Anaba et al. BMC Health Services Research          (2022) 22:269  
https://doi.org/10.1186/s12913-022-07670-7
RESEARCH Open Access
Factors associated with health insurance 
enrolment among ghanaian children 
under the five years. Analysis of secondary data 
from a national survey
Emmanuel Anongeba Anaba1, Akua Tandoh1, Foday Robert Sesay1,2 and Theopista Fokukora1,3* 
Abstract 
Background: Health insurance enrolment provides financial access to health care and reduces the risk of cata-
strophic healthcare expenditure. Therefore, the objective of this study was to assess the prevalence and correlates of 
health insurance enrolment among Ghanaian children under five years.
Methods: We analysed secondary data from the 2017/18 Ghana Multiple Indicator Cluster Survey. The survey was 
a nationally representative weighted sample comprising 8,874 children under five years and employed Computer 
Assisted Personal Interviewing to collect data from the participants. In addition, Chi-square and Logistic Regression 
analyses were conducted to determine factors associated with health insurance enrolment.
Results: The results showed that a majority (58.4%) of the participants were insured. Health insurance enrollment 
was associated with child age, maternal educational status, wealth index, place of residence and geographical region 
(p < 0.05). Children born to mothers with higher educational status (AOR = 2.14; 95% CI: 1.39–3.30) and mothers in the 
richest wealth quintile (AOR = 2.82; 95% CI: 2.00–3.98) had a higher likelihood of being insured compared with their 
counterparts. Also, children residing in rural areas (AOR = 0.75; 95% CI: 0.61–0.91) were less likely to be insured than 
children in urban areas.
Conclusion: This study revealed that more than half of the participants were insured. Health insurance enrolment 
was influenced by the child’s age, mother’s educational status, wealth index, residence, ethnicity and geographi-
cal region. Therefore, interventions aimed at increasing health insurance coverage among children should focus on 
children from low socio-economic backgrounds. Stakeholders can leverage these findings to help improve health 
insurance coverage among Ghanaian children under five years.
Keywords: Health insurance, Children under five years, Ghana, Enrolment, Factors
Background
Globally, protecting and improving the well-being of chil-
dren under five years remains a public health priority. 
For instance, Target 3.2 of the Sustainable Development 
Goals seek to end preventable deaths of newborns and 
*Correspondence:  preciatheo@gmail.com children under five years of age, with all countries aim-
1 Department of Population, Family and Reproductive Health, School ing to reduce neonatal mortality and under five mortality 
of Public Health, University of Ghana, P. O. Box, L.G. 13, Legon, Ghana by 2030 [1]. Evidence shows that under five mortality has 
Full list of author information is available at the end of the article
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Anaba et al. BMC Health Services Research          (2022) 22:269 Page 2 of 8
declined over the last three decades worldwide. Between services. Excluded in the NHIS benefit package are pro-
1990 and 2019, the under five mortality rate has reduced cedures such as dialysis for chronic renal failure, treat-
by 59%, thus from 93 deaths per 1000 live births to 38 ments for cancer (other than cervical and breast cancers), 
respectively [2]. Notwithstanding, the burden of under organ transplants and cosmetic surgery. Child immuniza-
five mortality remains high. For example, in 2019 alone, tion services, family planning and treatment of conditions 
about 14,000 children died every day before their fifth such as HIV/AIDS and tuberculosis are also not covered. 
