Determinants of National Health Insurance enrolment in Ghana across the life course: Are the results consistent between surveys?

Universal Health Coverage (UHC) aims to provide quality healthcare to all without financial hardship. Efforts to meet the aim of UHC will be greatly influenced by the global population ageing phenomenon. Older adults require greater levels of healthcare due to increasing illness and disability as ageing occurs, which complicates progress to UHC. Moreover, older adults in low and middle-income countries are often left without any regular income due to a lack of social pensions [1]. Social protection schemes in low and middle income countries are vital to the protection of older adults because in countries without social security systems, it is left to the individual to finance healthcare expenditures.

Ghana presents a crucial case study for the implementation of policies aimed at UHC in the context of population ageing in sub-Saharan Africa. Ghana is currently undergoing a profound demographic transition, with a large increase in the number of older adults. The percentage of people aged 60 and over is estimated to grow from 5% in 2015 to nearly 10% in 2050 [2]. In 2005 the country implemented a National Health Insurance Scheme (NHIS), designed to help improve equality of access to healthcare by offering affordable healthcare to all.

Prior to 2005, the Ghanaian health system was organised as a ‘cash and carry system’ with healthcare only obtained after payment. This was seen as highly inequitable and acted as a barrier to individuals getting timely and necessary treatment [3]. In response, the NHIS was set up which operates under a vision of being "a model of a sustainable, progressive and equitable social health insurance scheme in Africa and beyond" [4] and officially covers 95% of the common disease burden in its benefit package. Formally, it is a mandatory system; however, no penalties apply for not being a member of any health insurance scheme in Ghana. Those working in the formal labour sector subsidise the NHIS through an automatic payroll deduction [3, 5].

Previous research has been critical of the lack of evidence as to what influences uptake of the NHIS [6]. So far studies on NHIS enrolment have mainly focused on young and middle-aged adults, but have neglected to consider the extent to which these results can be generalised to older adults. For example, each of Blanchet, et al. [3], Ayitey, et al. [7] and Osei-Akoto and Adamba [5] examined demographic and socio economic factors that influence NHIS membership among adults without differentiating older adults from corresponding younger generations. This paper argues that it is important to consider younger and older adults separately due to differences in demographic and socio-economic characteristics as well as differences in health and disability status.

It is expected that older adults will make greater use of the NHIS than younger age groups as older adults are more vulnerable to disabilities and diseases. The 2010 Ghanaian Census showed that over 9% of older adults suffer from at least one disability compared to less than 3% of adults aged 18-49 years. Communicable diseases such as HIV and malaria are the main cause of disability-adjusted life-years (DALYs) until the age of 50, while for people aged 50 plus non-communicable diseases are the main cause of DALYs [8]. Furthermore, compared with younger adults, the educational status among older adults in Ghana is relatively low [9]. These differences in user characteristics can influence the uptake of health insurance significantly, which is why it is important to explore whether the correlates of NHIS enrolment differ between younger and older adults.

There is a lack of data focusing on older adults in sub-Saharan Africa which can explain the scarcity of studies looking at older adults in the region. Ghana has the advantage of having two nationally representative surveys that include a question on insurance coverage and sample all adults (inducing those aged 50 and over). They are the World Bank funded Ghanaian Living Standards Survey (GLSS) and the World Health Organization (WHO) Study on Global Ageing and Adult Health (SAGE). However, there are concerns about the reliability of different datasets for measuring NHIS enrolment, bringing into question the possibility of measuring health insurance coverage in Ghana accurately. Apoya and Marriott [10] estimated a total NHIS coverage of only 18% in 2009, while the National Health Insurance Authority (NHIA) reported a coverage of 62% in the same year [11]. The GLSS (2012/2013) estimated a coverage of 51% among people aged 18 and over and the SAGE (2007/2008) reported that 28% of survey participants (aged 18 and over) had NHIS coverage.

The objective of this paper is to investigate the correlates of NHIS enrolment, renewal and drop out among older adults, defined as those aged 50 plus, to assess whether they differ from younger adults (aged 18-49). In addition, the paper is particularly interested in examining whether the correlates of insurance affiliation differ depending on which survey is used. The correlates of NHIS coverage among younger and older adults are assessed using both the GLSS and SAGE. Comparing different datasets to look for consistency in results, especially relating to the determinants of enrolment, adds to the evidence base for the NHIS.

Demand patterns of insurance enrolment will reveal what factors influence the decision to partake in the NHIS. Knowledge of who is enrolled in the NHIS and why others are not provides an understanding as to whether opportunities to enrol are equal or whether enrolment patterns vary depending on socioeconomic status, sex or residence. For progress to UHC to be achieved in times of ageing populations, health policies have to benefit all, inclusive of both younger as well as older adults [12]. The findings of this paper can be used by policymakers to implement target-orientated policy measures to increase enrolment in the NHIS.

