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Background  One of the key functions of health insurance is to provide financial protection against high costs of health care, yet evidence of such protection from developing countries has been inconsistent. The current study uses the case of Ghana to contribute to the evidence pool about insurance's financial protection effects. It evaluates the impact of the country's National Health Insurance Scheme on households' out-of-pocket spending and catastrophic health expenditure.    Methods  We use data from a household survey conducted in two rural districts, Nkoranza and Offinso, in 2007, two years after the initiation of the Ghana National Health Insurance Scheme. To address the skewness of health expenditure data, the absolute amount of out-of-pocket spending is estimated using a two-part model. We also conduct a probit estimate of the likelihood of catastrophic health expenditures, defined at different thresholds relative to household income and non-food consumption expenditure. The analysis controls for chronic and self-assessed health conditions, which typically drive adverse selection in insurance.    Results  At the time of the survey, insurance coverage was 35 percent. Although the benefit package of insurance is generous, insured people still incurred out-of-pocket payment for care from informal sources and for uncovered drugs and tests at health facilities. Nevertheless, they paid significantly less than the uninsured. Insurance has been shown to have a protective effect against the financial burden of health care, reducing significantly the likelihood of incurring catastrophic payment. The effect is particularly remarkable among the poorest quintile of the sample.    Conclusions  Findings from this study confirm the positive financial protection effect of health insurance in Ghana. The effect is stronger among the poor group than among general population. The results are encouraging for many low income countries who are considering a similar policy to expand social health insurance. Ghana's experience also shows that instituting insurance by itself is not adequate to remove fully the out-of-pocket payment for health. Further works are needed to address the supply side's incentives and quality of care, so that the insured can enjoy the full benefits of insurance.

The financial protection effect of Ghana National Health Insurance Scheme: evidence from a study in two rural districts