birthday worldwide. More than half (53%) of under five However, these services are provided under alternative 
deaths in 2019 occurred in sub-Saharan Africa, with government programs. Apart from pregnant women and 
Nigeria and Somalia recording the highest under five children under five years, new members serve a waiting 
mortality rates (117 deaths per 1000 live births) [2]. Most period of three months after registration before access-
under five deaths are preventable with timely access to ing health care under the scheme. Further, members of 
quality healthcare services and child health interventions the scheme can access healthcare from health services 
[3]. Therefore, an integral recommendation—among providers accredited by the NHIA. These include public, 
many others—to accelerate progress towards reducing quasi-government, faith-based, some but not all private 
the mortality rate among children under five years is to health facilities and licensed pharmacies [15]. Despite the 
ensure health equity through universal health coverage. benefits of increased access to healthcare offered by NHIS 
So that all children can access essential health services membership and mandatory enrolment for all residents in 
without undue financial hardship [3]. Evidence shows Ghana, universal population coverage on the scheme has 
that health insurance enrolment is linked to increased proved challenging. As of 2021, the NHIS had an active 
access and utilisation of healthcare services [4] and bet- membership coverage of over 15 million people, equating 
ter health outcomes—particularly for maternal and child to about 53% of Ghana’s estimated population [16]. How-
health [5–10]. ever, a recent study examining NHIS enrolment within 
In Ghana, the under five mortality rate was estimated to the last decade showed that, on average, only about 40% 
be 46 deaths per 1000 live births in 2019 [11], higher than of all Ghanaians had ever registered with the Scheme [17]. 
the global rate of 38 deaths per 1000 live births. Financial That notwithstanding, utilization trends for in-patient 
constraints pose a significant barrier to accessing health- and outpatient care at NHIS accredited health facilities 
care services, including child health services [12]. There- continues to increase across the country [18, 19].
fore, under the National Health Insurance Act 650, the As part of efforts to increase coverage, a premium 
Government of Ghana established the National Health exemption policy for vulnerable populations, such as 
Insurance Scheme (NHIS) in 2003 to eliminate financial children under 18, was implemented. Thus, persons 
barriers to accessing health care [13]. Upon establish- below 18 years are exempted from paying annual premi-
ment, the scheme operated semi-autonomous Mutual ums [20] but must pay administrative charges, includ-
Health Insurance Schemes in districts across the country. ing the NHIS card processing fee [21].  Furthermore, in 
In 2012, a new law, Act 852, replaced Act 650. Under Act 2010, the National Health Insurance Authority decoupled 
852, all District Mutual Health Insurance Schemes were children under five years from their parents’ member-
consolidated under a National Health Insurance Author- ship. Therefore, children under five years can be active 
ity (NHIA) to ensure effective management and efficient members of the NHIS even if their parents are not active 
service delivery [14]. The primary sources of financing members [22]. In addition, private health insurance 
the NHIS comprise a National Health Insurance Levy schemes are emerging rapidly in Ghana, with premiums 
on selected goods and services, 2.5% contribution from based on the calculated risk of subscribers.
the National Social Security Scheme by formal sector The Ghana NHIS has been extensively investigated. 
workers, individual premiums mainly from informal sec- Prior studies among the adult population showed that 
tor workers, and miscellaneous funds from investment health insurance enrolment was associated with educa-
returns, grants, donations and gifts from international tional status, wealth, age, marital status, gender, type of 
donor partners and agencies [14]. occupation and place of residence [23–25]. In addition, 
Since its inception, Ghana’s NHIS has been consid- an analysis of the 2011 Ghana Multiple Indicator Cluster 
ered one of Africa’s model health insurance systems. The Survey (MICS) revealed that a majority (73%) of children 
benefit package of the NHIS covers the cost of treatment under five years were non-insured [26]. However, there is 
