A Systematic review of macro - and meso - determinants of national health insurance enrolment among older adults in Ghana

Abstract

: Achieving universal health coverage (UHC) through the National Health Insurance Scheme (NHIS) has been a priority for Ghanaian governments. Despite the plethora of studies conducted to explore the various factors that influence enrolment into the scheme, there remains a dearth in the literature with regards to a systematic review of the health- and system-level determinants of NHIS enrolment among older adults in Ghana. This study aimed to synthesize evidence on macro- and meso-level determinants of NHIS enrolment among older adults in Ghana. With literature from data repositories including Wiley Web of Science, PubMed, PsycINFO, Scopus, Ovid, Science Direct and Sage, we performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Out of 124 studies screened, the systematic review included 11 articles. The study identified 4 macro- and 3 meso-determinants of national health insurance enrolment among older adults in Ghana. Macro-determinants identified were perceived scheme benefits, affordability, proximity to NHIS offices, quality of administrative service delivery. Physical accessibility, quality of care, and staff attitude were identified as meso-determinants. The study recommends improving physical accessibility, quality of care, and staff attitude. Additionally, it suggests addressing perceived scheme benefits and improving the quality of administrative service delivery.

Keywords:

• National Health Insurance Scheme
• older adults
• enrolment
• Ghana
• scheme factors
• health system factors

PUBLIC INTEREST STATEMENT

The literature is replete with how older adults tend to utilize more healthcare services because of health challenges associated with increasing ageing. However, in Ghana and other developing countries, older adults tend to face financial barriers to healthcare utilization which impact on their utilization of formal healthcare services. This led to the introduction of a national health insurance policy by governments to achieve universal health coverage. Nevertheless, there is dearth of literature on health-system-level factors that influence older adults to enrol on the scheme. Drawing evidence from systematic synthesis performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the study revealed that perceived scheme benefits, affordability, proximity to NHIS offices, quality of administrative service delivery, physical accessibility, quality of care and staff attitude were macro- and meso-determinants of National Health Insurance enrolment among older adults in Ghana. The implications for policy, practice and future research have been discussed to inform policy and research decisions.

1. Introduction

Globally, evidence of an increasing population of older people abounds (United Nations, 2020; World Health Organization, 2015). Projections have shown that 80% of older people (1.6 billion) will live in low and middle-income countries (LMICs) by 2050 (Aboderin, 2010; Beard et al., 2012). While the share number of persons aged 60 years and over remains lower in sub-Saharan Africa (SSA) than elsewhere, the region has the fastest-growing population of older people (Aboderin, 2010; Saka et al., 2019; United Nations, 2015). Increasing from the current rate of 5% to 9.1% by 2050, its absolute number will see the sharpest rise globally, from 42.6 million in 2010 to 160 million by 2050 (Saka et al., 2019). The situation in Ghana bears a striking resemblance. According to Ghana’s demographic profile, persons aged 60 years and above constitute about 7% of the total population, which is among the highest in Africa (Mba, 2004). Similarly, the World Health Organization (WHO) has established that 11% of the population in Ghana was aged 50 years and older in 2005 (Kowal et al., 2010). In 2012, this proportion of older people increased to 11.7% as life expectancy at birth also increased from 59.5 years in 2008 to 61.4 years in 2012 (Duku et al., 2015; Mba, 2004). This demographic shift is expected to have dire consequences for health systems in Ghana since the country is already challenged with providing adequate and age-appropriate healthcare for older people (Agyemang Duah, 2018; Gyasi et al., 2020).

Additionally, ageing in Africa raises specific concerns due to its strong association with increased vulnerability. Limited access to age-appropriate healthcare services and high user fees often increases their health vulnerability (Crooks & Andrews, 2009; Issahaku & Neysmith, 2013; Parmar et al., 2014), as several others face higher levels of unmet healthcare needs (Mcintyre, 2004; Parmar et al., 2014; Saeed et al., 2012). Consequently, many older people have forgone treatments than the youth (Agyemang Duah et al., 2019; Kotoh & Van der Geest, 2016). With the growing population of older adults, the gap between healthcare needs and access is expected to grow further, particularly in the short-term (Alam et al., 2010; George-Carey et al., 2012; Holmes & Joseph, 2011). Acknowledging the increased susceptibility of older people to illness and their lower likelihood of meeting healthcare expenditures, the implementation of social health insurance (SHI) is key to improving health outcomes among this population cohort. Countries like Germany, Austria, Japan, Belgium, South Korea, and Israel have somehow achieved universal health coverage (UHC) through SHI (Nsiah-Boateng et al., 2020). To accelerate efforts towards UHC, several LMICs are experimenting with different health financing models, for instance, SHI and health protection schemes (Carrin & James, 2004, 2005; Kotoh & Van der Geest, 2016; Xu et al., 2005). These efforts signify attempts to lessen healthcare utilization barriers and financing gaps that hinder access to preventive and curative medical services among vulnerable populations. Health insurance through pooled funding is seen as an income-redistributive approach, that results in better access to health services among vulnerable groups by equalising the potential to pay for such services (Van Der Wielen et al., 2018; Van der Wielen et al., 2018b).

The Government of Ghana launched the National Health Insurance Scheme (NHIS) in 2003 through the enactment of the National Health Insurance Act (Act 650 of 2003) and Legislative Instrument (LI) 1809 (Kotoh & Van der Geest, 2016). The scheme provides financial risk protection or buffer to all Ghanaians and legally resident non—Ghanaians against the need to pay healthcare user fees at the point of service use for well-defined health problems (Dzakpasu et al., 2012; Gobah & Zhang, 2011; Nsiah-Boateng et al., 2020), contingent on enrolment and yearly membership renewal. Exemptions are however, provided for vulnerable groups: children below 18 years, older adults (70 years and above), indigents (Adei et al., 2019), pregnant women and mentally challenged persons (Kotoh & Van der Geest, 2016; Nsiah-Boateng & Aikins, 2018). Enrolment in the scheme peaked during the early years of execution and stagnated at around 40% of the population between 2011 and 2015 (Agyepong et al., 2016). As of June 2022, the NHIS enrolment pattern showed an official statistic indicating that the national population coverage had reached 54%, and the active membership had increased to over 16 million (National Health Insurance Authority [National Health Insurance Authority [NHIA], 2022).

