The Enrolment Paradox: Qualitative Evidence on Gendered Barriers to National Health Insurance for Ghana's Poorest Households.

Abstract

Ghana's National Health Insurance Scheme (NHIS) was established in 2004 to extend financial protection to all citizens and replace out-of-pocket payments at the point of care. Yet enrolment remains low among recipients of the Livelihood Empowerment Against Poverty (LEAP) cash transfer programme, Ghana's primary social protection instrument for the poorest households, despite formal premium exemptions. This study examined the lived experiences and enrolment motivations of LEAP household heads in two Ghanaian districts (Shai Osudoku, Greater Accra Region; Amansie West, Ashanti Region). Data were collected between 2017 and 2018. Eight focus group discussions (n=56) and eight key informant interviews were conducted and analysed thematically using NVivo. Two motivators were identified: perceived illness vulnerability and perceived financial benefits. Both operated through pronounced gender structures. Female household heads, especially widows and single mothers, were motivated by guaranteed financial access to care, because economic precarity rendered even minor illness expenditure catastrophic. Male household heads demonstrated lower perceived illness vulnerability, a pattern reflecting culturally enforced norms of masculine resilience rather than genuine health status advantage. Critically, strong motivation to enrol did not guarantee enrolment as structural barriers including premium-adjacent costs, administrative complexity, and documentation requirements blocked motivated but uninsured women from acting on their intent. These findings point to identifiable policy failures. The NHIS categorical exemption structure does not adequately capture situational vulnerability among LEAP women. Enrolment outreach is gender blind. And implementation of the formal LEAP-NHIS linkage is operationally weak. The paper concludes with evidence-grounded policy directions for gender-responsive NHIS reform and stronger integration between social protection and health insurance programmes in Ghana and comparable low- and middle-income country settings.