Table 3.

Summary of empirical studies evaluating relevant equity issues for the NHIS (Ghana)

Study Author, date	Study Question	Equity Issue/s	Sample/s	Principal Results	Conclusions
Akazili, 2011[20]	Analyse the distribution of health care financing in relation to ability to pay	Financing of health care	Ghana Living Standard Survey (GLSS) 2005/2006; Ministry of Finance and other relevant sources; primary household data from six districts	Financing is progressive due to progressivity of taxes (50% of funding). NHI levy is mildly progressive; formal sector NHI payroll deductions are progressive; informal sector NHI contributions are regressive. OOP payments (45% of funding) are regressive.	Extension of pre-payment cover to all in the informal sector is needed - possibly through tax. The pre-payment funding pool for health care needs to grow so budgetary allocation to the health sector can be enhanced.
Aryeetey, 2012[40]	Analyse strategies to identify poor for exemptions: means testing (MT), proxy means testing (PMT), participatory wealth ranking (PWR), geographic targeting (GT)	Access to health care	145–147 households per setting: urban, rural and semi-urban in Ghana	Cost of exempting one poor individual = US$15.87 to US$95.44; MT was most efficient and equitable in rural and urban settings with low-poverty incidence; GT was optimal in the semi-urban setting with high-poverty incidence. PMT and PWR were less equitable and inefficient although feasible in some settings.	MT is recommended in low-poverty urban and rural settings and GT is optimal strategy in high-poverty semi-urban setting. The study is relevant to other low-income countries that require identification and exemptions of the poor in social health insurance programmes.
Jehu-Appiah, 2011[42]	Identify & compare perceptions of insured & uninsured on NHIS; Explore association with decisions to voluntarily enrol & remain insured	Access to health care	Household survey of 3,301 households and 13,865 individuals	Scheme factors have the strongest association with voluntary enrolment & retention in NHIS (benefits, convenience & price) of NHIS. Negative on price of NHIS, provider attitudes and peer pressure. The uninsured are more negative about these factors.	Perceptions about providers, scheme factors & community attributes are important in household decisions to voluntarily enrol in the NHIS. Policy makers need to design interventions to address these and stimulate enrolment.
Jehu-Appiah, 2011[25]	Evaluate equity in enrollment in the NHIS; assess determinants of demand across socio-economic groups	Access to health care	Household survey of 3,301 households	Evaluation included: quality of care, service delivery, provider attitudes, benefits, price & convenience of NHIS, peer pressure & attitudes.’ Results show evidence of inequity as differences exist between the rich and the poor.	Better identification of the poor is needed & premium exemptions should be aggressively pursued. Scheme factors influence decisions to enrol & quality of care should be addressed to retain the rich. SES is a significant factor.
Mensah, 2010[44]	Evaluate MDGs 4 & 5 for mothers who are enrolled in the NHIS compared with those who are not	Access to health care	Women (18–49 years) from Brong Ahafo and Upper East. 400 NHIS members &1,600 non-members	NHIS women are more likely to receive prenatal care, deliver at a hospital, have their deliveries attended by trained health professionals, and experience less birth complications.	The NHIS is an effective tool for improving health outcomes among those who are covered. The government should promote further enrolment, in particular among the poor.
Nguyen, 2011[8]	Evaluate the impact of the NHIS on households’ OOP spending and catastrophic health expenditure	Access to health care; financing of health care	Household survey in two rural districts, Nkoranza and Offinso	NHIS coverage (2007) was 35%; OOP payment for care from informal sources & for uncovered drugs and tests occurred in NHIS but significantly less than the uninsured. Effect was strong among the poorest in the sample.	NHIS gives a positive financial protection effect, stronger among the poor. Social health insurance cannot fully remove OOP payments. Further work is needed on supply-side incentives & quality of care.
Sarpong, 2010[43]	Explore the association between socio-economic status (SES) and NHIS membership	Access to health care	Residents of the Asante Akim, north district of the Ashanti region (99 villages, 7,223 households)	38% subscribed to the NHIS, of these 21% were low, 43% middle and 60% high SES households. SES was significantly associated with NHIS subscription (high SES: Odds Ratio [OR] = 4.9 low SES OR = 1, reference group).	To achieve universal access to health care facilities for all residents of Ghana, in particular for individuals living under socio-economic constraints, increasing their subscription rates is necessary.
Witter, 2009[30]	Assess the NHIS (2005 to 2009) to inform NHIS developments & other innovations in the region	Financing of health care; access to health care	Literature plus stakeholder interviews at national, regional and district levels	NHIS is reliant on tax (70–75%); large exempted population (30%) ; coverage rose from 7% to 45%; growth in distressed schemes; VAT-based source is regressive; membership of NHIS is pro-rich & pro-urban; ‘squeezing out’ of non-members from health care utilisation; strengthening of purchasing needed.	Some trade-offs will be necessary to achieve universal coverage. In the long term, investment in the NHIS will only be justified if it is able to increase the cost-effectiveness of purchasing and the responsiveness of the system as a whole.

Notes: NHIS = National Health Insurance Scheme; OPD = Out-patient department; IPD = In-patient department; PMD = Patent medicine dealers; SES = Socio-economic status; OOP = out-of-pocket; MDG = Millenium Development Goal; VAT = Value-added Tax; OR = Odds Ratio.