BACKGROUND In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations. METHODS A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES. RESULTS Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme. CONCLUSIONS Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.

中文翻译：

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实施八年后，加纳农村地区的国民健康保险计划的报名情况。

背景技术2004年，加纳实施了国家健康保险计划（NHIS），以实现全民健康覆盖。在本文中，我们评估了实施八年后加纳北部两个主要农村地区的NHIS入学率和相关因素，重点关注贫困人口和弱势群体。方法从2012年7月至2012年12月，对以户主为调查对象的11175个随机抽样家庭进行了横断面调查。使用结构化调查表获得有关NHIS状况，成员类别和家庭成员的社会人口学特征的信息。主成分分析用于从家庭资产中计算财富指数，作为社会经济地位（SES）的估计值。使用logistic回归模型评估与NHIS入学相关的因素。根据他们的SES，进一步调查了每个家庭成员的入学决定背后的原因。结果在39,262名抽样人群中，大约有一半是通过有效的NHIS卡注册的。其中53.2％是通过自愿认缴保费缴付的，其余（46.8％）包括年龄在18岁以下的儿童，70岁及以上的老人，孕妇和正规部门的工作人员免缴保费。尽管有一项减免政策，以减轻贫困和脆弱家庭的灾难性医疗保健支出，但贫困人口仍仅申请了0.5％的NHIS成员资格，占贫困和其他社会脆弱性导致的总免税额的1.2％。然而，保费成本是NHIS注册（92.6％）和不续签（78.8％）的主要障碍，SES最低的成员受到的影响最大。18岁以下的儿童，女性，城市居民以及受过高等教育和SES的儿童更有可能加入该计划。结论尽管实行了政策豁免作为一种公平措施，但极少数穷人却很少被确定要豁免。政府必须紧急向社会福利部提供资源，以识别可申请NHIS的穷人。城镇居民以及受过高等教育和SES的人更有可能加入该计划。结论尽管实行了政策豁免作为一种公平措施，但极少数穷人却很少被确定要豁免。政府必须紧急向社会福利部提供资源，以识别可申请NHIS的穷人。城镇居民以及受过高等教育和SES的人更有可能加入该计划。结论尽管实行了政策豁免作为一种公平措施，但极少数穷人中的极少数人很少被认定为免税对象。政府必须紧急向社会福利部提供资源，以识别可申请NHIS的穷人。