for more than 95% of the disease conditions in Ghana. a paucity of literature on determinants of health insurance 
The range of services covered includes but are not lim- enrolment among children under five years. Therefore, 
ited to outpatient care, diagnostic services, in-patient this study aimed to determine factors associated with 
care, pre-approved medications, maternal care, ear, nose NHIS enrolment among children under five in Ghana 
and throat services, dental services and all emergency using nationally representative survey data. Generating 
 Anaba et al. BMC Health Services Research          (2022) 22:269 Page 3 of 8
empirical evidence about factors influencing enrolment is Table 1 Socio-demographic characteristics of children, mothers 
essential to inform policy to help Ghana achieve Universal and health insurance status in Ghana, 2017/18
Health Coverage and Sustainable Development Goals. Characteristic n %
Sex of child
Methods   Male 4369 49.2  Female 4505 50.8
In this study, we analysed the 2017/2018 Ghana MICS Age of child (months)
[27]. The 2017/18 MICS collected demographic and health   0–11 1700 19.2
data across Ghana, including rural and urban settings. The   12–23 1694 19.1
sampling of participants was done in two phases. The first   24–35 1750 19.7
phase involved selecting 660 enumeration areas from 20   36–47 1928 21.7  48–59 1802 20.3
strata, proportional to size. The second involved the selec- Mother’s education
tion of 13,202 households within the selected enumera-   Pre-primary/none 2428 27.3
tion areas. The weighted sample size of children under   Primary 1790 20.2
five years was 8,874. Ghana had ten administrative regions   Junior High School 3259 36.7
divided into 20 strata, of which ten are rural and ten are   Senior High School 954 10.8  Higher 443 5
urban. Participants were selected across all the regions Wealth quintile
and strata.  The inclusion criteria were under five children   Poorest 1966 22.2
in the selected households or those who passed the night   Second 1834 20.7
before the survey in the selected households. Data were   Middle 1769 19.9
collected using Computer Assisted Personal Interviewing   Fourth 1676 18.8  Richest 1630 18.4
(CAPI).  The under five questionnaire was administered Residence
to caregivers of children below five years. Trained field   Urban 3821 43.1
officers and supervisors collected the data between Octo-   Rural 5053 56.9
ber 2017 and September 2018. Details about the 2017/18 Region
MICS are provided elsewhere [28].   Western 931 10.5
The dependent variable in this study was health insur-   Central 926 10.4
ance status (i.e. is [name] covered by any health insurance?)   Greater Accra 862 9.7  Volta 710 8
coded as 1 = Yes and 0 = No. The independent variables   Eastern 953 10.7
identified in the literature included child and maternal   Ashanti 2111 23.8
characteristics. These include child’s age, maternal educa-   Brong- Ahafo 833 9.4  Northern 1055 11.9
tional status, wealth index, ethnicity, geographic region and   Upper East 282 3.2
place of residence. Details about the coding are provided in   Upper West 211 2.4
Table 1. The complex nature of the survey was accounted for Ethnicity
by employing the ‘svy’ STATA command. STATA/SE ver-   Akan 4091 46.1
sion 16 (StataCorp, College Station, Texas, USA) was used   Mole Dagbani 1503 16.9  Others (Ewe, Gruma etc.) 3280 37
to analyse that data. Descriptive statistics were computed Health insurance status
for participants’ characteristics and summarized in a table. 
  Insured 5186 58.4
The Chi-square test was employed to examine the associa-   Non-insured 3689 41.6
tion between participant characteristics and health insur-
ance status at the bivariate level. Binary Logistic Regression 
was employed to identify significant predictors of health no formal/pre-primary education, while 22.2% were in 
insurance enrolment among under five children. The results the poorest wealth quintile. Children from rural areas 
were reported at a 95% confidence level. constituted 56.9%. In terms of ethnicity, 46.1% of the 
participants were Akan, 16.9% were Mole-Dagbani, 
and 37% were of other ethnic groups, such as Ewe and 
Results Gruma. Details are provided in Table 1.
Descriptive statistics
The results showed that a majority of the participants 
(58.4%) were insured, while a substantial minority Bivariate analysis
(41.6%) were non-insured. Half of the participants were At the bivariate level, child age was significantly asso-
females (50.8%), and more than half (58%) were below ciated with health insurance enrolment (p < 0.05). 
