title: Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem?
abstract: BACKGROUND
  Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources.
  
  
  METHODS
  The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified.
  
  
  RESULTS
  Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS.
  
  
  CONCLUSIONS
  Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage.
authors.affiliation: Section for Health Promotion and Health Services Research, Department of Public Health, Faculty of Health, Aarhus University, Vennelyst Boulevard 6, 8000, Arhus C, Denmark. tonykkusi@gmail.com.|Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, P.O. Box LG 74, Legon, Accra, Ghana. tonykkusi@gmail.com.
authors.forename: Anthony
authors.initials: A
authors.lastname: Kusi
authors.affiliation: Section for Health Promotion and Health Services Research, Department of Public Health, Faculty of Health, Aarhus University, Vennelyst Boulevard 6, 8000, Arhus C, Denmark. ue@ph.au.dk.
authors.forename: Ulrika
authors.initials: U
authors.lastname: Enemark
authors.affiliation: Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK. Kristian.Hansen@lshtm.ac.uk.
authors.forename: Kristian S
authors.initials: KS
authors.lastname: Hansen
authors.affiliation: Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, P.O. Box LG 74, Legon, Accra, Ghana. fasante@ug.edu.gh.
authors.forename: Felix A
authors.initials: FA
authors.lastname: Asante
mesh_terms: D003430:Cross-Sectional Studies; D005869:Ghana; D006297:Health Services Accessibility / Q000191:economics* / Q000706:statistics & numerical data; D006801:Humans; D007341:Insurance; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D009313:National Health Programs / Q000191:economics* / Q000706:statistics & numerical data; D012959:Socioeconomic Factors