Who is excluded in Ghana s National Health Insurance Scheme and why: A Social, Political, Economic and Cultural (SPEC)-bystep

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1 Who is excluded in Ghana s National Health Insurance Scheme and why: A Social, Political, Economic and Cultural (SPEC)-bystep Analysis Felix A. Asante; Daniel K. Arhinful; Ama P. Fenny; Anthony Kusi, Gemma Williams, Divya Parmar

2 Outline Introduction Health system in Ghana National Health Insurance Scheme (NHIS) Objectives Methodology Results Conclusion and Recommendations

3 Introduction Ghana has a comprehensive social protection policy framework combination of strategies such as support in kind, cash transfers and exemptions BUT, evidence shows that access to these amenities by the poor and vulnerable is not assured (Sarpong et al, 2010; Jehu-Appiah et al. 2011). Social assistance Livelihood Empowerment against Poverty (LEAP) cash transfers School Feeding Programme for targeted public school children Pensions (formal sector) Social equity Human Trafficking Act 2005 Domestic Violence Act 2007 Disability Act The Children s Act 1998 Social insurance National Health Insurance Scheme

4 Health financing Broad strategy in Ghana and many developing countries (1990s): reduce government spending on the health sector curb shortages of essential medicines and medical supplies Increasing user fees without improving the quality of services provided resulted in reduced use of health facilities Ghana s solution- NHIS (Act 650) in 2003 move away from excessive reliance on the direct payment of health services to pre-payment and risk-sharing Aim: financial protection and access to healthcare services NHIS (Act 852) in Mandatory NHIS; Unified NHIS with District Offices; and premium exemptions for persons with mental disorders

5 National Health Insurance Scheme (NHIS) Largely state funded (National Health Insurance Levy 61%) 2.5% VAT Insurance premium (4%) Insurance premium; SSNIT 3,8% contribution; 15,6% Sector budget support; 2,3% Other income; 0,2% Investment income; 17,0% NHIL; 61% Operational in all districts across the country NHIS total inflow as at 31 December, 2009 Benefits package covers over 95% of the most common and prevalent disease conditions in Ghana

6 Key Players in NHIS Architecture MINISTRY OF HEALTH (MOH) Stewardship (Policy & Regulation) PROVIDERS (Public & Private) Submission of Claims Payment of Claims PURCHASER (NHIS) Provision of quality services Utilization of services SUBCRIBER Pays Premium Ensure provision of quality services

7 NHIS Positive results better utilisation of health facilities e.g. insured clients reporting at the outpatient department visits (OPD) 56% in 2010 to 82% in 2011 (Ghana Health Service, 2012) Exemption policy 60% of active members SSNIT pensioners Children <18 years Elderly 70+ Indigents Pregnant women LEAP beneficiaries Processing fee Premium Key challenge: still gaps in coverage - lower enrolment among the poor

8 Start of study: 47.9% had registered and had their valid NHIS cards by end of 2008 (NDPC, 2009) Latest: 35% of the national population are active NHIS members by the end of 2013 (NHIA, 2013) Majority of Ghanaians are not active members of NHIS Is social exclusion a reason?

9 Research question Who is excluded under NHIS and why?

10 Mixed methods approach involving both quantitative and qualitative tools HOUSEHOLD SURVEY Households IN 5 DISTRICTS Savelugu-Nanton Asutifi Ejisu-Juabeng Kweabebirem 4050 Abura-Asebu- Kwamamkese QUALITATIVE INTERVIEWS WITH KEY INFORMANTS Focused Group Discussions WITH BENEFICIARIES NHIA officials NGOs, CSOs, Health providers NHI scheme managers National stakeholders meeting to validate recommendations

11 Results

12 Current Health Insurance Status Previously insured 15% Registered but yet to receive card 4% Never insured 27% Currently insured (Active members) 54% Source: Health Inc Household survey, 2012

13 SPEC by-step Step 1: Awareness and reach of the NHIS Awareness and reach (100%) Step 2: Enrolment in the NHIS Never enrolled (27%) Ever enrolled (73%) Step 3: Previous members, members registered but with no card and active members Previous members (20%) Registered but with no card (6%) Active members (74%) Step 4: Active members: Users of health services by who reported ill (n=898) Non-users Users (95.4%) (4.6%)

14 Who is excluded in enrolment? Characteristics of the never insured and the ever registered members of the NHIS Residence Urban Rural Sex of the household head (n=4,036) Male Health insurance status Not registered (never insured) (n= 4,383) Ever registered (n=11,795) Female Belong to a social organisation Education: % of adults ( 18 years) who ever attended school (n=8,421) Wealth quintile (economic resources) First Second Middle Fourth Highest

15 Why exclusion Households in lower wealth brackets 54% never insured in bottom two wealth quintiles More men compared to women 75% never insured are males It is due to hardship. We don t have any work here except the farming work and we have children in school that is why we haven t done it. (Participant, Female FGD, Akwasipon) I don t go to the hospital because I don t get sick often. [Even] if I am sick I usually use herbs. It is painful when you don t use the card but have to renew it every year (Participant, Male FGD, Abura Amoada)

16 Adverse selection- healthy people less likely to enrol Never insured - negative perception of the NHIS - health insurance was meant for the poor and sick There is nothing wrong with me and I usually don t fall ill. If I have a headache I buy Para (paracetamol) 20 pesewas and chew and am free. If am dizzy I drink a bottle of malt [non alcoholic drink]. But my children take theirs (their cards) to the hospital (Participant, female FGD, Abura Adukrom)

17 What explains these findings? Profile of Active members (SPEC) Political/economic resources Better educated Access to transport Access to health facilities Economically better off Socio-cultural characteristics: Higher proportion belonged to social organisations Perceive NHIS to be a social support system that provides benefit for all

18 Reasons for non-renewal of membership by wealth quintile Wealth quintile Reason Lowest Second Middle Fourth Highest Total Premium/registration is expensive Does not fall sick Does not have money Does not know it had expired Never benefited from it in the past Registration centre far from community Other Total

19 Who is excluded in utilisation? USERS (reported ill 2 weeks before survey) 64% insured 65% educated 60% women Key determinants HEALTH INSURANCE STATUS EDUCATION GENDER Fewer men enrolled in the NHIS

20 Improving social health protection??? Systemic factors of the NHI scheme? Supply-side processes?

21 NHIS increase voice? NHIA Ineffective exemption policy Cumbersome registration process What are they saying? Delay in reimbursement of fees Quality health care not guaranteed Made to pay for prescriptions Long waiting times

22 Conclusion/Recommendations Are social exclusionary processes a reason??? High level of awareness of the NHIS but many people did not understand or accept the underlying principle of health insurance. Yes & No Physical accessibility to health facilities and registration centres Financial constraints - major barrier to healthcare access and enrolment

23 Health insurance DISSONANCE Collective benefit?? Improve the understanding and acceptance of the NHIS and the principles underlying social health insurance. Personal benefit?? Effective targeting of groups for exemptions and special efforts be made to register them on the scheme.

24 Thank you FUNDING Acknowledgements The Health Inc Project is funded by the European Commission s Seventh Framework Programme FP7/2007 under grant agreement No The views and conclusions presented in this presentation are the sole responsibility of the author and do not necessarily reflect the views of the Commission. HEALTH INC PARTNERS

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