Poor mental health is among the growing number of noncommunicable diseases in low- and middle-income countries. Despite poor mental health accounting for an already considerable and growing burden of disease in many low- and middle-income countries, policy action to confront the challenge has been limited, at both international and national levels. Recently, several low- and middle-income countries have embarked on the journey toward universal health coverage by expanding their public health insurance provision, with the ultimate objective of improving population health, in addition to other health system objectives. Mental health interventions typically may not have been specifically covered in the publicly funded benefit package, and this raises the question of whether, and if so, by how much, the expansion of public health insurance may have directly or indirectly contributed to improved mental health.
We assessed the impact of Ghana’s implementation of national health insurance on psychological distress.
Our study used the first wave of the 2009–2010 Ghana Social Economic Panel survey, including 10,007 respondents. We employed instrumental variable and propensity score matching methods to estimate the causal impact of health insurance on psychological distress, measured by the Kessler Psychological Distress Scale (K10). Higher K10 values indicate greater psychological distress.
The median K10 score in Ghana was 16 (P < 0.001), with a minimum of 10 (P < 0.001) and a maximum of 45 (P < 0.001). The results from the instrumental variable estimations, without matching, indicated that the K10 score for the insured was 11.8% lower (P < 0.001) than that of the uninsured. After running the instrumental variable regression on the matched sample, the K10 score for the insured was 10.6% (P < 0.001) lower than that of the uninsured. Similarly, the estimates based on propensity score matching indicated that the insured had a lower K10 score (− 0.023; P < 0.05). Furthermore, the beneficial impact of health insurance on psychological distress is larger for wealthier than poorer insurance members and varies across regions in Ghana. The findings were robust to the various estimation methods.
This study suggests that having health insurance is associated with reduced psychological distress and hence improved mental health, even though mental illness treatment or prevention were at best only partially covered by the National Health Insurance Scheme in Ghana.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price includes VAT (USA)
Tax calculation will be finalised during checkout.
Data used in the study is publicly available at the World Bank website: http://microdata.worldbank.org/index.php/catalog/2534.
Clarke K, Saville N, Bhandari B, Giri K, Ghising M, Jha M, et al. Understanding psychological distress among mothers in rural Nepal: a qualitative grounded theory exploration. BMC Psychiatry. 2014;14(1):60. https://doi.org/10.1186/1471-244X-14-60.
Drew N, Knapp M, Funk M. Mental health, poverty and development. J Public Ment Health. 2012;11(4):166–85. https://doi.org/10.1108/17465721211289356.
Callander EJ, Schofield DJ. Psychological distress increases the risk of falling into poverty amongst older Australians: the overlooked costs-of-illness. BMC Psychol. 2018;6(1):16. https://doi.org/10.1186/s40359-018-0230-7.
McLachlan KJJ, Gale CR. The effects of psychological distress and its interaction with socioeconomic position on risk of developing four chronic diseases. J Psychosom Res. 2018;109:79–85. https://doi.org/10.1016/j.jpsychores.2018.04.004.
Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, et al. The Lancet Commission on global mental health and sustainable development. The Lancet. 2018;392(10157):1553–98.
WHO. Mental health action plan 2013 - 2020. Geneva: Switzerland: World Health Organisation; 2013.
Degroote S, Ridde V, De Allegri M. Health Insurance in Sub-Saharan Africa: a scoping review of the methods used to evaluate its impact. Appl Health Econ Health Policy. 2019. https://doi.org/10.1007/s40258-019-00499-y.
Spaan E, Mathijssen J, Tromp N, McBain F, ten Have A, Baltussen R. The impact of health insurance in Africa and Asia: a systematic review. Bull World Health Organ. 2012;90(9):685–92. https://doi.org/10.2471/BLT.12.102301.
Mitra S, Palmer M, Pullaro S, Mont D, Groce N. Health insurance and children in low- and middle-income countries: a review. Econ Rec. 2017;93(302):484–500. https://doi.org/10.1111/1475-4932.12331.
Jacobs AW, Hill TD, Burdette AM. Health insurance status and symptoms of psychological distress among low-income urban women. Soc Mental Health. 2014;5(1):1–15. https://doi.org/10.1177/2156869314549674.