Since older persons suffer from a wide array of psychological distress, chronic conditions and multimorbidity (Banerjee et al., 2015; Gyasi & Phillips, 2018; McCracken & Phillips, 2017) which possibly increases their demand for healthcare, the need for older adults—which in this context refers to persons 50 years and above to enrol in the NHIS cannot be overemphasised. The health insurance scheme thus provides a financial cushioning against healthcare expenditure, thereby reducing financial exclusion as a barrier to healthcare use among older people (Agrigoroaei et al., 2017; Aguila et al., 2016; Oduro Appiah et al., 2020). It, therefore, shows the need for older persons to enrol in the NHIS. Literature on scheme-related and health-system-associated factors of NHIS enrolment among older adults in Ghana abound (Alatinga & Williams, 2015; Kotoh et al., 2018; Salari et al., 2019; Van Der Wielen et al., 2018; Van der Wielen et al., 2018a), but fragmented. This review was motivated by the fragmentation of the literature on the subject, aiming to bridge this gap and generate synthesized evidence to inform policy. In this paper, we conducted a systematic review that consolidates empirical literature to provide a more comprehensive understanding of the scheme (macro)- and health-system (meso) determinants of NHIS enrolment among older adults in Ghana. The authors, therefore, reviewed literature on how the perceived value, affordability, proximity to NHIS offices and designated registration and membership renewal centres, efficiency in registration, and overall satisfaction with healthcare delivery influenced older adults’ enrolment in the NHIS. Identifying and synthesising evidence on the scheme- and health-system determinants of NHIS enrolment among older adults in Ghana could be useful in proposing policy reforms that work to increase and sustain enrolment with the scheme while providing frameworks for accessible and improved healthcare delivery.

2. Literature review

2.1. Empirical review

The NHIS in Ghana was launched in 2003 as part of the government’s efforts to achieve UHC (Morgan et al., 2022; Quartey et al., 2023). The NHIS is an SHI program (Fenny et al., 2021; Osei Afriyie et al., 2022) that provides access to affordable and quality healthcare services to Ghanaians (Nsiah-Boateng & Aikins, 2018; Suchman et al., 2020). The scheme operates on the principle of risk pooling, where members make contributions to a common fund which is used to finance healthcare services for all members. Ghana’s NHIS established a National Health Insurance Fund (NHIF) to ensure its sustainability and smooth operation (Kipo-Sunyehzi et al., 2019). The NHIF is funded through various sources, including a health insurance levy, contributions from the Social Security and Pensions Scheme Fund, parliamentary allocations, investments made by the NHIS Council, and voluntary contributions (Kipo-Sunyehzi et al., 2019). NHIS targets two categories of persons for enrolment: all persons and particular groups, reconciling universal and particular groups’ provisions for health equity (Fuller, 1997). There are various pathways for enrolling in the NHIS, including community-based registration, registration through NHIS district offices, and registration through mobile registration teams (Kwarteng et al., 2020; Nsiah-Boateng et al., 2020). Enrolment costs for persons aged 18 years to 69 years are GH₵ 28.00 ($3.73) (Morgan et al., 2022; Quartey et al., 2023), and GH₵ 6.00 ($0.80) for active Social Security and National Insurance Trust (SSNIT) donors. However, exemptions are offered to vulnerable populations including older adults aged 70 and above, and the hard-core poor. Overall, Ghana’s NHIS offers financial assistance for the payment of healthcare user fees at the point of use, subject to enrolment and continuous membership renewal.

Several individual-level (Baozhen et al., 2019; Duku, 2018; Kotoh et al., 2018; Salari et al., 2019; Van Der Wielen et al., 2018; Morgan et al., 2022), scheme-related (Alatinga & Williams, 2015; Ayitey et al., 2013; Baozhen et al., 2019; Duku et al., 2015; Kotoh et al., 2018; Salari et al., 2019; Van Der Wielen et al., 2018; Van der Wielen et al., 2018a), and health-system (Alatinga & Williams, 2015; Baozhen et al., 2019; Duku et al., 2015; Kotoh et al., 2018; Salari et al., 2019; Van Der Wielen et al., 2018; Van der Wielen et al., 2018a) determinants have been found to influence NHIS enrolment among the generality of the Ghanaian population (Adjei-Mantey & Horioka, 2022; Salari et al., 2019) and older adults alike. At the individual-level, factors such as age (Alatinga & Williams, 2015; Ayitey et al., 2013; Duku et al., 2015), income (Van Der Wielen et al., 2018; Van der Wielen et al., 2018a, 2018b), education (Parmar et al., 2014; Salari et al., 2019; Van der Wielen et al., 2018a, 2018b), and health status (Salari et al., 2019; Van der Wielen et al., 2018a, 2018b) have been found to affect enrollment rates. Older adults with low income and education levels were found to be less likely to enrol due to financial constraints and limited awareness of the scheme. Additionally, older adults with chronic health conditions may be more likely to enrol in the scheme to access regular and affordable healthcare services.

Scheme-related determinants of NHIS enrolment (Salari et al., 2019; Van Der Wielen et al., 2018; Van der Wielen et al., 2018a) have been extensively discussed in the literature, and they refer to the attributes of the health insurance scheme that influence individuals to either enrol or not enrol in the scheme. Various scheme-related determinants have been identified, including enrolment fees, perceived benefits of the insurance scheme, proximity to NHIS offices and designated registration and membership renewal centres, and the quality of administrative service delivery at health insurance offices (Salari et al., 2019; Van Der Wielen et al., 2018; Van der Wielen et al., 2018a). Individuals may be deterred from enrolling in the NHIS due to high enrolment fees and a perception of limited benefits. Additionally, those residing far from NHIS offices and designated registration and membership renewal centers may encounter difficulties in accessing the scheme. Potential enrollees may face hindrances stemming from poor administrative service delivery at NHIS offices (Baozhen et al., 2019; Duku et al., 2015; Kotoh et al., 2018; Van der Wielen et al., 2018b). These scheme-related determinants are critical in shaping enrolment decisions and have significant implications for the achievement of universal health coverage in Ghana. To promote equitable access to healthcare services, policymakers and NHIS administrators must develop effective strategies that can enhance enrolment. Understanding the scheme-related determinants and addressing them adequately is essential in achieving the goal of providing affordable and accessible healthcare services for all Ghanaians. The NHIS has the potential to achieve universal health coverage in Ghana, but it requires the cooperation and support of all stakeholders, including policymakers and health insurance administrators, and the entire citizenry.