36 months. About three in ten (27.2%) mothers had Also, mothers’ education, wealth quintile, residence, 
Anaba et al. BMC Health Services Research          (2022) 22:269 Page 4 of 8
geographic region, and ethnicity were significantly asso- analysis level, it was found that children in the poor-
ciated with health insurance enrollment (p < 0.05) among est wealth quintile were less likely to be insured com-
children under five years. A majority (56.1%) of children pared with children in the second (AOR = 1.47; 95% 
aged 0–11 months were not insured with the National CI: 1.15–1.89), middle (AOR = 1.59; 95% CI:1.16–
Health Insurance Scheme. Less than half of children in 2.17), fourth (AOR = 1.73; 95% CI:1.28–2.35) and 
the Central Region were insured, while eight in ten chil- richest (AOR = 2.82; 95% CI: 2.00-3.98) wealth quin-
dren were insured in the Brong-Ahafo Region. Details are tiles. Children aged 0–11 months were less likely 
provided in Table 2. to be insured compared with children aged 12–23 
months (AOR = 1.72; 95% CI: 1.42–2.10). Children 
Multivariable analysis whose mothers had higher education were two times 
At the crude analysis level, health insurance enrolment (AOR = 2.14; 95% CI: 1.39–3.30) more likely to be 
was significantly predicted by wealth quintile, child’s insured compared with children whose mothers had no 
age, mother’s education, place of residence, geographi- formal education. In addition, children in rural areas 
cal region and ethnicity (p < 0.05). At the adjusted (AOR = 0.75; 95% CI: 0.61–0.91) had lesser odds of 
Table 2 Association between participant characteristics and health insurance status
Characteristic n Non-insured Insured Chi-square p-value
(%) (%)
Sex of child
  Male 4369 41.3 58.7 0.2961 0.7311
  Female 4505 41.8 58.2
Age of child (months)
  0–11 1700 56.1 43.9 29.3826  < 0.0001
  12–23 1694 43.6 56.4
  24–35 1750 34.6 65.4
  36–47 1928 37.7 62.3
  48–59 1802 37 63
Mother’s education
  Pre-primary/none 2428 42.6 57.4 149.8059  < 0.0001
  Primary 1790 49.4 50.6
  Junior High School 3259 41.5 58.5
  Senior High School 954 34.5 65.4
  Higher 443 20.1 79.9
Wealth quintile
  Poorest 1966 48.7 51.3 152.59  < 0.0001
  Second 1834 44.4 55.6
  Middle 1769 42.6 57.4
  Fourth 1676 41.1 58.9
  Richest 1630 29.1 70.9
Residence
  Urban 3821 35.8 64.2 92.0315  < 0.0001
  Rural 5053 45.9 54.1
Region
  Western 931 46.7 53.3 250.9397  < 0.0001
  Central 926 53 47
  Greater Accra 863 49.7 50.3
  Volta 710 42.5 57.5
  Eastern 953 39.3 60.7
  Ashanti 2111 41.9 58.1
  Brong- Ahafo 833 22.6 77.4
  Northern 1055 42.1 57.9
  Upper East 282 24.1 75.9
  Upper West 211 34.1 65.9
Ethnicity
  Akan 4091 42.2 57.8 7.3800 0.3330
  Mole Dagbani 1503 38.5 61.5
  Other (Ewe, Gruma etc.) 3280 42.3 57.7
A naba et al. BMC Health Services Research          (2022) 22:269 Page 5 of 8
being insured compared with children in urban areas. catastrophic health care expenditure and poverty [29]. 
Also, children in the Northern Region (AOR = 3.23; A similar study revealed that 57% of Ghanaian children 
95% CI: 2.18–4.80), Upper West Region (AOR = 4.82; below 18 years were covered by health insurance [21]. 
95% CI: 3.04–7.66) and Upper East Region (AOR = 8.74; Another household survey across three districts in Ghana 
95% CI: 5.35–13.40) had a higher probability of being reported that 55.9% of the participants were insured. A 
insured compared with children in the Greater Accra similar nationally representative survey demonstrated 
Region. Details are provided in Table 3. that 66% and 52.6% of women and men aged 15–49 years 
were insured respectively [30].
