Assessing the Effects of the National Health Insurance and Pension Schemes on Welfare Outcomes in Ghana. = 가나 국민건강보험 및 연금제도가 복지 성과에 미치는 영향 분석

다국어 초록 (Multilingual Abstract)

Ghana’s social protection system is anchored in two flagship social insurance schemes: the National Health Insurance Scheme (NHIS) and the National Pension Scheme (NPS). While each has been studied separately, less is known about whether dual participation in both schemes delivers higher welfare outcomes than participation in a single scheme. Guided by social insurance theory, social risk management, the capabilities approach, institutional complementarity, and the cumulative impact framework, this study examines the combined effects of NHIS and NPS participation on welfare outcomes among insured adults in Ghana, with particular attention to the roles of financial security and individual capacity.
The study creates a standardized welfare index by combining self-rated health, perceived poverty status, and life happiness using data from cross-sectional surveys. A two-group specification is used to describe scheme participation, separating persons enrolled in one scheme (NHIS or NPS) from those enrolled in both. Robust standard errors are used to estimate ordinary least squares regressions that account for age, gender, the number of children, dependents, employment status, and education. To investigate mechanisms and distributional patterns, the analysis uses moderation (educational level) and mediation (financial security).
The findings indicate that compared to single-scheme participation, dual NHIS–NPS involvement is linked to a slight, favorable, but statistically insignificant welfare difference. In contrast, welfare is consistently and strongly predicted by perceived financial security, and there are significant correlations between age and gender (female). According to mediation theories, the main way that dual participation has a welfare effect is through financial stability. On the other hand, moderation results simply suggest that people with higher capacities benefit more from dual coverage.
According to the study's findings, social insurance in Ghana primarily improves financial security, and having more programs does not always result in better wellbeing. It makes the case for changes that put benefit adequacy first, strengthen the connection between NHIS and NPS, and take intentional steps to advance inclusion and equity, especially for low-education and informal workers. In addition to outlining a research plan encompassing longitudinal designs, richer data, and comparative analysis, the study offers micro-level evidence to guide Ghana's shift from disjointed programs toward a more integrated and inclusive social security system.

국문 초록 (Abstract)

가나의 사회보호 체계는 국가건강보험제도(NHIS)와 국가연금제도(NPS)라는 두 가지 핵심 사회보험 체계를 기반으로 합니다. 각 제도에 대한 개별적인 연구는 이루어져 왔으나, 두 제도에 모두 참여하는 것이 단일 제도 참여보다 더 높은 복지 성과를 제공하는지에 대해서는 알려진 바가 적습니다. 본 연구는 사회보험 이론, 사회적 위험 관리, 역량 접근법, 제도적 보완성 및 누적 영향 프레임워크를 바탕으로, 가나의 보험 가입 성인을 대상으로 NHIS와 NPS 공동 참여가 복지 성과에 미치는 결합 효과를 조사하며, 특히 재정적 안정성과 개인적 역량의 역할에 주목합니다.
본 연구는 횡단면 조사 데이터를 활용하여 자기 기입 건강 상태, 인지된 빈곤 상태, 삶의 행복도를 결합한 표준화된 복지 지수를 산출했습니다. 제도 참여를 설명하기 위해 두 그룹 분류 방식을 사용하며, 단일 제도(NHIS 또는 NPS) 가입자와 두 제도 모두에 가입한 사람을 구분했습니다. 연령, 성별, 자녀 수, 부양가족 수, 고용 상태 및 교육 수준을 통제한 최소자승법(OLS) 회귀 분석을 실시하였으며, 강건한 표준 오차를 적용했습니다. 메커니즘과 분포 패턴을 조사하기 위해 교육 수준을 조절 변수로, 재정적 안정성을 매개 변수로 사용하여 분석을 진행했습니다.
연구 결과, 단일 제도 참여와 비교했을 때 NHIS-NPS 공동 참여는 복지 수준에서 약간의 긍정적인 차이를 보였으나 통계적으로 유의미하지는 않았습니다. 반면, 복지는 인지된 재정적 안정성에 의해 일관되고 강력하게 예측되었으며, 연령 및 성별(여성)과도 유의미한 상관관계를 나타냈습니다. 매개 이론에 따르면, 공동 참여가 복지에 미치는 주된 경로는 재정적 안정성을 통한 것입니다. 한편, 조절 효과 분석 결과는 역량이 높은 사람들이 공동 보장으로부터 더 많은 혜택을 받는다는 점을 시사합니다.
연구 결과에 따르면 가나의 사회보험은 주로 재정적 안정성을 개선하며, 프로그램 수가 늘어난다고 해서 반드시 웰빙이 향상되는 것은 아닙니다. 본 연구는 급여의 적절성을 우선시하고, NHIS와 NPS 간의 연계를 강화하며, 특히 저학력 및 비공식 부문 노동자를 위한 포용성과 형평성을 증진하기 위한 의도적인 조치가 필요함을 제안합니다. 또한, 종단적 설계, 더 풍부한 데이터 및 비교 분석을 포함한 향후 연구 계획을 제시함과 동시에, 가나가 단절된 프로그램에서 보다 통합적이고 포용적인 사회보장 체계로 전환하는 데 필요한 미시적 증거를 제공합니다.

