Extending Health Insurance to Informal Sector Workers in Ghana

Background: In many Low-and Middle-Income Countries (LMICs), extending health insurance to informal sector workers remains a key challenge for achieving Universal Health Coverage (UHC). In Ghana, despite the implementation of the National Health Insurance Scheme (NHIS), a significant proportion of informal sector workers are not insured or covered by the NHIS, exposing them to catastrophic health expenditure and impoverishment.
Purpose: Explore ways of extending health insurance to informal sector workers in Ghana.
Methods: This PhD research was composed of three key components: (1) a systematic review which examined the impacts of health insurance on UHC goals and identified the facilitators and barriers to the implementation and usage of these health insurance schemes amongst informal sector workers in LMICs, (2) a secondary national data analysis which assessed the impact of the Ghana NHIS on financial risk protection amongst informal sector workers and (3) a mixed-method (Q-sort methodology and qualitative) study examined health insurance design features which have the potential to improve the uptake and use of health insurance amongst informal sector workers in Ghana.
Results: The systematic review findings suggest that health insurance is a more sustainable and effective way of financing healthcare services compared to out-of-pocket payments. However, any health insurance intervention must move beyond traditional enrolment, financing and purchasing strategies. The findings from the secondary data analysis showed that while the NHIS offers financial risk protection for inpatient services, it does not comprehensively shield informal sector households from catastrophic health expenditure and impoverishment. The mixed-method study identified five distinct health insurance designs amongst informal sector workers.
Conclusion: The findings of this study challenge the common assumption that one health insurance design or model fits all informal sector workers and lay the ground for future research to understand how to operationalize the different health insurance features in an effective and cost-effective manner.