LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK.
LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK; School of Health Sciences, City University London, Northampton Square, London, EC1V 0HB, UK.
Soc Sci Med. 2017 Aug;186:10-19. doi: 10.1016/j.socscimed.2017.05.023. Epub 2017 May 10.
To help reduce child mortality and reach universal health coverage, Ghana extended free membership of the National Health Insurance Scheme (NHIS) to children (under-18s) in 2008. However, despite the introduction of premium waivers, a substantial proportion of children remain uninsured. Thus far, few studies have explored why enrolment of children in NHIS may remain low, despite the absence of significant financial barriers to membership. In this paper we therefore look beyond economic explanations of access to health insurance to explore additional wider determinants of enrolment in the NHIS. In particular, we investigate whether social exclusion, as measured through a sociocultural, political and economic lens, can explain poor enrolment rates of children. Data were collected from a cross-sectional survey of 4050 representative households conducted in Ghana in 2012. Household indices were created to measure sociocultural, political and economic exclusion, and logistic regressions were conducted to study determinants of enrolment at the individual and household levels. Our results indicate that socioculturally, economically and politically excluded children are less likely to enrol in the NHIS. Furthermore, households excluded in all dimensions were more likely to be non-enrolled or partially-enrolled (i.e. not all children enrolled within the household) than fully-enrolled. These results suggest that equity in access for socially excluded children has not yet been achieved. Efforts should be taken to improve coverage by removing the remaining small, annually renewable registration fee, implementing and publicising the new clause that de-links premium waivers from parental membership, establishing additional scheme administrative offices in remote areas, holding regular registration sessions in schools and conducting outreach sessions and providing registration support to female guardians of children. Ensuring equitable access to NHIS will contribute substantially to improving child health and reducing child mortality in Ghana.
为了降低儿童死亡率并实现全民健康覆盖，加纳于 2008 年将国民健康保险计划（NHIS）的免费会员资格扩大到儿童（18 岁以下）。然而，尽管已经免除保费，但仍有相当一部分儿童没有保险。迄今为止，很少有研究探讨为什么尽管加入 NHIS 不存在重大的经济障碍，但儿童的参保率仍然很低。在本文中，我们超越了对健康保险获取的经济解释，探索了 NHIS 参保的其他更广泛的决定因素。特别是，我们调查了通过社会文化、政治和经济视角衡量的社会排斥是否可以解释儿童参保率低的原因。数据来自 2012 年在加纳进行的一项针对 4050 个代表性家庭的横断面调查。创建了家庭指数来衡量社会文化、政治和经济排斥，并进行了逻辑回归来研究个人和家庭层面的参保决定因素。我们的结果表明，在社会、经济和政治上被排斥的儿童不太可能参加 NHIS。此外，在所有方面都被排斥的家庭比完全参保的家庭更有可能是非参保或部分参保（即家庭内并非所有儿童都参保）。这些结果表明，在社会排斥儿童方面，公平获得服务的目标尚未实现。应努力通过取消剩余的小额、每年可续期的注册费来提高覆盖率，实施和宣传将保费豁免与父母会员资格脱钩的新条款，在偏远地区设立额外的计划行政办公室，定期在学校举办注册会议，并开展外展活动以及为儿童的女性监护人提供注册支持。确保公平获得 NHIS 将为改善加纳儿童健康和降低儿童死亡率做出重大贡献。