Access to healthcare services is a fundamental human right that is enshrined in the Constitution of many countries, including Ghana. However, for older adults, accessing healthcare services under the NHIS can be hindered by health-system determinants (Alatinga & Williams, 2015; Baozhen et al., 2019). The literature identifies three critical health-system determinants that can either facilitate or hinder enrolment in the NHIS among older adults. Firstly, the availability and accessibility of health facilities are crucial (Duku, 2018; Kotoh et al., 2018; Parmar et al., 2014; Van Der Wielen et al., 2018; Van der Wielen et al., 2018b). Poor access to health facilities can deter older adults from enrolling in the NHIS, especially those living in rural areas, owing to spatial limitations. Secondly, the quality of healthcare services provided under the NHIS is another important determinant (Alatinga & Williams, 2015; Baozhen et al., 2019; Kotoh et al., 2018). Poor quality services can discourage older adults from enrolling in the NHIS, even if health facilities are available and accessible. Finally, the attitude of healthcare providers towards older adults is an essential determinant of NHIS enrolment. Negative attitudes towards older adults can discourage them from accessing healthcare services under the NHIS (Alatinga & Williams, 2015; Baozhen et al., 2019).

In conclusion, conducting a study on the macro- and meso- determinants of health insurance enrolment is crucial because they can significantly influence individuals’ decisions to enrol or not, and resulting in a profound impact on the overall performance of the healthcare system that extends beyond individual-level determinants. Policymakers and NHIS administrators need to understand these determinants to design effective strategies that can promote equitable access to healthcare services. This study aims to identify and synthesize the macro- and meso- determinants of NHIS enrolment and provide valuable insights into how the NHIS can be improved to enhance enrolment and contribute to the achievement of universal health coverage in Ghana.

2.1.1. Theoretical review

The study is underpinned by the Social Ecological Model (SEM). The SEM is a theoretical framework that describes the complex interplay between individual, interpersonal, community, and societal factors (Bronfenbrenner, 1977, 1994; Kilanowski, 2017; Trego & Wilson, 2021; Tudge et al., 2022). The SEM provides a useful framework for understanding the multiple levels of influence on health insurance enrolment in the context of the study on determinants of NHIS enrolment among older adults in Ghana. The model acknowledges that health behaviour is not solely determined by individual-level factors, such as attitudes and beliefs, but also by interpersonal, community, and societal-level factors. This is particularly relevant in the case of NHIS enrolment, where factors such as premium payment, membership renewal, and quality of healthcare services (Duku, 2018; Kotoh et al., 2018; Van Der Wielen et al., 2018; Van der Wielen et al., 2018b) are not just determined by individual choices but are also influenced by the social and cultural context in which individuals live. The SEM provides a comprehensive approach to examining these factors and their interplay, highlighting the need for multi-level interventions to improve NHIS enrolment among older adults in Ghana.

At the individual level, the SEM highlights factors such as age, gender, education, and income that may impact an individual’s decision to enrol in NHIS. For example, older adults may be more likely to enrol in NHIS due to their increased healthcare needs, while those with low levels of education or income may face barriers to enrolment due to lack of information or financial constraints. While the SEM framework does include an individual-level factor (Bronfenbrenner, 1994), this study will not specifically cover individual-level determinants such as age, gender, education, and income. Instead, the focus will be on scheme- and health-system factors that operate at the macro- and meso- levels, including premium payment, membership renewal, membership card replacement, geographical access to NHIS registration centres, quality of health care services, and health care staff attitudes towards older adults. By examining these determinants, the study can provide insights into how to improve NHIS enrolment among older adults in Ghana and help policymakers to develop targeted interventions and policies that address the specific barriers to enrolment at the macro and meso levels.

At the interpersonal level, the SEM highlights the importance of social networks, social support, and interpersonal communication (Bronfenbrenner, 1994; Hertler et al., 2018) in shaping health behaviours. For NHIS enrollment among older adults, interpersonal factors such as family and peer support may play a critical role in encouraging enrolment and providing assistance with the enrolment process. Additionally, the study explores the potential impact of community-based interventions or social marketing campaigns that leverage social networks to promote NHIS enrolment among older adults. Scheme- and health- system factors affect the availability and accessibility of NHIS enrolment and healthcare services, which can then influence interpersonal factors such as social support and communication. For instance, if premium payments are too high or renewal and card replacement processes are too complicated, older adults may face difficulties enrolling and may not receive the necessary support from family and peers. Similarly, if there are limited NHIS registration centres or poor-quality healthcare services, older adults may feel less inclined to enrol in NHIS, leading to a lack of social support and communication around enrolment. In this way, macro and meso-level factors can indirectly influence interpersonal factors, highlighting the need to examine these factors in tandem to better understand the determinants of NHIS enrolment among older adults. The reverse also holds.

Community-level factors play a significant role in determining NHIS enrolment among older adults in Ghana. These factors include the availability and accessibility of NHIS registration centres and the quality of healthcare services. The SEM provides a useful framework for understanding these determinants and identifying community-based interventions that can facilitate enrolment. Studies have shown that community-based campaigns can increase awareness and understanding of NHIS benefits and enrolment processes, while interventions to improve the availability and quality of healthcare services can reduce barriers to healthcare access and promote enrolment. Improving community-level factors can thus contribute to enhancing NHIS enrolment rates among older adults in Ghana.

At the societal level, structural and policy factors play a crucial role in shaping NHIS enrolment among older adults in Ghana. The SEM framework emphasizes the importance of identifying and addressing societal-level factors to promote enrolment. Studies suggest that government policies and regulations can impact enrolment rates and that policy changes can make enrolment more accessible and incentivize enrolment among older adults. Addressing societal-level factors can contribute to improving NHIS enrolment rates among older adults in Ghana.

One limitation of the SEM is that it can be challenging to apply to specific contexts and populations due to the multiple levels of influence and complex interactions between them. To address this limitation, the study focuses on specific determinants of NHIS enrolment among older adults that are most relevant to the Ghanaian context and provides detailed explanations of how each determinant fits within the SEM. In conclusion, the SEM provides a useful framework for understanding the multiple levels of influence on NHIS enrolment among older adults in Ghana. By considering interpersonal, community, and societal factors, the study identifies specific strategies to improve NHIS enrolment rates among older adults.

