt group.  

 To examine health seeking behaviours among the exempt group 

 To explore the extent to which the exempt group make OOPs at the point of service 

delivery. 



 

11 
 

1.5 Relevance of the study 

A lot of studies have been conducted regarding the health insurance scheme and those that 

looked at the exemption categories focused more on free maternal delivery and the 

exemption of the poor (indigent).  Yet, none of them have delved specifically into the 

under 18 years and the aged (70 years and above). This study sought to unravel the socio-

economic burden these groups, which constitute over 55 percent of the insured, encounter 

when it comes to healthcare utilization. The elderly and children under 18 years tend to 

utilize health care resources more often than those who fall within the working category 

(18 – 59 years).  

 In Japan for instance, the entire population is enrolled in mandatory health insurance, 

known as "Health-insurance-for-all”. It has been estimated that the medical expenditure 

for the elderly is already taking one-third of national health expenditure, and is projected 

to reach half of national health expenditure by the year 2025. Therefore this study can 

better inform policy for improving the implementation of exemptions under national 

health insurance scheme.  

 

1.6 Organization of Thesis 

This study has been categorised into five chapters. The first chapter looks at the 

background of the study, then to the problem statement. The research questions, objectives 

of the study and the relevance of the study. Chapter two reviews the relevant literature that 

are beneficial to the study both empirical and theoretical. The chapter also explains the 

theories under-pining the study. The third chapter explains the background characteristics 

of the study areas and the methodology that was employed in this study. Chapter four 



 

12 
 

presents the analysis and discussions of results and chapter five contains the summary, 

conclusion and the recommendations from the study for policy. 



 

13 
 

CHAPTER TWO 

LITERATURE REVIEW 

2.0 Introduction 

The aim of healthcare financing is to improve access to health services especially for those 

belonging to low-income households. Globally, countries are using different modes to 

reduce the burden posed by out-of-pocket payment (OOP) especially for the poor in 

particularly, Least Developed countries (LDCs).  This is because direct payments create 

financial hardships for some people especially the poor and thereby reduce access to 

health services. Healthcare financing according to the World Health Organization (WHO) 

is to ensure sustained funding, as well as to set the right financial incentives for providers, 

to guarantee that all individuals have access to effective public health service which is the 

raison d‟être for better personal health care. This is to reduce or eliminate the possibility 

that an individual will be unable to pay for such care, or will be impoverished as a result of 

trying to do so (WHO, 2006). 

This chapter discusses the literature that has guided the debate over healthcare financing in 

general and specifically on health insurance exemptions and utilization. This chapter is 

divided into six sections. It has an introduction followed by a review of literature covering 

the genesis of healthcare financing from a global perspective. Then healthcare financing in 

Africa and the case of Ghana are discussed. The fifth section discusses the challenges of 

Social Health Insurance in some developing countries and the Challenges of NHIS 

exemptions in Ghana. The final part of the chapter discusses the theoretical framework 

that underpin this study. 



 

14 
 

2.1 The Genesis of Global Health Care Financing  

Health financing is an important part of broader efforts to ensure social protection in 

health. Recognizing this, the WHO in 2005, committed to develop their health financing 

systems so that all people have access to services and do not suffer financial hardship 

paying for them. This goal was defined as universal health coverage which states that there 

should be universal access to health care service by everybody without any hindrances 

whatsoever (WHO, 2005). 

The basic idea of pooling resources to spread economic risk dated back to the ancient 

Greek where the citizens benefited from tax-supported public physicians.  Later on, the 

first compulsory health insurance law was enacted by the state of Prussia and years later 

under the new Germany, health insurance was made mandatory for all workers throughout 

the state. Later in the United Kingdom around 1911, the health insurance act was passed 

and this covered direct cash payment in the event of maternity or disability. Also, it 

covered the medical services of a worker who becomes ill. The success of the German 

health insurance scheme motivated other countries in Europe to emulate the model 

(Mladovsk & Mossialos, 2007). 

However, countries had to undergo reforms in their health financing to meet the growing 

financial burden that governments were saddled with. Private health insurance evolved 

dramatically in the mid-20
th

 century in the U.S.A and the purpose was to improve the 

social conditions of the working class. Yet, the contemporary system differs significantly 

from the 20
th

 century system because of universality and sustainability of the current 

systems (Mladovsk & Mossialos, 2007). 

In recent years, the call for universal health coverage has spurred on a global movement 

and this in 2005 led the World Health Assembly to appeal to governments to develop their 



 

15 
 

health systems, so that all people will have access to services and not suffer financial 

hardships (Cortez & Ramiro, 2013). This invitation was to underscore the urgency with 

which access and utilization was paramount to the WHO. Consequently, the General 

Assembly of the UN in December 2012, also called on governments to urgently scale-up 

efforts to accelerate the transition towards universal access to affordable and quality 

healthcare services and this inspired some 30 middle and lower income countries to 

implement programmes with the objective to advance this transition to Universal 

Healthcare (Cortez & Ramiro, 2013). 

In view of this, some countries have even enshrined the right to healthcare in their 

constitution and a typical example is Columbia where the right to healthcare is tagged the 

subsidize regime (SR) and this is being championed by the central government which is 

mandated to ensure that health service is available to the entire population. This therefore 

has improved healthcare services considerably for the past 20 years albeit all the 

difficulties.  

Healthcare financing has become so imperative that most countries are particularly using 

unique methodologies such as taxation, social health insurance, voluntary and private 

insurance, out-of-pocket (OOP) or user fees and donations to finance their health care 

(Mossialos et al., 2002). These forms of health financing seek to ensure that citizenry have 

access to affordable healthcare.   

However, a recent comparative study of healthcare financing in Asian countries showed 

that OOP payments were concentrated among the higher income groups. The richest 

quintile contributed more than half of OOP payments in Bangladesh, Indonesia, the 

Philippines, Sri Lanka and Thailand (Equity in Asia-Pacific Health Systems, 2005). 

Another study by O'Donnell, van Doorslaer et al. (2008), indicated that in some Asian 



 

16 
 

countries, the poor did not only pay less in absolute terms but less as a proportion of 

household resources. However, the study also found out that in countries such as Japan, 

Kyrgyz and Taiwan, OOP payment by people in the poorest quintile exceeded the share of 

their ability to pay, thus making OOP payments mildly progressive or proportional in most 

of these Asian countries. This therefore contradicts the common assertion that OOP 

payments are regressive (O'Donnell, van Doorslaer et al. 2008). 

