Improving Social Protection for the Poor: Health Insurance in Ghana. The Ghana Social Trust pre-pilot Project

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1 GLOBAL SOCIAL TRUST.. Improving Social Protection for the Poor: Health Insurance in Ghana The Ghana Social Trust pre-pilot Project Final Report The International Labour Organization March 2005

2 Copyright International Labour Organization 2005 Publications of the International Labour Office enjoy copyright under Protocol 2 of the Universal Copyright Convention. Nevertheless, short excerpts from them may be reproduced without authorization, on condition that the source is indicated. For rights of reproduction or translation, application should be made to the Publications Bureau (Rights and Permissions), International Labour Office, CH-1211 Geneva 22, Switzerland. The International Labour Office welcomes such applications. Libraries, institutions and other users registered in the United Kingdom with the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP [Fax: (+44) (0) ; in the United States with the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA [Fax: (+1) (978) ; or in other countries with associated Reproduction Rights Organizations, may make photocopies in accordance with the licences issued to them for this purpose. ISBN ISBN (Web pdf) First published 2005 The designations employed in ILO publications, which are in conformity with United Nations practice, and the presentation of material therein do not imply the expression of any opinion whatsoever on the part of the International Labour Office concerning the legal status of any country, area or territory or of its authorities, or concerning the delimitation of its frontiers. The responsibility for opinions expressed in signed articles, studies and other contributions rests solely with their authors, and publication does not constitute an endorsement by the International Labour Office of the opinions expressed in them. Reference to names of firms and commercial products and processes does not imply their endorsement by the International Labour Office, and any failure to mention a particular firm, commercial product or process is not a sign of disapproval. ILO publications can be obtained through major booksellers or ILO local offices in many countries, or direct from ILO Publications, International Labour Office, CH-1211 Geneva 22, Switzerland. Catalogues or lists of new publications are available free of charge from the above address, or by Visit our website: Printed by the International Labour Office, Geneva, Switzerland

3 Contents Page List of acronyms... Preface and project history... Acknowledgements... Executive summary... v vii ix xi Introduction The development and testing of methodologies to extend social security coverage to the excluded Introduction The Ghana Social Trust concept development Choice of hub - criteria Choice of satellites criteria Choice of benefit benefit analysis Analysis of benefit options Dangme West Analysis of benefit options Okwawuman Benefit analysis -conclusion Stakeholders Survey Introduction Summary of survey results Further stakeholder consultations Methodology of selection of beneficiaries Setting up the benefit delivery mechanism Outcomes and next steps Introduction Administering the benefit Developing the selection criteria Long-term financial sustainability considerations Activities to support the establishment of a pluralistic national health protection system Health budget Policy Advice to the Government on the National Health Insurance System Development of follow-up activities Capacity-building of SSNIT GST Ghana May 05.doc iii

4 4. Conclusions and recommendations Relevance of the project to the Government s National Health Insurance Plans General policy implications Opportunities and challenges Implications for the Global Social Trust concept Recommendations References Annex 1. Report on the workshop to launch the Ghana Social Trust Pilot Project Annex 2. Discussion Papers Nos Annex 3. ILO Health Insurance Survey Annex 4. Dangme West Health Insurance Scheme (DWHIS) / International Labour Organization (ILO): Premium Subsidization Project List of tables Table 1. Reasons why insurance coverage had not improved access to health care, Survey Dangme West and Kwahu South, List of figures Figure A. A revised model for a satellite health insurance system in Ghana... xiv Figure 1. A tentative outline of a satellite health insurance system in Ghana... 6 Figure 2. Educational attainment, Survey Dangme West and Kwahu South (2003) Figure 3. Gross household income, Survey Dangme West and Kwahu South (2003) Figure 4. Access to health facilities, Survey Dangme West and Kwahu South (2003) Figure 5. Cost of medical treatment, Survey Dangme West and Kwahu South (2003) Figure 6. Preferred system of health care, Survey Dangme West and Kwahu South (2003) Figure 7. Exemption categories, Survey Dangme West and Kwahu South (2003) Figure 8. Head of household by gender, Survey of potential beneficiaries in Dangme West Figure 9. (2003) and national data Age structure of household head, Survey of potential beneficiaries in Dangme West, Figure 10. Employment status, Survey of potential beneficiaries in Dangme West (2003) Figure 11. Educational Attainment, Survey of potential beneficiaries in Dangme West (2003) and national data Figure 12. Number of persons in household, Survey of potential beneficiaries in Dangme West (2003) Figure 13. Housing occupancy status, Survey of potential beneficiaries in Dangme West (2003) and national data Figure 14. State of dwelling, Survey of potential beneficiaries in Dangme West (2003) Figure 15. Electricity supply, Survey of potential beneficiaries in Dangme West (2003) Figure 16. Source of drinking water, Survey of potential beneficiaries in Dangme West (2003) and national data Figure 17. Delivery of benefit project process Figure 18. A revised model for a satellite health insurance system in Ghana Figure 19. Delivery of benefit in steady state system Figure 20. Proposed structure of the National Health Insurance Council Secretariat iv GST Ghana May 05.doc

