Western University Scholarship@Western Electronic Thesis and Dissertation Repository 4-29-2014 12:00 AM Determinants of Health Insurance Enrolment in Ghana's Upper West Region Jenna Dixon The University of Western Ontario Supervisor Dr. Isaac Luginaah The University of Western Ontario Graduate Program in Geography A thesis submitted in partial fulfillment of the equirr ements for the degree in Doctor of Philosophy © Jenna Dixon 2014 Follow this and additional works at: https://ir.lib.uwo.ca/etd Part of the Human Geography Commons, and the Other Geography Commons Recommended Citation Dixon, Jenna, "Determinants of Health Insurance Enrolment in Ghana's Upper West Region" (2014). Electronic Thesis and Dissertation Repository. 2057. https://ir.lib.uwo.ca/etd/2057 This Dissertation/Thesis is brought to you for free and open access by Scholarship@Western. It has been accepted for inclusion in Electronic Thesis and Dissertation Repository by an authorized administrator of Scholarship@Western. For more information, please contact [email protected]. DETERMINANTS OF HEALTH INSURANCE ENROLMENT IN GHANA’S UPPER WEST REGION (Thesis format: Integrated Article) by JENNA DIXON Graduate Program in Geography A thesis submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy The School of Graduate and Postdoctoral Studies The University of Western Ontario London, Ontario, Canada © Jenna Dixon 2014 Abstract This thesis aims to explore the determinants of enrolment in the National Health Insurance Scheme (NHIS) in Ghana’s Upper West Region (UWR). While studies on the theoretically “pro-poor” NHIS have thus far focused on wealth as driver of enrolment, the high rates of enrolment in the poorest and most deprived region of the country (the UWR) suggest that other factors underpin health insurance acquisition and maintenance. This study uses mixed methods that combine quantitative and qualitative techniques in order to better understand patterned differences between enrolled, never enrolled and dropped out members of the scheme. Results of a quantitative analysis ( n=2119) reveal that although wealth, education and desire for health insurance are primary determinants in enrolment, these factors impact men and women differently. As well, women with unreliable incomes, who reported being food insecure and those living with young children were more likely to drop out, whereas men, were more likely to drop out of the NHIS for being unsatisfied with services provided. The qualitative analysis, based on 17 focus group discussions ( n=211) and n=26 in-depth interviews, revealed that inequality is not just about poverty, but a reflection of rural subsistence based livelihoods and historic structural factors which clash with the rigid policy design of the NHIS. This study makes important contributions to theory, methodology and policy. Theoretically, this study demonstrates that poverty is only one of many determinants driving inequality in enrolment, with education and poor policy design actually resonating more powerfully. As well, it demonstrates the intensely gendered nature of health insurance enrolment where women’s access is tightly tied to mothering and other family related obligations. Methodologically it reflects the value of mixed methods research and context tailored quantitative design. Policy solutions are suggested, as the success of the NHIS rests on its ability to redress the inequality in the scheme and open up access to health care for Ghana’s rural poor. Key words : Health Insurance, NHIS, Gender, Health Policy, Ghana, Upper West Region ii Co-Authorship Statement This thesis is made up of a collection of papers which have been submitted for publication and are currently under peer review. The study problem, objectives and the relationship among the various manuscripts are outlined in the introductory chapter, while the study context is described in Chapter 2 and study methodology is described in Chapter 3. The research manuscripts are as follows: Chapter 4: Dixon, J., Luginaah, I. & Mkandawire, P., The National Health Insurance Scheme in Ghana’s Upper West Region: A Gendered Perspective of Insurance Acquisition in a Resource-Poor Setting, Revisions: Social Science & Medicine Chapter 5: Dixon, J., Luginaah, I. & Mkandawire, P., Gendered Inequalities within Ghana’s National Health Insurance Scheme: Are Poor Women Being Penalized with a Late Renewal Policy?, Forthcoming: Journal of Health Care for the Poor and Underserved Chapter 6: Dixon, J., Luginaah, I. & Richmond, C., “Us rural people are really suffering to enroll”: Examining the National Health Insurance Scheme in the context of Ghana’s Upper West Region, Submitted : Health & Place While all the papers are co-authored with my thesis supervisor and others, as