Discussion Further, our finding is similar to a study in Shanghai, 
The findings showed that more than half (58.4%) of the China, where 56.5% of children under eight years were 
participants were covered by health insurance. Thus, covered by health insurance [31]. However, health insur-
caregivers/parents of insured children were protected ance coverage in this study was higher than coverage in 
against out-of-pocket payment, which is a risk factor for other African countries. For instance, an analysis of data 
Table 3 Logistic Regression on predictors of health insurance status among children under five years in Ghana, 2017/18
Covariate/exposure Crude analysis Wald Adjusted analysis Adjusted 
OR (95% CI) p-value OR (95% CI) Waldp-
value
Sex of child
  Male 1(ref ) 0.7311 1 (ref ) 0.8045
  Female 0.98 (0.85–1.12) 0.98 (0.85–1.13)
Age of child (months)
  0–11 1(ref )  < 0.0001 1 (ref )  < 0.0001
  12–23 1.66 (1.37–2.00) 1.72 (1.42–2.10)
  24–35 2.42 (2.02–2.89) 2.70 (2.22–3.29)
  36–47 2.12 (1.76–2.55) 2.30 (1.88–2.81)
  48–59 2.17 (1.79–2.63) 2.44 (1.99–2.99)
Mother’s education
  Pre-primary/none 1(ref )  < 0.0001 1(ref ) 0.0002
  Primary 0.76 (0.62–0.93) 0.83 (0.67–1.02)
  Junior High School 1.05 (0.87–1.26) 1.16 (0.95–1.42)
  Senior High School 1.40 (1.09–1.81) 1.37 (1.02–1.82)
   Higher 2.96 (2.07–4.25) 2.14 (1.39–3.30)
Wealth quintile
  Poorest 1(ref )  < 0.0001 1(ref )  < 0.0001
  Second 1.19 (0.95–1.49) 1.47 (1.15–1.89)
  Middle 1.28 (0.98–1.66) 1.59 (1.16–2.17)
  Fourth 1.36 (1.05–1.76) 1.73 (1.28–2.35)
  Richest 2.31 (1.77–3.02) 2.82 (2.00–3.98)
Residence
  Urban 1(ref )  < 0.0001 1(ref ) 0.0002
  Rural 0.66 (0.55–0.79) 0.75 (0.61- 0.91)
Region
  Greater Accra 1(ref )  < 0.0001 1(ref )  < 0.0001
  Western 1.13 (0.77–1.63) 1.93 (1.32–2.80)
  Central 0.87 (0.60–1.26) 1.38 (0.92–2.08)
  Volta 1.33 (0.83–2.13) 2.81 (1.65–4.80)
  Eastern 1.52 (1.06–2.18) 2.68 (1.86–3.86)
  Ashanti 1.37 (0.99–1.89) 2.13 (1.50–3.02)
  Brong- Ahafo 3.38 (2.27–5.04) 6.61 (4.24–10.30)
  Northern 1.36 (0.97–1.90) 3.23 (2.18–4.80)
  Upper East 3.14 (2.21–4.44) 8.74 (5.35–13.40)
  Upper West 1.92 (1.33–2.76) 4.82 (3.04–7.66)
Ethnicity
  Akan 1(ref )  < 0.0001 1(ref )  < 0.0001
  Mole Dagbani 1.17 (0.94–1.45) 1.07 (0.80–1.43)
  Others (Ewe, Gruma etc.) 1.00 (0.83–1.19) 1.09 (0.90–1.31)
Anaba et al. BMC Health Services Research          (2022) 22:269 Page 6 of 8
from four African countries revealed that Ghana had the empirical evidence on the correlates and reasons for non-
highest health insurance coverage of 62.4% and 49.1% enrolment among children under five years. Hence, we 
for females and males respectively. Followed by Kenya recommend that future studies should explore these grey 
(18.2% for females and 21.9% for males), Tanzania (9.1% areas.