 

2.2 HealthCare Financing in Africa 

Healthcare financing in Africa has gained a lot of prominence and gone through several 

phases with governments promising different forms and mechanisms to achieve equity and 

access (Leighton, 1995). Undoubtedly, many methods of health financing mechanisms 

practiced in Europe were geared towards containing costs, yet in developing countries 

particularly Africa, health financing reforms emanated as a result of growing demand for 

improved healthcare when governments could no longer provide free healthcare with 

shrinking resources (Korankye, 2012).   

Given the emphasis on cost recovery in Africa, it is often argued whether cost recovery 

affects access to healthcare. It is however posited that user-fees serve as a blockade to 

utilization notably in the primary and preventive healthcare services. A study by Leighton 

(1995), in Cameroon found that the tendency for a sick person to visit a government 

hospital was 25 percent higher when fees were charged and quality improved. Yet this 

could hinder access to the service by the poor households because they have less money 

and may not borrow funds or trade-off any asset to pay for health cost, so African 

countries must consequently find alternative healthcare financing methods to deal with the 

mounting healthcare issues (Mwabu, 2008). 



 

17 
 

As a way of financing healthcare, social and private mutual health insurance schemes are 

some of the financing options being practiced in Africa. This involves spreading risk and 

cost of medical care by pooling resources mainly through premiums or tax related 

payments (Ndiaye, 2006).  Individual financing in Sub-Saharan Africa prevailed in 

traditional healthcare, with social financing predominating in the western medical care; 

although in Africa, government provides and finances healthcare through taxation for the 

whole population (Vogel, 1990; Ekman, 2004). In countries such as Senegal and Mali, 

health financing has been made mandatory for all formal sector workers via social 

security. Kenya practices the National Hospital Insurance Funds for formal employees, 

which has been replicated in other countries like Zambia, Nigeria, Liberia and DR Congo 

(Vogel, 1990). Yet countries like Burkina Faso, Ghana, Tanzania and Rwanda have 

reviewed and revised their financing mechanisms and have moved towards a more public 

social protection measure (Rosner et. al, 2012). Social insurance financing, when 

successful, can ensure equitable accesses to quality care by keeping premiums affordable 

to enhance utilization for all especially the poor. 

 

2.3 Health Care Financing in Ghana  

In Ghana, healthcare financing has gone through a plethora of changes since 

independence. The fact is that health financing is designed to cover all aspects of society: 

formal and informal sectors, rich and poor as well as rural and urban locations. It becomes 

more critical and overwhelming as developing countries seek to design and operate 

efficient health financing systems that can benefit all citizens and Ghana is no exception 

(Addae-Korankye, 2013). 



 

18 
 

The foundation of Ghana‟s healthcare system was laid by the British in the 19
th

 century 

with the sole intention of preserving the health of the colonial masters to combat and 

overcome the many tropical diseases in Ghana (Aidoo, 1982).  Health care during this 

period was free for the colonial masters, support workers and various opinion leaders 

(Twumasi, 1981). 

After independence through the 1970s, various governments tried several policies to 

ensure sustainable healthcare financing in the country (Abuosi, 2004). At independence, 

health facility attendance was free and patients were not required to do any out-of-pocket 

payment at points of health care delivery. This free healthcare service was financed solely 

through tax. However, during the 1970s, the proposal for user-fee regime was introduced 

and this was to enable government to cut down on her fiscal expenditure. Therefore before 

1989, health facilities were permitted to retain some of the revenue accrued from the fees 

collected to improve upon their services (Baah, 1994).  This user-fee regime introduced 

exemptions for citizens with particularly severe diseases. 

However, the post 1989 period saw the health institutions retaining all the fees collected to 

facilitate capitalization for the “Cash and Carry” scheme. This scheme was implemented 

in 1992 and was formerly known as the Revolving Drug Fund (Yevutsey & Aikins, 2010). 

The “cash and carry” system saw government withdrawing all subsides on healthcare 

delivery; thus, patients had to pay for full cost of drug purchases and services at the health 

facility. Under this system, patients were attended to by health professionals only after 

initial payment for the service was made. Even patients on emergencies had to pay at 

every point of service delivery. This certainly resulted in unnecessary deaths which 

provoked public outcry for the scheme to be abolished (Agbeve, 1997).  



 

19 
 

Although the “cash and carry” system demanded full cost recovery, exemptions were 

provided for patients suffering from leprosy, tuberculosis and other special diseases. 

Besides antenatal care, the aged (70 years and above), children under 5 years and the poor 

were all exempted (Government of Ghana, 1999). Yet these people were still making out-

of-pocket payments whenever they utilized health services out of ignorance. 

These exemptions under the user-fees (cash and carry) system were fraught with problems 

both from the service providers and the beneficiaries. One of such challenges from the 

service providers according to Nyanator and Kuzin (1999) was the pricing and collection 

systems that were decentralized by the Ministry of Health which made it difficult for the 

Ministry to monitor the effect of these fees. In their study in the Volta Region, Nyanator 

and Kuzin (1999) found out that exemptions were non-functional and with a population of 

about 30% living in poverty, the failure of the exemptions meant that fees were inhibiting 

access to the poor or had brought huge financial burden on this portion of the population. 

Besides user-fees, there was also full cost recovery for drugs which were introduced in 

1992 and that also added up to the term “cash and carry”. Inasmuch as this drugs policy 

contributed to the provision of improved and effective drugs, not all patients could bear 

the cost of the drugs. Therefore, poorer patients either took sub-standard drugs or smaller 

quantities of drugs than prescribed or resorted to self-medication and this posed great 

danger to their lives (Asenso-Okyere et al., 1999). 

The attitude of the health workers towards the patients also contributed to the challenges 

that bedevilled the cash and carry system. Among them were the incessant insults, clear 

evidence of polypharmy, exodus of health workers as the number of patients out grew 

health workers and the collection of un-approved consultation fees. All these challenges 



 

20 
 

precluded the poorer population from accessing health services (Asenso-Okyere et al., 

1999).   

These challenges that emanated from the various financing systems encouraged policy 

makers, academia and civil society organizations to search for an alternative and more 

sustainable health financing mechanism. Therefore in 2003, the National Health Insurance 

Act (Act 560) was passed and it was perceived as the antidote to eradicating financial 

barriers that hinder people to access healthcare. The Act (650) created Ghana‟s National 

Health Insurance Scheme (NHIS), with the mission to ensure that all Ghanaians had 

equitable universal access to an acceptable quality of essential health services without out-

of-pocket payment being required at the point of service use (Ghana Ministry of Health, 

2004). The scheme therefore became operational in 2004 (Hsiao & Shaw, 2007). 

