title: Who uses outpatient healthcare services under Ghana's health protection scheme and why?
abstract: The National Health Insurance Scheme (NHIS) was launched in Ghana in 2003 with the main objective of increasing utilisation to healthcare by making healthcare more affordable. Previous studies on the NHIS have repeatedly highlighted that cost of premiums is one of the major barriers for enrollment. However, despite introducing premium exemptions for pregnant women, older people, children and indigents, many Ghanaians are still not active members of the NHIS. In this paper we investigate why there is limited success of the NHIS in improving access to healthcare in Ghana and whether social exclusion could be one of the limiting barriers. The study explores this by looking at the Social, Political, Economic and Cultural (SPEC) dimensions of social exclusion.
  
  
  
  Using logistic regression, the study investigates the determinants of health service utilisation using SPEC variables including other variables. Data was collected from 4050 representative households in five districts in Ghana covering the 3 ecological zones (coastal, forest and savannah) in Ghana.
  
  
  
  Among 16,200 individuals who responded to the survey, 54 % were insured. Out of the 1349 who sought health care, 64 % were insured and 65 % of them had basic education and 60 % were women. The results from the logistic regressions show health insurance status, education and gender to be the three main determinants of health care utilisation. Overall, a large proportion of the insured who reported ill, sought care from formal health care providers compared to those who had never insured in the scheme.
  
  
  
  The paper demonstrates that the NHIS presents a workable policy tool for increasing access to healthcare through an emphasis on social health protection. However, affordability is not the only barrier for access to health services. Geographical, social, cultural, informational, political, and other barriers also come into play.
authors.affiliation: Economics Division, Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, P.O. Box LG 74, Legon, LG74, Accra, Ghana. amafenny@yahoo.co.uk.
authors.forename: Ama P
authors.initials: AP
authors.lastname: Fenny
authors.affiliation: Economics Division, Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, P.O. Box LG 74, Legon, LG74, Accra, Ghana.
authors.forename: Felix A
authors.initials: FA
authors.lastname: Asante
authors.affiliation: Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, LG 581, Legon, Accra, Ghana.
authors.forename: Daniel K
authors.initials: DK
authors.lastname: Arhinful
authors.affiliation: Economics Division, Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, P.O. Box LG 74, Legon, LG74, Accra, Ghana.
authors.forename: Anthony
authors.initials: A
authors.lastname: Kusi
authors.affiliation: School of Health Sciences, City University London, Northampton Square, London, EC1V 0HB, UK.
authors.forename: Divya
authors.initials: D
authors.lastname: Parmar
authors.affiliation: LSE Health, London School of Economics and Political Science, Houghton Street, 19, London, WC2A 2AE, UK.
authors.forename: Gemma
authors.initials: G
authors.lastname: Williams
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000191:economics / Q000706:statistics & numerical data*; D002648:Child; D002675:Child, Preschool; D003695:Delivery of Health Care / Q000191:economics; D005191:Family Characteristics; D005260:Female; D005869:Ghana; D006282:Health Personnel; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008875:Middle Aged; D009313:National Health Programs / Q000191:economics; D010045:Outpatients / Q000706:statistics & numerical data; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011203:Poverty / Q000706:statistics & numerical data; D012929:Psychological Distance; D011640:Public Policy; D011795:Surveys and Questionnaires; D055815:Young Adult
keywords: Ghana; National Health Insurance; Outpatient services; Utilisation