The effect of social health insurance on prenatal care: the case of Ghana
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The effect of social health insurance on prenatal care: the case of Ghana Stephen O. Abrokwah · Christine M. Moser · Edward C. Norton
Received: 24 November 2013 / Accepted: 1 August 2014 / Published online: 21 August 2014 © Springer Science+Business Media New York 2014
Abstract 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. Keywords
Prenatal care · Social health insurance · Two-part model
JEL Classification
I13 · I18 · O12
S. O. Abrokwah (B) Swiss Reinsurance America Holding Corp, 175 King st, Armonk, NY, USA e-mail: [email protected]; [email protected] C. M. Moser Department of Economics, Western Michigan University, 1903, W. Michigan Ave, Kalamazoo, MI, USA e-mail: [email protected] E. C. Norton Department of Economics and Health Management & Policy, University of Michigan & NBER, 1415 Washington Heights, M3108 SPH II, Ann Arbor, MI 48109, USA e-mail: [email protected]
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Introduction Slightly more than half of all maternal deaths occur in Sub-Saharan Africa. For example, in Ghana, the maternal mortality ratio in 2005 was estimated at 560 maternal deaths per 100,000 live births, compared to 12.7 maternal deaths per 100,000 live births in the US (World Health Organization 2007). A Ghanaian woman’s risk of dying from treatable or preventable complications of pregnancy and childbirth over the course of her lifetime is about 1 in 45, compared to 1 in 7,300 in the developed countries. This is partly due to a lack of adequate prenatal care (Ghana Health Service 2009a). A prenatal care model developed by the World Health Organization (WHO) recommends a minimum of four medical care visits and provides detailed instructions on the basic components of care for those visits for both developed and developing countries (World Health Organization 2001). However, prenatal care in most developing countries often fails to meet these standards due to lack of human resources, equipment, and supplies (Zanconato et al. 2006). Prenatal care costs include travel costs,
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