However, the principle of universal coverage revolves around both financial protection 

and unimpeded access to healthcare for all citizens as a necessary condition for health 

system equity (WHO 2008). 

The new system establishes that the informal workers‟ pay annual premium and this has 

been graduated according to one‟s earnings, yet subscribers mostly pay flat rates. Besides, 

the NHIS premium has been heavily subsidized to ensure affordability to healthcare and 

financial access for the vulnerable groups. Also, enrolment for the informal sector workers 

is voluntary under the NHIS and is subject to adverse selection of this potential group. 

The government under this scheme has exempted some groups of people from paying 

premium. However several vulnerable groups including the poor are not well targeted 

under the exempt category; causing them not to register (Saleh, 2012). The implication of 

this is that the risk pool of the NHIS is fractured, resulting in high cost and limited 

contribution from these vulnerable groups.   



 

21 
 

The removal of such fees as has been advocated by some as the way forward. Even though 

the removal of user fees in general often results in increased utilization, user fees removal 

in countries such as Uganda, Burundi, South Africa, Kenya, Sudan, Senegal, Liberia, 

Niger, Lesotho and Zambia have discovered serious issues related to quality and the high 

burden of increased utilization on the few existing healthcare professionals and facilities 

(Yates 2009).  

To assume that the removal of user fees will solve a country‟s healthcare financing 

problem is naive. Gilson and McIntyre (2005) argue that doing away with user fees should 

not be seen as a panacea that can be implemented easily. Rather, the policy should be 

thought of as part of a broader package of health system reforms to move towards 

universal coverage (Akazili, 2010).  

Besides, the government under the National Health Insurance Scheme aimed at providing 

quality, accessible, efficient and equitable health services to about 60% of Ghanaians by 

2015 and subsequently attaining universal coverage throughout the country (Ministerial 

Task Team, 2002). 

In terms of funding the National Health Insurance Scheme, (NHIS), the National Health 

Insurance levy (2.5 % of VAT) accounts for about 75% of the total NHIS funds and 

premium by the informal sector accounts for about 5%. The rest (20%) is by Social 

Security and National Insurance Trust (SSNIT) contributions for formal sector workers 

(NHIS ACT, 650; Akazili et.al 2012). The NHIS contributions is generally progressive; 

however, contributions by those in the informal sector is regressive. This is due to the fact 

that the premiums are mostly flat rate and this is a violation of the NHIS Act (650), yet 

due to the difficulty in ascertaining the income levels of the informal sector, the districts 

are compelled to resort to this channel (Akazili et.al 2012). 

 



 

22 
 

2.4 Challenges of Social health Insurance in some Developing Countries 

 Recently, interest has been growing among development policy-makers with regard to 

social protection as a way of tackling poverty reduction in most developing countries. 

Health care is one of the determinants of an individual‟s welfare and as the need for health 

care grows, there is also a massive growth of healthcare services to match – up the 

growing demand (Swani et.al, 2012).  In their work on Equity financing and the use of 

health care in Ghana, Tanzania and South Africa, Mills et al, (2012) opined that out-of-

pocket payments are continuously regressive in most Organization of Economic Co-

operation and Development (OECD) countries and yet progressive in several Asian 

countries. The progressivity of the OOP is because poorer households cannot afford to pay 

and access health care services and therefore the rich pay higher to cushion that of the 

poor.  

However, the exempt groups in the various health insurance schemes (HIS) across the 

world face many challenges when accessing health services. According to Russell and 

Gilson (1997), countries with official exemption policies for the poor and vulnerable are 

faced with numerous obstacles such as information to create the awareness as well as 

administrative, economic, and political challenges all of which affect these exemption 

groups (Russell & Gilson, 1997). 

The beneficiaries who are exempted from payment of premiums has resulted in increased 

utilization of the health care services, leading to increase in workload for the service 

providers. According to Liem, Duc and Axelson (2008), after 15 years of health reforms in 

Vietnam, almost half of the population are benefiting from some form of insurance and 

this has increased utilization of health services tremendously. Similarly, in China, D.R 

Congo and Kenya the use of health care at the in-patient care has doubled for members in 

voluntary insurance as compared to the non-insured population (Criels & Kegels, 1997). 



 

23 
 

The positive side of the increased utilization of health services means that ailments that 

hitherto beneficiaries would not have sought medical care for are now being reported at 

the hospitals during the initial stages and this has reduced mortality rate in most of 

developing countries. According to Anderson (2004), without good health, people may 

experience debilitating diseases and an unnecessarily short life span. Fortunately, social 

health insurance has become one panacea to this concern.  

Yet, the burden of workload on the healthcare practitioners and other ancillary staff have 

increased tremendously and this has caused the waiting times at health centres to be 

extremely high. According to Swami et al (2012), who looked at the problems and 

prospects of micro health insurance in Botswana, increased utilization of health services 

has led to an increased workload for hospital staff. Thus, patients who visit public health 

care facilities are made to wait for a considerable longer time before they are attended to 

by a doctor and this affects the quality of care received. Therefore, most of the people 

joined the Itekanele scheme to enjoy the services that came with it. The waiting time in 

this regard was not disaggregated according to sex. However, in terms of the differences in 

waiting time between men and women at the service centres, Kazanjian, Morettin and Cho 

(2004), asserted that women wait much longer than men when accessing healthcare. They 

studied Canadian women and healthcare utilization and concluded that women wait longer 

when it comes to treatment of diseases like asthma and waiting time is longer for men 

concerning mental health sickness.  

In some situations, the exempt and even the insured are unable to access healthcare 

because of distance to these health facilities, coupled with the bad nature of the roads 

mostly in the rural communities. A study conducted by Ali, Bhatti and Kuroiwa (2008) in 

Pakistan on challenges to and utilization of reproductive healthcare in Pakistan used a 

cross-sectional survey to enrol 170 health facilities from nineteen randomly selected 



 

24 
 

districts in the Punjab and North-West Frontier Province (NWFP). Their findings indicate 

that geographical remoteness, (distance) hinders access and also delays the process of 

transferring seriously ill patients to higher level care facilities for treatment. Ali et al., 

(2008) further posited that many maternal deaths would be avoided if geographical 

obstacles and timely access to health facilities is addressed.  

