Sustainability of national health insurance scheme in Ghana: what is the effect of enrolment on retention and what are the constraints?

Background Globally, health remains an important issue on governments agenda. Subsequently, the health insurance scheme was introduced in Ghana to reduce out-of-pocket payments for healthcare delivery. However, there are several challenges facing the scheme including continuous membership (retention) and financial constraints. These issues pose threat to the sustainability of the scheme. This study examined the effect of NHIS enrolment status on NHIS retention status in Ghana. The study further assesses the socio-demographic determinants of the NHIS retention and the major constraints in Ghana. Methods The expected utility theory of decision-making on health insurance underpins the study. The study’s sample is drawn from the Ghana Living Standards Survey Round 7 (2016/2017) and the Heckman probit estimation technique is used to address the potential endogeneity in the sample selection process. Results There is positive effect of NHIS enrolment on the NHIS retention decision. Again, the study shows that the NHIS retention is driven by factors such as being female, being married, higher education, urban locality and household expenditure affect NHIS retention status positively. However, younger age and household size were found to deter NHIS retention status. The study further identified finance as the main constraint for the NHIS non- retention in Ghana (66.6%) followed by poor service delivery (12.5%). The financial constraint was higher for females (69.1%) than males (64.0%). It is also higher for rural areas (75.4%) than urban areas (48.8%). Conclusions Government should continue to strengthen efforts towards improving the quality of NHIS service delivery and monitor the implementation particularly in the rural areas. Again, government should continue to subsidize the health insurance premium particularly for the poor and the youth in Ghana. Also, public education should continue to be strengthened on the NHIS renewal process in Ghana.