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Sustainability of Health Insurance Enrollment: Evidence from a Field Experiment in Ghana
Last registered on August 24, 2017

Pre-Trial

Trial Information
General Information
Title
Sustainability of Health Insurance Enrollment: Evidence from a Field Experiment in Ghana
RCT ID
AEARCTR-0002376
Initial registration date
August 24, 2017
Last updated
August 24, 2017 10:24 PM EDT
Location(s)
Primary Investigator
Affiliation
Cornell University
Other Primary Investigator(s)
PI Affiliation
Ghana Business School
PI Affiliation
Cornell University
Additional Trial Information
Status
Completed
Start date
2011-09-03
End date
2014-12-30
Secondary IDs
Abstract
This project aims to understand how to promote and sustain health insurance enrollment in Ghana. We also evaluate the impacts of insurance coverage on a host of health outcomes and healthcare utilization. To achieve our objectives, we hired local researchers in Ghana to help run experiments and collect various household and individual data. This study is going to make two contributions to the literature. First, our study will be among the first to document evidence of intervention on enrollment sustainability of nationwide insurance. Second, our study will be among the first to focus in pricing on health insurance in low-income countries.
External Link(s)
Registration Citation
Citation
Asuming, Patrick, Hyuncheol Kim and Armand Sim. 2017. "Sustainability of Health Insurance Enrollment: Evidence from a Field Experiment in Ghana." AEA RCT Registry. August 24. https://doi.org/10.1257/rct.2376-1.0.
Former Citation
Asuming, Patrick et al. 2017. "Sustainability of Health Insurance Enrollment: Evidence from a Field Experiment in Ghana." AEA RCT Registry. August 24. http://www.socialscienceregistry.org/trials/2376/history/20782.
Sponsors & Partners

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Experimental Details
Interventions
Intervention(s)
We conducted three main interventions in our study at community level: a subsidy to payment of NHIS premium and fees, an education campaign, and convenience. Additionally, we also provided multiple interventions: education and convenience, education and subsidy, subsidy and convenience, and education and subsidy and convenience. Households within communities that were randomly selected to receive the subsidy intervention were randomly assigned to receive three possible subsidy levels for insurance premiums and fees: 1/3 subsidy (GHC 4 or USD 2.67), 2/3 subsidy (GHC 8.10 or USD 5.40) or full subsidy (GHC 12.20 or USD 8.13). Subsidies were given in the form of vouchers with a two-month validity period and redeemable only at the Wa West District Mutual Health Insurance Schemes (DMHIS). The voucher specified names, ages and gender of all household members, expiration date and where it should be redeemed. The education campaign intervention provided basic intervention on the NHIS including registration information, premiums and exemptions, and benefits of the scheme as well as general education on the importance of being insured. Communities which received convenience intervention had visits from trained fieldworkers to provide information and answer questions about NHIS.

We limit our sample communities to those with 30 – 400 residents which are located at least 1km from the nearest other community. This size restriction was due to budgetary considerations considering our interventions were at the community level. The distance restriction was to minimize spillover of education and convenience interventions to neighboring communities. There were 61 communities and 680 households and 4,625 individuals that satisfied these restrictions.
Intervention Start Date
2011-10-01
Intervention End Date
2011-10-30
Primary Outcomes
Primary Outcomes (end points)
We are interested in several outcomes. First, determinants of enrollment and its sustainability to NHIS. We will explore whether individuals that received intervention enrolled more than those who did not receive intervention. We will differentiate three types of intervention: any intervention, multiple intervention, such as education, subsidy, and convenience, and each of seven interventions. An individual received any intervention if she received any of interventions, including standalone and multiple interventions. Multiple intervention means an individual received more than one intervention. An intervention received a multiple education intervention if she received either education and subsidy, education and convenience, or education and subsidy and convenience.
Second, we measure causal effects of insurance coverage on utilization of health care, financial protection, and health outcomes. The measures for utilization of health care include whether an individual visited a health care facility in the last four weeks, in the last six months, visited a health care facility for malaria treatment in the last four weeks, and number of visits in the last six months. The measure for financial protection includes whether an individual made an out-of-pocket expenditure for health service in the last six months.
Third, we also explore whether various heterogeneities among those who received intervention exist and affect insurance enrollment and its sustainability. We will measure heterogeneities based on illness and utilization of NHIS for illness or injury treatment.
Heterogeneity measures for illness and utilization of NHIS for illness or injury treatment include the following measures that occurred in the last four weeks or six months: whether an individual got any illness, got any malaria episode, had limited ability to perform normal daily tasks, and visited a health facility.
Primary Outcomes (explanation)
Secondary Outcomes
Secondary Outcomes (end points)
Secondary Outcomes (explanation)
Experimental Design
Experimental Design
Baseline survey was conducted in September 2011. Intervention was conducted in October 2011. First and second follow-up surveys were conducted in April 2012 and December 2014, respectively.