for females and 9.5% for males) and Nigeria (1.1% for In addition, the findings revealed that health insur-
females and 3.1% for males) [32]. The difference in find- ance enrolment was influenced by child’s age, mother’s 
ings may be attributed to contextual factors and health educational status, wealth index, region, ethnicity and 
insurance policies. For instance, Ghana’s National Health place of residence. Children whose mothers were less 
Insurance Scheme (NHIS) covers more than 95% of the educated had low likelihoods of being insured. A similar 
disease conditions in the country, including medica- study found that well-educated mothers were more likely 
tions, medical investigations, outpatient and in-patient to enroll their children on health insurance [37]. Another 
services. Also, women who register with NHIS have study in Shanghai, China, showed that children of women 
access to free maternal health services, such as antenatal, with low education were less likely to be covered by 
delivery and postnatal services. Children under 18 years, health insurance [31, 32]. A probable explanation is that 
indigents, the elderly, persons with disability or mental less educated mothers may lack adequate understanding 
disorders, Social Security and National Insurance Trust of the health insurance process and the benefits package 
(SSNIT) contributors and pensioners are exempted from due to their inability to access information [5]. Evidence 
paying premiums but must renew their membership shows that Ghanaian women who had access to informa-
every year [33]. tion were more likely to be insured [38]. Women with 
In addition, we found that four in ten children were higher educational status are more empowered to make 
not covered by health insurance.  Therefore, parents/car- health-seeking decisions. Also, children from wealthy 
egivers of uninsured children would have to pay-out-of families were more likely to be covered by health insur-
pocket when accessing child health care services. Out-of- ance. Previous studies have supported this finding [39]. 
pocket payment has the potential of putting caregivers at Another study in Shanghai, China, revealed that children 
risk of catastrophic healthcare expenditure and poverty. from the lowest income households had lesser odds of 
Also, parents of non-insured children are more likely to being insured [31]. A possible explanation is that wealthy 
postpone or delay seeking health care, hence putting the parents/caregivers have large disposable incomes. Hence, 
child’s life at risk of poor health outcomes [34]. This find- they can afford health insurance premiums, NHIS card 
ing is similar to findings from previous studies in Ghana processing charges, and annual renewal fees. It implies 
and elsewhere. For instance, a study revealed that 43.2% that the purpose of the NHIS as a pro-poor social inter-
of Ghanaian children under eighteen years were unin- vention has not been well achieved.
sured [21]. Another study among children under seven Also, children in rural areas had lower chances of being 
years in Shanghai, China, reported that 43.5% of the insured. A study in Ghana reported that women living 
participants were uninsured [31]. This finding may be in remote settings had lower odds of insurance cover-
explained by individual, financial, country-specific and age than those staying in urban areas [37]. A conceivable 
health system-related factors [22]. In Ghana, children explanation for this finding is that parents of children 
under five years are exempted from paying NHIS premi- residing in urban areas may have easy access to health 
ums. However, they must pay membership card process- insurance offices. In Ghana, few NHIS offices are sited 
ing fees and renewal fees every year [33]; hence, it may in rural areas, leading to delays in registering and print-
pose a barrier for their caregivers. ing insurance cards. There are also few NHIS personnel 
Furthermore, recent evidence shows that persons and logistics in the rural areas compared to the urban 
insured with Ghana’s NHIS still pay out-of-pocket for areas [36]. These factors may explain the disparities in 
services in accredited health facilities [35]. Reasons for insurance coverage across the place of residence. It was 
non-registration or non-renewing of membership with revealed that children from the nine other administrative 
the NHIS include financial constraints, lack of confidence regions were more likely to be insured than those from 
in the scheme, dissatisfaction with services, shortage of the Greater Accra Region, Ghana’s capital city. A similar 
insured medications, long waiting time, payment of ille- study reported that children in the Greater Accra region 
gal charges and non-use of health services [36]. Going were more likely to be non-insured compared with the 
forward, the Ministry of Health, National Health Insur- other regions in Ghana [21]. The Greater Accra region 
ance Authority, Ministry of Gender, Children and Social has the lowest health insurance coverage in Ghana [40].