5 List of acronyms CHAG DMHI DWHIA DWHIS GEA GHS GST HIPC ILO ILO-FACTS MHO NHI NHIC NHIF NHIS PMHI PRSP SOC/FAS SSNIT TUC Christian Health Association of Ghana District Mutual Health Insurance Dangme West Health Insurance scheme Administration Dangme West Health Insurance Scheme Ghana Employers Association Ghana Health Service Global Social Trust Debt initiative for Heavily Indebted Poor Countries International Labour Organization International Financial and Actuarial Service of the ILO Mutual Health Organization National Health Insurance National Health Insurance Council National Health Insurance Fund National Health Insurance System Private Mutual Health Insurance Poverty Reduction Strategy Papers Financial, Actuarial and Statistical Services Branch Social Security and National Insurance Trust Trades Union Congress Exchange rate: 1US$ = 8400 cedis. (Note: The exchange rate used in the section of the Annexes may be different) GST Ghana May 05.doc v

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7 Preface and project history As we move into the twenty-first century, a fundamental challenge faces the world. Too many people are too poor. 1.2 billion people one person in five are living on less than one dollar a day. And 3 billion people half the world s population live on less than two dollars a day. More than a challenge, this shameful fact highlights a failure to ensure that the world s wealth is distributed equitably, so that no-one is in real need. For many years, an international institutional framework has been in place, stating the commitments of the global community. The International Covenant on Economic, Social and Cultural Rights recognizes the right of everyone to an adequate standard of living including adequate food, clothing and housing, and to the continuous improvement of living conditions. 1 And in 2000, at the Millennium Summit, the United Nations concluded that urgent action was needed to address the world s problems, and that one of the most serious problems was poverty. The member states therefore resolved to halve, by the year 2015, the proportion of the world s people whose income is less than one dollar a day. 2 Alongside this commitment from governments, we must recognize and salute the genuine desire of the majority of the world s citizens to see a more just and equitable global society, and the will of millions of many ordinary people in the richest nations to contribute to that goal. In 1944 the ILO declared that poverty anywhere is a threat to prosperity everywhere. 3 The impact of poverty on global prosperity, and security, has been amply and repeatedly demonstrated in the sixty years since that declaration. The ILO occupies a unique place in the battle to eradicate poverty, having recognized two key components: employment for those who are able to work, and social transfers for those who are not. There are those who think that social protection is an add-on, something that can only be achieved when prosperity has been attained. The ILO and its constituents have long recognized that social protection is, rather, a factor contributing to development and prosperity. Income security and health care, for example, can increase productivity and labour market mobility. In 2001, ILO constituents discussed social security at the International Labour Conference. They concluded that one of the main areas for future action and research was extending and improving social security coverage. The coming together of institutional commitments to eradicate poverty and improve social security coverage, and the belief in the willingness of citizens to join this effort gave birth to the idea for a Global Social Trust. This document traces the genesis of that idea, and the first efforts to put it into practice in Ghana. 1 Article 11 of United Nations: International Covenant on Economic, Social and Cultural Rights, 1966 (New York, 1966). 2 Paragraph 19 of United Nations General Assembly: United Nations Millennium Declaration 55/2 adopted by the United Nations General Assembly on 8 Sep (New York, United Nations, September 2000). 3 Article I (c) of the Declaration of Philadelphia adopted by the ILO in 1944 (Philadelphia, 1944). GST Ghana May 05.doc vii

