Abstract
Background: The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2004 with the goal
of achieving universal coverage within 5 years. Evidence, however, shows that expanding NHIS coverage and especially
retaining members have remained a challenge. A multilevel perspective was employed as a conceptual framework and
methodological tool to examine why enrolment and retention in the NHIS remains low.
Methods: A household survey was conducted after 20 months educational and promotional activities aimed at improving
enrolment and retention rates in 15 communities in the Central and Eastern Regions (ERs) of Ghana. Observation, indepth
interviews and informal conversations were used to collect qualitative data. Forty key informants (community
members, health providers and district health insurance schemes’ [DHISs] staff) purposely selected from two casestudy
communities in the Central Region (CR) were interviewed. Several community members, health providers and
DHISs’ staff were also engaged in informal conversations in the other five communities in the region. Also, four staff
of the Ministry of Health (MoH), Ghana Health Service (GHS) and National Health Insurance Authority (NHIA) were
engaged in in-depth interviews. Descriptive statistics was used to analyse quantitative data. Qualitative data was analysed
using thematic content analysis.
Results: The results show that factors that influence enrolment and retention in the NHIS are multi-dimensional and cut
across all stakeholders. People enrolled and renewed their membership because of NHIS’ benefits and health providers’
positive behaviour. Barriers to enrolment and retention included: poverty, traditional risk-sharing arrangements
influence people to enrol or renew their membership only when they need healthcare, dissatisfaction about health
providers’ behaviour and service delivery challenges.
Conclusion: Given the multi-dimensional nature of barriers to enrolment and retention, we suggest that the NHIA
should engage DHISs, health providers and other stakeholders to develop and implement intervention activities to
eliminate corruption, shortage of drugs in health facilities and enforce the compulsory enrolment stated in the NHIS
policy to move the scheme towards universal coverage.