Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling, who is not and why? Caroline Jehu-Appiah a, d, * , Genevieve Aryeetey a , Ernst Spaan a , Thomas de Hoop b , Irene Agyepong c, d , Rob Baltussen a a Department of Primary and Community Care, Radboud University Nijmegen Medical Center, The Netherlands b Radboud University Nijmegen, Center for International Development Issues, The Netherlands c University of Ghana, School of Public Health, Ghana d Ghana Health Service, Ghana article info Article history: Available online 18 November 2010 Keywords: Equity Determinants Perceptions Social health insurance Socio-economic status Ghana abstract To improve equity in the provision of health care and provide risk protection to poor households, low- income countries are increasingly moving to social health insurance. Using data from a household survey of 3301 households conducted in 2009 this study aims to evaluate equity in enrollment in the National Health Insurance Scheme (NHIS) in Ghana and assess determinants of demand across socio-economic groups. Specifically by looking at how different predisposing (age, gender, education, occupation, family size, marital status, peer pressure and health beliefs etc) enabling (income, place of residence) need (health status) and social factors (perceptions) affect household decision to enrol and remain in the NHIS. Equity in enrollment is assessed by comparing enrollment between consumption quintiles. Determinants of enrolling in and dropping out from NHIS are assessed using a multinomial logit model after using PCA to evaluate respondent’s perceptions relating to schemes, providers and community health ‘beliefs and attitudes’. We find evidence of inequity in enrollment in the NHIS and significant differences in deter- minants of current and previous enrollment across socio-economic quintiles. Both current and previous enrollment is influenced by predisposing, enabling and social factors. There are, however, clear differ- ences in determinants of enrollment between the rich and the poor. Policy makers need to recognize that extending enrollment will require recognition of all these complex factors in their design of interventions to stimulate enrollment. Ó 2010 Elsevier Ltd. All rights reserved. Introduction Equity has long been considered an important goal in the health sector. Yet inequities between the poor and the better-off persist (O’Donnell, Doorslaer, Wagstaff, & Lindelow, 2008). Empirical evidence shows that allocation of spending by governments in low- income countries across services within the health sector may generally not favour the poor (Castro-Leal, Dayton, & Mehra, 2000; Preker & Carrin, 2004; Yazbeck, 2009). Typically the share of the subsidy to the poorest quintile is significantly less than that to the richest 20% (Preker & Carrin, 2004) and the health sector may actually exacerbate inequalities, by serving the wealthiest more than the poor (Yazbeck, 2009). This has generated a renewed concern for poverty reduction and equity in health and its moni- toring and evaluation (Gwatkin, 2000; Yazbeck, 2009). In recent years, to improve equity in the provision of health care and provide risk protection to poor households, low-income coun- tries are increasingly moving away from “user fees” to pooling arrangements. A critical question for understanding the relationship between pooling arrangements and the poor is, who is covered by health insurance (Yazbeck, 2009). While there is consistent evidence of MHO’s in reaching a large number of poor people who would otherwise be excluded, the evidence regarding whether such schemes reach the poorest is mixed (Jakab & Krishnan, 2004; Preker & Carrin, 2004). Whereas some studies show schemes are equitable in terms of enrollment across socio-economic groups (Diop, Yazbeck, & Betran,1995; Polonsky et al., 2009; Schneider & Diop, 2001) others show the poorest are excluded resulting in low levels of both vertical and horizontal equity (Arhin-Tenkorang, 2001; Bennet, Creese, & Monasch, 1998; Ekman, 2004; Musau, 1999). * Corresponding author. Department of Primary and Community Care, Radboud University Nijmegen Medical Center, PO Box 9110, 6500 Nijmegen, The Netherlands. Tel.þ31 24 361 3119. E-mail address: carojehu@yahoo.co.uk (C. Jehu-Appiah). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2010.10.025 Social Science & Medicine 72 (2011) 157e165