title: Household perceptions and their implications for enrollment in the National Health Insurance Scheme in Ghana.
abstract: OBJECTIVE
  This paper identifies, ranks and compares perceptions of insured and uninsured households in Ghana on health care providers (quality of care, service delivery adequacy, staff attitudes), health insurance schemes (price, benefits and convenience) and community attributes (health 'beliefs and attitudes' and peer pressure). In addition, it explores the association of these perceptions with household decisions to voluntarily enroll and remain in insurance schemes.
  
  
  METHODS
  First, data from a household survey of 3301 households and 13,865 individuals were analysed using principal component analysis to evaluate respondents' perceptions. Second, percentages of maximum attainable scores were computed for each cluster of perception factors to rank them according to their relative importance. Third, a multinomial logistic regression was run to determine the association of identified perceptions on enrollment.
  
  
  RESULTS
  Our study demonstrates that scheme factors have the strongest association with voluntary enrollment and retention decisions in the National Health Insurance Scheme (NHIS). Specifically these relate to benefits, convenience and price of NHIS. At the same time, while households had positive perceptions with regards to technical quality of care, benefits of NHIS, convenience of NHIS administration and had appropriate community health beliefs and attitudes, they were negative about the price of NHIS, provider attitudes and peer pressure. The uninsured were more negative than the insured about benefits, convenience and price of NHIS.
  
  
  CONCLUSIONS
  Perceptions related to providers, schemes and community attributes play an important role, albeit to a varying extent in household decisions to voluntarily enroll and remain enrolled in insurance schemes. Scheme factors are of key importance. Policy makers need to recognize household perceptions as potential barriers or enablers to enrollment and invest in understanding them in their design of interventions to stimulate enrollment.
authors.affiliation: Department of Primary and Community Care, Radboud University Nijmegen Medical Center, PO Box 9101, 6500HB Nijmegen, The Netherlands. c.jehu-appiah@elg.umcn.nl
authors.forename: Caroline
authors.initials: C
authors.lastname: Jehu-Appiah
authors.forename: Genevieve
authors.initials: G
authors.lastname: Aryeetey
authors.forename: Irene
authors.initials: I
authors.lastname: Agyepong
authors.forename: Ernst
authors.initials: E
authors.lastname: Spaan
authors.forename: Rob
authors.initials: R
authors.lastname: Baltussen
mesh_terms: D000293:Adolescent; D000328:Adult; D001294:Attitude to Health; D005191:Family Characteristics; D005260:Female; D005869:Ghana; D006801:Humans; D008297:Male; D017057:Medically Uninsured; D008875:Middle Aged; D009313:National Health Programs; D011203:Poverty; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D055815:Young Adult