3. Study design

3.1. Methods

A systematic review, an approach to evidence synthesis, was conducted to gain a deeper understanding of scheme-and health- system determinants of NHIS enrolment among older adults in Ghana. Systematic reviews are known for their rigorous and comprehensive approach to identifying and synthesizing evidence from multiple studies (Higgins et al., 2019). This is especially important for a study like this, which seeks to identify and evaluate all available evidence on the determinants of health insurance enrollment among older adults in Ghana. A systematic review typically employs a transparent and replicable methodology that allows other researchers to evaluate the quality of the study and verify its findings (Dickersin et al., 1994; Higgins et al., 2019). This level of transparency and replicability is essential for ensuring the validity and reliability of the study’s conclusions. Furthermore, a systematic review is the most appropriate review methodology for this study because it is designed to minimize bias and error by using a structured and comprehensive approach to identify, select, and synthesize all available evidence on a specific research question (Higgins et al., 2019).

The methodology used in this study employed a five-stage approach (Bambra, 2011; Bougioukas et al., 2018) that included defining the research question and objectives, establishing the scope of the study, comprehensively searching various databases to identify relevant studies that met the inclusion criteria, screening the identified studies for relevance, and assessing the quality of the studies. The data were analyzed by synthesizing the findings from the included studies, identifying patterns and trends, and drawing conclusions. Finally, the research team presented the results of the analysis clearly and concisely. The five-stage methodology ensured a systematic approach to the research process, allowing for a rigorous and transparent synthesis of the available evidence.

3.2. Inclusion criteria

The systematic review focused on the scheme- and health-system factors that influence NHIS enrolment among older adults in Ghana. This included core areas of perceived worth of the scheme, affordability of premiums, proximity to NHIS offices and designated registration and membership renewal centres and administrative efficiencies (macro or scheme factors) and proximity to health facilities, quality of healthcare services and staff attitude (meso or health-system factors). Since no standard definition exists for older people, the World Health Organization (WHO) definition of older adults was adopted for the study. WHO (2011) defines an older adult as an individual who is 50 years or above. While this is lower than the 60 years or above often used by the United Nations (UN), it aligns with the lower life expectancy of developing countries (Ghana Statistical Service, 2013; UN, 2013). Specifically, the included papers were empirical studies that addressed scheme- and health-system determinants of enrolment in the health protection scheme among older adults in Ghana. Peer-reviewed articles published in the English Language, from January 2010 to July 2020 and contained evidence from Ghana were studies that met the inclusion criteria. The choice of the year range was premised on the rise to prominence of research on the determinants of NHIS enrolment in Ghana.

3.3. Exclusion criteria

Articles excluded were based on predisposing, enabling and need factors of NHIS enrolment. Other excluded papers were conference abstracts, book chapters, papers that present opinions, editorials, commentaries and reviews. The exclusion of reviews of any form from the eligible papers was premised on the basis that reviews are not empirical studies—but secondary studies rely on evidence from existing articles. In this study, we set out to review only empirical papers as such, the inclusion of reviews of any form will have constituted an anomaly. Additionally, papers published before 2010 and in any other part of the world other than Ghana were excluded—since research on the predictors of enrolment in the NHIS shot into the limelight from 2010 onwards. The exclusion of papers published before 2010 is premised on the fact that these studies were largely on the financing of the scheme, and the effects of enrolment on service utilization for specific ailments (Ansah et al., 2009; Dalaba, 2009; Rajkotia, 2009; Sekyi, 2009), challenges confronting the scheme (Boakye, 2008), and factors contributing to low enrolment in the scheme (Prah, 2006), without disaggregated evidence for older adults on determinants of enrolment in the health protection scheme. These studies were therefore considered inconsequential to the attainment of the study’s objective.

3.4. Problem identification

In the first stage of the systematic review, the we defined the research question and objectives and established the scope of the study. We identified key research questions to answer and developed objectives to guide the study. The scope of the study was defined by determining the population, interventions, comparisons, outcomes, and study designs that would be included in the review. We recognized that a well-defined research question and scope were critical to ensuring a focused systematic review that produced relevant research findings.

The formulation of appropriate research questions helps in the retrieval of relevant literature or articles (Bettany-Saltikov, 2012). The PICO (T) [population, intervention, comparative intervention, outcome and time] approach was used to develop the review question (Bettany-Saltikov, 2012; Doody & Bailey, 2016). PICOT approximates the essential elements of the research question and is an upheld pedagogical model (Welty et al., 2012). The PICOT components were (P) older adults, (I) National Health Insurance Scheme (NHIS), (C) no comparisons were made, (O) enrolment in the NHIS and (T) 2010 to 2020 (Welty et al., 2012). By using this framework, we ensured that the research question was specific, relevant, and answerable. The framework helped to ensure that the review is focused and that the research findings are relevant to the research question. It also promotes systematic and transparent research, leading to reliable findings. This approach helped provide targeted and actionable recommendations for improving health policies and programs, ultimately leading to better health outcomes for older adults, in this case, NHIS enrolment among older adults in Ghana.

3.5. Search strategy and selection procedure

The second stage of the systematic review involved conducting a comprehensive search of various databases to identify relevant studies that meet the inclusion criteria. During this stage, the researchers used a range of search terms and strategies to ensure that all relevant studies were identified. The inclusion criteria were used to guide the search process. The goal was to identify all relevant studies that met the inclusion criteria, and to provide a comprehensive and unbiased analysis of the evidence.

The search for published articles was conducted in seven electronic databases, namely Wiley Web of Science, PubMed, PsycINFO, Scopus, Ovid, Science Direct and Sage. The suggested guidelines by the Joanna Briggs Institute (JBI) were used to develop the search strategy (Badu et al., 2019; Pearson et al., 2014). Specifically, a three-step search approach was implemented to support the search for articles (refer to Table 1). A preliminary restricted search was undertaken in PubMed and Wiley Web of Science. The text and words within the title and abstract and the index terms from this preliminary search results were analysed (Pearson et al., 2014). A second search containing all the index terms and the identified keywords was then repeated across the five remaining databases (refer to Table 1). Lastly, the reference lists of all eligible studies that were electronically missed were manually hand-searched (Armstrong et al., 2015; Badu et al., 2019; Pearson et al., 2014).