the first author I conducted the actual research, which involved problem identification, literature review, data analysis, and writing. iii Acknowledgments There are many people that need to be thanked for their contribution to the development and completion of my dissertation. First and foremost on that list is my amazing supervisor, Dr. Isaac Luginaah who made this all possible. I am so glad that I took his graduate course all those many years ago and he could bring me into the world of health geography! Never failing in encouragement or making time for me, I could not have asked for a better mentor. I have learned so much over the past few years under his guidance. He also has been instrumental in providing opportunities for conferences, learning and travel so that I may develop as a well-rounded academic. I am extremely grateful for everything he has provided. From him I have learned that success is a mixture of hard work, passion and a (really) good laugh. Thank you. I would also like to thank Dr. Chantelle Richmond for being such a great role model, both academically and personally. As well, thank you to Dr. Jamie Baxter and Dr. Godwin Arku for your endless support and guidance with my project. To the staff of UWO Geography, who are the glue to such a wonderful and well-run department. Joe, Lori, Caroline, Angelica, Barbara and Karen – thank you, we would be lost without you. Great thanks to the organizations that provided the generous financial support to conduct this research: International Development Research Centre , Ottawa Canada; the Africa Initiative , a multi-year, donor-supported program jointly undertaken by The Centre for International Governance Innovation and Makerere University to contribute to the deepening of Africa’s capacity and knowledge; an Ontario Graduate Scholarship ; and a Doctoral Award from Canada’s Social Sciences and Humanities Research Council. A deep thank you to all twelve of my wonderful research assistants in the UWR. The passion and care that they displayed for this research made all of the difference. A special nod to Caesar, who I now count as a life long friend. Caesar’s passion for this work took it well beyond what it would have been otherwise. He also took great care of my Canadian sister and me on various trips back to the UWR and we are forever indebted to him. Thank you also to Elijah (and the whole Bisung family), who is now my new brother here at University of Waterloo. As well, my gratitude goes to all the Taabazuing family for their iv great hospitality (and never ending meals!). Finally, thanks to Dr. Galaa and the University of Development Studies for bringing this wonderful team together and storing my surveys in his house for all those months! Thank you to the fantastic members of the EEHL that have supported me both past and present. Foremost amongst those of course is my big brother Paul, and my little sister Andrea. Thank you both for being a shoulder to cry on and a constant source of encouragement (sounds cliché but it is true!). To many other people to do justice to: Tor, Vincent, Emily, Frederick, Faith, Josh, May, Yvonne, Chad, Caren, Odwa, Leith, Victoria, Sarah, Ellena, Sarah, Lydia, Joseph and Germaine. Thank you to the whole team, it is a great environment to learn and grow in. Karen, thank you for being both an inspiration helping me feel like a real person once again. Trisha, thanks for being my besty right from our days as lowly Masters students! To my family who has always supported me through the good and the tough. To Mom, Ross, Alan and Georgia, thank you so very much for all you have done to support me over the years. Thank you also to Amy, for always being there to let me talk it out (cousin by marriage, sister by heart). I would also like to thank my cousin Ryan for inspiring me to go to graduate school in the first place. And thank you to my newest family members: Sean, Pam, John, Marilu and John, I am happy to join the clan! To my baby Zuri, my true true source of happiness. To the love of my life: Pat I do not have the words to tell you how much you mean to me and how much you have gotten me through. You have seen me through every step of my PhD and are so much a part of everything I do. I am so lucky to have found you, and cannot wait to spend the rest of our lives discovering the world together. Thank you for everything. Finally, my deepest gratitude goes to the men and women of the UWR who sacrificed their time away from work, farms and children to participate in this research. I am forever touched by my time in the UWR and I promise to work hard to get you heard. v Table of Contents Abstract ..............................................................................................................................