Protection and health providers would have to collabo- Moreover, we found that children from regions with a 
rate to improve health insurance coverage for Ghanaian high incidence of poverty were more likely to be insured. 
children under five years. However, there is a need for This finding was expected because the poor perceive 
A naba et al. BMC Health Services Research          (2022) 22:269 Page 7 of 8
health insurance as a form of social security that protects Acknowledgements
them against catastrophic health care expenditure dur- EAA, FRS, TF are receiving funding as PhD candidates from the HRP Alliance, 
part of the UNDP/UNFPA-UNICEF-WHO-World Bank Special Programme 
ing health emergencies [41]. This finding may explain why of Research, Development and Research Training in Human Reproduction 
the poorest region in Ghana (Upper East region) has the (HRP), a cosponsored programme executed by the World Health Organization 
highest NHIS coverage [40]. Additionally, health insur- (WHO), to complete their studies.
ance enrolment was associated with child’s age. Thus, Authors’ contributions
children aged twelve months or older were more likely to EAA: Conceptualization, data curation, formal analysis, writing of original draft, 
be insured. A similar study in Shanghai, China, reported review and editing. AT: Conceptualization, writing of original draft, review 
and editing. FRS: Conceptualization, Methodology, reviewing and editing. TF: 
that older children were less likely to be uninsured [31]. Conceptualization, writing of original draft, reviewing and editing. All authors 
The Free Maternal Health Policy may explain this find- read and approved the final manuscript. 
ing. In Ghana, pregnant women who register with the 
Funding
NHIS have free maternal health care services up to three The author did not receive any funding for this study.
months postpartum [42]. Our findings imply that vulnera-
ble children did not have health insurance. Consequently, Availability of data and materials
The data used in this study is owned by UNICEF, therefore, the authors cannot 
their caregivers/parents may be predisposed to cata- share the data. Interested persons can contact UNICEF for the data (contact 
strophic health care expenditure. Besides, evidence shows via accra@unicef.org). The authors confirm they did not have any special 
that uninsured children are predisposed to poor health access or privileges to the data that other researchers would not have.
outcomes [43]. Therefore, in the quest to increase health 
insurance coverage, future interventions should prioritize Declarations
children from the low socio-economic background. Ethics approval and consent to participate
The Ghana Health Service and Ghana Statistical Service approved the proto-
cols for the 2017/18 MICS. Therefore, ethical approval for this study was not 
Strengths and limitations of the study relevant.  Informed consent was obtained from parents or caretakers of all 
One major strength of this study is that we analysed children. A formal request to use the raw data was made to UNICEF through 
nationally representative data so the findings from this their website (https:// mics.u nicef. org/ surve ys). Permission to use the raw 
data was granted by UNICEF.  The study was performed in accordance with 
study can be generalized to the population. This study relevant regulations and guidelines. Data used in this study was anonymised 
is one of the few studies in Ghana investigating socio- before use.
demographic determinants of child health insurance. 
Consent for publication
However, this study is not devoid of limitations. Cross- Not applicable.
sectional studies cannot establish causal relationships, 
so the findings should be interpreted with caution. In Competing interests
The authors declare that they have no competing interests.
addition, health insurance status was self-reported by 
caregivers/parents of the children. Therefore, it may be Author details
1
subjected to social desirability or recall biases.  Department of Population, Family and Reproductive Health, School of Public 
Health, University of Ghana, P. O. Box, L.G. 13, Legon, Ghana. 2 34 Military Hospi-
tal, Wilberforce, Freetown, Sierra Leone. 3 Department of Public Health, Faculty 
Conclusions of Science and Technology, Cavendish University, P.O. Box 33145, Kampala, 
This study demonstrated that more than half of the children Uganda. 
were covered by health insurance. Health insurance enrol- Received: 20 September 2021   Accepted: 23 February 2022
ment was associated with wealth index, mother’ educational 
status, child’s age, type of residence, geographical region and 
ethnicity. Policymakers can leverage these findings to help 
improve health insurance coverage for children in Ghana. References
Interventions that seek to improve health insurance coverage  1. United Nations.: Transforming our World:The 2030 Agenda for Sustainable Development. In.; 2015.
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