The findings showed that more than half (58.4%) of the participants were covered by health insurance. Thus, caregivers/parents of insured children were protected against out-of-pocket payment, which is a risk factor for catastrophic health care expenditure and poverty [29]. A similar study revealed that 57% of Ghanaian children below 18 years were covered by health insurance [21]. Another household survey across three districts in Ghana reported that 55.9% of the participants were insured. A similar nationally representative survey demonstrated that 66% and 52.6% of women and men aged 15–49 years were insured respectively [30].
Further, our finding is similar to a study in Shanghai, China, where 56.5% of children under eight years were covered by health insurance [31]. However, health insurance coverage in this study was higher than coverage in other African countries. For instance, an analysis of data from four African countries revealed that Ghana had the highest health insurance coverage of 62.4% and 49.1% for females and males respectively. Followed by Kenya (18.2% for females and 21.9% for males), Tanzania (9.1% for females and 9.5% for males) and Nigeria (1.1% for females and 3.1% for males) [32]. The difference in findings may be attributed to contextual factors and health insurance policies. For instance, Ghana’s National Health Insurance Scheme (NHIS) covers more than 95% of the disease conditions in the country, including medications, medical investigations, outpatient and in-patient services. Also, women who register with NHIS have access to free maternal health services, such as antenatal, delivery and postnatal services. Children under 18 years, indigents, the elderly, persons with disability or mental disorders, Social Security and National Insurance Trust (SSNIT) contributors and pensioners are exempted from paying premiums but must renew their membership every year [33].
In addition, we found that four in ten children were not covered by health insurance. Therefore, parents/caregivers of uninsured children would have to pay-out-of pocket when accessing child health care services. Out-of-pocket payment has the potential of putting caregivers at risk of catastrophic healthcare expenditure and poverty. Also, parents of non-insured children are more likely to postpone or delay seeking health care, hence putting the child’s life at risk of poor health outcomes [34]. This finding is similar to findings from previous studies in Ghana and elsewhere. For instance, a study revealed that 43.2% of Ghanaian children under eighteen years were uninsured [21]. Another study among children under seven years in Shanghai, China, reported that 43.5% of the participants were uninsured [31]. This finding may be explained by individual, financial, country-specific and health system-related factors [22]. In Ghana, children under five years are exempted from paying NHIS premiums. However, they must pay membership card processing fees and renewal fees every year [33]; hence, it may pose a barrier for their caregivers.
Furthermore, recent evidence shows that persons insured with Ghana’s NHIS still pay out-of-pocket for services in accredited health facilities [35]. Reasons for non-registration or non-renewing of membership with the NHIS include financial constraints, lack of confidence in the scheme, dissatisfaction with services, shortage of insured medications, long waiting time, payment of illegal charges and non-use of health services [36]. Going forward, the Ministry of Health, National Health Insurance Authority, Ministry of Gender, Children and Social Protection and health providers would have to collaborate to improve health insurance coverage for Ghanaian children under five years. However, there is a need for empirical evidence on the correlates and reasons for non-enrolment among children under five years. Hence, we recommend that future studies should explore these grey areas.
In addition, the findings revealed that health insurance enrolment was influenced by child’s age, mother’s educational status, wealth index, region, ethnicity and place of residence. Children whose mothers were less educated had low likelihoods of being insured. A similar study found that well-educated mothers were more likely to enroll their children on health insurance [37]. Another study in Shanghai, China, showed that children of women with low education were less likely to be covered by health insurance [31, 32]. A probable explanation is that less educated mothers may lack adequate understanding of the health insurance process and the benefits package due to their inability to access information [5]. Evidence shows that Ghanaian women who had access to information were more likely to be insured [38]. Women with higher educational status are more empowered to make health-seeking decisions. Also, children from wealthy families were more likely to be covered by health insurance. Previous studies have supported this finding [39]. Another study in Shanghai, China, revealed that children from the lowest income households had lesser odds of being insured [31]. A possible explanation is that wealthy parents/caregivers have large disposable incomes. Hence, they can afford health insurance premiums, NHIS card processing charges, and annual renewal fees. It implies that the purpose of the NHIS as a pro-poor social intervention has not been well achieved.
Also, children in rural areas had lower chances of being insured. A study in Ghana reported that women living in remote settings had lower odds of insurance coverage than those staying in urban areas [37]. A conceivable explanation for this finding is that parents of children residing in urban areas may have easy access to health insurance offices. In Ghana, few NHIS offices are sited in rural areas, leading to delays in registering and printing insurance cards. There are also few NHIS personnel and logistics in the rural areas compared to the urban areas [36]. These factors may explain the disparities in insurance coverage across the place of residence. It was revealed that children from the nine other administrative regions were more likely to be insured than those from the Greater Accra Region, Ghana’s capital city. A similar study reported that children in the Greater Accra region were more likely to be non-insured compared with the other regions in Ghana [21]. The Greater Accra region has the lowest health insurance coverage in Ghana [40].
Moreover, we found that children from regions with a high incidence of poverty were more likely to be insured. This finding was expected because the poor perceive health insurance as a form of social security that protects them against catastrophic health care expenditure during health emergencies [41]. This finding may explain why the poorest region in Ghana (Upper East region) has the highest NHIS coverage [40]. Additionally, health insurance enrolment was associated with child’s age. Thus, children aged twelve months or older were more likely to be insured. A similar study in Shanghai, China, reported that older children were less likely to be uninsured [31]. The Free Maternal Health Policy may explain this finding. In Ghana, pregnant women who register with the NHIS have free maternal health care services up to three months postpartum [42]. Our findings imply that vulnerable children did not have health insurance. Consequently, their caregivers/parents may be predisposed to catastrophic health care expenditure. Besides, evidence shows that uninsured children are predisposed to poor health outcomes [43]. Therefore, in the quest to increase health insurance coverage, future interventions should prioritize children from the low socio-economic background.
Strengths and limitations of the study
One major strength of this study is that we analysed nationally representative data so the findings from this study can be generalized to the population. This study is one of the few studies in Ghana investigating socio-demographic determinants of child health insurance. However, this study is not devoid of limitations. Cross-sectional studies cannot establish causal relationships, so the findings should be interpreted with caution. In addition, health insurance status was self-reported by caregivers/parents of the children. Therefore, it may be subjected to social desirability or recall biases.
