Uptake of health insurance by the rural poor in Ghana: determinants and implications for policy

Introduction Financing access to healthcare services in developing countries remains a major challenge despite recent advances towards implementation of various health insurance policies in many low and middle-income countries. The use of health insurance is considered an important means to achieve universal health coverage. However, uptake of health insurance in most developing countries remains low as a result of several challenges. Empirical evidence of factors restraining enrolment is rare in many developing countries including Ghana. This paper therefore sought to investigate the factors associated with the uptake of health insurance products and the implications thereof for policy, using Awutu Senya West District of Ghana as case study. Methods A logit model was used to analyze data from 178 respondents randomly selected from two microfinance groups operating in the study area. Results The results indicate that insurance uptake is higher among younger people, but lower among women. Older women are however more likely to take up health insurance compared to older men. In addition, the study reveals that insurance uptake increases with level of education but decreases with household size. Conclusion The study concludes that even though the premium on health insurance coverage in Ghana is arguably low, socio-demographic characteristics such as age, sex, literacy level and household size affect the decision to enroll. Adequate public sensitization on the benefits of the scheme and decreasing the statutory age for exemption from premium payment, especially in rural localities, are some of the measures suggested to enhance health insurance uptake in Ghana and other developing countries.


Introduction
The cost of providing healthcare services is one of the growing concerns and major budgetary challenges facing most countries [1,2]. Expenditure on healthcare services remains a large proportion of household incomes in many developing countries with many poor households unable to pay for sudden unexpected healthcare bills due to high incidence of poverty and low incomes.
Many people in rural communities rely on traditional sources in addressing their healthcare needs due to inaccessibility to and high cost of orthodox healthcare services. Avoidance of catastrophic health expenditures and the need to strive towards universal health coverage have called for the need to develop models of health insurance to tackle these challenges [3][4][5]. Consequently, governments in many developing countries have resorted to health insurance schemes that seek to pool resources in order to offer subsidized healthcare services for their populations. Health insurance typically refers to insurance cover against the risk of personally incurring medical expenses. The provision of subsidized and affordable health insurance coverage is essential for the attainment of universal health coverage, which is an important goal set forth under the Sustainable Development Goals (SDGs).
Recognizing the importance of a healthy population in national development and the impelling social obligation to provide universal health coverage for its citizens, the government of Ghana in 2003 put in place a system of health insurance scheme that subsidizes the cost of basic healthcare services for its citizenry. This made Ghana the first country in sub-Saharan Africa to institute a National Health Insurance Scheme (NHIS) to enroll its citizens onto health insurance [1]. The institution of the NHIS was an effort by the government of Ghana to accelerate the attainment of universal health coverage. The National Health Insurance Scheme seeks to avert the burden of out-of-pocket payment for healthcare services through a system of pooling resources to finance health expenditures of the insured. The NHIS is a form of national health insurance and seeks to provide equitable access and financial coverage for basic healthcare services. The scheme is operational across the country and participation is voluntary as with any insurance policy. To improve efficiency of operation and accessibility to healthcare services, District-level Health Insurance Schemes have been established. Insurance cover under the National Health Insurance Scheme (NHIS), which runs concurrently with a cash-andcarry system that requires out-of-pocket payments for the uninsured, has been recognized as a successful social intervention mechanism despite some challenges confronting the scheme. A onetime premium payment was proposed by the erstwhile National Democratic Congress (NDC) government in 2009, but the proposal did not go beyond rhetoric. Currently, the scheme operates through the payment of a yearly premium, with the elderly and indigent populations receiving free enrolment onto the scheme.
Despite the general acceptability of health insurance as a means to attaining universal health coverage, uptake of health insurance has not reached desired expectations in most countries, including Ghana [2]. A number of studies have been carried out in many countries in an attempt to gain a better understanding of the factors limiting uptake of health insurance, especially in developing countries [6][7][8][9][10][11]. Understanding the factors inhibiting health insurance uptake will help policy makers to design more effective health insurance schemes to ensure attainment of universal health coverage.
Empirical evidence of the factors influencing health insurance uptake indicate that age plays an important role in enrolment.
Studies by [6] indicate that health insurance cover increases with age. This was attributed to increment in additional healthcare needs and increased financial security of older people. This finding is supported by other studies [8,12]. Other empirical studies show a significant difference in health insurance coverage based on gender.
Other studies indicate lower ownership of health insurance cover by men because they are perceived to be risk-takers while women have higher health insurance coverage due to their greater need for more health services [8,12]. However, [6] found no significant difference in health insurance coverage based on gender differences. A number of empirical studies suggest a positive association between health insurance coverage and the level of education, attributable to higher purchasing power and access to information on health insurance [8,13,14]. A study by [7] found that possessing tertiary education is positively related to health insurance uptake in rural Kenya. Education enhances the health seeking behavior of individuals, thus influencing insurance uptake.
Household size also influences health insurance uptake according to the extant literature. A positive association between household size and uptake of health insurance was observed by [13]. On the other hand, [8] and [15] observed an inverse relationship between household size and health insurance coverage in Kenya and Nigeria respectively. Additional household members exert financial strain on the household which may lead to lower insurance coverage. While [7] did not find any relationship between household size and health insurance coverage in Kenya, [6] observed that averaged sized households in Kenya were more likely to enroll in health insurance Page number not for citation purposes 3 compared to smaller and larger households. Furthermore, according to [7], having knowledge of the benefits of health insurance is positively related to health insurance uptake. Knowledge of the benefits of health insurance is influenced by educational level, accessibility to health extension services, proximity to health facilities and the availability of qualified health personnel. Majority of the population in developing countries are rural hence the likelihood of many people being unaware of the benefits of certain government programmes and policies cannot be ruled out.
Additionally, [7,9,16] respectively identified higher uptake of health insurance among married women in Kenya, Ghana and South Africa. These studies associated higher insurance uptake of married couples to pooling of financial resources leading to increased income and hence, the ability to afford health insurance cover. In another study, [6] observed that the likelihood for married patients in Kenya to take up health insurance cover was 10 times higher than unmarried patients. Reasons given by the authors included the avoidance of catastrophic health expenditure, the increased collective pooled income of the spouse and the desire to insure children. In another study, [8] argued that some employers provide insurance cover for spouses and children accounting for the increased likelihood of enrolment through the spouse's insurance cover. A positive association between being married and possessing health insurance was also reported by [15] and [17]. Furthermore, [8] observed that more educated women have a higher likelihood to take up health insurance. This indicates that provision of education to women is likely to spur health insurance uptake in developing countries. Other factors affecting insurance uptake include employment status [18][19][20] and level of income. A positive relationship between household income and health insurance uptake was observed by [10,11] in their studies on health insurance uptake in Ghana. Despite the numerous benefits associated with enrolment in the national health insurance scheme (NHIS) and efforts by the scheme providers to ensure high enrolment rates, studies indicate that many Ghanaians are not enrolled. For instance, although indigents are entitled to free enrolment in the national health insurance scheme, [2] observed that procedures for the identification of the poor indigents remain ineffective thereby excluding many from receiving free health care. Consequently, the number of indigents enrolled in the NHIS continues to decline over the years. Also, economic and financial barriers have led to NHIS membership that is skewed against the poor and marginalized. It is in the light of the foregoing that this study was carried out to investigate the factors affecting enrolment onto the health insurance schemes, especially by the rural poor in Awutu Senya West District of Ghana, and the implications of the research findings to health policy in Ghana. The study solicited responses from participants in two microfinance groups operating in the study area. The data was subjected to econometric analysis in order to draw conclusions.   Table 3. The predictors of health insurance uptake included age, sex, education, household size, and the interaction term for age and sex. From Table 2, insurance uptake is lower among older people as indicated by the negative and significant coefficient of the age variable. A unit increase in the age of the respondent decreases the probability of taking up insurance by 0.08. However, with an increase in age above a certain threshold, insurance uptake begins to increase. In other words, insurance uptake initially decreases with age but participation in low-income jobs due to low capabilities [22,23]. This is reflected in the small absolute amounts of savings by the respondents in this study. The amount of saving was used as a proxy for respondents' level of income which impacts levels of health insurance uptake.