Lindeboom M, Portrait F, van den Berg Gerard J. An econometric analysis of the mental-health effects of major events in the life of older individuals. Health Econ. 2002;11(6):505–20. https://doi.org/10.1002/hec.746.
Kataoka SH, Zhang L, Wells KB. Unmet Need for Mental Health Care Among U.S. Children: Variation by Ethnicity and Insurance Status. Am J Psychiatry. 2002;159(9):1548–55. https://doi.org/10.1176/appi.ajp.159.9.1548.
Mandal B, Roe B. Job loss, retirement and the mental health of older Americans. J Ment Health Policy Econ. 2008;11(4):167–76.
McMorrow S, Gates JA, Long SK, Kenney GM. Medicaid expansion increased coverage, improved affordability, and reduced psychological distress for low-income parents. Health Aff. 2017;36(5):808–18. https://doi.org/10.1377/hlthaff.2016.1650.
Araya R, Lewis G, Rojas G, Fritsch R. Education and income: which is more important for mental health? J Epidemiol Community Health. 2003;57(7):501.
Lund C, Breen A, Flisher AJ, Kakuma R, Corrigall J, Joska JA, et al. Poverty and common mental disorders in low and middle income countries: a systematic review. Soc Sci Med. 2010;71(3):517–28. https://doi.org/10.1016/j.socscimed.2010.04.027.
Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, et al. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. The Lancet Psychiatry. 2018;5(4):357–69. https://doi.org/10.1016/S2215-0366(18)30060-9.
Peltzer K, Naidoo P, Matseke G, Louw J, McHunu G, Tutshana B. Prevalence of psychological distress and associated factors in tuberculosis patients in public primary care clinics in South Africa. BMC Psychiatry. 2012;12(1):89. https://doi.org/10.1186/1471-244X-12-89.
Tian D, Qu Z, Wang X, Guo J, Xu F, Zhang X et al. The role of basic health insurance on depression: an epidemiological cohort study of a randomized community sample in northwest China. BMC Psychiatry. 2012;12:151. https://doi.org/10.1186/1471-244x-12-151.
Giedion U, Andrés Alfonso E, Díaz Y. The impact of universal coverage schemes in the developing world: a review of the existing evidence. Washington, DC: World Bank; 2013.
Acharya A, Vellakkal S, Fiona T, Edoardo M, Ambika S, Margaret B et al. The impact of health insurance schemes for the informal sector in low- and middle-income countries: a systematic review. Policy Research Working Papers. The World Bank; 2013.
Dake FAA. Examining equity in health insurance coverage: an analysis of Ghana’s National Health Insurance Scheme. Int J Equity Health. 2018;17(1):85. https://doi.org/10.1186/s12939-018-0793-1.
Kotoh AM, Aryeetey GC, Van der Geest S. Factors that influence enrolment and retention in ghana’ national health insurance scheme. Int J Health Policy Manag. 2017;7(5):443–54. https://doi.org/10.15171/ijhpm.2017.117.
Aryeetey GC, Westeneng J, Spaan E, Jehu-Appiah C, Agyepong IA, Baltussen R. Can health insurance protect against out-of-pocket and catastrophic expenditures and also support poverty reduction? Evidence from Ghana’s National Health Insurance Scheme. Int J Equity Health. 2016;15(1):116. https://doi.org/10.1186/s12939-016-0401-1.
Okoroh J, Essoun S, Seddoh A, Harris H, Weissman JS, Dsane-Selby L, et al. Evaluating the impact of the national health insurance scheme of Ghana on out of pocket expenditures: a systematic review. BMC Health Serv Res. 2018;18(1):426. https://doi.org/10.1186/s12913-018-3249-9.
van der Wielen N, Channon AA, Falkingham J. Does insurance enrolment increase healthcare utilisation among rural-dwelling older adults? Evidence from the National Health Insurance Scheme in Ghana. BMJ Glob Health. 2018;3(1):e000590. https://doi.org/10.1136/bmjgh-2017-000590.
Lambon-Quayefio M, Owoo NS. Determinants and the impact of the National Health Insurance on neonatal mortality in Ghana. Health Econ Rev. 2017;7(1):34. https://doi.org/10.1186/s13561-017-0169-z.
Brugiavini A, Pace N. Extending health insurance in Ghana: effects of the National Health Insurance Scheme on maternity care. Health Econ Rev. 2016;6(1):7. https://doi.org/10.1186/s13561-016-0083-9.
