The Impact of Social Health Insurance on Household Fertility Decisions

While fertility rates generally fall over time as an economy develops, there is also evidence, primarily from developed countries, of pro-cyclical fertility. Fertility rates are correlated with short-run economic fluctuations because women delay pregnancy in poor economic times and periods of uncertainty, and increase fertility when conditions improve. Because health insurance reduces the cost of childbirth and medical care for children, the introduction of social health insurance may have the same effect on fertility as a positive income shock. This paper examines whether the introduction of social health insurance in Ghana had a positive, pro-cyclical effect on fertility decisions. Using data from the 2005/2006 Ghana Living Standards Surveys (GLSS) conducted shortly after the roll out of the insurance programme and the 2012/2013 GLSS, we compare fertility decisions of insured and uninsured women. To control for self-selection into the insurance programme, we exploit district-level variation in the dates of implementation of the national health insurance to instrument for insurance enrolment. We find evidence of a pro-cyclical fertility effect at the individual level. This is consistent with an increase in national fertility rates observed around the time the programme was introduced. The increase in fertility, however, appears to have been temporary; we find no effect of insurance on fertility in the more recent data.