Does health insurance improve health for all? Heterogeneous effects on children in Ghana

•Ghana’s National Health Insurance Scheme improves child health on average.•However, four out of the ten regions did not see significant benefits from the scheme.•Benefits are concentrated in lower-income households in regions with a high quality of care.•Further evidence points to the importance of health care utilization to explain these results. This paper assesses whether health insurance is successful in improving health. More specifically, it investigates whether a same health insurance scheme has differentiated impacts on children depending on the way it is implemented and on the characteristics of the beneficiaries. To do so, I analyze the case of Ghana’s National Health Insurance Scheme that provides free coverage for children and has decentralized operations. I exploit the Multiple Indicator Cluster Survey of 2011 and I use propensity score matching to account for selection in the scheme. The study finds that, even though the NHIS is successful in improving health outcomes among insured children in Ghana, gains are not shared equally across regions. To understand this regional heterogeneity, mechanisms are investigated. The positive impact of health insurance is concentrated among the lower-income households in regions with a high quality of public health care. Further evidence points to the importance of health care utilization to explain these results. This paper sheds a new light on the mixed results of the literature on the impact of health insurance on health outcomes. It provides an understanding of the sources of the heterogeneous impact of a National Health Insurance Scheme and highlights the importance of context and implementation as drivers of its effectiveness. Such evidence is relevant for both the evaluation and monitoring of existing health care schemes and for the implementation of new large-scale public policies.