According to Onokerhoraye (1999), private and public health facilities are unevenly 

distributed and that regions with hard terrain and rough physical environment are mostly 

neglected. The implication is that distance between the rural dwellers and health centers 

are farther apart with its attendant problems of high transportation fares and longer travel 

times.  Using 160 rural households through randomly selected agricultural zones in Kogi 

state, Awoyemi, Obayelu and Opaluwa (2011) in their study on distance and utilization of 

health care services in rural Kogi state of Nigeria recommended that to improve patronage 

of health services, distance to health facilities and the total cost of seeking health attention 

needs to be reduced to the barest minimum to enhance access to improved health services 

by various socio-economic groups in the area. 

The practice of taking unapproved fees from the exempt and insured by hospital staff 

leaves much to be desired and poses a huge challenge to the smooth implementation of the 

scheme. Beneficiaries have reported of nurses and other para-hospital staff taking money 

from them before proper care is administered to them. In a study conducted by Sharma, 

Smith, Sonneveldt, Pine, Dayaratna and Sanders (2005) on formal and informal fees in 

maternal health in five countries: Egypt, Peru, Kenya, India and Vietnam, it was 

discovered that staff members usually demand payment from patients when they are 

discharged. Indeed, all the women interviewed resented these informal costs; yet, in order 

to make peace, they reluctantly paid to avoid any distasteful experiences. Sharma et al 

(2005) also indicated that in Egypt, nurses and other health facility workers were more 



 

25 
 

aggressive and straightforward with their demand. They concluded that generally, in all 

the five countries, women were not cognizant of the waivers and the exemptions for 

maternal health services. For instance they found out that in Peru, beneficiaries were 

aware of the existence of exemptions; yet, they consistently had to pay for laboratory tests. 

All these informal fees have become a burden on these poor households and has alienated 

some of them from accessing formal health care. 

In conclusion, user fees payment throughout the world and especially in developing 

countries constitute a significant health care barrier and measures to abolish it has also 

enhanced access to and utilization of health care services notably among poor households 

(Ataguba & McIntyre, 2012; Witter, Garshong & Ridde, 2013). Certain concerns 

expressed by service providers include the indiscriminate use of health facilities by 

beneficiaries who at times abuse the system as well as the late reimbursement of claims by 

the regulators to the service providers which affect the smooth operations of the health 

facilities and hence influences providers‟ behaviour towards the insured (Dalinjong & 

Laar, 2012). 

 

2.5 Challenges of the Exemptions Policy in Ghana  

The elderly population globally is experiencing incremental growth of about 11.5 percent 

of the world‟s total population and it is projected to increase to about 2 billion by 2050 

(UNFPA, 2012). Majority of this elderly population are found in developed countries 

compared to developing countries such as Ghana which has a relatively young population. 

The elderly population of Ghana rose incredibly from about 215 thousand in 1960 to 1.6 

million in 2010. However, the general population is considerably youthful according to the 

population pyramid (GSS, 2013). The dichotomy of these age categories (elderly and 



 

26 
 

young), concerning their health, leaves much to be desired. These two groups constituted 

about 56 percent of the total membership of the National Health Insurance Scheme (below 

18 years: 51.2 %; 70 years and above: 4.5 %) in 2011 (NHIA Report, 2012). These cohort 

age groups have different health needs and this is evident in the kinds of diseases that 

affect them. For instance about 53 percent of deaths in Ghana are related to 

communicable, infectious and parasitic disease like malaria and pneumonia which are the 

leading causes of mortality and morbidity among children under 14 years. Regarding 

adults over 60 years, 67 percent of deaths are mostly from non-communicable diseases 

like cardiovascular, high blood pressure and others (World Bank Health Report, 2011). 

The implication is that the use of health services amongst these groups would go up 

significantly. 

There has been an extensive coverage given to health insurance especially in Ghana by 

various studies (Blanchet, Fink & Osei-Akoto, 2012; Owusu et al., 2012; Blaese, 2012). 

However, few studies have devoted attention to the issue of exemptions (Aryeetey et al., 

2010; Jehu-Appiah et al., 2010). Besides, the debate as to whether exemptions address 

equity concerns is still lingering on (Derbile & Geest, 2012; Jehu-Appiah, 2010). An 

evaluation study by Witter et al., (2007: 61) observed that although exemptions enjoy wide 

popularity, there are „important problems with disbursing and sustaining … funding, and 

with budgeting and management.‟ 

Another disturbing factor is the lack of public awareness about exemption packages. In a 

study conducted in the three northern regions in Ghana, Derbile and Geest (2012) from 

their survey on exemptions, observed that 61% of respondents did not know about 

exemptions for the poor unlike that of antenatal exemptions (84%), under-five exemptions 



 

27 
 

(79%) and exemptions for the aged (62%). According to their results, majority did not 

know the modalities for accessing exemptions. 

Similarly, limited public awareness of specific categories of exemptions has been 

observed by others (Garshong et al., 2002; Aikins & Arhinful, 2005). In the Volta Region 

for instance, people generally lacked knowledge or did not believe that exemptions were 

granted at health facilities (Nyonator et al., 1994). The lack of public awareness about the 

specific exemptions categories may be emanating from the nature of education on 

exemptions by the various institutions. Besides, excessive demand by the under-fives and 

ante-natal exemptions has accounted for a lot of financial burden on the health care system 

and this undoubtedly serves as a disincentive for exemption education (Derbile & Geest, 

2012). 

Exemptions indeed have reduced delays in accessing care for pregnant women, yet 

workloads of health workers have increased tremendously and this has really affected 

quality of care negatively (Witter, Garshong & Ridde, 2013). Moreover, in order to accrue 

the full reimbursement from the NHIA, service providers are reluctant to refer patients to 

other hospitals. In their exploratory study of the policy process of early implementation of 

the free NHIS coverage for pregnant women in Ghana, Witter, Garshong and Ridde (2013) 

further concluded that maternal utilization and other health indicators are improving, yet 

supervised deliveries remain low. 

Based on the ongoing discussions and other literature, very limited studies have addressed 

exemptions and the socio-economic challenges when it comes to utilization. This study 

attempts to contribute to filling this knowledge gap. 

 



 

28 
 

2.6 Utilization of HealthCare Services – The Theoretical Framework  

Health Insurance Schemes (HIS) have improved utilization of the health services all over 

the world. Indeed, in most developing countries, HIS has become the panacea in dealing 

with access and utilization. This section therefore examines some of the theories and 

models that have underpinned health care utilization. There are a lot of determinants that 

affect a person‟s ability to utilize health care. Prominent among them are culture, 

economics, access, perception, knowledge, belief / efficacy, age, gender roles and social 

status (Rebhan, 2011). 

