The National Health Insurance Scheme in Ghana's Upper West Region: a gendered perspective of insurance acquisition in a resource-poor setting.

Ghana's National Health Insurance Scheme (NHIS) was designed as a pro-poor strategy to create wider access to health care. While recent studies have shown that wealth is an important factor in enrolment in the scheme, there is little understanding of its interlinkages with the geographical divisions and deep-seated deprivation in the northern region. In response to the nexus of poverty, gender and access to health care, this research took place in Ghana's Upper West Region (UWR), one of the poorest regions and yet paradoxically touting the highest enrolment rates. Using data from a population survey (n = 2119) collected between May to December 2011, we used multinomial regression to examine factors that influence enrolment, controlling for theoretically relevant covariates. Findings reveal that although wealth and desire for health insurance are contributing factors, education was the primary determinant in both never enrolling and in dropping out, and that these factors impact men and women differently. The study also shows that Muslims were less likely to enrol and also women living in non-nuclear households were far more likely to dropout. Our results demonstrate clear gendered divisions in accessing the NHIS, and raised serious equity concerns in the UWR. By focussing on the context of the UWR, we show the importance of understanding intra-household bargaining and resource allocation via the gender dynamics related to health insurance procurement and maintenance, and discuss associated policy implications.