Vertical equity in access to health insurance services: A qualitative analysis of perceptions and enrolment in the Jirapa Municipality, North-western Ghana

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Abstract Abstract Background: Cost continues to be an important barrier to accessing health services in Low and Middle Income Countries (LMICs) partly due to the inability of health systems in those settings to adequately implement equity measures that aim to offer financial protection to disadvantaged population groups such as indigenous and rural residents. Drawing on a framework for assessing financial access to health services, this article provides evidence of vertical inequity in the distribution of the cost of national health insurance contribution among rural and urban residents in a municipality in northern Ghana. Methods: A qualitative approach was used to collect and analyse the data. Specifically, the concurrent use of in-depth interviews and observation provided the needed data to critically analyse the relationship between location, livelihoods and ability to pay for health insurance services. Results: The paper argues that flat rate contributions for populations in the informal sector of the economy and lack of flexibility and adaptability of timing premium collections to the needs of the poor contradict the vertical equity objectives of the National Health Insurance Scheme (NHIS). The current payment arrangement makes the cost of NHIS membership disproportionately higher for rural residents. Conclusion: As this might deter them from enrolling in the scheme as much as their urban counterparts, we advocate strict adherence and implementation of the scheme’s vertical equity measures through the adoption of the Ghana National Household Register (GNHR) as a tool for ensuring that contributions are graduated according to income and collection is well-timed.

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