Date of Award


Degree Name

Doctor of Philosophy



First Advisor

Dr. Christine Moser

Second Advisor

Dr. Donald Meyer

Third Advisor

Dr. Hyunkeun Cho


Social health insurance, maternal health outcomes, child health outcomes, developing countries, Ghana, economics


About 25% of all maternal deaths occur during pregnancy; 99% of these maternal deaths occur in developing countries and half of these occur in Sub-Saharan Africa (WHO 2015). Two of the eight Millennium Development Goals are to reduce infant mortality and improve maternal and child health outcomes. To improve health outcomes and reduce the financial burden on households, a number of developing countries, including Ghana, Botswana, and Croatia, have introduced social health insurance programs which are heavily subsidized. This dissertation is a collection of three essays evaluating how maternal and child health care-seeking behavior, utilization and outcomes changed as a result of the availability of insurance coverage in Ghana. In general, results from this dissertation show that social health insurance enables women to seek prenatal care earlier, reduces infant mortality, reduces the incidence of low birth weight and increases child’s health care utilization.

The first essay evaluates the effect of access to social health insurance on the timing of the first prenatal care visit for pregnant women. This essay uses survival analysis techniques, particularly the Multilevel Multi process (MLMP) model and the Mixed Proportional Hazard (MPH) model, which controls for endogeneity in survival data analysis. This essay utilizes data from two rounds of the Ghana Living Standards Survey (GLSS), GLSS V (2005/2006) and GLSS VI (2012/2013) to evaluate how the timing of first prenatal visits has changed over time. My results show that women who enrolled in the insurance program receive prenatal care earlier in their pregnancies than uninsured women.

The second essay investigates the effect of social health insurance on infant mortality in Ghana using the 2014 Demographic and Health Survey (DHS). This essay addresses the issue of endogeneity in actual insurance status by using the district-level variation in the dates of implementation of the national health insurance. Maternal fixed-effects are also used to control for unobserved individual-specific differences across women in the sample. My results show that having access to insurance reduces infant mortality, and this result is more pronounced among children in rural areas compared to those in urban areas.

The third essay investigates the effects of social health insurance on children’s health care utilization and health outcomes using a two-stage least squares (2SLS) technique. One of the Millennium Development Goals is to improve children’s health outcomes. An important policy question is therefore to evaluate how the availability of social health insurance impacts children’s health care utilization as well as their health outcomes (e.g., the birth weight of babies). My results show that access to insurance increases the probability that a mother seeks treatment for her sick child, reduces the incidence of low birth weight, but has no impact on vaccination.

Access Setting

Dissertation-Open Access