Does the National Health Insurance Scheme provide financial protection to households in Ghana?
BACKGROUND
Excessive healthcare payments can impede access to health services and also disrupt the welfare of households with no financial protection. Health insurance is expected to offer financial protection against health shocks. Ghana began the implementation of its National Health Insurance Scheme (NHIS) in 2004. The NHIS is aimed at removing the financial barrier to healthcare by limiting direct out-of-pocket health expenditures (OOPHE). The study examines the effect of the NHIS on OOPHE and how it protects households against catastrophic health expenditures.


METHODS
Data was obtained from a cross-sectional representative household survey involving 2,430 households from three districts across Ghana. All OOPHE associated with treatment seeking for reported illness in the household in the last 4 weeks preceding the survey were analysed and compared between insured and uninsured persons. The incidence and intensity of catastrophic health expenditures (CHE) among households were measured by the catastrophic health payment method. The relative effect of NHIS on the incidence of CHE in the household was estimated by multiple logistic regression analysis.


RESULTS
About 36% of households reported at least one illness during the 4 weeks period. Insured patients had significantly lower direct OOPHE for out-patient and in-patient care compared to the uninsured. On financial protection, the incidence of CHE was lower among insured households (2.9%) compared to the partially insured (3.7%) and the uninsured (4.0%) at the 40% threshold. The incidence of CHE was however significantly lower among fully insured households (6.0%) which sought healthcare from NHIS accredited health facilities compared to the partially insured (10.1%) and the uninsured households (23.2%). The likelihood of a household incurring CHE was 4.2 times less likely for fully insured and 2.9 times less likely for partially insured households relative to being uninsured. The NHIS has however not completely eliminated OOPHE for the insured and their households.


CONCLUSIONS
The NHIS has significant effect in reducing OOPHE and offers financial protection against CHE for insured individuals and their households though they still made some out-of-pocket payments. Efforts should aim at eliminating OOPHE for the insured if the objective for establishing the NHIS is to be achieved.
Section for Health Promotion and Health Services Research, Department of Public Health, Aarhus University, Vennelyst Boulevard 6, 8000, Århus 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.
Anthony
A
Kusi
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.
Kristian Schultz
KS
Hansen
Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, P.O. Box LG 74, Legon, Accra, Ghana. fasante@ug.edu.gh.
Felix A
FA
Asante
Section for Health Promotion and Health Services Research, Department of Public Health, Aarhus University, Vennelyst Boulevard 6, 8000, Århus C, Denmark. ue@ph.au.dk.
Ulrika
U
Enemark
D000293:Adolescent; D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000191:economics; D005191:Family Characteristics; D005260:Female; D005869:Ghana / Q000453:epidemiology; D005102:Health Expenditures; D006801:Humans; D019458:Insurance Coverage / Q000191:economics*; D007348:Insurance, Health / Q000191:economics; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008875:Middle Aged; D009313:National Health Programs / Q000191:economics*; D010045:Outpatients; D011795:Surveys and Questionnaires; D055815:Young Adult