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Author ORCID Identifier



Open Access Dissertation

Document Type


Degree Name

Doctor of Philosophy (PhD)

Degree Program


Year Degree Awarded


Month Degree Awarded


First Advisor

Leonce Ndikumana, Ph.D.

Second Advisor

James Heintz, Ph.D.

Third Advisor

Gerald Epstein, Ph.D.

Fourth Advisor

Mwangi wa Gĩthĩnji, Ph.D.

Subject Categories

Growth and Development | Health Economics | Health Services Administration | Health Services Research | Income Distribution | Insurance | Public Economics | Public Health Education and Promotion


Access to quality health services is essential for maintaining a healthy population and economic development hence the growing global consensus that universal health coverage is necessary. Ghana attempts to expand access by making basic health services free at the point of delivery through its National Health Insurance Scheme (NHIS). Prior studies indicate NHIS increases demand for health services, but questions remain about its impact on out of pocket payments, quality of services, and the financial viability of the program. Hence, this dissertation analyzes the financial risk in health care seeking, the effect of NHIS on out of pocket payments and access to quality health care, and the financial viability of NHIS compared with the outcomes of Rwanda’s community-based health insurance programs with similar objectives but different approaches. The empirical analyses uses data from the Ghana Living Standards Survey conducted in 2005-2006 covering 37,212 individuals in 8,868 households, data from the 2008 Ghana Demographic and Health Survey V covering 9919 respondents aged 15-49 years, and data logging from other sources. The methods include two-stage multivariate regression modelling and maximum likelihood estimations. The study finds health expenditures respond strongly to need and weakly to income, the poor are more likely than the rich to pay of pocket for health care, and catastrophic out of pocket payments occur in all income groups and significantly among the poor. The need for uninsured services and ability to pay significantly determine of out of pocket payments by the insured. These findings imply that NHIS expands access to desired health services for the better-offs but does not eliminate catastrophic out of pocket payments, especially for the poor. Attitude of health worker, rather than the technical effectiveness of services, significantly predicts dissatisfaction with quality. The Rwandan model is more equitable than NHIS, but NHIS spends ten times more per capita. Drawing from Ghana’s and Rwanda’s experience, effective strategies for national health insurance programs must include i) practical means-testing in setting insurance premiums to improve equity ii) mandatory enrollments by whole households as a strategy for financial sustainability iii) client-based performance-evaluation in provider reimbursements to improve client satisfaction.