To Alter or Not to Alter: The Fate of Exemptions For

Children Under Five Years Under National Health Insurance

Presentation at AfHEA Inuagural Conference,

10 – 14th March 2009, Accra.

By Mr. Patrick Apoya

Background

• Ghana has tested a variety of health financing mechanisms over the last two decades– Free care health, – user fees/cash and carry, – user fee exemptions for vulnerable groups– health insurance

• Effectiveness, efficiency, sustainability and public acceptability among the key drivers for continued search for new models.

Cash and Carry

• Cash and carry a key component of World Bank/IMF backed Structural Adjustment programs in the mid-1980s,

• Hailed then by the proponents as the key to resuscitation of the national health system– Then described as grave yards

• Concerns about potential social catastrophe rubbished, and proponents insisted “any possible negative impact on society could only be short-lived, may be for a year or two, and no more

Cash and Carry

• Evidence after a decade was to the contrary:– Low utilization rate of health facilities– Misery and death were the consequences for the

poor and vulnerable• By the mid-1990s, system began to create acute

social and political difficulties• Some relief was sought for vulnerable groups in

1997, covering basic health care for children under 17 years, pregnant women and the aged (70+ years).

User fee exemptions policy

• Started in 1997 to date (in principle)• Exemptions covered ff demographic groups:

– All children under five years of age– Pregnant women– People aged 70+ years

Health Insurance

• The search for health insurance in Ghana has a long history, but practical implementation was not until 1990, led by the Catholic church and community members

• Attracting considerable interest and attention of donors and health professionals after 5 years, – Then politicians after 10 years

Health Insurance ctd

• From just one district in 1990, the concept of community health insurance spread slowly at first, then rapidly across the country in a decade.

• Became a core campaign issue in 2000, having won the confidence of politicians as a promising solution to the health crises.

• National Health Insurance Law passed in 2003

The Mix

• NHIS Law did not invalidate the user fee exemptions policy

• Law exempted ff demographic groups, among others, from payment for NHIS:– Children under 18 years whose parents enrolled

with the NHIS– People aged 70+ years

• Pregnant women (later through donor grant)• NHIS supposed to work alongside Exemptions

Inclination

• By all measure, system was more inclined towards NHIS:– Operational difficulties and late reimbursement

did not amuse providers– Interest of donors leaned more towards NHIS than

exemptions– Government completely silent over exemptions

The Problem

• Exemptions and NHIS widely claimed to improve access to health care;– Yet, their actual (individual and combined)

contribution to reduction of households’ health care financial burden not known.

• NHIS offer more health care but less population coverage than exemptions

• Exemptions cover more population, but less health care.

Research Questions

• What share of the total annual health care costs for user fee-exempted groups is financed by the exemptions scheme only, assuming optimal performance, or in addition to health insurance?

• How dependable are user fee exemptions and health insurance as financing mechanisms in terms of population coverage, ease of access, continuity of service, sustainability, equity, satisfaction of beneficiaries?

Study Objective

• General Objective– To assess the individual and combined

contribution of the exemptions scheme and health insurance to improved access to health care services by exempted groups.

Specific Objectives

• Determine total annual costs of health care that households incur for exempted groups.

• Determine the individual and combined contribution of the exemptions scheme and health insurance schemes to financing the costs of health care for the exempted group for different households.

Study Objectives

• Determine the health seeking behavior of households who have access to the exemptions scheme and have health insurance cover simultaneously, as compared to households who have access to the exemptions scheme only.

• Recommend further considerations of the exemptions policy under the National Health Insurance scheme, as to whether exemptions should continue, phased out, fused into National Health Insurance scheme or be redesigned

Conceptual Framework

Max Exemptions Coverage

U5 Pop A Exemptions Only B Out of Pocket Payments

Insurance coverage

C Exemptions D Insurance Only

+ Insurance

Health Care Services Max

HypothesesA is significant in cost and number of people covered Maintain Exemptions   B > A only in sub district with poorly implementation