In studying health care utilization, various scholars have propounded several theories that 

examine this phenomenon and among them is the Parsons‟ Sick Role theory (1951). This 

theory basically postulates that “any sick person adopt a role of being ill”. This theory has 

four tenets and these are that: 

 The individual is not liable for being ill and cannot be well without any assistance 

 The person is exempted from normal duties 

 The general situation of being ill is an undesirable state 

 To get well, the individual has to seek medical care and follow the treatment regime 

Generally, this theory typifies the behaviour of a sick person or individual (Rebhan, 2011) 

and cannot be used for this study because it only describes the role of a sick person 

without recourse to the obstacles in seeking treatment. 

 

The next theory which has been used to explain healthcare utilization is Suchman‟s (1965) 

stages of medical care. This theory proposes five stages which can inform an individual‟s 

decision to utilize healthcare or otherwise. These stages are: 

  

 The individual‟s symptoms experience (pain, feeling sick) as indicative of illness. 



 

29 
 

 The individual‟s assumption of a sick role where they explore all the treatment 

options 

 The medical care contact. At this stage, the individual looks for a professional 

healthcare system and according to Suchman, this is affected by their social 

networks, which may be either “parochial or cosmopolitan”. That is a person 

whose social network is parochial may delay medical care as compared to the one 

with a cosmopolitan social network (Wolinsky, 1988). 

 The assumption of a dependent-patient role and the acceptance of a professional 

healthcare treatment. Situations where the patient and the professional have 

different opinions about the illness can disrupt this stage (Wolinsky, 1988). 

 The final stage is the individual‟s recovery from illness and this is contingent on the 

person moving from the position as patient. Where the illness is terminal, then he 

/she may assume a persistently sick role.  

These stages are represented in figure 2.1 below: 



 

30 
 

Figure 2. 1 Suchman‟s Stages of Illness and Medical Care (1965) 

 

  

  

                                                                                                           

Source: Adapted from Rabhan (2011) 

This theory was also not appropriate for this study because the focus was limited to stages 

of illness and medical care but did not dwell so much on access and utilization. Mechanic 

(1978) propounded a theory of healthcare utilisation from a psychological perspective and 

proposed ten (10) determinants of illness behaviour including the following: 

 The importance of deviant signs and symptoms 

 Individual‟s perception of symptoms and its severity 

 Disruptions caused by the illness to the normal routine  

 Frequency of symptoms and their persistence 

 Individual tolerance of symptoms 

 Knowledge and cultural assumptions of the illness 

 The denial of illness emanating from basic needs 

 Assumption of illness disrupting needs 

 Alternative interpretation of symptom expression 

 Availability of treatment with consideration on location, economic cost, 

psychological and treatment cost 

Symptom 
Experience 

Assumption 
of Sick Role 

Medical 
care 
Contact 

Dependent-
Patient role 

 Recovery 
from illness 

Terminal 
illness 



 

31 
 

Consequently, this theory articulates that “autonomy and heteronomy” influence health 

care utilization. Yet what it failed to discuss was the determining factors that can influence 

or affect an individual in accessing healthcare when all these signs and symptoms evolve. 

 

The behavioural model of healthcare utilization developed by Andersen (1968) was the 

final theory to be considered. This is one of the most frequently used frameworks for 

analysing the factors associated with patient utilization of healthcare service.  This theory 

is what underpins this study. The initial purpose of Andersen‟s behavioural model was to 

understand why some families‟ use health services, define equitable access to healthcare 

and assist in developing policies to promote equity (Andersen 1968). He posits that an 

individual‟s access to and use of healthcare services is dependent on three factors: 

 The predisposing factors: issues that influence the use of health care services and 

these are categorised into three determinants: the social structure (education, 

occupation, ethnicity, social networks, social interactions, and culture), the health 

beliefs (attitudes, values, and knowledge that people have towards the health care 

system) and lastly the demographics (age and sex). 

 The second is the enabling factors such as the logistical aspects that may boost or 

impede one from obtaining healthcare (access to health services, income, health 

insurance, and a regular source of care, travel, extent and quality of social 

relationships; available health personnel and facilities, and waiting time). 

 Lastly the need factors: the most immediate cause of health service utilization 

(self-perceived health status, chronic and acute illness).  

 



 

32 
 

Figure 2.2: Andersen‟s Health Utilization Model 

 

   

 

 

 

Source: Adapted from Wolinsky (1988) 

The assumption is that the interactions that exist between these complex factors can 

produce a utilization outcome which may be at variance across socio-economic groups. 

This is because vulnerability of a given population inadvertently affects healthcare access 

and usage (Andersen, 1995; Jehu-Appiah, Aryeteey, Spaan, Agyepong & Baltussen, 

2012).  

This model is appropriate for this study as compared to the others in the sense that it 

considers all the factors ranging from predisposing, enabling and needs based which either 

influence or hinder one from utilizing health services. Besides, considering the exempt 

group in general and below 18 years and the 70 years and above in particular, the 

interaction of these factors may affect the utilization of healthcare which may reduce the 

benefit of the insurance coverage (Aryeetey et al., 2012).  

The behavioural model, from the time it was first developed (Andersen 1968), has been 

extensively critiqued. Yet, its use for examining the context within which utilization 

occurs has not been reviewed. Nonetheless the model has been criticized for lack of focus 

on social interactions, social networks and culture (Bass & Noelker, 1987; Guendelman, 

1991; Portes, Kyle & Eaton, 1992).  

Predisposing 
factors 

Needs Based 
Characteristics 

Enabling 
Characteristics 

Utilization of 
Health 
services 

Social Structure 
Health Beliefs 
Demographics 

Personal/Family 
Resources 
Community 
Resources 

Perceived Health 
needs 
Clinically 
evaluated needs 



 

33 
 

However, in their work on “understanding the context of health care utilization”, Phillips, 

Morrison, Andersen, and Aday (1998), examined how the context within which utilization 

occurs (the role of environment and provider-related factors) has been largely neglected. 

They considered studies that have utilised the behavioural model during a 20 year period 

to ascertain whether these studies included the environmental and provider related variable 

(contextual variables) and how these variables were measured. Furthermore 

“environment” and “provider-related” factors are the new variables added to the original 

utilization model by Anderson. Yet, understanding the interactions between beneficiaries 

and service providers is of great essence to health programme and policy managers to 

ascertain the level and extent of utilization (Philips et al., 1998) and this is the crux of this 

study. 