Baseline survey collected information on demographic characteristics, employment, health history, general health and utilization of healthcare services, expected future health, enrollment in the NHIS and health behaviors for all household members. Information on knowledge of health insurance was collected from household heads or an adult respondent present if the household head was not present. Information on pre-natal care, delivery and post-natal care was collected for all women aged 15 to 49 years. We also collected additional information on household characteristics, including ownership of assets, and GIS information on all communities and health facilities in the district.

The first follow-up survey collected additional information on general health and utilization of healthcare services, expected future health, enrollment in the NHIS and health behaviors for all household members. The second follow-up survey used an abbreviated questionnaire that collected information on knowledge of health insurance, current enrollment status, subjective and objective health outcomes in the past twelve months.
Experimental Design Details
Randomization Method
Assigning the treatment to communities in which individuals reside is done randomly by a computer random number generator. Households were not aware of this randomization. It remains unknown to them even after receiving interventions.
Randomization Unit
Communities are randomly assigned to treatment and control groups. Households that live within communities in the treatment group are automatically included as treatment households. Similarly, households within control communities are included as control households.

As for subsidy level intervention, randomization was conducted in household level. Households that reside within communities that received subsidy intervention were randomized to receive a particular subsidy level (1/3, 2/3, and full subsidy).
Was the treatment clustered?
Yes
Experiment Characteristics
Sample size: planned number of clusters
60 communities.
Sample size: planned number of observations
4,625 individuals
Sample size (or number of clusters) by treatment arms
1. Control group: 22 Communities, 167 Households, 1,174 Individuals.
2. Treatment group: 38 Communities, 476 Households, 3,541 Individuals.

By treatment arms:

1. Subsidy only: 8 Communities, 102 Households, 706 Individuals.
2. Education only: 3 Communities, 32 Households, 268 Individuals.
3. Convenience only: 7 Communities, 126 Households, 906 Individuals.
4. Education and convenience: 5 Communities, 39 Households, 278 Individuals.
5. Subsidy and convenience: 7 Communities, 60 Households, 463 Individuals.
6. Subsidy and education: 4 Communities, 50 Households, 300 Individuals.
7. Subsidy and education and convenience: 4 Communities, 67 Households, 530 Individuals.


Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
IRB
INSTITUTIONAL REVIEW BOARDS (IRBs)
IRB Name
IRB Office, Columbia University
IRB Approval Date
2011-09-11
IRB Approval Number
IRB-AAAI6013
IRB Name
Ghana Health Service Ethical Review Committee
IRB Approval Date
2011-09-29
IRB Approval Number
GHS-ERC 02/7/11
IRB Name
Cornell Institutional Review Board for Human Participants
IRB Approval Date
2013-09-28
IRB Approval Number
1309004138
Post-Trial
Post Trial Information
Study Withdrawal
Intervention
Is the intervention completed?
Yes
Intervention Completion Date
October 30, 2011, 12:00 AM +00:00
Is data collection complete?
Yes
Data Collection Completion Date
December 30, 2014, 12:00 AM +00:00
Final Sample Size: Number of Clusters (Unit of Randomization)
60 Communities
Was attrition correlated with treatment status?
No
Final Sample Size: Total Number of Observations
643 Households and 4,625 Individuals.
Final Sample Size (or Number of Clusters) by Treatment Arms
1. Subsidy only: 8 Communities, 102 Households, 706 Individuals. 2. Education only: 3 Communities, 32 Households, 268 Individuals. 3. Convenience only: 7 Communities, 126 Households, 906 Individuals. 4. Education and convenience: 5 Communities, 39 Households, 278 Individuals. 5. Subsidy and convenience: 7 Communities, 60 Households, 463 Individuals. 6. Subsidy and education: 4 Communities, 50 Households, 300 Individuals. 7. Subsidy and education and convenience: 4 Communities, 67 Households, 530 Individuals.
Data Publication
Data Publication
Is public data available?
No
Program Files
Program Files
Reports, Papers & Other Materials
Relevant Paper(s)
REPORTS & OTHER MATERIALS