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Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana’s National Health Insurance Scheme
  1. Tia M Palermo1,
  2. Elsa Valli2,
  3. Gustavo Ángeles-Tagliaferro3,4,
  4. Marlous de Milliano3,
  5. Clement Adamba5,
  6. Tayllor Renee Spadafora6,
  7. Clare Barrington3,4
  8. LEAP 1000 Evaluation Team
    1. 1 Department of Epidemiology and Environmental Health, University at Buffalo – The State University of New York, Buffalo, New York, USA
    2. 2 Social and Economic Policy Unit, United Nations Children's Fund, Office of Research Innocenti, Firenze, Italy
    3. 3 UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
    4. 4 Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
    5. 5 School of Education and Leadership, University of Ghana, Accra, Ghana
    6. 6 Social Policy and Evidence Section, United Nations Children's Fund, Accra, Ghana
    1. Correspondence to Dr Tia M Palermo; tiapaler{at}


    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.

    • health policy
    • public health
    • economics
    • cash transfers
    • health insurance waivers
    • Ghana

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    • Collaborators UNICEF Office of Research – Innocenti: Tia Palermo (co-principal investigator), Elsa Valli, Richard de Groot; Institute of Statistical, Social and Economic Research, University of Ghana: Isaac Osei-Akoto (co-principal investigator), Clement Adamba, Joseph K. Darko, Robert Darko Osei, Francis Dompae and Nana Yaw; Carolina Population Center, University of North Carolina at Chapel Hill: Clare Barrington (co-principal investigator), Gustavo Angeles, Sudhanshu Handa (co-principal investigator), Frank Otchere, Marlous de Miliano; Navrongo Health Research Centre: Akalpa J. Akaligaung (co-principal investigator) and Raymond Aborigo.

    • Contributors TMP, EV, GA-T, MdM, CA, TRS and CB were involved in the study design, interpretation of data and contributed to drafting of the article. TMP, EV, GA-T, MdM, CA, TRS and CB had access to the data. TMP and EV wrote the first draft of the manuscript and all authors critically reviewed the manuscript and contributed to writing the final draft. EV carried out statistical analysis, and EV, GA-T, CA and TMP contributed to modelling and interpretation of statistical analyses. MdM and CB conducted qualitative analysis. TMP, EV, GA-T, MdM, CA, TRS and CB approved the final version. A majority of the work for this paper was completed while the corresponding author (TMP) was affiliated with UNICEF Office of Research – Innocenti and she has since moved to the University at Buffalo (SUNY).

    • Funding Funding for this study was provided to the United Nations Children’s Fund by the United States Agency for International Development and the Canadian International Development Agency. The funders did not play any role in the data collection, analysis or interpretation of findings.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval The quantitative component was reviewed by the Ethics Committee for the Humanities of the University of Ghana and the qualitative component by the Institutional Review Boards at University of North Carolina at Chapel Hill and Navrongo Health Research Centre.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement No data are available.