Date of Award


Degree Name

Doctor of Philosophy



First Advisor

Dr. Christine Moser

Second Advisor

Dr. Donald J. Meyer

Third Advisor

Dr. Edward Norton


social health insurance, alternative care, modern health care, prenatal care, adverse selection, moral hazard


More than 2 billion people live in developing countries with health systems constrained by inequitable access and inadequate funding. The World Health Organization estimates that more than 150 million of these people suffer financial breakdown every year having to make unexpected out-of-pocket expenditures for emergency care.

To improve health and reduce the financial burden on households, a number of developing countries, including Ghana, Colombia, and Peru, have recently introduced social health insurance programs which are heavily subsidized. The dissertation is a collection of three essays looking at how individual health care choices changed as a result of the availability of insurance coverage in Ghana.

The first essay evaluates health care choices and out-of-pocket expenditures after the introduction of social health insurance covering modern health care services. When ill, an individual decides between a set of alternatives; no care, alternative (traditional) medicine, modern care and both alternative and modern care. My results show that when health insurance becomes available, individuals either switch to modern medical care or complement alternative care with modern care. I also find that out-of- pocket expenditures decrease significantly across all the different types of care as a result of health insurance.

The second essay studies the effect of health insurance on household fertility decisions and examines whether the effect is due to women likely to become pregnant seeking out insurance (adverse selection effect) or women with insurance changing fertility decisions (moral hazard effect). To disentangle the effects of adverse selection from moral hazard, I exploit district-level variation in the dates of implementation of the national health insurance to instrument for insurance enrollment. My results suggest that both adverse selection and moral hazard effects were present and fertility increased with insurance.

The third essay examines the role of social health insurance on prenatal care and expenditure using a two-part model. Results show that health insurance increases the propensity of pregnant women to seek prenatal care relative to the uninsured. Insured pregnant women are more likely to seek prenatal care, but conditional on any spending, they spend less out-of-pocket compared to the uninsured.

Access Setting

Dissertation-Open Access