Table 1. Search strategy and selection procedure

Steps	Database	Search Terms and Keywords
One	(Initial search in PubMed and Wiley Web of Science)	ALL (“enrol”*) AND (“health insurance” OR “NHIS”) AND (“scheme” OR “health system”) (“older adults” OR older people OR “adults”)
Two	(Search across, Scopus, PsycINFO, Science Direct, Ovid, and Sage)	ALL (“enrol”* OR “register”* OR “join”) AND (“health insurance” OR “NHIS” OR “health protection”) AND (“scheme value” OR “affordability” OR “proximity to office” OR “enrolment processes”) AND (“older adults” OR older people OR “adults” OR “older folks” OR “older individuals”) (“enrol”* OR “register”* OR “join” OR “subscribe”) AND (“health insurance” OR “NHIS” OR “health protection” OR “health cover”) AND (“access to healthcare” OR “quality health services” OR “staff attitude” OR “staff behaviour”) AND (“older adults” OR older people OR “adults” OR “older folks” OR “older individuals” OR “elderly”)
Three		Hand searching of the reference lists

The selection of eligible articles (see Figure 1) adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher et al., 2010; Moher et al., 2015). Five researchers critically and independently appraised the titles of articles that were retrieved and approved those meeting the selection criteria. The titles and abstracts were reviewed and agreement was reached on those needing full-text screening. The full screening was done following the inclusion and exclusion criteria.

Figure 1. Flow chart of studies included in the review based on PRISMA.

3.6. Data management and extraction

In the third stage of the systematic review, we screened the identified studies for relevance and assessed their quality. We evaluated the studies to determine whether they met the inclusion criteria and assessed their quality. To achieve this, we reviewed the titles, abstracts, and full texts of the studies to determine their relevance to the research question. We used Cochrane Risk of Bias tool to evaluate the risk of bias in the included studies.

No fixed standards for the appraisal of the validity of scientific literature exist (Young & Solomon, 2009). The guide to a critical assessment of literature by Young and Solomon (2009) was employed to evaluate the selected papers. The data extraction form was divided into sub-sections, for instance, the study details (authors and year of publication), the objective of the paper, and the primary subject area of the paper (scheme or health system determinants). The authors critically appraised and retained all eleven papers for analysis. Inter-rater reliability, which provides for a comparison of the same event by more than one observer (Botma et al., 2010) was employed to establish the quality of the appraisal tool (Foster & Shurtz, 2013). The reviewers independently evaluated the included papers and assigned scores or ratings based on established criteria. The scores assigned by each reviewer were then compared to determine the degree of agreement or consistency among the reviewers. The Spearman Correlation Coefficient was used to determine the inter-rater reliability of their scores. A significant correlation was found between the scores of all the five reviewers. The strongest correlation exists between reviewers 1 and 2 while the weakest correlation exists between reviewers 2 and 5. Refer to Table 2 for more details.

Table 2. The inter-rater reliability between the reviewers

Spearman Correlation Coefficients, N=11 Prob > [r] under H0: Rho = 0
	Reviewer 1	Reviewer 2	Reviewer 3	Reviewer 4	Reviewer 5
Reviewer 1		0.940*	0.765*	0.816*	0.794*
		0.000	0.006	0.041	0.025
Reviewer 2			0.774*	0.811*	0.627*
			0.005	0.044	0.009
Reviewer 3				0.771*	0.817*
				0.036	0.018
Reviewer 4					0.091*
					0.008
Reviewer 5

Note: *. Correlation is significant at the 0.05 level

3.7. Data synthesis

In the fourth stage, we synthesized the findings from the included studies, identified patterns and trends, and concluded. We aimed to provide a comprehensive and unbiased analysis of the evidence. To synthesize the findings, we used a narrative approach. We carefully analyzed the data to identify common themes, discrepancies, and gaps in the evidence. This analysis helped to provide a broader understanding of the research question and to draw robust conclusions. This stage of the review was crucial in ensuring that the research findings were accurately interpreted and that the conclusions drawn were evidence-based.

The thematic approach to evidence synthesis was used to tease-out evidence from the extracted data (Braun & Clarke, 2006; Denscombe, 2017). To operationalize the thematic analysis, the following procedures were executed. The authors reviewed all eleven papers and identified various subject matters from the papers. The identified subject matters were read and re-read by the authors for data familiarisation to gain an in-depth feeling as well as get a better meaning of the results. These subject matters were classified based on their associations and relatedness. Further classification was done, where the initially identified subject matters relating to determinants of enrolment in the NHIS were grouped under themes. At this stage, each subject matter was classified under a major theme to provide meaning and coherence. The thematic analysis provided for the identification of patterns, seeing associations, grouping, making comparisons and subsuming particulars, noting relationships between variability and finding intervening factors (see Table 3).

Table 3. The key emerging themes

Themes	Sub-themes	N^a	Papers
Scheme-related factors	Affordability of enrolment fee	8	Salari et al. (2019); Van Der Wielen et al. (2018); Van der Wielen et al. (2018a); Kotoh et al. (2018); Alatinga and Williams (2015); Duku et al. (2015); Parmar et al. (2014); Ayitey et al. (2013)
	Perceived benefits of the insurance	4	Baozhen et al. (2019); Kotoh et al. (2018); Alatinga and Williams (2015); Duku et al. (2015)
	Proximity to NHIS offices and registration centres	4	Baozhen et al. (2019); Van der Wielen et al. (2018b); Kotoh et al. (2018); Duku et al. (2015)
	Quality of administrative service delivery at localized health insurance secretariats	4	Baozhen et al. (2019); Van der Wielen et al. (2018b); Kotoh et al. (2018); Duku et al. (2015)
Health system factors	Availability of health facilities	5	Van Der Wielen et al. (2018); Van der Wielen et al. (2018b); Duku (2018); Kotoh et al. (2018); Parmar et al. (2014)
	Quality of healthcare delivery under NHIS	3	Baozhen et al. (2019); Kotoh et al. (2018); Alatinga and Williams (2015)
	Staffs attitude	2	Baozhen et al. (2019); Alatinga and Williams (2015)

Note: N^a: Number of papers that reported on a determinant

4. Results

In the fifth stage of the systematic review, we presented the findings clearly and concisely. The discussion section was also included, which provided context for the findings and their implications for practice and future research.

5. Description of the reviewed articles

From the total of one hundred and twenty-four (124) articles downloaded, only eleven articles met the inclusion criteria. Five of the articles were cross-sectional surveys in which the authors obtained primary data from older adults on associated factors (including scheme and health system determinants) of NHIS enrolment. Six of the papers used secondary data from rounds 5, 6 and 7 of the Ghanaian Living Standards Survey (GLSS); the 2014 Ghanaian Demographic and Health Survey (DHS); the 2011 Multiple Indicator Cluster Survey (MICS) and 2007–2008 Study on Global Ageing and Adult Health (SAGE).