The lack of social security and increasing healthcare demands in older age suggest that the establishment of comprehensive universal health insurance systems may be particularly valuable in ensuring equal access to healthcare in sub-Saharan Africa. The study carried out here advances the literature on insurance enrolment by analysing factors associated with insurance enrolment among older adults in Ghana as a separate population group. It indicates that correlates of insurance membership overlap between younger and older adults with only minor exceptions. This suggests that healthcare reforms to increase insurance affiliation can be beneficial across both population groups. Such a finding appears especially clear when it comes to promoting higher coverage among the poor. Despite scaled-to-income fees that, in theory, should mitigate skewed enrolment according to wealth, the findings suggest that insurance enrolment increases with wealth. This finding confirms that of other researchers e.g. [7, 16, 26]. Despite the theoretical argument that health insurance will improve access to healthcare, low enrolment among the poorest indicates a failure of policy to ensure equal access. For example, local district offices in Ghana have been found to be charging flat premium payments across the board due to difficulties in determining the socioeconomic group [27]. More research is needed on whether the "core poor" and people over 70 are aware of the premium exemption. Awareness of social protection schemes seems to be a problem in Ghana. Other social protection programmes, including the Livelihood Empowerment Against Poverty (LEAP), have shown low awareness and a low uptake [28]. More research is needed on whether the registration fee hinders enrolment as, even for those exempt from the insurance premium itself, the registration fee is a requirement. Kusi and Enemark [29] revealed that the registration fee imposes a burden on very poor households.

In order to overcome the gap in insurance enrolment between rich and poor, external financial support needs to be increased and premiums need to decrease. Government subsidies or donor funding are seen as one path to stabilizing the health finance system in the long run. To increase enrolment, efforts need to be undertaken to ensure that all people who fall below the poverty line and are aged 70 and over are aware of the premium exemption in the NHIS. To improve insurance coverage among the poor, additional policy initiatives should be considered such as travel reimbursement, particularly for those living in rural areas where insurance coverage was found to be low.

An increase in education was found to significantly increase insurance affiliation for both younger and older adults. This finding underlines that of Ayitey, et al. [7] who showed that with rising education, NHIS enrolment increases. It is unlikely that there is a direct causal link between higher education and increased NHIS awareness among older adults. In the GLSS round 6 (2012/2013) less than 0.5% of respondents reported that they did not know about the system. Also Schultz, et al. [30] found no evidence that health education increased NHIS enrolment. Further research is needed to fully understand and explain the differences in NHIS enrolment by education status.

Comparing NHIS coverage of 18-49 year olds by gender, the GLSS shows a higher enrolment rate among females compared to males. This is in line with previous research by Ayitey, et al. [7] who also found that the NHIS uptake in Ghana is greater among women compared to men. However, in contrast, the results from the SAGE data point to a higher level of coverage among males. These differences can, in part, be attributed to differences in the timing of the fieldwork and the policy environment. Since July 2008, all pregnant women who attend antenatal care in one of the NHIA accredited facilities are exempt from the NHIS premium payment as they are automatically registered in the scheme upon arrival. They and their newborn child are entitled to NHIS benefits until 3 months after the delivery [31]. The fieldwork for the SAGE took place between May 2007 and June 2008. This means that during the SAGE data collection period, the premium exemption for pregnant women was not yet in place, which could account for the lower coverage among women particularly in reproductive age. Both surveys showed significantly lower likelihood of insurance drop out among females in both age groups. Women might be more aware of the benefits provided by the NHIS as women tend to be responsible for the health and wellbeing of the household [6].

With regards to age, this study found that an increase in age among older adults is associated with a greater probability of being insured in the NHIS. This refers back to the hypothesis that people assess their health status before insurance enrolment [32] and that older adults are more likely to invest in their health due to increasing usage of healthcare with age. Further analysis in this paper showed that older adults also had a slightly lower probability of dropping out of insurance coverage compared to younger adults. This could be due to the above-described greater need of health insurance coverage with increasing age. In addition, older adults might have had more time to re-enrol after dropping out. The opportunity cost of going to the district office to enrol tends to be lower for older adults as they are less likely to have to take a day off work. Younger adults tend to have less time to enrol and have greater opportunity costs like missing time at work. Following this argument, older adults may also have had more opportunities to enrol in the first instance. Younger adults may have dropped out but not yet re-enrolled as they need less healthcare than older adults. Women especially might not feel the need for insurance coverage after childbirth.

When treating the surveys as two cross-sectional surveys, they indicate an increasing trend in NHIS enrolment. Trends in enrolment can be attributed to changes in health polices and economic circumstances in Ghana including NHIS facility accreditation in 2009 to improve quality and access to care, free enrolment for pregnant women in 2008, economic growth and increasing per capita income, and more general improvements of the NHIS over time. In 2007/2008, when the SAGE was conducted, the NHIS was still a new system. Over 10 years on from its implementation, it has now been allowed some time to learn from experience and improve its services.

Finally, this paper was interested in answering the question of whether the correlates of insurance affiliation differ depending on which survey (GLSS or SAGE) is used. Because of the fact that the true population correlates of insurance coverage are unknown, it is difficult to estimate which of the surveys delivers more accurate results. Comparing survey results can,  however, give reassurance to analyses of the determinants of NHIS coverage. The findings give assurance that both datasets (GLSS and SAGE) are suitable for research on insurance affiliation and that both surveys produce comparable results.

Using both timely and also less recent surveys indicates that although the gap in coverage among rich and poor and urban and rural residents appears to have decreased, these factors still determine NHIS coverage of younger and older adults. The same holds for education. Increased efforts are needed to ensure equal access to care in moving towards UHC. The results in this paper highlight the need to introduce specific measures to target those groups with low enrolment and those who are at the highest risk of dropping out. The existence of insurance alone is not sufficient and efforts are needed to target the poorest and less well educated members of society at all ages to ensure equal access to care across the life course.