 

2.7 Conceptual Framework 

Conceptually, the determining factors of health care utilization can be grouped under three 

main themes - environmental, population characteristics and individual health behavioural 

factors (Andersen, 1995; Phillips, Morrison, Andersen & Aday, 1998) (see figure 2.3). 

The environmental factors comprise factors that reflect the economic climate, relative 

wealth, politics, level of stress and prevailing norms of the society health care systems 

(Phillips, Morrison, Andersen & Aday, 1998). The effect of environmental factors on 

health care utilization according to Wan (1981), has a positive relationship to the amount 

and type of utilization.  



 

34 
 

Figure 2.3: Determinants of Healthcare Utilization 

 

 

 

  

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source: Adapted from Andersen (1995); Phillips, Morrison, Andersen & Aday, 

(1998) 

 

The population characteristics comprises of predisposing, enabling and need factors as can 

be seen in figure 2.3. The predisposing factors impact on the attitudes concerning 

insurance which either motivate or hinder one‟s access to health care. These factors 

include education, occupation, ethnicity, family size, age, sex, attitudes to health care, 

values and knowledge as far as health related issues are concerned. The enabling factors 

aid or impede one from obtaining healthcare and comprise variables such as place of 

residence, knowledge of health insurance, regular source of care, travel time, availability 

of health personnel, facilities and waiting time. Self-perceived health status, chronic and 

acute illness as need factors represent the immediate cause of health care utilization. The 

interactions among the major themes as identified, although may differ across socio-

Predisposing factors 
Social Determinants  

Health beliefs 

Demographics  

 

 

Needs Based Factors 
Perceived health needs 

Clinically evaluated needs 

 
 

Enabling 

factors 
Personal / Family 

Resources 

Community 

Resources 

Environmental 

Factors 
External Environment 

 

Health care 

Utilization  



 

35 
 

economic groups can affect health insurance enrolment and access to health care 

utilization (Aryeteey, 2012). 

 

2.8 Summary and Conclusion  

The chapter started with the review of literature on the genesis of healthcare financing; 

how it began with the ancient Greeks and trickled down to Germany in Europe and then 

the U.S.A. Health insurance and how it is being practiced in this contemporary era was 

also discussed citing examples from South America and Asia. The consideration of the 

African context regarding healthcare financing was also discussed and the Ghanaian 

context was the final issue under this first part. Then the final part considered some of the 

challenges with regard to social health insurance in some developing countries and 

exemptions under the NHIS in Ghana. The review established that healthcare financing 

through social and mutual health insurance schemes have indeed brought relief to the poor 

when it comes to OOP and other catastrophic payments. Besides, as governments consider 

the best mechanism to finance health, utilization has also improved considerably among 

poor households. However, countries have tried different forms of health financing such as 

establishing National Hospital Insurance funds as is the case in Kenya, Zambia, Nigeria, 

Liberia and D.R. Congo or establishing National Health Insurance Schemes as is found in 

Ghana, Tanzania and Rwanda. 

The review also established that Ghana‟s healthcare financing has gone through numerous 

changes from independence to the present. Besides, the NHIS which is currently being 

implemented was promulgated to bridge the gap between the rich and the poor in terms of 

access to healthcare and also to reduce OOP at the service centres. However the 

exemptions under the scheme are confronted with some challenges when accessing 



 

36 
 

healthcare.  Some of these challenges are as a result of the limited knowledge of their 

exemptions and the financial relief that comes with it. According to the literature, about 34 

percent of Ghanaians are currently enrolled unto the scheme (NHIA Report, 2011) and this 

includes the exempt who constitute about 70 percent of the total subscriber base of the 

NHIS.  

After the literature review, the theory to be used for the study was discussed after 

assessing three theories. The main theory used for this study was the behavioural model by 

Andersen (1968) which posits that there are three determinants that affect one‟s behaviour 

towards healthcare and these are the predisposing, enabling and needs factors. 

 



 

37 
 

CHAPTER THREE 

STUDY AREA AND METHODOLOGY 

3.0 Introduction 

This chapter gives an insight into the study areas and the methodology that was used to 

carry out this study.  The study was conducted in three districts across three main agro-

ecological zones in Ghana, namely Kwaebibirim in the coastal zone, Asutifi and Savelugu 

/ Nanton districts representing the forest and savannah zones respectively. 

 

3.1 The Study Area 

3.1.1 Kwaebibirm District  

The Kwaebibirim is one of the 22 districts in the Eastern Region with Kade being the 

capital which is about 85km from Koforidua the Regional capital. 

 

3.1.1.1 Location and Size 

The Kwaebibirim district was carved out of the West Akim district in 1988 by a 

Legislative Instrument (L.I) 1425. There are 212 communities in the district with Kade as 

the capital. There are about six urban areas in the district and the rest of the settlements are 

very small rural communities. The District is located in the South-western corner of the 

Eastern Region of Ghana, between Latitudes 1 degree 0‟W and O degree 35.‟E and 

Longitudes 6 degrees 22‟N and 5 degrees 75‟S. On the North, it is bounded by the Birim 

North District, on the East by Atiwa District and East Akim Municipal, on the south East 

by Suhum Kraboa Coaltar District, and West Akim Municipal, and on the South-west by 

the Birim Central Municipal and on the West by Akyemansa District. The District has a 

surface area of about 1, 230 square kilometers. 



 

38 
 

3.1.1.2 Climate & vegetation 

The District lies within the semi-equatorial climate zone and experiences double maxima 

rainfall pattern. The District‟s maximum rainfall period coincides with the planting season 

which is ideal for agricultural activities. Regarding the vegetation of the area, it lies within 

the semi-deciduous forest region with low-lying species of hard wood. Also, the district 

has two forest reserves, which is the East-Ayaola Forest and the West Atiwa Forest 

Reserves. These reserves cover a very large area and in addition, large plantations of teak 

have been planted outside the forest (Kwaebibrim District Assembly, 2013: Ghana 

Districts, 2014). 

 

3.1.1.3 Population Size 

The district is one of the highly populated ones in the region with a population of 192,562 

according to the 2010 population and housing census with inter-censual growth rate of 

1.9%. Over two thirds of the population lives in rural areas. Concerning the sex 

distribution of the population, there are more females (98,002) about 51 percent than 

males 49 per cent (94,560) (Ghana Districts, 2014; Ghana Statistical Service, 2012). The 

population has not had any major growth as compared to other districts and this can be 

attributed to the deprived nature of the district with no major industries and companies 

except small scale mining and agriculture. 