6. Themes generated from the data

Based on commonalities identified in the studies, the following sub-themes were developed as auxiliaries to scheme- and health- system determinants of NHIS enrolment among older adults in Ghana. Enrolment fees, perceived benefits of the insurance, proximity to NHIS offices and designated registration and membership renewal centres and the quality of administrative service delivery at health insurance offices were the sub-categories under macro (scheme) factors that influence enrolment. Availability of health facilities, quality and satisfaction with healthcare services and the attitude of healthcare providers were the sub-themes under meso (health-system) factors that determine NHIS enrolment (see Table 3).

7. Macro (Scheme-related) determinants of NHIS enrolment

Scheme-related determinants of NHIS enrolment denote attributes of the health insurance scheme that influence individuals to enrol or not to enrol in the scheme. Enrolment fees, perceived benefits of the insurance scheme, proximity to NHIS offices and designated registration and membership renewal centres and the quality of administrative service delivery at health insurance offices were the specific scheme-related determinants identified in the literature.

7.1. Affordability of enrolment fee

Enrolling in a health protection scheme like Ghana’s NHIS requires the payment of an enrolment fee and yearly premiums. A major theme that runs through the articles reviewed is that the scheme is pro-rich biased. As such, the enrolment decision of older adults is largely influenced by their ability to afford the enrolment fee and yearly premiums (Alatinga & Williams, 2015; Ayitey et al., 2013; Duku et al., 2015; Kotoh et al., 2018; Parmar et al., 2014; Salari et al., 2019; Van Der Wielen et al., 2018; Van der Wielen et al., 2018a). By this, older adults who have the financial capacity to afford the enrolment fee and yearly premiums were more likely to enrol in the scheme compared to those from poor households. This is highly linked to income as an enabling factor under the individual determinants of NHIS enrolment. Although poverty contributes to low enrolment, it is only an important factor among the poorest and some poor households with many members.

7.2. Perceived benefits of the insurance scheme

Four of the articles reported perceived benefits of the scheme as a determinant of older adult’s decision to enrol in the health protection scheme (Alatinga & Williams, 2015; Baozhen et al., 2019; Duku et al., 2015; Kotoh et al., 2018). When older adults perceive the scheme as beneficial by lessening their healthcare expenditure, the likelihood of enrolling is high. On the contrary, when they perceive the scheme to be of no benefit to them, the likelihood to enrol is low. Therefore, the perceived cost-benefit variance in the premium payment and the usage of health services is a determining factor in the decision to enrol. Acceptance of the NHIS card at health facilities as a form of guarantee of payment increases enrolment in the scheme among older adults (Baozhen et al., 2019; Duku et al., 2015). To this end, once the NHIS meets the objective for which it was set up (to provide a buffer to Ghanaians especially the poor, the vulnerable and the aged as far as healthcare utilisation is concerned); it serves as a facilitating factor for enrolment among older people.

7.3. Proximity to NHIS Offices

Four papers reported an association between proximity to NHIS offices and registration centres and the enrolment of older adults (Baozhen et al., 2019; Duku et al., 2015; Kotoh et al., 2018; Van der Wielen et al., 2018b). All four papers reported that proximity to the national health insurance office or registration centres increases the possibility of older adults enrolling in the scheme. In cases where older people lived close to registration centres, they tend to enrol; but their likelihood to enrol in the NHIS decreases as farther away they reside from registration centres. This is attributed to the mobility challenge older adults encounter, as such travelling to far distances to get registered in the scheme becomes a problem. Nearness to a registration centre, therefore, serves as an incentive to enrol in the health insurance scheme.

7.4. Quality of administrative service delivery at District Health Insurance Schemes (DHISs)

Service delivery at health insurance offices is the fourth scheme-related determinant identified in the literature. Precisely, four papers (Baozhen et al., 2019; Duku et al., 2015; Kotoh et al., 2018; Van der Wielen et al., 2018b) reported an association between service delivery at localised health insurance offices and registration outlets and enrolment among older adults. Procedural delays in addition to systemic and structural constraints such as inadequate office accommodation, equipment malfunctioning and materials inadequacy undermined the efficient functioning of District Health Insurance Schemes (DHISs). Consequences of these challenges are delays in the issuance of cards and long queues at registration centres – an occurrence that reduces the likelihood of older adults enrolling. Conversely, the papers reported that efficient and timely registration increases the tendency of older adults to enrol since they do not have to join long queues and suffer the unfortunate event of coming back at a later date(s) to capture their data (with its associated time, transportation and financial burden).

8. Meso (Health- system) determinants of NHIS enrolment

Health-system determinants of NHIS enrolment denote elements within the health care delivery structure that facilitates or hinders enrolment decision of individuals (in this case older adults). Three main health-system determinants of NHIS enrolment among older adults were the availability and accessibility of health facilities; quality of healthcare services under the scheme; and attitude of healthcare providers were identified.

8.1. Availability and accessibility of health facilities

Health economics literature is replete with the declining rate of health service utilisation with distance from health facilities. This ultimately has a cascading effect on NHIS enrolment decisions of older adults since the farther away they are from health facilities, the lower the likelihood of healthcare utilization (all things being equal). This effect was reported by five papers (Duku, 2018; Kotoh et al., 2018; Parmar et al., 2014; Van Der Wielen et al., 2018; Van der Wielen et al., 2018b). Travel time to health facilities, accompanied by high transport costs were put forward as barriers to health service use (especially when juxtaposed against alternatives, like the use of traditional medicine and reliance on self-medication for quick relieve from health complications). For instance, Duku (2018) found that a longer travel time to health facilities is associated with lower NHIS enrolment rates among older adults. This finding suggests that the closer a health facility is to where older adults live, the more likely they are to enrol in the NHIS. A minute increase in travel time, which could be due to factors such as distance, traffic, or transportation costs, reduces the odds of NHIS enrolment by 2%. Further, access to health facilities positively influenced insurance enrolment among older adults 50 years and above, with the strongest effect found among those above 70 years (Van Der Wielen et al., 2018). This is telling of the inverse relationship between NHIS enrolment and distance to health facilities.

