Achieving Universal Health Coverage Through Ghanaian National Insurance Scheme

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The Ghanaian National Insurance Scheme aims to achieve universal health coverage by ensuring affordable healthcare regardless of ability to pay. The scheme focuses on equity in healthcare financing, emphasizing both horizontal and vertical equity. Policy makers justify the link between healthcare payments and ability to pay, considering healthcare expenses as involuntary expenditures. The introduction of the NHIS in 2003 marked a significant step towards making healthcare accessible to all residents.

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The Progressivity of the Ghanaian National The Progressivity of the Ghanaian National Health Insurance Scheme and the Implications Health Insurance Scheme and the Implications for Achieving Universal Coverage for Achieving Universal Coverage Eugenia Amporfu Kwame Nkrumah University of Science and Technology 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Universal coverage is achieved in a health system when all residents of an economy are able to have access to adequate healthcare at affordable prices (Currin and James, 2004). Requirements: adequate healthcare healthcare financing system that ensures affordability to care regardless of ability to pay. ** 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Types of equity in HC financing Horizontal Equity: people of the same ability to pay make the same contribution Vertical equity: People of unequal ability to pay make appropriately dissimilar payment for health care progressivity progressivity of HC financing 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Why Equity of healthcare? The ethical justification for equalizing access to health care is health equalizing Why is health equalizing important? Necessary for individual to flourish as a human being (Wagstaff and Doorslaer, 2000) 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Policy makers find it justifiable to link payment of healthcare with its ability to pay because Healthcare payments are involuntary item of expenditure which is caused by an unwanted health shock and that society as a whole is willing to share in absorbing the burden (Wagstaff, ___). 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

The Ghanaian National Insurance Scheme (NHIS) was introduced in 2003 to make healthcare affordable to all regardless of ability to pay Premium range: 7.20 48.00 GHc to ensure equity Vertical equity The purpose of this study is to measure the progressivity of the NHIS 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

NHIS registered members 2009 Informal adults Informal adults 29.4 SSNIT contributors SSNIT contributors 6.1 SSNIT pensioners SSNIT pensioners 0.5 Pregnant women 5.5 Indigents 2.3 Children less than 18 49.4 Adults aged 70 and above 6.75 29.4 6.1 0.5 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Coverage by region Ashanti region 70.77 Greater Accra region 40.3 lowest in the country 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Sources of financing in the NHIS There are five sources: 2009 Premium 19.4% 19.4% Non SSNIT contributors: 15.6% SSNIT contributors 3.8 NHI levy 61.0% 61.0% Investment income 17 Sector budget support 2.3 Other income 0.2 15.6% 3.8% 17% 2.3% 0.2% 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

NHI levy borne by all residents: registered and unregistered Premium out of pocket payment, important for universal coverage. 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Assessing the Progressivity 1. Examine the share of premium in ATP 2. Compare shares of premiums payments of proportions of the members ranked by ATP with their share of ATP: i.e. compare concentration curves with the Lorenz curve. Criterion: if L(p) = L(ATP) -> equity if L(p) < L(ATP) -> Progressive if L(p) > L(ATP) -> Regressive 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Measuring Progressivity The Kakwani Index measures the degree of proportionality (progressivity). The computation: K= C G Simpler method: h y 2 2 = + + i i R e R i i 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Where R2= the variance of R R = the fractional ranking of premium hi= the premium paid = the mean of premiums paid yi= the ATP = the mean of ATP 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Useful for comparison Gender Location Education Marital Status 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Data Description Survey data used: Kumasi and Accra Sample size 1080 Age Females Kumasi Tertiary Education Secondary Education Primary Education Illiterates Premium Consumption Expenditure Income 41.4 43.2 14.9 40.2 41.2 15 3.6 GH 21.5 (mean) GH 5002 (mean) GH 775 (mean) 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Results 0.35 0.3 0.25 Premium 0.2 utilization 0.15 0.1 0.05 0 Poorest second third fourth richest 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Results: L(p) vs L(ATP) 120 100 80 premium 60 Lorenz 45 degree 40 20 0 poorest 2nd 3rd 4th richest 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Results: L(p), L(oop) vs L(ATP) 120 100 80 premium lorenz 60 oop 45 degree 40 20 0 poorest second third fourth richest 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Regression Results P P- -value value 0.000 Kakwani index for regression without dummies -0.363 Coefficient for control group Kumasi Kumasi Tertiary Tertiary Secondary Secondary Female Married Married -.031 -.451 -.196 -.166 -.042 -.104 .000 .001 .004 .323 .035 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Conclusion Premiums are regressive Disproportionate contribution by the poor The degree of regressivity is higher in Kumasi than Accra HH with tertiary education HH with Secondary education HH is married Not affected by gender of HH 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Implication for universal coverage Kumasi has a higher patronage than Accra The educated are more likely to value health and hence less likely to drop out. The married? 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011

Policy recommendations Need to increase the cap on premium to increase the amount paid by the rich. Marital status could be taken into account when setting premiums Minimize the variation of progressivity across regions. 2ndConference of the African Health Economics and Policy Association (AfHEA) Saly Senegal, 15th- 17thMarch 2011