Evaluating the impact of national health insurance in Ghana

Health insurance schemes are rapidly increasing in developing countries. Yet there is limited evidence on whether enrollment increases health care utilization and ultimately health outcomes. Recognizing the potential of prepayment schemes to eliminate user fees and increase access to health care, Ghana enacted the National Health Insurance Act in 2003, mandating the establishment of district-level insurance schemes. As one of the first health insurance programs implemented on a national scale in Africa, it is important to understand the effects of this ambitious initiative.

This study examines changes in insurance enrollment over time and membership effects on health seeking behavior, health care utilization, and OOP expenditures. Funded by USAID and conducted by Health Systems 20/20 in partnership with the Ghana Health Service, the study utilizes a pre- and post-test design; baseline data were collected prior to NHI implementation in 2004 and a follow-up survey conducted in 2007. Both rounds included household surveys in 2 districts and client exit interviews in 6 districts. Surveys captured information on household characteristics and health care seeking behavior. In addition, in-depth interviews district scheme managers at follow-up to assess operational aspects of implementation.

The baseline survey found that 51% of ill household members first self-treated, and nearly 70% sought care from informal providers. About half eventually sought care from a trained provider. Those who were members of a previously existing community health insurance program were more likely to seek such care than nonmembers. Regression analysis found that insured individuals were nearly twice as likely to seek such care. Whereas outpatient care cost about $3 per visit, inpatient expenditures varied considerably, from $7-60. Insurance membership did not affect outpatient fees, but it did protect individuals from catastrophic inpatient fees. Comparative analysis is underway, and will assess changes effected by NHI.

In light of major health sector reform in Ghana, the study findings will provide useful information on the effects of NHI on utilization and payment for health care, and can offer recommendations for improvement as well as validation of the current program.