8.2. Quality of healthcare services under the scheme

Older adults’ perception of the care provided under the NHIS influences their enrolment decision. Three papers reported that quality care under the NHIS increases the possibility of enrolling whereas poor services under NHIS reduce the potential to enrol among older adults (Alatinga & Williams, 2015; Baozhen et al., 2019; Kotoh et al., 2018). This low-quality service manifests itself in the unavailability of drugs and other essential supplies for insured patients receiving treatment under the scheme, paying for drugs by insured patients and long waiting times. The shortage of drugs on the National Health Insurance Drug List undermines healthcare providers’ desire to provide quality service to insured patients. According to Kotoh et al. (2018), this shortage is attributed to delays in claim payment which is expected to be within four weeks after claim submission to DHISs but does not happen. These intricate factors act to create healthcare utilization barriers for older adults. In response, the likelihood to enrol decreases for persons greatly affected while it motivates others when these factors are favourable.

8.3. Attitude of healthcare providers

Two papers reported that the behaviour and conduct of health professionals toward individuals seeking healthcare under the scheme motivated or hindered the enrolment decision of older adults (Alatinga & Williams, 2015; Baozhen et al., 2019). Alatinga and Williams (2015) discovered that welcoming attitudes by health professionals towards insured older adults using health services form a positive opinion among other older adults. This positive opinion ultimately has a positive effect on the decision to enrol in the scheme (all things being equal). However, the reverse is true when negative perceptions and opinions are formed among older adults following the demonstration of poor attitudes towards insured persons seeking healthcare under the NHIS. The positive attitudes include the exhibition of professionalism and good communication by healthcare workers. On the contrary, unhealthy behaviours like deliberately keeping insured patients while attending to those who pay cash in addition to the illegal sale of drugs covered by the NHIS reduce the likelihood of enrolling in the scheme.

9. Discussion

We conducted a systematic review that recapitulates past empirical literature to provide a comprehensive understanding of the NHIS-related and health-system determinants of NHIS enrolment among older adults in Ghana. The need for such a study is premised on the absence of reviews of such nature within the research landscape in Ghana, despite the exigencies of such reviews to inform policy by providing a holistic understanding of NHIS enrolment among older adults. To achieve this objective, a comprehensive literature search was conducted using keywords in some notable databases. The downloaded articles were screened in light of some pre-determined inclusion and exclusion criteria. Through this procedure, eleven papers were retained, as they met the inclusion criteria of being an empirical study that addressed scheme and health-system determinants of enrolment in NHIS among older adults in Ghana; and is a peer-reviewed article published in the English Language, from January 2010 to July 2020. By way of finding, affordability of NHIS enrolment fees, proximity to NHIS offices and designated registration and membership renewal centres and efficiency in registration were identified as NHIS-related factors (macro factors) that influenced enrolment in the scheme among older adults. Again, the availability of health facilities, the quality of health services under the NHIS scheme and the attitude of healthcare providers towards persons seeking healthcare under the NHIS policy were health-system factors that influenced older adults’ willingness to enrol in the health protection scheme. Overall, the study provided evidence of the effect that can help in proposing policy reforms that work to garner interest and desire among older adults to register with the scheme.

The cost of enrolment was identified as a scheme factor that determines NHIS enrolment among older adults. For older adults from poorer socio-economic backgrounds, enrolment fees and yearly premiums were perceived as barriers that reduce the likelihood of enrolling. This consequently makes the scheme a pro-rich bias health protection scheme according to the literature. Price, which includes registration fees and yearly premium as an associated factor of NHIS enrolment has been reported in previous studies on social-health protection schemes (Asante & Aikins, 2008; Basaza et al., 2007; Bennett et al., 1998; Chankova et al., 2008; De Allegri et al., 2006; Jakab et al., 2001; Musau, 1999; Schmidt et al., 2006). A conceivable solution to address this rests in the enhanced implementation of premium exemptions or waivers for poor older adults (Aryeetey et al., 2010; Jakab & Krishnan, 2004; Jehu-Appiah et al., 2010). Possibly, this could include a reduction of the minimum exemption age to 60 years to coincide with the retirement age in Ghana (see the Ghana National Pensions (Amendment) Act, 2014 Act 883). Since most workers who go on pension are faced with financial constraints.

Perceived benefits of the scheme as a determinant corroborates the multiplicity of studies where scheme benefits served as a motivating factor for individuals’ decision to enrol in health protection schemes (Durairaj et al., 2010; Jehu-Appiah et al., 2011; Mensah et al., 2010; Nsiah-Boateng & Aikins, 2018). It behoves that sensitization on the prospects of the scheme is increased. Again, proximity to NHIS offices and service delivery at localized health insurance secretariats determining enrolment aligns with past research (Boateng & Awunyor-Vitor, 2013; Carrin et al., 2005; De Allegri et al., 2009; Jehu-Appiah et al., 2011). Scheme administrators should address operational difficulties that appear to hamper enrolment and timely issuance of identification cards.

For older adults, in particular, physical accessibility of health services is a major determinant of healthcare utilisation since they are less mobile, thus making it challenging to travel long distances to seek healthcare. Long distance to health facilities’ influence on enrolment decisions among older adults concur with other studies (Adu, 2015; Akazili et al., 2014; Osei-Akoto & Adamba, 2011). Again, Kusi et al. (2015) found that most households who enrolled lived less than 2 km from the nearest NHIS-accredited health facilities—demonstrating the influence of distance to health facilities on NHIS enrolment. The review showed that insurance enrolment is related to the provision of health facilities within a “reasonable range,” beyond which inclination to enrol will diminish as a result of the cascading effect of healthcare use. Timely and quality services to insured patients were identified as a determinant of enrolment among older adults while the reverse also holds. There are known issues with the NHIS concerning long queues, long waiting times and overall dissatisfaction with services (Dalinjong & Laar, 2012). Reforms that improve healthcare delivery and meet patients’ needs are recommended since such reforms could benefit older persons who are often physically not able to queue for a long time while waiting for care—and have a spillover effect on NHIS enrolment. Furthermore, the review coincides with previous research where negative provider attitudes and interpersonal relationships have been acknowledged in other countries (De Allegri et al., 2006; Dong et al., 2009; Kyomugisha et al., 2009) as a major determinant of the decision to enrol in health protection schemes. It also partly supports the findings of Jehu-Appiah et al. (2011) where although not found to be expressively associated with enrolment decisions, provider attitudes were perceived negatively and hence merited consideration to increase overall satisfaction with being enrolled in the scheme. Interventionist (in-service training) and reactionary (sanctions) policies are commended to ensure that the behaviour of healthcare providers is in line with standards, procedures and principles guiding their profession.

