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

Over the last two decades, the concept of social health insurance (SHI) has gained attention in social policy development discourse [1–3]. SHI is seen as the most sustainable healthcare financing model for providing financial risk protection for majority of the population in low and middle-income countries (LMICs) [4, 5]. The SHI concept has become more imperative following the World Health Assembly’s call for universal health coverage (UHC) in health systems in 2005 [1, 6] and the inclusion of UHC in the UN Sustainable Development Goals (SDGs) in 2015. The SDG goal 3, target 8, mandates member countries to “Achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all” by the year 2030 [7, 8]. The overarching goal of UHC is that in an event of illness or sickness, all people will have access to the quality, essential health service they need without being exposed to financial hardship [2, 7].

Many African countries particularly those in the sub-Saharan Africa (SSA) are at different stages of SHI implementation aimed at achieving UHC [9, 10]. It is a general belief that UHC is a panacea for reducing out-of-pocket payment and inequity in access to and utilization of healthcare services [6, 9]. One distinct characteristic for SHI attractiveness in the sub-region is that it does not depend exclusively on public finance, but instead shares the responsibility of health financing among the population [11, 12].

Ghana, a lower middle-income country in SSA, implemented a National Health Insurance Scheme (NHIS) in 2004 to provide financial risk protection for all residents [13–17]. It was fashioned out to address the challenges of the out-of-pocket payment system of paying for healthcare services in the 1990s, popularly referred to as “cash and carry”. The cash and carry system was introduced at that time to recover at least 15% of recurrent expenditure and drugs [13, 18, 19] but it led to increased inequality in healthcare access and preventable deaths [10, 14, 18, 20]. The NHIS is managed by the National Health Insurance Authority (NHIA), a regulatory body mandated by law to oversee operations of public and private health insurance schemes in the country [21]. Since its implementation, the NHIS has made gains in population coverage, increased access to healthcare services by reducing out-of-pocket payment and contributed to raising revenue of healthcare providers [10].

At present, the NHIA has 159 district offices and five satellite offices across the 10 administrative regions of the country. It also has over 4000 network of public and private healthcare providers nationwide, rendering services under the minimum benefit package to card-bearing members [22]. The NHIS reportedly covers 95% of disease conditions afflicting the population [14, 21] and the benefit package is same for all card-bearing members. Broadly, it covers general consultation and medicines at the outpatient and inpatient departments; minor surgeries; admissions at the general wards; maternal care services; dental services; ear, nose and throat (ENT) services; and all emergency services. It, however excludes preventive services provided by the Ministry of Health, for example, immunization [14]. Services that have the potential to threaten sustainability of the scheme, for example, surgeries other than road traffic accidents and non-essential health services such as cosmetic surgeries are also excluded from the benefit package [14, 20, 21]. The NHIS is largely tax-financed through a 2.5% valued-added tax (VAT) on selected goods and services [17, 20, 21]. Other sources of funding include two and a half percentage point deductions from the formal sector workers social security contributions, premium from the informal sector workers, internally generated funds from activities of the scheme and donor support from development partners [20, 21].

Membership of the scheme is mandatory, but enforcement has been challenging, making enrolment practically voluntary. Members are broadly categorized into exempt and non-exempt groups. The exempt groups comprise those who do not pay premium to the scheme; persons below the age of 18 years, elderly aged 70 years and above, indigents (extreme poor), Social Security and National Insurance Trust (SSNIT) pensioners and beneficiaries of the Livelihood Empowerment Against Poverty (LEAP) programme. The formal sector workers or contributors of SSNIT are also exempted because their premium is income-rated and deducted at source. Following implementation of the free maternal healthcare policy in July, 2008 [23], pregnant women are also added to exempt group. However, all members of the exempt group with the exception of indigents, LEAP beneficiaries and pregnant women, pay registration and renewal fee of GHS8.00 ($1.18) and GHS5.00 ($1.13), respectively. The non-exempt groups are those who pay premium directly to the scheme, and they are the workers in the informal sector of the economy. In addition to the premium, the informal sector workers also pay registration and renewal fees. By design, the premium is graduated from GHS7.20 ($1.62) to GHS48.00 ($10.83) based on income levels of the members. However, due to lack of data on income levels, particularity for the informal sector workers, a flat premium is charged during registration but varies from GHS15.00 ($3.39) in the rural areas to GHS22.00 ($4.97) in the cities.