 

3.1.1.4 Migration 

The presence of abundant potentials in mining and agriculture has become a recipe for the 

influx of people from other parts of Ghana. This is evident in the settlement of different 

kinds of ethnic orientations. The Akans constitute 67 percent of the ethnic group in the 

district. In addition, there are Northerners, Ewes, Gas-Adangmes and other minority tribes, 



 

39 
 

who have all settled in the district and are engaged in farming and mining activities 

(Ghana Districts, 2014; Kwaebibrim District Assembly, 2013) 

 

3.1.1.5 District Economy 

The district is endowed with both mineral and forest resources and has one of the best 

terrains for agriculture in the entire country. The various species of timber such as 

mahogany, emire, odum and wawa are widely available in the district‟s expansive forest 

areas. The district can boast of diamonds and gold deposits. Crop farming is the 

predominant economic activity and thus serves as the source of livelihood for over 72% of 

the population. The district produces a wide variety of both cash crops such as cocoa, cola, 

oil palm and citrus and food crops including plantain, cocoyam, cassava and cereals, as 

well as vegetables. The main industrial activity of the local economy is agro-based. 

Arguably, the district can boast of the largest oil palm mill in West Africa at Kwae, 

operated by the Ghana Oil Palm Plantation Development Company Limited (Kwaebibrim 

District Assembly, 2013). 

 

3.1.1.6 Health  

The health delivery system in the Kwaebibirem District consists of 2 hospitals, 4 health 

centres, 3 community clinics, 1 maternity home, 6 Reproductive and Child Health (RCH) 

centres and 4 Community-based Health Planning Services (CHPS) compounds. In 

addition to the above, outreach clinical activities are organized in most communities which 

lack established health facilities. Access to health care services in the district is impeded 

by the poor road network which hampers smooth health delivery in the district.  The 

district hospital is located at Kade and it also serves as a referral point.  Yet, the St. 



 

40 
 

Dominic hospital at Akwatia which is a mission hospital, offers specialized treatment in 

the district (Kwaebibrim District Assembly, 2013).  

3.1.2 Asutifi District 

The Asutifi district is one of the twenty two (22) municipal and district assemblies in the 

Brong Ahafo Region and was carved out of the larger Ahafo District by LI 1485 in 1988. 

Kenyasi is the district capital and it is about 50 kilometres away from Sunyani, the 

regional capital of the Brong Ahafo Region (Ghana Districts, 2014). The district is 

however endowed with a variety of resources which when properly managed would help 

develop the area and improve the standard of living for the people. 

 

3.1.2.1 Location and Size 

Asutifi District is located between latitudes 6°40' and 7°15' North and Longitudes 2°15' 

and 2°45' West. It shares boundaries with Sunyani District in the North, Tano District to 

the North East, Dormaa District to North West, Asunafo District in the South West and 

Ahafo Ano District (Ashanti Region) in the South East. The district is made up of 117 

settlements and is typically rural with a total land surface area of 1,500 Sqkm (Ghana 

Districts; Asutifi District Assembly, 2013).  

 

3.1.2.2 Climate and Vegetation 

The district lies within the wet semi-equatorial zone marked by double rainfall maxima 

with a mean annual rainfall which is also ideal for crop cultivation. The district has a moist 

semi-deciduous forest. Man‟s activities notably farming, lumbering and occasional bush 

fires have however disturbed this vegetation. This has changed some areas into a derived 

wooded savannah; however, large areas of forest reserves still exist and these include the 

following:  



 

41 
 

 Biaso Shelter Belt:  29.5 km
2
 

 Bia Tam Forest Reserve:  91.4 km
2
 

 Asukese Forest Reserve: 180.1 km
2
 

 Goa Forest Reserve: 23.8 km
2
 

 Desiri Forest Reserve:  151.0 km
2
 

These forest reserves together cover a total of about 475.6 square kilometres about 30% of 

the entire land surface area of the district. Traditional authority plays an important role in 

the southern part of Ghana where most minerals deposits are located. At the local level 

where traditional status continues to command respect, chiefs and sub chiefs exert control 

and power over land and land resources through land allocations as they are regarded as 

the custodians of the land (Asutifi District Development Plan, 2002; Newmont Ghana, 

2005). 

 

3.1.2.3 Population Size   

The population of the district is estimated to be about 105,843 with a growth rate of 2.5 

per cent per annum (GSS, 2012). Regarding the population distribution, there are more 

females 51 % (50,797) than males 49% (50,046) and this is consistent with the national 

distribution where the female population is more than the male population. The need to 

target women in any development programme in the district can therefore not be over-

emphasized. The high rate of increase in the population in the district is as a result of the 

emergence of Newmont Mining Company and its ancillary activities like illegal mining 

(galamsey) which is accelerating uncontrollably. This has brought a lot of people into the 

district which hitherto, was one of the lowly populated areas.  



 

42 
 

3.1.2.4 Migration 

Ethnic diversity is high, due to immigration over the past 50 years of persons seeking land 

to farm. About 54 percent of the people are migrants (mainly Ashantis), with Bonos the 

indigenes constituting only 9 percent of the population (Asutifi District Development Plan, 

2004).  These immigrants have however stayed in the district since time immemorial and 

hence do identify with the area. With the advent of Newmont Gold Ghana Limited, the 

migration pattern has changed drastically with people migrating to the district from all 

over the country. However, the Ashantis remain the dominant ethnic group followed by 

the Bonos and other minority ethnic groups like the Gas, Ewes and people from the 

Northern Ghana (Asutifi District Development Plan, 2004). 

 

3.1.2.5 District Economy 

The predominant economic activity in the District is subsistence agriculture (mostly 

farming) which engages about 77 percent of the economically active labour force with 

limited income due to the low output. About 96 percent of those engaged in other 

occupations outside agriculture still take up agriculture as a minor activity. The service 

sector accounts for 21 percent of the active labour force consisting mainly of trading and 

this leaves the industrial sector with only one percent (Asutifi District Development Plan, 

2004). Besides, non–farming sources of income are limited and two–thirds (2/3) of adults 

have no employable skills other than farming. However with the advent of New Mount 

Ghana Limited, the situation has changed. About 65% are now engaged in agriculture and 

the service sector accounts for about 30 percent. Women occupy a large part of the 

agricultural workforce and generate the majority of the non-farm income (Newmont 

Ghana, 2005).  



