title: Extending health insurance in Ghana: effects of the National Health Insurance Scheme on maternity care.
abstract: BACKGROUND
  There is considerable interest in exploring the potential of social health insurance in Africa where a number of countries are currently experimenting with different approaches. Since these schemes have been introduced recently and are continuously evolving, it is important to evaluate their effectiveness in the enhancement of health care utilization and reduction of out-of-pocket expenses for potential policy suggestions.
  
  
  OBJECTIVE
  To investigate how the National Health Insurance Schemes (NHIS) in Ghana affects the utilization of maternal health care services and medical out-of-pocket expenses.
  
  
  METHODS
  We used nationally-representative household data from the Ghana Demographic and Health Survey (GDHS). We analyzed the 2014 GDHS focusing on four outcome variables, i.e. antenatal check up, delivery in a health facility, delivery assisted by a trained person and out-of-pocket expenditure. We estimated probit and bivariate probit models to take into account the issue of self selection into the health insurance schemes.
  
  
  RESULTS
  The results suggest that, also taking into account the issue of self selection into the health insurance schemes, the NHIS enrollment positively affects the probability of formal antenatal check-ups before delivery, the probability of delivery in an institution and the probability of being assisted during delivery by a trained person. On the contrary, we find that, once the issue of self-selection is taken into account, the NHIS enrollment does not have a significant effect on out-of-pocket expenditure at the extensive margin.
  
  
  CONCLUSIONS
  Since a greater utilization of health-care services has a strong positive effect on the current and future health status of women and their children, the health-care authorities in Ghana should make every effort to extend this coverage. In particular, since the results of the first step of the bivariate probit regressions suggest that the educational attainment of women is a strong determinant of enrollment, and those with low education and unable to read are less likely to enroll, information on the NHIS should be disseminated in ways that reach those with little or no education. Moreover, the availability of government health facilities in a region is associated with higher likelihood of enrollment in the NHIS. Accordingly, extending geographical access is an important strategy for expanding NHIS membership and improving access to health-care.
authors: Department of Economics, University Ca' Foscari of Venice, Cannaregio 873, 30121, Venezia, Italy. brugiavi@unive.it.
authors: Agar
authors: A
authors: Brugiavini
authors: Department of Economics, University Ca' Foscari of Venice, Cannaregio 873, 30121, Venezia, Italy. n.pace@unive.it.
authors: Noemi
authors: N
authors: Pace
keywords: Health insurance; Maternity care; Out-of-pocket expenses