Getting the Poor to Enroll in Health Insurance, and Its Effects on Their Health: Evidence from a Field Experiment in Ghana

Many developing countries have recently instituted social health insurance schemes (SHIs) to ease financial barriers to utilization of healthcare services and help mitigate the effects of adverse health shocks. Although these SHIs offer generous terms and benefits, enrollment remains low especially among the poorest households who are the intended primary beneficiaries. This paper implements randomized interventions to (i) understand the reasons for low enrollment; (ii) estimate the effects of insurance coverage on utilization of healthcare, financial protection and health; and (iii) provide insights into intra-household allocation of health resources. My results show that imperfect information, and insurance premium and fees affect enrollment. The demand for insurance is price elastic in the sense that small subsidies generate substantial enrollment effects. I find that insurance coverage leads to increased utilization of healthcare services, reduced out-of-pocket payments among individuals with prior positive expenses and improvement in health outcomes. My results suggest strong complementarities between providing information and providing subsidies in utilization and health outcomes, an indication of the importance of the combined interventions for achieving changes in health-seeking behavior and outcomes. Finally, I find evidence of son preference in the allocation of health resources within households. ∗Department of Economics, Columbia University, New York, NY 10027. Email: [email protected]. I am grateful to Douglas Almond, Pierre-Andre Chiappori, Cristian Pop-Eleches and Eric Verhoogen for their guidance and support. I thank Ama Baafra Abeberese, Giacomo De Giorgi, Supreet Kaur, Hyuncheol Kim, Wojciech Kopczuk, Leigh Linden, Corrine Low, Bernard Salanie and participants of the Applied Micro Colloquium and Development/Applied Micro Worskhop at Columbia for helpful comments and discussions. I also thank Hillary Babuna, Siapha Kamara, Adamu Mukaila, George Osei-Bimpeh, Titus Sorey and all staff of SENDGhana and Wa West District Mutual Health Insurance Scheme for various forms of assistance with the fieldwork. I am especially grateful to Santa Aaron, Mumuni Abdul-Kadir, Salifu Abdulai, Mavis Antoinette, Seidu Asonne, John Gambo, Adamu Hamidu, Paschal Kuusavih, Edward Tabiasinaa and Mudasir Yussif for their diligent fieldwork. Fieldwork was generously supported by SEND-Ghana. Opinions expressed here are solely mine and do not necessarily reflect those of SEND-Ghana.