 

43 
 

3.1.2.6 Health   

The district has one major hospital which also serves as a referral centre: the Saint 

Elizabeth District Hospital located at Hwidiem and owned and managed by the Roman 

Catholic Church. Also, there are five other health centres managed by the Ministry of 

Health, seven CHPS Compounds, three Private Maternity homes; three Homeopathic 

clinics and sixty trained Traditional Birth Attendants (TBAs) all rendering varying degrees 

of health services in the district (DHMT Report, 2010). Yet the district indeed has 

challenges that affect the smooth health care delivery, such as lack of qualified personnel, 

inadequate medical staff at the community clinics and lack of medical officers for the 

hospitals (GhanaDistricts.com, 2014; Asutifi District Assembly, 2013).   

 

3.1.3 Savelugu-Nanton District 

Savelugu/ Nanton is one of the 20 districts in the Northern Region with Savelugu as the 

capital. It is located about 30km from Tamale the regional capital and is used in this study 

to represent the savannah zone. 

 

3.1.3.1 Location and Size 

The District is one of the twenty (20) administrative districts of the Northern Region. It 

was established by PNDC Law 207 under the Legislative Instrument of 1988. It was 

carved out of the then Western Dagomba District Council, which included 

Tolon/Kumbungu and Tamale Metropolitan Assembly. It shares boundaries with West 

Mamprusi in the North, Karaga to the East, Tolon/Kumbungu in the West and Tamale 

Metropolitan Assembly to the South. The District‟s total land area is 1,790.70 sq. km and 

is made up of 149 communities (GhanaDistricts.com, 2014) 



 

44 
 

3.1.3.2 Climate and Vegetation 

The area experiences single maxima rainfall and is prone to periodic flooding during the 

wet season; thus, making the land convenient for rice cultivation. The annual rainfall 

pattern is erratic at the beginning of the raining season and intensifies as the season 

progresses. Temperatures are usually high, averaging 34
o
C. The generally high 

temperatures as well as the low humidity is brought about by the dry harmattan. The area 

finds itself in the interior guinea Savannah woodland with the capacity to sustain large-

scale livestock farming as well as cultivation of staples like rice, groundnuts, yams, 

cassava, maize, cowpea and sorghum. The trees found in the area are drought resistant and 

hardly shed their leaves completely during the long dry season. Notable among them is the 

Shea tree (Savelugu-Nanton District, 2013; GhanaDistricts.com, 2014). 

 

3.1.3.3 Population Size and Growth  

The district has a population of 139, 283, made up of 49% males (67,531) and 51% 

females (71,752) according to the 2010 population and housing census. The average 

household size is about 9. The district has a land area of 1,790.7sq.km with a population 

density of 61 persons per sq. km (GSS, 2012).  

 

3.1.3.4 Migration 

There are 149 communities in the District; yet, only six can be described as urban while 

the other 143 communities can be described as rural. Nearly 80% of the populace resides 

in these rural communities and 20% in the few urban towns. The dominant ethnic groups 

located in the district are the Dagombas. However, there are other minority tribes like the 

Fulanis and Ewes who are mostly engaged in cattle rearing and fishing 

(GhanaDistricts.com, 2014). 



 

45 
 

3.1.3.5 District Economy 

The district economy is predominantly agrarian based and employs about 97 percent of the 

economically active population, which is between 18-54 years. The major food crops 

cultivated include maize, rice, yam, soya beans, cowpea and groundnut. The potential to 

increase food production is very high if modernized agriculture is effectively practiced. 

Yet, there are problems of erratic rainfall, post-harvest losses, and high cost of farm inputs. 

Only about three percent of the population is involved in industrial activities, trade and 

service sectors and gainful employment. This has culminated into low income levels in the 

area and women are poorer than the men because men have access to and control over 

resources such as land compared to the women (Savelugu-Nanton District, 2013; 

GhanaDistricts.com, 2014). 

 

3.1.3.6 Health 

The major health facility in the district is the Savelugu Hospital which is manned by a 

doctor and other health professionals. Also, there is one health centre, two health posts, 

three community clinics and two CHPS Compounds, all under the auspices of the District 

Health Directorate. In addition there are two private clinics and Traditional Birth 

Attendants (TBAs). Generally, health service delivery in the district is not encouraging 

because of the limited number of clinics and also the poor nature of the roads which makes 

accessing healthcare very difficult for people who are located in the hinterlands. This has 

encouraged the people to indulge in self-medication which is prevalent in the district 

(Savelugu-Nanton District, 2013). 



 

46 
 

3.2 Methodology 

This section discusses the methods and approaches that were used to undertake this study. 

The study employed both qualitative and quantitative methods for data collection and 

analysis. Moreover, the study shares the opinion expressed by many researchers such as 

Chigunta (2006) that qualitative and quantitative research methods are not alternatives to 

each other, but rather complement each other in addressing particular problems. This study 

used two main sets of data, that is a secondary data set and a set of primary data collected 

through in-depth interviews and focus group discussions (FGDs).  

The quantitative data which served as the secondary data was conducted in three districts 

across the three main ecological zones of Ghana.  

 

3.2.1 Sampling Technique  

3.2.1.1 Quantitative Sampling   

The quantitative data was collected through a cross-sectional district representative 

household survey between January and April, 2011 involving 2,430 households randomly 

sampled from 81 Enumeration Areas (EAs) based on the 2000 Ghana population and 

housing census. A household questionnaire was developed and administered to the 

household heads or any knowledgeable person in the house. Children were not interviewed 

directly, rather their parents responded on their behalfs. For each district, 28 E.As were 

sampled taking into consideration urban, peri-urban and rural communities. Listing of all 

households in each E.A was done after which respondents were selected using random 

sampling method. After using the simple random sampling method to select the 

households, systematic approach was used to select the Nth respondents in each structure. 



 

47 
 

Therefore in each district, people from 840 households were interviewed, that is 30 

households per E.A. 

3.2.1.2 Qualitative Sampling 

Although group interviews are often used simply as a quick and convenient way to collect 

data from several people simultaneously, focus groups explicitly use group interaction as 

part of the method (Kitzinger, 1995). FGDs have several merits. For instance by gathering 

people with different backgrounds and experiences under one roof with the aim of eliciting 

responses on an event or a concept, a particular comment or gesture by a participant can 

help remind others to better explain their feeling.  Thus, through FGDs, participants get 

the needed opportunity to listen and interact with others and their verbalized experiences 

and this enhances the quality of