25/02/ :49 Subject: Ghana: where 'successful health insurance' is neither successful nor in fact health insurance

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1 25/02/ :49 Subject: Ghana: where 'successful health insurance' is neither successful nor in fact health insurance Dear all In Oxfam s continuing efforts to promote discussion and evidence-based debate on health care financing and delivery in poor countries we are circulating this on the topic of the National Health Insurance Scheme (NHIS) in Ghana. The World Bank and some other international aid agencies frequently cite Ghana as an example of how social health insurance can work in poor countries.[i] The truth is that while substantial progress has been made in health financing in the country over the last decade, the current system remains seriously inequitable and punishes the poorest. Typically social health insurance (SHI) is financed predominantly by employment-based contributions and has two main goals to increase revenues and to improve the equity and efficiency of the health system. In this context any suggestion that Ghana gives the world a good practice example of health insurance ignores a number of critical facts: that the Ghana NHIS is funded predominately by tax rather than insurance contributions, that it has failed to increase overall funding for health, and that it is the features and systems of the insurance scheme itself that significantly contribute to ongoing inequity and inefficiency within the health system. The analysis below provides more detail and evidence on the challenges faced by the NHIS in Ghana and on the welcome ambition and decision of the new government to move away from a contribution-based system to a single nominal lifetime payment with extensive exemptions, paid for by increased tax revenues. The decision, if implemented well, offers the chance for Ghana to build a truly universal health system accessible to all Ghanaians, which could be the envy of Africa. Please note that you can opt out of receiving these s at any time by sending an to Ghana where successful health insurance is neither successful nor in fact health insurance Ghana s National Health Insurance Scheme (NHIS) was introduced in 2003 and has been operational since It has been part financed throughout by a series of World Bank loans, and has benefited from significant amounts of World Bank technical support.[ii] The scheme was introduced in response to public demands for the removal of the old cash and carry system of user fees that led to large scale exclusion from health care and financial suffering. The implementation of the NHIS has improved access and reduced financial barriers for its members. However, to suggest that Ghana provides a good practice example of social health insurance for other poor countries to learn from ignores the fact that the scheme is in fact predominately tax rather than insurance funded

2 and is failing against its key stated objectives: to increase revenues for health and to improve the equity and efficiency of the health system. These issues are discussed in turn: Reaching the poor? Claims from the government and the World Bank that after five years the NHIS now covers more than 60% of the Ghanaian population[iii] appear exaggerated and misleading. In recent research, Witter and Garsong[iv] provide a more accurate estimate by counting only those members who hold valid membership cards and explicitly discounting fraudulent and inaccurate membership claims from insurance providers. This approach puts the coverage rate at more like 45%.[v] While this growth in membership is nevertheless impressive, the overall figure sadly hides deep and serious inequity within the system: Only 29% of the poorest Ghanaians are enrolled compared to 64% of the richest. This means that while everyone is paying for the NHIS through taxation it is the better-off who are disproportionately reaping the benefits of public subsidies for health.[vi] Insurance coverage for the poorest members of the population fell from 4% in 2005 to 1% in 2008 in a country where 28% of the population are living below the poverty line.[vii] The informal sector, including large sections of the population with the most unstable and often lowest revenues, are the only group that are required to voluntarily join and pay premiums individually and in cash. Unfairly, they are also paying more per head than others in the scheme.[viii] Membership levels of the informal sector are likely to tail off as recent surveys revealed that affordability is given as the main reason for not joining the scheme by 91% of poor households. [ix] Data suggests that the non-insured, commonly the less well-off, may be using fewer services and/or less expensive services as a result of increased tariffs for health services outside of the NHIS. Insurance financing is likely to reinforce and perpetuate historical imbalances in the level and quality of services across different areas and regions in Ghana as reimbursement payments flow to those facilities already in a strong position to attract more patients. These tend to be higher-level facilities such as hospitals and similarly those districts and regions with higher levels of infrastructure to facilitate access.[x] The poor who are disproportionately located in rural and remote areas with poor infrastructure are at an automatic disadvantage. Insurance or a tax financed health system? The principle source of funding for most social health insurance models is earmarked contributions by employees and their employers. In Ghana 70-75% of the NHIS is tax financed through a 2.5% health insurance levy added to VAT this means all Ghanaians are contributing financially to the health system despite less than half of the population benefiting from the scheme. A further 20-25% of funds come from contributions from those employed in the formal sector and currently only 5% from informal economy worker contributions. The NHIS s heavy reliance on tax funding erodes the notion that it can accurately be described as insurance and in reality is more akin to a tax-funded national health care