8 The original project funding was made available under the umbrella agreement on the financing of technical co-operation between the Dutch government and the ILO the Technical Co-operation Resource Allocation Mechanism (TC-RAM). The original summary of the project description reads as follows: This project aims at the piloting of a new methodology to extend the coverage of social protection to informal sector communities. It will test in collaboration with National Social Insurance Schemes whether these schemes can support community based social protection arrangements through the concept of satellite schemes. This concept envisages the continued mentoring and financial support of community-based schemes through formal sector social insurance. Supporting community based schemes could become a new branch of activities for national social insurance schemes. These pilot projects are a component of SOC/FAS feasibility analysis of a Global Social Trust network. During the project execution it became obvious that, in the Ghanaian case, the testing of possible links between national social insurance schemes and satellite schemes required more than management by a single technical adviser supported by national staff. The Ministry of Health was under a tight deadline set by the President to introduce a National Health Insurance System that planned to include the existing and emerging community and District-based Mutual Health Insurance schemes (DMHIs) in a hub-satellite relationship. It was obvious that the project needed to respond to government requests to support the design and implementation process of that arrangement if it was to avoid operating in isolation of the government s development plans. That support required a much bigger team and added a whole new dimension to the project work. In addition to testing certain support mechanisms for community based schemes expertise was needed in: social health insurance planning and policy design; health insurance financing and national health financing; and health insurance management. The ILO appointed a Chief Technical Adviser, Mr David Tumwesigye, to the project. In addition, the Ghanaian Social Security and National Insurance Trust (SSNIT) agreed to second two officials (Messrs. Benjamin Yankah and Tetteh Carboo) to the enlarged project; and the Government of the United Kingdom seconded Ms Fiona Kilpatrick of the Department of Work and Pensions to act as Project Co-ordinator. She also co-ordinates the Global Social Trust Initiative of the ILO. When it became obvious that the ILO would be seeking to extend the project into a fully fledged Global Social Trust Pilot Project, it became known as the Global Social Trust Pilot Project. viii GST Ghana May 05.doc

9 Acknowledgements This project is the result of extensive teamwork between experts in Ghana and an international support team. It benefited from a consortium of donors (the Governments of the Netherlands and the United Kingdom; the Ghana Social Security and National Insurance Trust (SSNIT); and the ILO) as well as support from many individuals. We are grateful to all those listed below and others too numerous to mention. Hon Dr. Kwaku Afriyie, Minister of Health, Ghana Dr. Sam Akor, Director Project Planning, Monitoring and Evaluation, Ministry of Health, Ghana Government of the Netherlands Hon Cecilia Bannerman, Minister of Lands and Mines (former Minister of Manpower Development and Employment), Ghana Hon Yaw Barimah, Minister of Manpower Development and Employment, Ghana Mr. Kwasi Osei, Director General, SSNIT Dr. Sam Adjei, Deputy Director General, Ghana Health Service Dr. Irene Agyepong, Dr. Margaret Gyapong, Ms. Evelyn Ansah, Mr. Francis Fiifi Arkorful and all staff of Dangme West Health Insurance Scheme Mr. Kofi Adusei, Ministry of Health Mr. K.T.K. Agban, District Chief Executive, Dangme West Mr. Osei Bimpong and all staff of Public Affairs Dept, SSNIT Ms. Valerie Quarmyne, General Manager Admin, SSNIT Mrs. Amartey, General Operations, SSNIT Mr. William Siaw and all staff of Informal Sector Social Security Project Mr. Robert Nsiah, FIT-Ghana Ms. Sandra Baldwin, Health Adviser, United Kingdom Department for International Development (DFID) Dr. Andreas Grueb, The Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) Ms. Helen Dzikunu and Ms Hanne Thorup, DANIDA All staff of Dangme West Health Research Unit Mr. Peter Kodua-Tweneboa, Senior Welfare Officer, Dangme West District Ms. Rose Asane, Social Development Department, Dangme West District Mr. Francis Abofra, Planning Officer, Dangme West District All staff of the ILO projects office, Accra Mr. Johnson Fasemkye, Finance Department, UNDP Accra Particular recognition is due to the Ghana Social Trust country team: Mr. David Tumwesigye, Chief Technical Adviser, Ghana Social Trust Mr. Benjamin Markin Yankah, Finance Expert to the Project Mr. Tetteh Carboo, Administrative Expert to the Project Mr. Kwabena Awuku, SSNIT, Project Driver. GST Ghana May 05.doc ix

