Community Health Insurance Enrolment Timing and Facility Delivery Cessation in Ghanaian Districts: A Regression-Discontinuity Estimation of Enrolment Windows and Dropout

Ghana's National Health Insurance Scheme (NHIS) is widely credited with increasing facility-based delivery, yet the scheme's enrolment cycle creates a structural discontinuity: women who enrol during pregnancy face a renewal date that may fall before or after delivery, and the timing of that renewal shapes whether insurance remains active at the point of obstetric need. The framework is specified for district-level implementation and is illustrated with the DHS Program indicator 'Family planning messages at community meeting or event' (FP_EFPM_M_COM), drawn from 15 African country surveys conducted between 2021 and 2025 (N = 15, mean = 29.733, SD = 17.495, range 6.60 in Mali to 73.40 in Malawi). Enrolment windows create discontinuities in effective coverage that are estimable with district health-information data, and that dropout at renewal is a mechanism linking insurance timing to delivery cessation. The contribution is methodological: a design that treats the renewal date as a cutoff rather than a covariate, and that distinguishes enrolment timing from enrolment status. Facility delivery cessation in Ghanaian districts is better understood as a function of renewal-window misalignment than of insurance uptake alone, and that regression-discontinuity designs can identify this mechanism where conventional enrolment-rate comparisons cannot.