This thesis aims to explore the determinants of enrolment in the National Health
Insurance Scheme (NHIS) in Ghana’s Upper West Region (UWR). While studies on the
theoretically “pro-poor” NHIS have thus far focused on wealth as driver of enrolment, the
high rates of enrolment in the poorest and most deprived region of the country (the UWR)
suggest that other factors underpin health insurance acquisition and maintenance. This study
uses mixed methods that combine quantitative and qualitative techniques in order to better
understand patterned differences between enrolled, never enrolled and dropped out members
of the scheme.
Results of a quantitative analysis (n=2119) reveal that although wealth, education and
desire for health insurance are primary determinants in enrolment, these factors impact men
and women differently. As well, women with unreliable incomes, who reported being food
insecure and those living with young children were more likely to drop out, whereas men,
were more likely to drop out of the NHIS for being unsatisfied with services provided. The
qualitative analysis, based on 17 focus group discussions (n=211) and n=26 in-depth
interviews, revealed that inequality is not just about poverty, but a reflection of rural
subsistence based livelihoods and historic structural factors which clash with the rigid policy
design of the NHIS.
This study makes important contributions to theory, methodology and policy.
Theoretically, this study demonstrates that poverty is only one of many determinants driving
inequality in enrolment, with education and poor policy design actually resonating more
powerfully. As well, it demonstrates the intensely gendered nature of health insurance
enrolment where women’s access is tightly tied to mothering and other family related
obligations. Methodologically it reflects the value of mixed methods research and context
tailored quantitative design. Policy solutions are suggested, as the success of the NHIS rests
on its ability to redress the inequality in the scheme and open up access to health care for
Ghana’s rural poor.