10 The country team was supported by an ILO team consisting of Ms Fiona Kilpatrick (Project co-ordinator), Ms. Karuna Pal, Mr. Florian Léger and Ms. Diane Vergnaud (all of the Financial, Actuarial and Statistical Services Branch (SOC/FAS) of the ILO in Geneva); and Mr, Chinedu Moghalu of the Regional Office of Africa. The project was supervised by Mr. Michael Cichon, Chief, SOC/FAS. Mr. Cornelius Dzakpasu, Director of the ILO Office in Nigeria, facilitated co-operation with various levels of the Government of Ghana and with other ILO projects operating in parallel to the Ghana Social Trust pre-pilot Project. In particular, the project team co-ordinated activity with that of the Decent Work teams in Accra and Geneva. Professor Charles Normand of the London School of Hygiene and Tropical Medicine, and Dr. Raymond Wagener of the Inspection Générale de la Sécurité Sociale of Luxembourg served as project advisers at different stages of the project. The project also closely coordinated its activities with a World Bank Health Care team lead by Mr. Alex Preker and Ms. Laura Rose. The ILO-commissioned survey was carried out by Market Decisions Limited of Accra, under the supervision of Mr. George Fugah, Director. The Social Security and National Insurance Trust (SSNIT) of Ghana supported the project by hosting the project s country team and seconded two officials to the project. The Government of the United Kingdom seconded Ms. Kilpatrick to serve as a project coordinator and financed most of her missions. Sincere thanks are due to the Government of the Netherlands who financed the major share of this project under the Dutch-ILO umbrella agreement on technical co-operation. x GST Ghana May 05.doc

11 Executive summary The International Labour Conference in June 2001 concluded a discussion on social security by renewing the commitment of the International Labour Organization (ILO) to the extension of social security coverage and the improvement of the governance, financing and administration of social security. As a result, the Financial, Actuarial and Statistical Services Branch of the ILO (SOC/FAS) through its International Financial and Actuarial Service (ILO-FACTS) developed an innovative concept, the Global Social Trust, wherein individuals in the industrialized economies contribute a modest monthly sum (around 5) into a trust fund which is used to support the extension of social security in developing countries. The host government makes a commitment to take over the funding of the extended protection gradually over a number of years until the provision is fully funded on a sustainable basis. The feasibility of the benefit delivery mechanisms was tested in the Ghana Social Trust pre-pilot Project, which set out with two primary objectives: to develop and test methodologies for the extension of social protection benefits (health care) to excluded members of society especially in the informal sector; and to support the establishment of a pluralistic national health protection system in Ghana. The project took place against a background of substantial health insurance reform in Ghana, as the Government worked to replace the 20 per cent of health care costs met through the current pay-as-you-go system (cash and carry) with a national health insurance scheme. The remaining 80 per cent would be met, as now, from the national health budget. This is to be achieved through building and expanding on a network of existing voluntary Mutual Health Organizations (MHO) at the district level. Legislation was enacted in August Funding is to come from a monthly transfer of two and one-half per cent of each person s seventeen and one-half percent contribution to the Social Security and Pensions Scheme Fund (SSNIT insured members), and from a two and one half per cent national health insurance levy; and health insurance premiums. The development and testing of methodologies to extend social security coverage to the excluded Preparatory work The Ghana Social Trust project developed the concept of linking the formal and informal sectors in a hub-satellite relationship, whereby the formal sector acts as a partner and sponsor of smaller community-based social security schemes in the informal sector. In Ghana the vision was that a national agency would act as a hub partner for the district voluntary MHOs ( satellites ) which had grown up over the preceding ten years, broadly under the aegis of the Government. The hub had to have national coverage and the technical and administrative capacity to support the MHOs; and the MHO selected for the pre-pilot had to have likewise the technical and administrative capacity to deliver the benefit, and a benefit package and structure which would make it relatively simple to extend access to the non-covered. The benefit had to be designed to maximize the impact of the available funding. There was no national agency existant in Ghana which met the necessary criteria, so the project office acted as a virtual hub. The MHO selected for the pre-pilot was in Dangme West, in the Greater Accra region, which was well established and had a benefit package GST Ghana May 05.doc xi

