Is Enrolment in the National Health Insurance Scheme in Ghana Pro-Poor? Evidence from the Ghana Living Standard Survey

Background: Earlier studies have found enrolment in the Ghana National Health Insurance Scheme (NHIS) as pro-rich. In recent years, the NHIS has embarked on aggressive enrolment of the poor and vulnerable to reverse the trend. This article examines equity in enrolment in the NHIS to inform policy decisions on progress towards realisation of universal health coverage (UHC).   Methods: Secondary analysis of data from the sixth round of the Ghana Living Standards Survey (GLSS 6). The survey was conducted between 18 October 2012 and 17 October 2013 with 16,774 household heads. Equity in enrolment was assessed using concentration curves and bivariate and multivariate analyses to determine associated factors. Findings: Survey participants had a mean age of 46 years and mean household size of four persons. About 71% of households interviewed had at least one person enrolled in the NHIS. Households in the poorest wealth quintile (73%) had enrolled significantly (p<0.001) more than those in the richest quintile (67%). The concentration curves further showed that enrolment was slightly disproportionally concentrated among poor households, particularly those headed by males. However, multivariate logistic analyses showed that the likelihood of NHIS enrolment increased from poorer to richest quintile and from low to high level of education. Other factors including age, sex, household size, household setting, and geographic region were significantly associated with enrolment. Interpretations: From 2012-2013 enrolment in the NHIS was higher among poor households, particularly male-headed households, although multivariate analyses demonstrated that the likelihood of NHIS enrolment increased from poorer to richest quintile and from low to high level of education. Policy makers need to ensure equity within and across gender as they strive to achieve UHC.   Funding Statement: The authors declare: "None." Declaration of Interests: ENB is an employee of the National Health Insurance Authority, however his affiliation did not influence findings of this study. JPR and JN declare no competing interests. Ethics Approval Statement: Not Required.