There are several studies on enrolment in the NHIS, particularly population coverage, renewal of membership and equity [17, 24–31]. However, the settings and data of these studies are limited. A study that examined enrolment by member groups was limited to one region and found significant differences among them [31]. Another study that examined enrolment by geographical region used data from literature for only two periods, 2005 and 2008 and found variations across the regions [17]. What is lacking in literature so far, is longitudinal analysis of a national level enrolment data of the NHIS to examine trends and characteristics by geographical region and member groups. The present study seeks to fill this gap by analysing population coverage, membership retention and growth rates over an 8-year period. This study focuses on one of the three dimensions of UHC-population coverage [7, 32]. We believe that findings of this study would inform policy decision-making to improve enrolment, revenue and risk pooling of the NHIS. The study would also serve as evidence for LMICs implementing SHI programmes.

Examination of the trends and characteristics of enrolment in the NHIS over the last eight years shows a decreasing trend of enrolment with significant variations among geographical regions and member groups. In the first four years of the study period, 2010–2013, there was a general increase in the number of individuals enrolling in the scheme and those renewing their memberships. These resulted in a steady growth in membership over the same period. Beyond 2013, the proportion of the population enrolling in the scheme showed an upward trend up to the year 2015 and declined consistently thereafter. However, the number of members renewing their memberships assumed a downward trend after the first four years of the study period and growth in membership declined remarkably over the same period.

The findings may be attributed to the voluntary participation in the scheme as explained by the conceptual framework for this study [33] In such SHI programmes or schemes, individuals are more willing to join at the initial stages, hoping to receive the benefits promised [33]. Therefore, apathy sets in if the benefits promised are below expectation of the members. Aside this natural tendency, other probable reasons for the decreasing trend of enrolment and renewal of membership are lack of knowledge of the scheme resulting from ineffective education and sensitization programmes, religious and cultural norms and poverty [30, 33]. Other plausible reasons are systemic factors including lengthy waiting times at registration centres, occasional shortage of registration materials, lengthy payment of provider claims and perceived poor quality of healthcare provider services. Many studies have found these factors to be associated with low enrolment and renewals in the scheme [29, 30, 34, 37, 48]. It is also possible that members of the scheme have a better alternative risk protection against their healthcare cost, for example, they may prefer other health protection schemes or out-of-pocket payment due to perceived poor quality of care for NHIS card-holders.

Although the NHIS has a one month waiting period for first time enrolees, the downward trend in enrolment may indicate adverse selection, a situation where individuals only enrolled in the scheme when they need healthcare services and refuse to renew their membership after receiving care. Evidence shows that insurance programmes with low participation and high turnover are more likely to suffer from adverse selection, leading to high claims payment, increased administrative expenses and reduced revenues [27, 33]. The pregnant women are more likely to indulge in this unhealthy practice because they are exempted from paying contribution to the scheme. Thus, there is an increased incentive for them to enrol when they get pregnant and refuse to renew their membership after delivery. This situation is a challenge in most SHIs and could threaten sustainability when left unaddressed because it reduces revenue and risk pooling. Our findings are consistent with a number of studies on the NHIS [24, 31, 37].

Findings of the study also show significant differences in enrolment and renewal among the ten administrative regions of the country. Individuals in the predominantly urban regions such as Ashanti and Greater Accra, are significantly enrolling in the scheme more than any other region. This trend of enrolment may be attributed to a number of factors including population density and availability of healthcare facilities and health workforce. The more urbanised regions have higher population; thus, may have higher number of individuals who were not previously enrolled in the scheme compared to the less densely populated regions such as Upper East and Upper West. In addition, there are more healthcare facilities and professionals, both in the public and private sectors in the two urbanised regions than any other region. Evidence shows that availability of these resources improves enrolment by providing geographical access to healthcare services [24, 30, 34]. Besides, individuals living in these two largely urbanised regions could afford to pay the NHIS premium due to improved economic opportunities and relatively low incidence of poverty. The findings support studies by Van der Wielen [49] and Dake [50] which show higher NHIS coverage of individuals living in urban areas than those in the rural areas.