3 system, but one that excludes half the population. The majority (77%) of those who remain uninsured today cannot afford to pay the insurance premium required.[xi] Achieving health care for all in Ghana will mean scaling up to cover all those who cannot pay their own insurance. To fund this will mean even greater reliance on additional taxbased financing. Increased revenue for health and increased efficiency? Many commentators incorrectly regard the NHIS as contributing additional funding for health in Ghana. The reality is that its growth appears to have substituted for other public revenue funds from the NHIS are included in the health sector budget, and what it adds is then deducted from the Ministry of Finance s own budget allocation to the sector.[xii] Furthermore, contrary to the efficiency gains predicted, the NHIS is unfortunately riddled with inefficiency and cost-escalation problems, as has been a common experience of implementing social health insurance worldwide: The administration system introduced to process over 800,000 individual insurance claims each month through 145 District mutual health insurance schemes under the NHIS is complex, fragmented, expensive and slow. Major delays in provider payments have developed and as of the end of 2008 around $34 million was owing to health facilities.[xiii] While rising utilisation could increase efficiency by reducing unit costs, this would also lead to further efficiency losses due to the additional cost of revenue collection and NHIS overhead costs. Like many health insurance schemes the NHIS suffers from fraud and moral hazard with providers gaming the system to maximise reimbursement payments. The new DRG tariff structure introduced in 2008 (paying per episode of care, according to disease groups) has exacerbated problems of gaming with some facilities showing a doubling of NHIS claims within the first month. The introduction of fee-for-service for medication has seen an increase in the number of drugs per prescription from 4.5 in 2005 to 6 in 2008.[xiv] There are also concerns of perverse incentives within the insurance scheme to provide more curative and less preventative health care. An increasing number of private providers have been accredited under the NHIS with the argument that this will widen access. However, tariffs for using private providers are higher and some commentators believe this will be another driver of cost escalation.[xv] Improved governance and accountability? It is widely assumed by the World Bank and increasingly by other aid agencies and governments that splitting the role of purchaser and provider within a health system will help to improve provider accountability and responsiveness. With the NHIS failing on its chief objectives of raising additional revenue and improving equity and efficiency, perhaps its value added might lie here. Unfortunately this is not the case. The NHIS faces

4 severe constraints even managing claims effectively, never mind acting as an active purchaser to ensure health care is appropriate and effective. [xvi] Problems of accountability and transparency are exacerbated by a complex, confusing and fragmented institutional insurance architecture with unclear lines of responsibility and division of labour. Routine data is kept confidential and information on the activities of the District mutual health insurance schemes is largely unavailable. Looking forward It is misleading to describe Ghana as a poor country success story for social health insurance. The NHIS could be more accurately described as a tax funded system with a third-party membership and payment channel which works to exclude the majority of poor Ghanaians and leads to inefficiency and cost escalation. The theoretical value-added of establishing this parallel system, which brings significant transaction costs, have not been realised. There is no doubt that the people of Ghana, and the new government they elected in 2009, have recognised many of the problems outlined in this summary. The new government have laid out plans to move away from an insurance-based system in 2010 and introduce a nominal one-off payment for access from the age of 18 with extensive exemptions. This progressive decision should be welcomed and its implementation supported by international aid agencies. However, anecdotal evidence suggests that far from supporting this decision, aid donors are trying hard to water it down. This would be a significant missed opportunity. Based on current evidence and the repeated demands of Ghanaian citizens for free health care Oxfam, in partnership with national organisations and networks ISODEC, the Alliance for Reproductive Health and the Essential Services Platform are calling for: An urgent and public commitment from the government that the one-off fee will be modest and affordable for the majority of Ghanaians and not actuarially determined. An accurate costing analysis of providing universal access to health care free at the point of use and an identified financing gap to implement this. Increased tax based financing for health care, focussing on progressive taxation options including a National Health Oil Levy on all oil revenues. Increased aid for health from international agencies and bilateral donors to meet the financing gap. A move away from any fee-for-service provider payments to a global budgets or appropriate alternative system and look to streamline or even dismantle the parallel purchaser insurance architecture as a means of reducing fragmentation, inefficiency and unnecessary costs. Increased investment in expanding, improving and regulating the performance of health care providers so that all citizens can access quality and effective prevention, treatment and care services. An open and transparent process throughout so that citizens, organised civil society and parliamentarians can track progress, analyse evidence and input into the decision making and implementation of the new health financing policy

5 [i] For example: Ghana & Rwanda Set the Example on Scaling Up Health Insurance in Africa XTN/0,,contentMDK: ~menuPK:351958~pagePK: ~piPK: ~the SitePK:351952,00.html [ii] See for example, Ghana Health Insurance projecthttp://web.worldbank.org/external/projects/main?pagepk= &pipk=73230&the SitePK=351952&menuPK=351984&Projectid=P and thesitepk=40941&projectid=p [iii] XTN/0,,contentMDK: ~menuPK: ~pagePK: ~piPK: ~t hesitepk:351952,00.html [iv] Witter and Garshong (2009) Something old or something new? Social health insurance in Ghana BMC International Health and Human Rights, 9:20 [v] Witter and Garshong 2009, Op Cit. [vi] 2008 NDPC survey (published May 2009), [vii] The government of Ghana has a very narrow definition of the poorest that is used for the NHIS, known as the indigent population. Civil Society has criticised this definition as far too narrow and excluding the many millions more people below the poverty line. [viii] Interviews conducted on behalf of Oxfam found that while the informal sector premium was supposed to be a standard fee, in reality premia charged commonly fall between 15 and 25 Ghana cedis per person. This compares to a government subsidy in 2008 of 14 Ghana cedis per member). [ix] 2008 NDPC Survey, Op Cit. [x] Witter and Garshong 2009, Op Cit. [xi] 2008 NDPC survey found that: on average 77% of individuals who have not registered with the scheme attribute their non-registration status to affordability issues. The proportion is even higher among the rural dwellers (85%) than urban dwellers (64.5%). [xii] Witter and Garshong 2009, Op Cit. [xiii] Ibid. [xiv] Ibid. [xv] Ibid. [xvi] Ibid. Anna Marriott

6 Health Policy Advisor Development Finance and Public Services Team Oxfam GB +44 (0) Oxfam works with others to overcome poverty and suffering. Oxfam GB is a member of Oxfam International and a company limited by guarantee registered in England No Registered office: Oxfam House, John Smith Drive, Cowley, Oxford, OX4 2JY. A registered charity in England and Wales (no ) and Scotland (SCO )

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