Social Capital And Enrolment In Social Health Insurance: The Experience Of Ghana’s National Health Insurance Scheme (Nhis)

ABSTRACT

In response to calls for studies that highlight the social determinants of Social Health Insurance

enrolment, this study investigated the forms of social capital (SC) in selected communities in

Ghana and how they influence the enrolment decision. It also explored how SC structures in the

selected communities could be leveraged to drive enrolment in Ghana’s National Health Insurance

Scheme (NHIS). Situated in an interpretive paradigm, the study adopted a qualitative research

methodology with semi-structured interviews, focus group discussions and documentary reviews

as the key data collection tools. The data was analyzed thematically in a six staged process.

The study established that SC capital facilitates enrolment decisions in three main ways; bonding,

bridging and linking. Although weakening in recent years, bonding SC expressed through

solidarity, trust and reciprocity within the familial unit is prevalent, providing social support to

people in the communities. Bonding influences the enrolment decision in several ways. Solidarity

creates a sense of responsibility in family members to impress on others to register. Family, friends

and neighbours are trusted sources of information on the NHIS and whether positive or negative,

such information influenced the enrolment decision. On the other hand, bridging SC in the form

of groups and associations was also found to be predominant with religious groups, as the most

important. The groups and associations compensated for the weakening bonds in traditional family

structure. Linking SC in the form of relationships with state institutions seemed weak, with less

engagement between community and state institutions, and mistrust in public officials and

institutions reinforced some negative sentiments among respondents which affected decisions to

enroll. The study revealed that key structures and local community organisations including,

traditional rulers, religious groups, trade unions, business groups NGO’s, CBO’s and their leaders,

are trusted and have a social advantage and their involvement in the NHIS will serve as a badge of

assurance and accountability, and thereby drive people to enrol.

The study makes a number of contributions to enhance understanding of enrolment in social health

insurance (SHI). Situating the enrolment analysis in a SC framework moves the argument beyond

the prevailing dominant explanation that economic factors are the most important determinants of

enrolment. The study demonstrates that in addition to economic factors, other considerations based

on solidarity, reciprocity and trust relations within and among communities shape people’s

decision to enroll in voluntary SHI. By this, SC has proven to be sharper and comprehensive in

explaining enrolment outcomes. Also, the study’s careful examination of the SC structures and

actors that impinge on enrolment (policy outcomes) in a manner which hitherto, had not been so

clearly articulated in this study offers a more nuanced understanding of the subtle relations

between individuals, communities and government institutions, as well as the strategies through

which policies can be embedded and complemented by these structures.