The two regions, Upper East and Upper West which recorded significantly lower enrolment of new members over the study period are predominantly more rural; thus, have less healthcare infrastructure and health professionals, high incidence of poverty and low level of education. These factors serve as barriers to enrolment [18, 24, 34, 35, 51]. There is also evidence of strong religious and cultural norms in these regions that mitigate against enrolment in the NHIS, for example, some of the women may have to seek consent from their spouses before they can take certain personal decisions such as visiting healthcare facilities for treatment [30, 51, 52]. Our findings contrast that of past trend analyses, where individuals in the largely rural regions such as Upper East, Upper West, Western, Central and Volta enrolled in the scheme more than those in the urbanised regions, Ashanti and Greater Accra [17, 28]. Probably, this is due to dissatisfaction of services with the scheme and healthcare providers as shown in other studies [24, 34–36]. However, the significant differences in enrolment among the geographical regions are consistent with similar studies [17, 28].

Our study also shows significant variations in enrolment among the defined member groups of the NHIS. Persons below the age of 18 years and workers in the informal sector of the economy are significantly enrolling in the scheme more than any other member group. The higher number of persons below the age of 18 years in the scheme is understandable; they are more susceptible to diseases and therefore more likely to enrol for protection against their healthcare cost. Also, persons below the age of 18 years are exempted from paying premium and this serves as an incentive for their parents to enrol them in the scheme. Although this trend is good for achieving UHC [53], there would be a need for adequate subsidies to cater for the expected increase in provider claims cost to the scheme and prevent sustainability threat because persons below the age of 18 years are more likely to utilize healthcare services and incur higher cost than the other member groups.

The significantly high enrolment of the informal sector group may be due to their higher proportion in the employment sector and lack of social security for them, especially social health protection. This group constitutes about 80% of the workforce in the country and face a number of risks including lack of unemployment insurance, employment-based health insurance and statutory pensions. Thus, weighing the cost-benefit combination of enrolling in the NHIS, majority of them would make a rational decision to join the scheme. The high enrolment of the informal sector group is also encouraging because it would boost revenue and ensure maximum risk pooling for long term viability of the scheme. The findings also show that the poor and vulnerable groups such as indigents, the aged, SSNIT pensioners and the pregnant women are less enrolled, consistent with a number of studies [18, 25, 31, 52]. The significant differences in enrolment among the member groups also corroborate other studies [28, 31].

Our findings suggest the need for enforcement of the mandatory enrolment stipulated in the National Health Insurance Act (ACT 852 of 2012) to increase enrolment and enlarge the risk pool. This can be done by making the NHIS card a pre-requisite for obtaining or acquiring certain services, for example, driver license, employment in public and private sectors, etc. as is being done with enrolment in second cycle and tertiary educational institutions in the country. To address the anticipated claims cost from increased enrolment, the regulator (the NHIA) could rally support from civil society organisations or groups for the proposed increment in the health insurance levy and SSNIT contribution deductions and levy on tobacco and sugar sweetened drinks. Alternatively, the NHIA could propose to government to decouple the health insurance levy from the VAT and lodge the money directly into the National Health Insurance Fund (NHIF). This would ensure readily available funds for payment of healthcare provider claims and continuous provision of services to the NHIS members.

The study reveals that enrolment in the NHIS is  declining and there are significant differences among the geographical regions of the country and member groups. Individuals in the urbanised regions are enrolling in the scheme more than those in the rural regions and persons below the age of 18 years and the informal sector workers are enrolling more than the other member groups. The decreasing trend in enrolment and significant disparities observed could reduce revenue and risk pooling and eventually compound the sustainability challenges facing the scheme. Innovative strategies such as the use of mobile phone application for registration and renewal would be useful for improving enrolment towards achieving UHC. Addressing supply-side challenges such as delays in payment of healthcare provider claims and unauthorized co-payments as found in several studies would also be necessary to improve satisfaction of the members and ensure continuous enrolment.