목차 (Table of Contents)

• Table of Contents
• ABSTRACT 3
• LIST OF DIAGRAMS 7
• CHAPTER I: INTRODUCTION 9
• 1.1 INTRODUCTION 9
• 1.2 BACKGROUND OF RESEARCH 10
• 1.3 PURPOSE OF RESEARCH 11
• 1.4 PROBLEM STATEMENT 12
• 1.5 RESEARCH QUESTIONS 14
• 1.6 SIGNIFICANCE AND RELEVANCE OF THE STUDY 14
• CHAPTER II - LITERATURE REVIEW 16
• 2.1 INTRODUCTION 16
• 2.2 CONCEPT OF WELFARE OUTCOMES 16
• 2.2.1 Multidimensional Approaches 16
• 2.2.2 Objective and Subjective Dimensions of Welfare Outcomes 17
• 2.3 KEY PERSPECTIVES OF SOCIAL INSURANCE AND WELFARE OUTCOMES 18
• 2.3.1 Globalization and Social Insurance 18
• 2.3.2 Good Governance and Welfare Outcomes 20
• 2.4 THEORETICAL FOUNDATIONS 21
• 2.4.1 Capabilities Approach 21
• 2.4.2 Social Insurance Theory 24
• 2.4.3 Social Risk Management (SRM) Framework 26
• 2.4.4 Institutional Complementarity Theory 28
• 2.4.5 The Cumulative Impact Framework 29
• 2.5 EMPIRICAL STUDIES ON THE SOCIAL INSURANCE SCHEMES 31
• 2.5.1 National Health Insurance Scheme 31
• 2.5.2 National Pension Scheme 32
• 2.6 CONTEXTUALIZATION AND HYPOTHESES 32
• 2.6.1 Welfare Outcomes of Dual Participation in Social Insurance Schemes 32
• 2.6.2 Financial Security as a Determinant of Welfare 33
• 2.6.3 Interaction of Social Insurance Scheme Participation and Individual Capacity 34
• CHAPTER III: RESEARCH APPROACH AND METHODOLOGY 36
• 3.1 RESEARCH CONTEXT 36
• 3.2 VARIABLES AND MEASUREMENTS 38
• 3.2.1 Dependent Variable: Welfare Outcomes 38
• 3.2.2 Independent Variable: Scheme Participation 39
• 3.2.3 Mediating Variable: Financial Security 39
• 3.2.4 Moderating Variable: Individual Capacity 39
• 3.2.5 Control Variable: Demographics 40
• 3.3 METHODOLOGY AND DATA COLLECTION 40
• 3.3.1 Research Design 40
• 3.3.2 Source of Data 40
• 3.3.3 Sampling Approach 41
• 3.4.4 Data Analysis 41
• CHAPTER IV: RESULTS AND FINDINGS 42
• 4.2 DESCRIPTIVES 42
• 4.2.1 Descriptive Statistics of Sample Population 42
• 4.2.2 Descriptive Statistics by Scheme Participation Groups 43
• 4.2.3 Cross-Tabulation of Scheme Participation Groups 44
• 4.3 RELIABILITY AND VALIDITY OF CONSTRUCTS 45
• 4.3.1 Reliability Statistics 45
• 4.3.2 Correlation Statistics Among Dependent Variables 45
• 4.3.3 Bivariate Associations Among Welfare, Financial Security, and Covariates 46
• 4.3.4 Multicollinearity Regression with Covariates 47
• 4.4 STATISTICAL ANALYSES RESULTS 48
• 4.4.1 Model 1: Scheme Participation Predicting Welfare 48
• 4.4.2 Model 2: Scheme Participation Predicting Financial Security 49
• 4.4.3 Model 3: Welfare Outcomes Predicted by Scheme Participation and Financial Security 49
• 4.4.4 Model 4: Moderation by Educational Level (Scheme Group and Educational Level) 50
• CHAPTER V: ANALYSES AND DISCUSSIONS 51
• 5.1 INTRODUCTION 51
• 5.2 EMPIRICAL ANALYSIS 52
• 5.3 LINKING RESEARCH QUESTION AND HYPOTHESES TO FINDINGS 53
• 5.4 SUMMARY 55
• 5.5 THEORETICAL INTERPRETATION OF THE FINDINGS 57
• 5.5.1 Social Insurance Theory and Social Risk Management 57
• 5.5.2 Capabilities Approach and the Distribution of Welfare Gains 59
• 5.5.3 Cumulative Impact and Institutional Complementarity 60
• 5.6 COMPARISON WITH PREVIOUS EMPIRICAL STUDIES 61
• 5.6.1 Health Insurance, Financial Protection, and Welfare 62
• 5.6.2 Pensions, Income Security, and Wellbeing 63
• 5.6.3 Integrated Social Insurance and Multi-Programme Effects 64
• 5.6.4 Summary 65
• CHAPTER VI: LESSONS, RECOMMENDATIONS, AND CONCLUSION 67
• 6.1 KEY LESSONS FROM THE STUDY 67
• 6.1.1 Lessons on Welfare Effects of Scheme Participation 67
• 6.1.2 Lessons on the Role of Financial Security 67
• 6.1.3 Lessons on Inequality and “Capacity to Benefit” 68
• 6.2 POLICY IMPLICATIONS AND RECOMMENDATIONS 68
• 6.2.1 Implications for NHIS and NPS Design 68
• 6.2.2 Implications for Integration of NHIS–NPS and System Design 69
• 6.2.3 Implications for Equity and Inclusion 70
• 6.2.4 Summary 70
• 6.3 LIMITATIONS OF THE STUDY 71
• 6.4 DIRECTIONS FOR FURTHER STUDIES 72
• 6.5 CONCLUSION 72
• BIBLIOGRAPHY 74
• APPENDICE 80
• APPENDIX I: SURVEY QUESTIONNAIRE FOR THE RESPONDENTS 80
• APPENDIX II: DESCRIPTIVE STATISTICS OF RESPONDENTS 88
• APPENDIX III: ROBUSTNESS CHECK USING STRUCTURAL EQUATION MODELING (SEM) ANALYSIS 102
• 국문초록 118
• ACKNOWLEDGEMENT 120