Determinants of health insurance uptake:
Many studies have reported a positive association between age and insurance uptake [6,8,12] [6] in Kenya did not find any significant difference in health insurance uptake on the basis of respondent's gender. However, some studies have indicated lower insurance uptake by men because they are perceived to be risk-takers while other studies have indicated higher health insurance coverage by women due to their greater need for more healthcare services [8,12]. However, the result suggests that as women grow older they place higher premium on their healthcare needs more than older men do.
The result is consistent with a priori expectation because of the role education plays in enhancing quality decision-making. Education improves the health seeking behavior of individuals. In other words, educated people are more able to acquire and process information leading to informed decisions that enhance their well-being.
Education potentially also increases purchasing power and access to health insurance information resulting in higher insurance uptake by educated people. Similar results have been obtained by [8,13,24].
The relationship between household size and insurance uptake implies that larger households are less likely to have insurance cover. As the household increases in size, the available resources are strained so that there is little money laid aside to cater for health insurance. The result agrees with [8,15] in their study of factors influencing health insurance uptake in Nigeria and Kenya respectively. Also, [25] found household size to be negatively Page number not for citation purposes 6 related with health insurance uptake in Kenya. In other studies, [8] observed higher health insurance coverage among average sized households in Kenya while [7] found no relationship between household size and health insurance uptake in rural Kenya.

Conclusion
The study sought to examine the predictors of health insurance uptake by rural dwellers using the Awutu Senya West District of Ghana as case study. Using a multivariate logit model, the study identified the following as determinants of health insurance uptake: respondent's age, sex, educational level as well as household size.
The following conclusions emerge from the findings of the study: 1) Insurance uptake is lower among older people but increases at a certain threshold. 2) Insurance uptake is lower for female respondents as compared to males.
3 effort is therefore required in this regard. Using the local media, radio, television programs and durbars to sensitize rural dwellers will achieve higher enrolment rates.
What is known about this topic  The emergence of health insurance schemes in developing countries as a means to universal health coverage is well known; Page number not for citation purposes 7  It is also known that certain socio-economic, demographic and institutional factors affect health insurance uptake;  Patronage of health insurance remains low in most many countries, especially in developing countries.

What this study adds
 The life cycle effect on health insurance uptake has not been examined in most studies but this was addressed in this study;  This study modeled the interaction of age and gender, key variables affecting health insurance uptake, thereby providing a result that was hitherto unknown.

Competing interests
The authors declare no competing interests.

Authors' contributions
The design of the study, data collection and entry were carried out by the first author. The second author carried out the econometric analysis and wrote the first draft. The review of the draft manuscript went through several stages in-between the two authors who both agreed to the final manuscript for publication. Table 1: Data description and summary statistics of the respondents Table 2: Summary statistics of the insured and uninsured    Ϯ signifies the test of difference in means between insured and uninsured. ***, ** and * stand for statistical significance at 1, 5 and 10 percent level, respectively