Clement Adamba's (University of Ghana) presentation at the Transfer Project Workshop in Arusha, Tanzania on 3rd April 2019.

1. The impact of Ghana LEAP 1000 on NHIS
enrolment and morbidity
Clement Adamba, Ph.D.
On Behalf of the LEAP 1000 Evaluation Team
Transfer Project Workshop
Arusha, Tanzania
April 3rd, 2019

2. LEAP 1000 Evaluation Team
UNICEF Office of Research – Innocenti: Tia Palermo (co-Principal Investigator),
Richard de Groot, Elsa Valli;
Institute of Statistical, Social and Economic Research (ISSER), University of Ghana:
Isaac Osei-Akoto (co-Principal Investigator), Clement Adamba, Joseph K. Darko,
Robert Darko Osei, Francis Dompae and Nana Yaw;
Carolina Population Center, University of North Carolina at Chapel Hill: Clare
Barrington (co-Principal Investigator), Gustavo Angeles, Sudhanshu Handa (co-
Principal Investigator), Frank Otchere, Marlous de Miliano;
Navrongo Health Research Centre (NHRC): Akalpa J. Akaligaung (co-Principal
Investigator) and Raymond Aborigo.

3. Background
• Broad-ranging benefits of cash transfers widely recognized.
• Poverty reduction, improved living conditions, enhanced psyco-social well-
being
• However, few to no impacts on longer-term and second-order
impacts related to nutrition, learning outcomes and morbidity.
• Integrated social protection: complement cash with additional
inputs, service components or linkages to external services

4. The Ghana LEAP programme
• Ghana Livelihood Empowerment Against Poverty (LEAP) – national
programme reaching 327,000 HHs
• Pilot in two regions in Northern Ghana, app. 6,000 households with
infants/pregnant woman
• Selection based on demographic eligibility and proxy means test
(PMT)
• Cash transfers: GH₵38 – 53 (USD 9.50 – 13.25) per month
• Approximately 14% of baseline consumption expenditures
• Integrated SP component: fee waiver for enrolment in National
Health Insurance Scheme (NHIS)

5. Methods: Evaluation Design and sample
 2-year mixed method, quasi-experimental,
longitudinal study
 8,058 households enumerated by
government and 3,619 determined eligible
 PMT scores range: 6.1 – 8.7
 Evaluation aimed to include 1,250 households +
10% on either side of PMT cut-off
 Baseline (Jul-Sept 2015), Endline (Jul-Sept
2017)
 Final evaluation sample N=2,497 households
(1,262 T and 1,235 C)
 Final analysis sample: N=4,926 children 6 – 59
months
Districts: Yendi, Karaga, East Mamprusi,
Bongo Garu Tempane

6. NHIS
ENROLMENT &
RENEWAL
Ghana LEAP 1000
(© Elsa Valli)

7. NHIS enrollment by age group, by age & time
ADULTS (aged 18+)CHILDREN (aged 7-17)
44.7%
44.8%45.1%
31.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Endline
Treated Comparison
31.9%
41.4%
32.6%
27.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Endline
Treated Comparison
15pp***14pp***

8. NHIS enrolment impacts: household level
98%
78%
16%
96%
69%
8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HH has at least one member ever
NHIS insurance
HH has at least one member with
valid NHIS insurance card
HH has all members with valid
NHIS insurance card
Treatment Comparison
7.7pp***
5pp
0.1pp

9. Reasons for not renewing NHIS
1
1
6
8
11
80
2
5
7
10
12
70
0 10 20 30 40 50 60 70 80 90 100
Has not been sick
Waiting time at renewal too long
Not aware had to be renewed annually
Travel time/cost too high
Did not realised card expired
Enrolment fee/premium too expensive
Treatment Comparison
Other responses: <1%
(office closed, poor
quality care, card lost, no
time, etc.)

10. Amount paid for last renewal
45%
23%
5%
27%
43%
25%
4%
27%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
1-5 GHS 6-10 GHS 11-20 GHS >21 GHS
Comparison Treatment

11. MORBIDITY,
HEALTH SEEKING
BEHAVIOUR &
HEALTH
EXPENDITURES
Ghana LEAP 1000
(© Elsa Valli)

12. No impacts on morbidity (adults & children); Positive
impacts on health-seeking (adults)
12%
70%
19%
72%
12%
75%
19%
65%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Illness in last 2 weeks Sought care for illness
in last 2 weeks
Illness in last 2 weeks Sought care for illness
in last 2 weeks
Treatment Comparison
0.2pp
Children (7-17 years) Adults (18+ years)
11pp***
0.9pp
-9pp

