Background: Access to health insurance is expected to have positive effect in improving access to healthcare and
offer financial risk protection to households. Ghana began the implementation of a National Health Insurance
Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of
its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS
contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis
of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to
examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and
a burden on their resources.
Methods: The study uses data from a cross-sectional household survey involving 2,430 households from three
districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using
the household budget-based approach based on the normative definition of affordability. The burden of the NHIS
contributions to households is assessed by relating the expected annual NHIS contribution to household non-food
expenditure and total consumption expenditure. Households which cannot afford full insurance were identified.
Results: Results show that 66% of uninsured households and 70% of partially insured households could afford full
insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household
non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%)
socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two
lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the
insurer and health system problems also affect enrolment in the NHIS.
Conclusion: Affordability of full insurance would be a burden on households with low socio-economic status and
large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim
at abolishing the registration fee for children, pricing insurance according to socio-economic status of households
and addressing the inimical non-financial factors to increase NHIS coverage.