The effect of social health insurance on prenatal care: the case of Ghana

  • Stephen O. Abrokwah
  • Christine M. Moser
  • Edward C. Norton


Many developing countries have introduced social health insurance programs to help address two of the United Nations’ millennium development goals—reducing infant mortality and improving maternal health outcomes. By making modern health care more accessible and affordable, policymakers hope that more women will seek prenatal care and thereby improve health outcomes. This paper studies how Ghana’s social health insurance program affects prenatal care use and out-of-pocket expenditures, using the two-part model to model prenatal care expenditures. We test whether Ghana’s social health insurance improved prenatal care use, reduced out-of-pocket expenditures, and increased the number of prenatal care visits. District-level differences in the timing of implementation provide exogenous variation in access to health insurance, and therefore strong identification. Those with access to social health insurance have a higher probability of receiving care, a higher number of prenatal care visits, and lower out-of-pocket expenditures conditional on spending on care.


Prenatal care Social health insurance Two-part model 

JEL Classification

I13 I18 O12 


  1. Asenso-Boadi, F. (2009). Ghana’s National Health Insurance System: Design, implementation perspectives. Presentation on behalf the CEO of NHIA, at the African Health Economics and Policy Association Conference, 10th March, Accra.Google Scholar
  2. Belotti, F., Deb, P., Manning, W. G., & Norton, E. C. (2014). Tpm: Estimating two-part models. Stata Journal (forthcoming).Google Scholar
  3. Boehmer, U., & Williamson, J. (1996). The impact of women’s status on infant mortality rate: A cross-national analysis. Social Indicators Research, 37(3), 333–360.CrossRefGoogle Scholar
  4. Chen, C., & Liu, T. (2004). The role of Taiwan’s national health insurance program in influencing adequate prenatal care. International Journal of Health Planning and Management, 19, 113–130.PubMedCrossRefGoogle Scholar
  5. Chen, L., Chen, C., & Yang, W. (2008). The influences of Taiwan’s National Health Insurance on women’s choice of prenatal care facility: Investigation of differences between rural and non-rural areas. BMC Health Services Research, 8, 67.PubMedCrossRefPubMedCentralGoogle Scholar
  6. Cokkinides, V. (2001). Health Insurance coverage—Enrollment and adequacy of prenatal care utilisation. Journal of Health Care for the Poor and Undeserved, 12, 4.Google Scholar
  7. Corman, H., & Grossman, M. (1985). Determinants of neonatal mortality rates in the U.S. Journal of Health Economics, 4, 213–236.PubMedCrossRefGoogle Scholar
  8. Dow, W. H., & Norton, E. C. (2003). Choosing between and interpreting the Heckit and two-part models for corner solutions. Health Services and Outcomes Research Methodology, 4(1), 5–18.CrossRefGoogle Scholar
  9. Duan, N., Manning, W., Morris, N., & Newhouse, P. (1982). A comparison of alternative models for the demand for medical care. Journal of Business & Economic Statistics, 1(2), 115–126.Google Scholar
  10. Duan, N. (1983). Smearing estimate: A nonparametric retransformation method. Journal of the American Statistical Association, 78, 605–610.CrossRefGoogle Scholar
  11. Ghana Health Service. (2009a). Evaluation of the Ghana National Health Insurance Scheme. Bethesda, MD: Health Systems 20/20 Project and Abt Associates Inc.Google Scholar
  12. Ghana Health Service. (2009b). Annual report 2009. Accra: Ghana Health Service.Google Scholar
  13. Republic of Ghana. (2004). National Health Insurance Regulations, 2004 (L.I.1809). Accra.Google Scholar
  14. Ghana Statistical Service. (2008). Ghana Living Standards Survey V Report.Google Scholar
  15. Grossman, M., & Jacobowitz, S. (1981). Variations in infant mortality rates among counties of the United States: The role of public policies and programs. Demography, 18, 695–713.PubMedCrossRefGoogle Scholar
  16. Hay, W., & Olsen, J. (1984). Let them eat cake: A note comparing alternative models of the demand for medical care. Journal of Business & Economic Statistics, 2(3), 279–282.Google Scholar
  17. Kaestner, R. (1999). Health insurance, the quantity and quality of prenatal care, and infant health. Inquiry, 36, 2.Google Scholar
  18. Long, Q., Zhang, T., Hemminki, I., Tang, X., Huang, K., & Tolhurst, R. (2010). Utilisation, contents and costs of prenatal care under a rural health insurance (New Co-operative Medical System) in rural China: Lessons from implementation. BMC Health Services Research, 2010(10), 301.CrossRefGoogle Scholar
  19. Osborne, J. (2010). Improving your data transformations: Applying the Box–Cox transformations. Practical Assessment, Research & Evaluation, 15(12), 1–9.Google Scholar
  20. Powell-Jackson, T., Hanson, K., Whitty, C. J., & Ansah, E. K. (2013). Who benefits from free healthcare? Evidence from a randomized experiment in Ghana. Journal of Development Economics, 107, 305–319.CrossRefGoogle Scholar
  21. Simkhada, B., Teijlingen, R., Porter, M., & Simkhada, P. (2008). Factors affecting the utilisation of antenatal care in developing countries: Systematic review of the literature. Journal of Advanced Nursing, 61(3), 244–260.PubMedCrossRefGoogle Scholar
  22. Smith, V., & Sulzbach, S. (2006). Community-based health insurance and access to maternal health services: Evidence from three West African countries. Social Science and Medicine Journal, 66, 2460–2473.CrossRefGoogle Scholar
  23. World Bank. (2007). Project appraisal document on a proposed credit to the Republic of Ghana for a Health Insurance project. Washington, DC: World Bank.Google Scholar
  24. World Health Organization. (2001). WHO antenatal care randomized trial—Manual for the implementation of the new model. Geneva: WHO.Google Scholar
  25. World Health Organization. (2007). Maternal mortality in 2005—Estimates developed by WHO, UNICEF, UNFPA, and the World Bank. Geneva: WHO.Google Scholar
  26. World Health Organization. (2010). Country cooperation strategy: At a glance. Geneva: WHO.Google Scholar
  27. Zanconato, G., Msolomba, R., Guarenti, L., & Franchi, M. (2006). Antenatal care in developing countries: The need for a tailored model. Seminars in Fetal Neonatal Medicine, 11(1), 15–20.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Stephen O. Abrokwah
    • 1
  • Christine M. Moser
    • 2
  • Edward C. Norton
    • 3
  1. 1.Swiss Reinsurance America Holding CorpArmonkUSA
  2. 2.Department of EconomicsWestern Michigan UniversityKalamazooUSA
  3. 3.Department of Economics and Health Management & PolicyUniversity of Michigan & NBERAnn ArborUSA

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