13. No impacts on health expenditures
2.3
1.4
7.7
4.8
3.1
2.0
7.8
5.0
0
1
2
3
4
5
6
7
8
9
Real health expenditures Real medication and
consultation expenditures
Real health expenditures Real medication and
consultation expenditures
Treatment Comparison
Children (7-17 years) Adults (18+ years)

14. Do results change by quality and distance of
the health facility?
Nearest health facility within 5 KM
• Larger effect on health seeking for adults (22pp). Still not significant
for children (but positive and larger)
• No impact on morbidity or health expenditures
Nearest health facility top tertile of quality
• Positive impact on health expenditures for adults (5.9 GH₵). Still not
significant for children (but larger)
• No differential impact on morbidity or health seeking

15. Summary and conclusions
• Positive impacts on NHIS enrolment, underscoring
success of integrated social protection approach
• lingering gaps for full household coverage and renewal
• Cost is the most common reason for not
enrolling/renewing NHIS
• No impact on morbidity or health expenditure
• Positive impact on health seeking behaviour (adults only)
• Quality of health facilities matters for health
expenditures; distance matters for health seeking
behaviour

16. Acknowledgements
We are grateful for the support of the Government of Ghana for the implementation of this
evaluation, in particular William Niyuni, Mawutor Ablo and Richard Adjetey from the Ministry of
Gender, Children and Social Protection. In addition, the UNICEF Ghana team was instrumental
to the success of this report: Sara Abdoulayi, Luigi Peter Ragno, Jennifer Yablonski, Sarah Hague,
Maxwell Yiryele Kuunyem, Tayllor Spadafora, Christiana Gbedemah and Jonathan Nasonaa
Zakaria.
We would also like to acknowledge the hard-working field teams of ISSER and NHRC, who
conducted the data collection for this study to the highest standards.
Funding for the evaluation was generously provided by the United States Agency for
International Development (USAID) and the Canadian International Development Agency
(CIDA). Additional funding to include intimate partner violence modules in the evaluation and
to produce this paper was received from an Anonymous donor and the American World Jewish
Services by the UNICEF Office of Research—Innocenti via the US Fund for UNICEF. We thank
Laura Meucci and Michelle Kate Godwin for grant administrative support.

17. Meda ase
Asante
Zikomo
Thank you
Ghana LEAP 1000
(© Michelle Mills)

18. Additional slides

19. 98%
49%
78%
16%
96%
44%
69%
8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HH has at least one
member ever NHIS
insurance
HH with all members
ever NHIS insurance
HH has at least one
member with valid NHIS
insurance card
HH has all members with
valid NHIS insurance
card
Treatment Comparison
NHIS enrolment at the household-level
5pp
7.7pp***
0.1pp
3.6pp

20. Reasons for not renewing/ never having enrolled with NHIS
All Comparison Treatment P-value of
diff.
Ever enrolled but no valid NHIS 41.54 44.65 38.77 0.00
N 15,252 7,201 8,051
Enrolment fee/premium too expensive 75.32 80.34 70.14 0.00
Did not realised card expired 11.36 10.61 12.14 0.54
Travel time/cost too high 9.28 8.40 10.19 0.37
Not aware had to be renewed annually 6.77 6.22 7.34 0.31
Has not been sick 1.59 1.49 1.70 0.68
Waiting time at renewal too long 3.05 1.15 5.00 0.00
Poor quality care with NHIS - preferred
services not covered
0.32 0.19 0.45 0.18
NHIS office closed 0.44 0.19 0.70 0.19
Other (card lost, no time, etc.) 0.25 0.19 0.32 0.22
N 6,336 3,215 3,121
Never enrolled with NHIS 18.98 22.29 16.02 0.00
N 15,252 7,201 8,051
Enrolment fee/premium too expensive 65.44 65.28 65.64 0.92
Travel time/cost too high 14.94 17.67 11.56 0.02
Waiting time at renewal too long 4.85 4.23 5.62 0.24
Poor quality care with NHIS - preferred
services not covered
3.30 2.36 4.47 0.01
Don't understand NHIS 0.28 0.19 0.39 0.39
Other 10.84 10.14 11.71 0.41
N 2,905 1,607 1,298

21. Transportation time and cost of going to renew NHIS card, all individuals
0%
18% 19%
33%
30%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Zero 30 minutes
or less
31-60
minutes
61-120
minutes
Over 2
hours
36%
41%
19%
4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Nothing 1-9 GHS 10-19 GHS 20+ GHS
Time to travel Amount spent for transportation