Association for Public Policy Analysis & Management

Background: Despite the low premium and the generous benefits of social health insurance in developing countries, enrollment rate and health care utilization rate remain low. In this paper, we study the promotion of health insurance enrollment, the sustainability of increased enrollment, and the impacts of insurance coverage on both health care utilization and health outcomes.

Method: In Northern Ghana, we randomly provided a subsidy for the health insurance premium and fees (Subsidy), information on national health insurance (Education), and the option for individuals to sign up health insurance in their community (Convenience), all independently. As a result, we established eight study groups including the control group. Our sample includes 4,625 individuals of 643 households in 61 communities. All interventions were randomized at the community level.

Data: We implemented a baseline survey in September 2011, and short- and long-run follow-up surveys after six months (April 2012) and three years (December 2014) from the initial intervention.

Findings: We find that one time intervention of Subsidy and Education promote insurance coverage by 34 percentage point (125%) and 13 percentage point (48%) in the short-run. Even though it was a one time, short-term intervention, valid only for a year, its impacts on enrollment attenuated but sustained in the long-run (on average 17.3% point increase). Insurance coverage leads to an increase of health care utilization such as the number of health care facility visits and malaria treatment both in the short- and long-run. However, positive health outcome, measured by number of sick days, in the short-run completely disappeared in the long-run. Moral hazard such as decreased use of malaria bednet and safe water technology explains this pattern, at least partially.