Temsah G, Wang W, Mallick L. The impact of health insurance on maternal health care utilization: evidence from Ghana, Indonesia and Rwanda. Health Policy Plan. 2017;32(3):366–75. https://doi.org/10.1093/heapol/czw135.
Mensah J, Oppong JR, Schmidt CM. Ghana’s National Health Insurance Scheme in the context of the health MDGs: an empirical evaluation using propensity score matching. Health Econ. 2010. https://doi.org/10.1002/hec.1633.
Ibrahim A, Esena RK, Aikins M, O’Keefe AM, McKay MM. Assessment of mental distress among prison inmates in Ghana’s correctional system: a cross-sectional study using the Kessler Psychological Distress Scale. Int J Mental Health Syst. 2015;9:17. https://doi.org/10.1186/s13033-015-0011-0.
WHO. Mental health: Ghana situational analysis. 2019. https://www.who.int/mental_health/policy/country/ghana/en/. Accessed 13 May 2017.
Addo R, Nonvignon J, Aikins M. Household costs of mental health care in Ghana. J Mental Health Policy Econ. 2013;16(4):151.
Eatona J, Oheneb S. Providing sustainable mental health care in Ghana: A demonstration Project. 2015.
WHO. Promoting mental health: Concepts, emerging evidence, practice: Summary report. 2004.
Uddin MN, Islam FMA, Al Mahmud A. Psychometric evaluation of an interview-administered version of the Kessler 10-item questionnaire (K10) for measuring psychological distress in rural Bangladesh. BMJ Open. 2018;8(6):1–11.
Biddle DJ, Kelly PJ, Hermens DF, Glozier N. The association of insomnia with future mental illness: is it just residual symptoms? Sleep Health. 2018;4(4):352–9. https://doi.org/10.1016/j.sleh.2018.05.008.
Adisah-Atta I. Financing health care in Ghana: are Ghanaians willing to pay higher taxes for better health care? Findings from Afrobarometer. Soc Sci. 2017;6(3):90.
Akazili J, McIntyre D, Kanmiki EW, Gyapong J, Oduro A, Sankoh O, et al. Assessing the catastrophic effects of out-of-pocket healthcare payments prior to the uptake of a nationwide health insurance scheme in Ghana. Glob Health Act. 2017;10(1):1289735. https://doi.org/10.1080/16549716.2017.1289735.
Akazili J, Welaga P, Bawah A, Achana FS, Oduro A, Awoonor-Williams JK, et al. Is Ghana’s pro-poor health insurance scheme really for the poor? Evidence from Northern Ghana. BMC Health Serv Res. 2014;14(1):637. https://doi.org/10.1186/s12913-014-0637-7.
NHIA. National Health Insurance: Annual report 2009.
Rajkotia Y, Frick K. Does household enrolment reduce adverse selection in a voluntary health insurance system? Evidence from the Ghanaian National Health Insurance System. Health Policy Plan. 2011;27(5):429–37. https://doi.org/10.1093/heapol/czr057.
Witter S, Garshong B. Something old or something new? Social health insurance in Ghana. BMC Int Health Hum Rights. 2009. https://doi.org/10.1186/1472-698x-9-20.
Bonfrer I, Breebaart L, Van de Poel E. The Effects of Ghana’s National Health Insurance Scheme on Maternal and Infant Health Care Utilization. PloS One. 2016;11(11):e0165623-e. https://doi.org/10.1371/journal.pone.0165623.
Jehu-Appiah C, Aryeetey G, Spaan E, de Hoop T, Agyepong I, Baltussen R. Equity aspects of the National Health Insurance Scheme in Ghana: who is enrolling, who is not and why? Soc Sci Med. 2011. https://doi.org/10.1016/j.socscimed.2010.10.025.
Jehu-Appiah C, Aryeetey G, Agyepong I, Spaan E, Baltussen R. Household perceptions and their implications for enrolment in the National Health Insurance Scheme in Ghana. Health Policy Plan. 2012;27:222–3. https://doi.org/10.1093/heapol/czr032.
Nsiah-Boateng E, Aikins M. Trends and characteristics of enrolment in the National Health Insurance Scheme in Ghana: a quantitative analysis of longitudinal data. Glob Health Res Policy. 2018;3:32. https://doi.org/10.1186/s41256-018-0087-6.