Redesign Exemptions

C >A only among group enrolled with health insurance Fuse into Health Insurance

•   A is not significant in both sub districts Discard Exemptions

Methods

• Formative Study• Qualitative study

– FGDs• Quantitative study – 500 households in 2 sub

districts in Nkoranza Ditrict of B/A region– Household Interviews to collect information on

health facility attendance of target group– Review of health facility attendance to trace services

and costs associated with above– Data analyses using SPSS+ 11

Results Sub district Insurance Status

  Yes No Number

Nkoranza 69.0 31.0 155

Bonsu 64.2 35.8 151

Total 66.7 33.3 306

Annual Health Care Costs

Table 2: Mean Cost of Health Care per Person per Year US$

Mean        

Sub District Card CostConsultation cost

Medicines Cost Other Costs

Nkoranza 0.6 2.0 8.7 7.3

Bonsu 0.4 0.3 1.7 4.1

Total 0.5 1.2 5.5 5.7

Mean Annual Health Care Costs

Service

a) Mean Cost per person per visit

b) Average # Visits per person per year

c) Mean Annual Cost per capita

d) Ave. # patients per household per year

e) Mean Annual Cost per Household

A. OPD Services          OPD Card (Paid for once/year 0.5 1.5 0.6 1.4 0.8

Consultation 2.0 1.5 3.0 1.4 4.3

Medicines 8.7 1.5 1.3 1.4 18.2

Other Costs 0.7 1.5 1.1 1.4 1.5Sub total for OPD Services 11.9 1.5 17.9 1.4 25.1

Financing by Exemptions

Service

Mean Annual Cost/household

Amount Bearable by Exemptions only Under Ideal Implementation

% Financing burden payable by Exemptions only

Total Amount Bearable by Exemptions Under Ideal Implementation

% Total Financing burden payable by Exemptions

Actual Amount Borne by Exemptions only currently

% Financing burden actually Borne by Exemptions only

OPD Card 0.8 0.04 5.07 0.2 20.9 0.03 3.74Consultation 4.3 0.3 6.81 4.3 100.0 0.12 2.95

Medicines 18.2 1.9 10.39 17.6 96.7 0.00 0.00Other Services 1.5 0.03 1.97 0.03 2.0 0.03 1.67

Total 25.1 2.3 9.09 22.0 89.1 0.18 0.73

Financing by Health Insurance

Service

Mean Annual Cost/household

Amount Bearable by Insurance only Under Ideal Implementation

% Financing burden payable by Insurance only

Total Amount Bearable by Insurance Under Ideal Implementation

% Total Financing burden payable by Insurance

Actual Amount Borne by Insurance currently

% Financing burden actually Borne by Insurance

OPD Card 0.8 0.6 71.15 0.67 87.00 0.66 85.68

Consultation 4.3 0.00 0.00 3.96 93.19 3.87 91.03

Medicines 18.2 0.3 1.81 16.03 88.12 16.03 88.12Other Services 1.5 1.45 98.03 14.93 98.03 1.23 82.69

Total 25.1 2.4 9.59 22.15 89.57 21.81 88.21

Legible coverage - population

Max Exemptions Coverage

U5 Pop A= 33% B = 0% 0%

Insurance coverage

C = 66% D = 0%

Health Care Services Max

Actual coverage - population

Max Exemptions Coverage

U5 Pop A = 4.8% B = 16.6%Insurance

coverage

C = 0% D = 78.6

Health Care Services Max

Legible coverage - Costs

Max Exemptions Coverage

U5 Pop A= 9.09% B = 1.34%

Insurance coverage

C = 79.98% D = 9.59%

Health Care Services Max

Actual coverage - Costs

Max Exemptions Coverage

U5 Pop A= 0.73% B = 11.06%

Insurance coverage

C = 0% D = 88.21%

Health Care Services Max

Summary of Key Findings• Only 0.73% of the legible total annual cost of

health care is financed by exemptions, instead of a potential 89.57%, meaning 0.82% effectiveness rate

• Out of pocket payments rose from 1.34% to 11.06% as a result of poor implementation of exemptions

• Health Insurance financing up to 88.21% of eligible costs

• Practical value of the 79.9% of costs qualified for dual-financing is zero, as no costs are shared.

Conclusion

• Exemptions scheme should be redesigned to work more effectively for the benefit of the 33.3% who do not currently have insurance cover.

• Option of discarding exemptions in the future not far remote should NHIS penetration rise.– At above 95% coverage of the total population by

health insurance, the negative effect at the population level would be marginal upon discarding the exemptions scheme altogether.