This paper examined how health insurance subscription in Ghana is influenced/shaped by perceptions of health service quality when healthcare cost is paid for using NHIS card. This was necessary in the light of the overriding goal of a national health insurance programme in Ghana—creating wealth through health by making access equitable in the country. The results show that perception of service quality was strongly related to ownership of health insurance and this was more pronounced in females than males.
Overall, the results show similarity to previous research on reasons for non-enrolment in health insurance schemes, particularly in sub-Sahara Africa. Quality of services provided to subscribers compared to those making out-of-pocket payments remains significant. For instance, the key reason for non-subscription and declining membership in a mutual health organisation (MHO) in Guinea Conakry was the poor quality of care offered to members of the scheme at health facilities . Related findings have been reported about a community health insurance (CHI) in Uganda .
In terms of total enrolment in the insurance programme, our results evidence higher prevalence of subscription among women than men. Reasons that may account for this include: first, women are somewhat risk averse than men. Among men, low perception of risk could be attributed to male ‘misconception’ of physical superiority and therefore are unlikely to participate in programmes, which seek to pool and share risks associated with cost of health services. Literature on adoption of innovation also point out that men generally are late adopters (e.g. ) and are unlikely to own an insurance cover.
Also, the high enrolment of women more than men may be an artefact of prevailing policy of free health care for pregnant women. Under Ghana’s health insurance policy, pregnant women are part of the exempt category. This is more plausible given the age inclusion criteria for males (15–59 years) and females (15–49y years). The majority of these women were either pregnant or had been in the last five years to survey. This position is further strengthened other results from the study – pregnant women at the time of the survey reported higher tendency of being a subscriber than those unsure or did not know they were pregnant; this is consistent with a similar study in Burkina Faso .
Regarding perception of service quality and NHIS subscription, our findings reveal the importance of improving quality of healthcare in general and particularly among subscribers given the pro-poor nature of the programme. Perhaps, the concurrent running of the scheme with out-of-pocket payment could be contributing to perception of poor quality to subscribers. Martin and McMillan  noted that running a health insurance programme contemporarily with out-of-pocket payments might result in strict implementation of prescription, which can expose subscribers of health insurance to clinical consequences and thereby affect views of quality. It is imperative that quality of care in terms of convenience, scheme administrative arrangements, and provider attitudes can enhance enrolment if clients are satisfied with services provided by insurance providers .
Psychological theory also offers plausible reasons for female-male differential judgement of quality and how this affects outcomes. For instance, Darley and Smith  note that while females process information more comprehensively, consider both subjective and objective attributes of services and observant of delicate cues, men, on the other hand, are selective in information processing, use heuristics more frequently and are likely to miss details. This may account for the gender differences. Atinga, Abiiro  for instance observed that women were more likely to drop out of the NHIS due to quality concerns than males in informal settlements in Accra, Ghana. In a context where women in the reproductive ages (sample for this study) seem to have more life threatening health needs challenges as a result of childbirth see, , the health insurance managers ought to be concerned about total quality management. In a previous study,  the authors found that women enrolled in the NHIS were more likely to utilize antenatal services than those not enrolled regardless of socioeconomic status.
One striking finding is the high prevalence of NHIS ownership in the Upper West region among both males and females, albeit it is the poorest region in Ghana . This is a positive observation in the sense that the NHIS is a pro-poor intervention. The equity goal in respect of access to health care is enhance with more registration in high poverty incidence areas. Unfortunately, however, in another high poverty incidence region, the Upper East, females were unlikely to own a health insurance, although more vulnerable to health problems during the reproductive period. Another finding worth our comment is the lower proportion of women in Ashanti region being subscribers to the NHIS. Perhaps, the trial of capitation provider-payment system started in the region, which received a lot of public criticisms, might be responsible for the low coverage of females in the scheme. Once again, these findings highlight the distortions and inconsistencies in equity for a pro-poor policy such as the NHIS in Ghana. Indeed, removing costs which leads to inequities in access to healthcare is one of the cardinal objectives of the intervention. Consequently, more needs to be done to propel enrolment in high poverty index regions.
The findings also revealed regional-level heterogeneity in perception of quality of health services provided under the insurance. Quality of health services coverage in the country is characterised by significant inequities in favour of the southern portion of the country . Despite this, respondents, women and men in the three northern regions (Northern, Upper East and West) generally had better perceptions of the quality of healthcare with NHIS than those in the other regions. Apparently, this may be due to differential access and experiences with higher standards of care, largely in the private sector compared to the public , which are less likely to be cited in any of the three northern regions than the other parts of the country . Thus, those at areas with relatively larger pool of options may demand higher quality of services as compared to regions with limited alternatives.
Our findings show that among women, formal education offered better prospects for owning a health insurance but not really the case for males. Unlike a previous study  in Ghana where female education was less effective in predicting health insurance subscription, in this paper, the association observed widens significantly with increasing education. The effect of wealth in this study on women’s health insurance subscription was minimal. Thus, education appears more empowering to women than wealth. Kumi-Kyereme and Amo-Adjei (23) made similar observations regarding the minimal role of wealth in women’s health insurance subscription. On the other hand, among men, it is rather wealth, which substantially increased the odds of insurance ownership rather than education. Thus, we notice varying associations of education and wealth on health insurance subscription among men and women.
We also note that perception of quality declined with increased in wealth. In areas where there is high proliferation of private insurance options, the rich are inclined to subscribe to private than national insurance programmes  but that is not the case in Ghana. The more plausible reason that could be accounting for the wealth gradient in perception of quality is that they may have higher expectations of quality services that is underpinned by ability to pay, likelihood of being urban areas, better educated and exposure to varied standards of healthcare. Possibly too, with the scheme mainly funded through 2.5 % VAT, the rich may expect/demand more quality attributes since they contribute more to financing the scheme through taxes.
Despite the important findings made in this study, the limitations imposed by the data need to mentioning. First, by relying on a cross sectional data, it is impossible to account for unobserved heterogeneity. The key explanatory variable (perception of quality of health care using NHIS as payment method) for this paper was also measured as perception, which makes it subject. These perceptions maybe fueled by third-party narratives about previous services received and that calls for caution in interpreting the findings.