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. 2019 Nov 4;9(11):e028726.
doi: 10.1136/bmjopen-2018-028726.

Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana's National Health Insurance Scheme

Tia M Palermo  1 , Elsa Valli  2 , Gustavo Ángeles-Tagliaferro  3   4 , Marlous de Milliano  3 , Clement Adamba  5 , Tayllor Renee Spadafora  6 , Clare Barrington  3   4 ; LEAP 1000 Evaluation Team
Collaborators, Affiliations

Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana's National Health Insurance Scheme

Tia M Palermo et al. BMJ Open. .

Abstract

Objectives: The study aimed to understand the impact of integrating a fee waiver for the National Health Insurance Scheme (NHIS) with Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer programme on health insurance enrolment.

Setting: The study was conducted in five districts implementing Ghana's LEAP 1000 programme in Northern and Upper East Regions.

Participants: Women, from LEAP households, who were pregnant or had a child under 1 year and who participated in baseline and 24-month surveys (2497) participated in the study.

Intervention: LEAP provides bimonthly cash payments combined with a premium waiver for enrolment in NHIS to extremely poor households with orphans and vulnerable children, elderly with no productive capacity and persons with severe disability. LEAP 1000, the focus of the current evaluation, expanded eligibility in 2015 to those households with a pregnant woman or child under the age of 12 months. Over the course of the study, households received 13 payments.

Primary and secondary outcome measures: Primary outcomes included current and ever enrolment in NHIS. Secondary outcomes include reasons for not enrolling in NHIS. We conducted a mixed-methods impact evaluation using a quasi-experimental design and estimated intent-to-treat impacts on health insurance enrolment among children and adults. Longitudinal qualitative interviews were conducted with an embedded cohort of 20 women and analysed using systematic thematic coding.

Results: Current enrolment increased among the treatment group from 37.4% to 46.6% (n=5523) and decreased among the comparison group from 37.3% to 33.3% (n=4804), resulting in programme impacts of 14 (95% CI 7.8 to 20.5) to 15 (95% CI 10.6 to 18.5) percentage points for current NHIS enrolment. Common reasons for not enrolling were fees and travel.

Conclusion: While impacts on NHIS enrolment were significant, gaps remain to maximise the potential of integrated programming. NHIS and LEAP could be better streamlined to ensure poor households fully benefit from both services, in a further step towards integrated social protection.

Trial registration number: RIDIE-STUDY-ID-55942496d53af.

Keywords: Ghana; cash transfers; economics; health insurance waivers; health policy; public health.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Proportion of children (5–17 years old) with valid National Health Insurance Scheme card for the current year.
Figure 2
Figure 2
Proportion of adults (18+ years old) with valid National Health Insurance Scheme card for the current year.
See this image and copyright information in PMC

References

    1. World Bank The state of social safety nets 2018. Washington, DC: World Bank, 2018.
    1. Bastagli F, Hagen-Zanker J, Harman L, et al. . Cash transfers: what does the evidence say? A rigorous review of programme impact and of the role of design and implementation features. The Overseas Development Institute: Oxford, 2016.
    1. Baird S, Ferreira FHG, Özler B, et al. . Relative effectiveness of conditional and unconditional cash transfers for schooling outcomes in developing countries: a systematic review. Campbell Systematic Reviews 2013;9:1–124. 10.4073/csr.2013.8 - DOI
    1. Davis B, Handa S, Hypher N, et al. . From evidence to action: the story of cash transfers and impact evaluation in sub Saharan Africa. Oxford University Press: Oxford, 2016.
    1. Ranganathan M, Lagarde M. Promoting healthy behaviours and improving health outcomes in low and middle income countries: a review of the impact of conditional cash transfer programmes. Prev Med 2012;55(Suppl):S95–105. 10.1016/j.ypmed.2011.11.015 - DOI - PubMed

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