Determinants of enrollment in the NHIS for women in Ghana

Background The National Health Insurance Scheme (NHIS) was introduced in 2005 to provide equitable access to healthcare. Furthermore, concessions were made for pregnant women, yet inequities in access continue to exist. This study explores whether dimensions of social exclusion explain why some groups of women are not benefitting from the scheme. Methods Data was collected from 4050 representative households in five districts. Logistic regression is used to examine the factors that determine enrolment of women under the NHIS. Results The study sample consists of a sub-sample of 3,173 women out of whom 58% were insured. The majority (64.9%) of the women were in the reproductive age (15-45 years). The results show that wealth status, age, health status, locality, perception about the quality of care at health facilities and perception of the NHIS, are the key factors that determine enrolment into the scheme. Conclusion With women dominating the informal sector of Ghana’s economy which is often characterised by relatively low incomes, these inequities in access need to be addressed

Equitable access to health insurance for socially excluded children? The case of the National Health Insurance Scheme (NHIS) in Ghana

To help reduce child mortality and reach universal health coverage, Ghana extended free membership of the National Health Insurance Scheme (NHIS) to children (under-18s) in 2008. However, despite the introduction of premium waivers, a substantial proportion of children remain uninsured. Thus far, few studies have explored why enrolment of children in NHIS may remain low, despite the absence of significant financial barriers to membership. In this paper we therefore look beyond economic explanations of access to health insurance to explore additional wider determinants of enrolment in the NHIS. In particular, we investigate whether social exclusion, as measured through a sociocultural, political and economic lens, can explain poor enrolment rates of children. Data were collected from a cross-sectional survey of 4050 representative households conducted in Ghana in 2012. Household indices were created to measure sociocultural, political and economic exclusion, and logistic regressions were conducted to study determinants of enrolment at the individual and household levels. Our results indicate that socioculturally, economically and politically excluded children are less likely to enrol in the NHIS. Furthermore, households excluded in all dimensions were more likely to be non-enrolled or partially-enrolled (i.e. not all children enrolled within the household) than fully-enrolled. These results suggest that equity in access for socially excluded children has not yet been achieved. Efforts should be taken to improve coverage by removing the remaining small, annually renewable registration fee, implementing and publicising the new clause that de-links premium waivers from parental membership, establishing additional scheme administrative offices in remote areas, holding regular registration sessions in schools and conducting outreach sessions and providing registration support to female guardians of children. Ensuring equitable access to NHIS will contribute substantially to improving child health and reducing child mortality in Ghana

Assessment of Heavy Metal Contamination and Distribution in Surface Soils and Plants along the West Coast of Ghana

Onshore oil drilling activity is ongoing at Jubilee oil fields, Ghana. This activity could lead to heavy metal exposure with consequential adverse effects on public health in nearby coastal communities. Therefore, we assessed heavy metal levels and spatial distribution in soils and plants from the west coast of Ghana to obtain baseline values for monitoring heavy metal exposure. Surface soils were collected from six coastal communities, and analyzed for arsenic, cadmium, copper, mercury, lead, selenium and zinc using atomic absorption spectrophotometer. Mean heavy metal concentrations in soil samples were 2.06, 6.55, 0.016, 21.59, 0.18 and 39.49mg/kg for arsenic, copper, mercury, lead, selenium and zinc, respectively. Mean heavy metal concentrations in plants were 2.70, 17.47, 3.17, 91.74, 1.51 and 9.88mg/kg for arsenic, cadmium, copper, lead, selenium and zinc, respectively. Concentrations of arsenic, cadmium and lead in plants exceeded WHO/FAO permissible limits. Enrichment factor for arsenic was significant and extremely high for selenium, while geoaccumulation index showed moderate pollution for selenium. Soil contamination factors for arsenic, lead, and selenium indicated considerable contamination. In view of these findings remediation methods must be adopted to safeguard the communities. The data will be useful for future monitoring of heavy metal exposure in the communities and to assess the impact of the ongoing crude oil drilling activity on the environment

Who uses outpatient healthcare services under Ghana’s health protection scheme and why?

Background: 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. Methods: 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. Results: 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. Conclusion: 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

Social capital and active membership in the Ghana National Health Insurance Scheme - a mixed method study

BACKGROUND: People’s decision to enroll in a health insurance scheme is determined by socio-cultural and socio-economic factors. On request of the National health Insurance Authority (NHIA) in Ghana, our study explores the influence of social relationships on people’s perceptions, behavior and decision making to enroll in the National Health Insurance Scheme. This social scheme, initiated in 2003, aims to realize accessible quality healthcare services for the entire population of Ghana. We look at relationships of trust and reciprocity between individuals in the communities (so called horizontal social capital) and between individuals and formal health institutions (called vertical social capital) in order to determine whether these two forms of social capital inhibit or facilitate enrolment of clients in the scheme. Results can support the NHIA in exploiting social capital to reach their objective and strengthen their policy and practice. METHOD: We conducted 20 individual- and seven key-informant interviews, 22 focus group discussions, two stakeholder meetings and a household survey, using a random sample of 1903 households from the catchment area of 64 primary healthcare facilities. The study took place in Greater Accra Region and Western Regions in Ghana between June 2011 and March 2012. RESULTS: While social developments and increased heterogeneity seem to reduce community solidarity in Ghana, social networks remain common in Ghana and are valued for their multiple benefits (i.e. reciprocal trust and support, information sharing, motivation, risk sharing). Trusting relations with healthcare and insurance providers are, according healthcare clients, based on providers’ clear communication, attitude, devotion, encouragement and reliability of services. Active membership of the NHIS is positive associated with community trust, trust in healthcare providers and trust in the NHIS (p-values are .009, .000 and .000 respectively). CONCLUSION: Social capital can motivate clients to enroll in health insurance. Fostering social capital through improving information provision to communities and engaging community groups in health care and NHIS services can facilitate peoples’ trust in these institutions and their active participation in the scheme

Making neoliberal states of development: the Ghanaian diaspora and the politics of homelands

For impoverished African states the attraction of inward flows of capital is vital and migrants are one such source of finance. Some governments actively encourage this, which brings out tensions between national affiliation and more particularistic forms of identification. This paper examines this in the context of Ghana. Between the mid-1970s and the late 1990s there was large-scale out-migration from Ghana, creating what has been termed a ‘neo-diaspora’. The migrants have mainly settled in cities in Western Europe and North America where they have developed institutional networks linking them to other diasporic locations and to Ghana. These migrants have complex identities forged from multiple meetings in numerous places. Some of these are rooted in hometown, clan, and family attachments and the obligations this brings. The current government (in line with many developing countries) is making a major play to ‘harness’ the diaspora for political support and inward investment. Tensions are being played out about dual citizenship and whether the migrants’ economic commitments to Ghana are matched by rights as full citizens. The Ghana government has to tread a careful path between attracting investment and garnering the right sort of political support, since people in the diaspora often have an ambivalent relationship to domestic politics. One of the vehicles through which the Ghanaian state seeks to square this is through encouraging hometown associations in various cities in the global North to fund development at the local level through various local – local partnerships. Hence, the nation, the national good, and development are being promoted through particularistic ethnic and locality-based organisations, which brings to light multiple and overlapping political communities