Electronic Thesis and Dissertation Repository


Doctor of Philosophy




Dr. Isaac Luginaah


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.