12 covering selected outpatient care, and inpatient care up to a ceiling of cedis 400,000 (i.e. US$48) per case. The benefit selected was the subsidy of 75 per cent of the health insurance premium for the poorest. As the concept was developed, full discussions and consultations were carried out with a variety of stakeholders: the Ministry of Health and the Ghana Health Service; the social partners; health insurers; community representatives; and development partners. A key event in this process was a two-day workshop held in February 2003 to discuss the concept and the wider issues of national health insurance reform. The workshop participants fully endorsed the concept. Also as part of the preparatory stage of the project, the ILO commissioned a survey of usage of, and attitudes to, health care and health insurance in two districts: Dangme West, and Kwahu South (the latter in the Eastern Region). A sample of 1,000 people was interviewed, and data collected on demographics; employment and incomes of households; access to health care provision; recent medical history; awareness of health insurance, particularly MHOs; factors affecting membership of MHOs; and attitudes to exemption from or reductions of health insurance premiums for the poor. The data collected was a useful illustration of the socio-economic environment in which the project would take place, and later provided comparisons with national data and more narrowly focused data in Dangme West. Broadly, the survey showed reasonably high awareness of District Mutual Health Insurance schemes (DMHI); and people viewed them positively and wanted to join, but were inhibited by the cost of premiums and a lack of knowledge or understanding of how health insurance worked. This highlighted key areas to be tackled in the project. Identification of beneficiaries The project sought to establish a methodology for identifying beneficiaries which combined local, community-based knowledge and experience gained during the project in order to develop a set of objective criteria which could be used nationally. The latter were particularly important to providing a national baseline selection procedure which could be adapted to different circumstances in different regions. Extensive consultations were held with community representatives and health insurance registrars in Dangme West to this end. One of the key issues to emerge was that, while it was difficult to draw up a list of objective criteria from the start, everyone knew who were the poorest people in their communities. Some suggested identification based on particular socio-economic groups (widows, disabled people, orphans, the unemployed etc), but this was rejected as it did not necessarily indicate poverty on its own. It was therefore decided that a list would be drawn up on the basis of local knowledge, and would then be verified. At the verification stage, the circumstances of the potential beneficiaries would be assessed and used later to draw up the list of indicators. The list was prepared in August 2003, and initially identified 2,500 households. Subsequent verification eliminated duplicate registration and households which could not be found, reducing the number to 1,633. Of those, eleven households were found not to be poor, resulting in a final list of 1,622 households, or about 8,000 individuals. A questionnaire completed by those 1,622 households showed high incidences of elderly people; unemployment or insecure incomes; low levels of educational attainment; and large household size. Housing conditions were generally poor, and access to basic amenities (clean drinking water, electricity, toilets) was low. xii GST Ghana May 05.doc

13 Benefit delivery mechanism On the basis of available funding, and the number of households identified, it was calculated that the project could subsidize 75 per cent of the insurance premium for each person for three years. The premium is cedis 20,000 plus a registration fee of cedis 5,000 (i.e. the total being approximately US$3), with lesser amounts for children under 5 and elderly above 69. The Dangme West Health Insurance Administration (DWHIA) then proceeded to register those identified, collect the members 25 per cent of the premium and issue them with identity cards (ID). The cards are identical to those of other scheme members in order to avoid any stigma being attached to the poorest. Essentially the process is: identification, verification, registration, collection of premium and issue of identity cards. Some difficulties arose with the registration process, notably in collecting photos of the beneficiaries for the ID cards. This was overcome to some extent by ad hoc measures to subsidize the cost of photos. However, while people were apparently keen to participate, they were less keen to take the time for registration. The timing of registration is also important; the normal registration period is aligned with harvest time when more people have cash available. The registration of beneficiaries was later in this first year, making it harder for them to find the necessary money. The number of households registered by September 2004 was around 800. It is hoped that this will increase in the second year of operation as the process is further developed. Outcomes and next steps The experience of the pre-pilot has been that the basic structures outlined in the original concept appear to be achievable, and require modification only to adapt to local circumstances. The fundamental hub-satellite structure is the most appropriate to deliver the benefit, and a methodology has been established to identify beneficiaries. The hub-satellite model required modification, taking into account developments in legislation for and implementation of the new National Health Insurance System (NHIS), and particularly the establishment of the National Health Insurance Council (NHIC), which will effectively take on the role of the hub. The revised model is illustrated in Figure A below. GST Ghana May 05.doc xiii

