title: Can health insurance protect against out-of-pocket and catastrophic expenditures and also support poverty reduction? Evidence from Ghana's National Health Insurance Scheme.
abstract: Ghana since 2004, begun implementation of a National Health Insurance Scheme (NHIS) to minimize financial barriers to health care at point of use of service. Usually health insurance is expected to offer financial protection to households. This study aims to analyze the effect health insurance on household out-of-pocket expenditure (OOPE), catastrophic expenditure (CE) and poverty.
  
  
  
  We conducted two repeated household surveys in two regions of Ghana in 2009 and 2011. We first analyzed the effect of OOPE on poverty by estimating poverty headcount before and after OOPE were incurred. We also employed probit models and use of instrumental variables to analyze the effect of health insurance on OOPE, CE and poverty.
  
  
  
  Our findings showed that between 7-18 % of insured households incurred CE as a result of OOPE whereas this was between 29-36 % for uninsured households. In addition, between 3-5 % of both insured and uninsured households fell into poverty due to OOPE. Our regression analyses revealed that health insurance enrolment reduced OOPE by 86 % and protected households against CE and poverty by 3.0 % and 7.5 % respectively.
  
  
  
  This study provides evidence that high OOPE leads to CE and poverty in Ghana but enrolment into the NHIS reduces OOPE, provides financial protection against CE and reduces poverty. These findings support the pro-poor policy objective of Ghana's National Health Insurance Scheme and holds relevance to other low and middle income countries implementing or aiming to implement insurance schemes.
authors.affiliation: School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG 13, Legon, Ghana. gcaryeetey@ug.edu.gh.
authors.forename: Genevieve Cecilia
authors.initials: GC
authors.lastname: Aryeetey
authors.affiliation: Rutgers, Arthur van Schendelstraat 696, Utrecht, Netherlands.
authors.forename: Judith
authors.initials: J
authors.lastname: Westeneng
authors.affiliation: Department for Health Evidence, Radboud University Medical Canter, P.O. Box 9101, 6500 HB, Nijmegen, Netherlands.
authors.forename: Ernst
authors.initials: E
authors.lastname: Spaan
authors.affiliation: African Development Bank, Human Development Department, Tunis, Tunisia.
authors.forename: Caroline
authors.initials: C
authors.lastname: Jehu-Appiah
authors.affiliation: School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG 13, Legon, Ghana.
authors.forename: Irene Akua
authors.initials: IA
authors.lastname: Agyepong
authors.affiliation: Department for Health Evidence, Radboud University Medical Canter, P.O. Box 9101, 6500 HB, Nijmegen, Netherlands.
authors.forename: Rob
authors.initials: R
authors.lastname: Baltussen
mesh_terms: D000328:Adult; D000368:Aged; D003695:Delivery of Health Care / Q000191:economics; D004651:Employment / Q000706:statistics & numerical data; D005191:Family Characteristics; D005260:Female; D005869:Ghana; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006801:Humans; D007182:Income; D007348:Insurance, Health / Q000191:economics / Q000706:statistics & numerical data*; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008875:Middle Aged; D009313:National Health Programs / Q000191:economics; D011203:Poverty / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires
keywords: Catastrophic expenditure; Ghana; Health insurance; Out-of-pocket expenditure; Poverty reduction