Ernest A, Isaac O-A, Robert DO, Udry C. Ghana socioeconomic panel survey: report of the baseline survey. 2011.
Socioeconomic Panel Survey: 2009–2010. The World Bank, Microdata Library. http://microdata.worldbank.org/index.php/catalog/2534/get_microdata. Accessed 13 May 2017.
Kessler RC, Barker PR, Colpe LJ, et al. Screening for serious mental illness in the general population. Arch Gen Psychiatry. 2003;60(2):184–9. https://doi.org/10.1001/archpsyc.60.2.184.
Slade T, Johnston A, Oakley Browne MA, Andrews G, Whiteford H. 2007 national survey of mental health and wellbeing: methods and key findings. Aust N Z J Psychiatry. 2009;43(7):594–605. https://doi.org/10.1080/00048670902970882.
Furukawa Toshi A, Kawakami N, Saitoh M, Ono Y, Nakane Y, Nakamura Y, et al. The performance of the Japanese version of the K6 and K10 in the World Mental Health Survey Japan. Int J Methods Psychiatr Res. 2008;17(3):152–8. https://doi.org/10.1002/mpr.257.
Sipsma H, Ofori-Atta A, Canavan M, Osei-Akoto I, Udry C, Bradley EH. Poor mental health in Ghana: who is at risk? BMC Public Health. 2013;13(1):288. https://doi.org/10.1186/1471-2458-13-288.
Duku SKO, Asenso-Boadi F, Nketiah-Amponsah E, Arhinful DK. Utilization of healthcare services and renewal of health insurance membership: evidence of adverse selection in Ghana. Health Econ Rev. 2016;6(1):43. https://doi.org/10.1186/s13561-016-0122-6.
Amponsah S. Adverse selection, moral hazard, and income effect in health insurance: the case of Ghana. Bull Polit Econ Tokyo Int Univ. 2013;14:35.
Cameron AC, Trivedi PK. Microeconometrics using stata. College Station: Stata; 2010.
Angrist JD, Pischke J-S. Mostly harmless econometrics: an empiricist’s companion. Princeton: Princeton university Press; 2008.
Stock JH, Yogo M. Testing for weak instruments in linear IV regression. In: Andrews DWK, Stock JH, editors. Identification and Inference for econometric models: essays in honor of thomas rothenberg. Cambridge: Cambridge University Press; 2005. p. 80–108.
Wooldridge JM. Econometric analysis of cross section and panel data. Cambridge: MIT; 2010.
Jowett M, Deolalikar A, Martinsson P. Health insurance and treatment seeking behaviour: evidence from a low-income country. Health Econ. 2004;13(9):845–57. https://doi.org/10.1002/hec.862.
Lu C, Chin B, Lewandowski JL, Basinga P, Hirschhorn LR, Hill K, et al. Towards universal health coverage: an evaluation of Rwanda Mutuelles in its first eight years. PLoS One. 2012;7(6):e39282.
Cheung D, Laffargue J-P, Padieu Y. Insurance of Household Risks and the rebalancing of the Chinese economy: health insurance, health expenses and household savings. Pac Econ Rev. 2016;21(3):381–412. https://doi.org/10.1111/1468-0106.12179.
Cheung D, Padieu Y. Heterogeneity of the effects of health insurance on household savings: evidence from rural China. World Dev. 2015;66:84–103. https://doi.org/10.1016/j.worlddev.2014.08.004.
Jung J, Liu Streeter J. Does health insurance decrease health expenditure risk in developing countries? The case of China. South Econ J. 2015;82(2):361–84. https://doi.org/10.1002/soej.12101.
Trujillo AJ, Portillo JE, Vernon JA. The impact of subsidized health insurance for the poor: evaluating the Colombian experience using propensity score matching. Int J Health Care Finance Econ. 2005;5(3):211–39. https://doi.org/10.1007/s10754-005-1792-5.
Wirtz VJ, Santa-Ana-Tellez Y, Servan-Mori E, Avila-Burgos L. Heterogeneous effects of health insurance on out-of-pocket expenditure on medicines in Mexico. Value Health. 2012;15(5):593–603. https://doi.org/10.1016/j.jval.2012.01.006.