14 Figure A. A revised model for a satellite health insurance system in Ghana Ghana Social Trust (GST) SSNIT contributions Health insurance Levy collected by Ministry of Finance Central exemptions fund from Ministry of Health Transfer of funds HUB National Health Insurance Council and Secretariat which holds funds in the National Health Insurance Fund District or regional office Transfer of funds and technical support District or regional office District or regional office District or regional office Identification of poor and request for funds Transfer of premium subsidy x% MHO MHO MHO MHO MHO MHO MHO MHO Insured persons pay (1-x) % of premium Source: ILO. The methodology for identifying and registering beneficiaries tested is essentially sound and it should be possible to replicate it elsewhere. However, work will have to be done to develop the objective selection criteria to be used in addition to the community-based identification process. Developing the selection criteria Work done suggests that the selection criteria have to strike a balance between simplicity/clarity and sufficient sensitivity to combine several criteria which, when brought together, are a reliable indication of severe poverty. Income is one obvious indicator, as are living conditions. But in areas where all cash incomes are severely limited, and housing conditions are generally poor, other criteria must come into play. A differentiation also has to be made between the causes of poverty and the indicators. In some cases these can be separated, but in others a single factor may be both a cause and an indicator: for example, unemployment. Another issue is the difference between conditions in rural and urban areas. Based on the experience of the pre-pilot, we suggest that the criteria used include: marital status (widowed or divorced with children); employment status; xiv GST Ghana May 05.doc

15 state of dwelling; access to utilities (water, toilets, electricity); non-ownership of land (in rural areas); ownership of livestock (principally in rural areas, although this would apply to some extent in urban areas; and based on sheep, goats and poultry); access to transport in rural areas. Long-term financial sustainability considerations One major issue of the NHIS is to ensure its financial sustainability. While interim financing for some future pilots might be secured through international donors, ultimately the resources for funding the district (satellite) mutual health insurance schemes will have to be provided through either social health insurance contributions or general tax revenues. One possible source of financing is the funds freed up through the debt relief arrangements for Heavily Indebted Poor Countries (HIPC), and while available information is limited, it appears that this will be useful in establishing an exemptions fund for the poor in Ghana. A more detailed long-term financial plan has to be worked out to establish the precise amounts available. Nevertheless, if long-term international subsidies might not be necessary, there will be a need for medium-term subsidies to: (a) (b) assist to fully establish a functioning subsidization mechanism across the whole country, and top up the subsidies of the National Health Insurance Fund (NHIF) to reach all the poor till the government s resource allocation to subsidies is fully operational. ILO activities to support the establishment of a pluralistic national health protection system In the course of the Ghana Social Trust project, SOC/FAS worked closely with the Government to provide policy and technical advice on the new National Health Insurance System. Health budget The ILO, in partnership with the Government of Ghana carried out a financial study which provided an assessment of the evolution of the costs involved in providing public health care and its financing during the next decade. For this exercise a health budget model was developed, which provided a tool for evaluating different health care outcomes resulting from various policy options. The result was a first preliminary version built on a limited database, which allows for simulations of alternative financial scenarios and should serve as a planning tool for timing the introduction of various elements of the NHIS. A critical condition for financial equilibrium during the coming years is that the government will not reduce its financial commitment to the health sector and hence all new sources of revenues are truly additional resources. In the longer-term future, the Government of Ghana will probably either have to bear a higher share of the public health GST Ghana May 05.doc xv

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