10. Implications for policy, practice and future research

Attributes of the NHIS and healthcare delivery system in Ghana that motivate or hinder enrolment in the NHIS among older adults were examined in this paper. The results show the value placed on the health expenditure buffer provided by the scheme, affordability of registration fee, proximity to and administrative efficiencies as scheme factors and proximity to health facilities, quality of healthcare services and staff attitudes as health-system factors that influence enrolment decisions. These findings have several policy implications. First, there is the need for continuous review of exemption criteria, particularly the minimum age. At best, it should be scaled down to 60 years to increase enrolment among older adults. Second, the results prove the need for sensitization of older adults on the prospects of the scheme, especially for older adults. Addressing the endemic barriers that hinder the smooth operation of the scheme, particularly the timely registration and issuance of cards constitute the third policy implication. Developing an integrative and holistic approach to health service delivery seems likely to promote enrolment since barriers to healthcare use (physical accessibility issues, quality of services and staff attitudes) plays an important role in older adults’ decision to enrol in the health protection scheme. Adopting measures such as increasing the availability of health facilities, especially in areas where there are supply deficits; improving provider-to-patient ratio (through increased employment of healthcare workers); implementing scheduled services for most health services and integrating mHealth into the formal healthcare delivery system; in addition to monitoring staff attitudes to ensure compliance with rules, regulations and principles of their profession are some of the integrative and holistic strategies that can improve overall healthcare delivery in Ghana. Finally, future research should examine health insurance enrolment and the likelihood of healthcare utilisation among older adults from a spatial perspective.

11. Limitations of the study

The study has a potential weakness in that it did not take into account chance agreement when measuring inter-rater reliability. This means that there may be an overestimation of the level of agreement between the reviewers, as the presence of chance agreement can inflate the agreement score. Therefore, the study findings may not accurately reflect the actual level of agreement between the reviewers. Additionally, the included studies were heterogeneous in terms of their study design, participants, interventions, and outcomes, making it difficult to compare and synthesize the results. To address the issue of heterogeneity, the systematic review employed a narrative synthesis approach, which involved a qualitative analysis of the included studies rather than a quantitative meta-analysis. This approach allowed for a more nuanced understanding of the determinants of national health insurance enrolment among older adults in Ghana, despite the heterogeneity of the studies. Furthermore, the quality of the included studies varies, potentially impacting the validity and reliability of the review. Finally, the review is limited by the availability of data from the included studies, which may be incomplete or missing, making it challenging to draw meaningful conclusions. Despite the potential for publication bias, we conducted a comprehensive search of multiple databases and grey literature, to minimize the impact on the review findings.

12. Conclusion

This systematic review identified and synthesized scheme- and health- system determinants of NHIS enrolment among older adults in Ghana. With literature from data repositories including Wiley Web of Science, PubMed, PsycINFO, Scopus, Ovid, Science Direct, and Sage, we performed a systematic synthesis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Out of 124 studies found, the systematic review included 11 articles. The study identified 4 macro- and 3 meso- determinants of NHIS enrolment among older adults in Ghana. The specific determinants identified were perceived scheme benefits, affordability, proximity to NHIS offices, procedural smoothness as macro-determinants, physical accessibility, quality of care, and staff attitude as meso-determinants. The results indicate that the value placed on the health expenditure buffer offered by the scheme, affordability of registration fee, proximity to and administrative efficiencies (scheme- factors) and proximity to health facilities, quality of healthcare services and staff attitudes (health- system factors) influence enrolment decisions among older adults. The findings provide insight into the need to revise the exemption criteria for older adults, with emphasis on reducing the minimum exemption age to at least 60 years as well as expediting enrolment processes. Moreover, the results highlight the need to tackle the health- system barriers to formal healthcare utilization among older adults. By improving physical accessibility, quality of care, and staff attitudes, as well as addressing perceived scheme benefits, affordability, proximity to NHIS offices, and procedural smoothness, it is possible to increase NHIS enrolment among older adults in Ghana.

Abbreviations

DHISs	=	District Health Insurance Schemes
DHS	=	Demographic and Health Survey
GLSS	=	Ghanaian Living Standards Survey
LMICs	=	Low and Middle-Income Countries
MICS	=	Multiple Indicator Cluster Survey
NHIA	=	National Health Insurance Authority
NHIS	=	National Health Insurance Scheme
PICOT	=	Population, Intervention, Outcome and Timeframe
PRISMA	=	Preferred Reporting Items for Systematic Reviews and Meta-Analyses
SAGE	=	Study on Global Ageing and Adult Health
SHI	=	Social Health Insurance; SEM: Socio Ecological Model
SSNIT	=	Social Security and National Insurance Trust
UHC	=	Universal Health Coverage

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The authors declare that they have no funding support

Notes on contributors

Anthony Kwame Morgan

Anthony Kwame Morgan holds a Master of Science Degree in Development Policy and Planning and a Bachelor of Arts Degree in Geography and Rural Development from Kwame Nkrumah University of Science and Technology, Ghana. His research interest covers issues related to public Health, Health Services Research, Ageing, Rural Development, and Poverty and Livelihood Studies.

Dina Adei

Dina Adei is a Associate Professor at the Department of Planning, Kwame Nkrumah University of Science and Technology (KNUST), Ghana. Her research interest covers areas such as Health Services Planning, Occupational Health and Safety; Macroeconomic policy and planning; and Human-Environment Interactions.

Williams Agyemang-Duah

Williams Agyemang-Duah is currently a PhD Student at the Department of Geography and Planning, Queen’s University, Canada. His research interests include Geographies of Health and Healthcare; Geographies of Ageing, Geographies of Care, and Human-Environment Interactions.

Prince Peprah

Prince Peprah is currently a PhD Student at the Social Policy Research Centre/Centre for Primary Health Care and Equity, University of New South Wales, Australia. His research interests include healthcare access, use and services research, culture and health literacy, primary health care and refugee health.

Anthony Acquah Mensah

Anthony Acquah Mensah holds an MPhil in Planning from the Department of Planning, Kwame Nkrumah University of Science and Technology, Ghana. His research interests cover Land Governance, Smart Cities, Urban Planning and Health Systems.