Galárraga O, Sosa-Rubí SG, Salinas-Rodríguez A, Sesma-Vázquez S. Health insurance for the poor: impact on catastrophic and out-of-pocket health expenditures in Mexico. Eur J Health Econ. 2010;11(5):437–47. https://doi.org/10.1007/s10198-009-0180-3.
Waters HR. Measuring the impact of health insurance with a correction for selection bias—a case study of Ecuador. Health Econ. 1999;8(5):473–83. https://doi.org/10.1002/(SICI)1099-1050(199908)8:5%3c473:AID-HEC453%3e3.0.CO;2-C.
NHIA. National Health Insurance: Annual report 2010. Ghana: NHIA2010.
Jowett M. Theoretical insights into the development of health insurance in low-income countries. Discussion Paper 188. Centre for Health Economics. 2004.
Chemin M. Informal groups and health insurance take-up evidence from a field experiment. World Dev. 2018;101:54–72. https://doi.org/10.1016/j.worlddev.2017.08.001.
Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70(1):41–55.
Imbens GW. Matching methods in practice: three examples. J Hum Resour. 2015;50(2):373–419.
Dehejia RH, Wahba S. Causal effects in nonexperimental studies: reevaluating the evaluation of training programs. J Am Stat Assoc. 1999;94(448):1053–62.
Funk MJ, Westreich D, Wiesen C, Stürmer T, Brookhart MA, Davidian M. Doubly robust estimation of causal effects. Am J Epidemiol. 2011;173(7):761–7. https://doi.org/10.1093/aje/kwq439.
Garrido MM, Kelley AS, Paris J, Roza K, Meier DE, Morrison RS, et al. Methods for constructing and assessing propensity scores. Health Serv Res. 2014;49(5):1701–20. https://doi.org/10.1111/1475-6773.12182.
Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med. 2009;28(25):3083–107. https://doi.org/10.1002/sim.3697.
Caliendo M, Kopeinig S. Some Practical guidane for the implementation of propensity score matching. J Econ Surv. 2008;22(1):31–72. https://doi.org/10.1111/j.1467-6419.2007.00527.x.
Baicker K, Allen HL, Wright BJ, Taubman SL, Finkelstein AN. The effect of medicaid on management of depression: evidence from the oregon health insurance experiment. Milb Q. 2018;96(1):29–56. https://doi.org/10.1111/1468-0009.12311.
Baicker K, Taubman SL, Allen HL, Bernstein M, Gruber JH, Newhouse JP, et al. The Oregon experiment—effects of medicaid on clinical outcomes. N Engl J Med. 2013;368(18):1713–22. https://doi.org/10.1056/NEJMsa1212321.
Finkelstein A, Taubman S, Wright B, Bernstein M, Gruber J, Newhouse JP, et al. The Oregon health insurance experiment: evidence from the First year*. Q J Econ. 2012;127(3):1057–106. https://doi.org/10.1093/qje/qjs020.
Ohrnberger J, Fichera E, Sutton M. The relationship between physical and mental health: a mediation analysis. Soc Sci Med. 2017;195:42–9. https://doi.org/10.1016/j.socscimed.2017.11.008.
Agyapong VIO, Osei A, Farren CK, McAuliffe E. Task shifting–Ghana’s community mental health workers’ experiences and perceptions of their roles and scope of practice. Global health action. 2015;8:28955. https://doi.org/10.3402/gha.v8.28955.
Gilbert DJ, Dako-Gyeke M. Lack of mental health career interest among Ghanaian social work students: implications for social work education in Ghana. Soc Work Educ. 2018;37(5):665–76. https://doi.org/10.1080/02615479.2018.1447102.
We are grateful to Professor Andrew Jones, Department of Economics, University of York, for his insightful comments and suggestions to improve the paper.
This study received no funding, it is part of the PhD thesis of the corresponding author.
Conflict of interest
Gowokani Chijere Chirwa, Marc Suhrcke, Rodrigo Moreno-Serra declare that they have no conflict of interest.
About this article
Cite this article
Chirwa, G.C., Suhrcke, M. & Moreno-Serra, R. The Impact of Ghana’s National Health Insurance on Psychological Distress. Appl Health Econ Health Policy 18, 249–259 (2020). https://doi.org/10.1007/s40258-019-00515-1