1. 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 – 14 th March 2009, Accra. By Mr. Patrick Apoya

2. 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.

3. 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

4. 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).

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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?

12. 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.

13. 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.

14. 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

15. Conceptual Framework Max Exemptions Coverage U5 Pop A Exemptions Only B Out of Pocket Payments I nsurance coverage C Exemptions D Insurance Only + Insurance Health Care ServicesMax

16. Hypotheses A 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

17. 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

18. Results Sub districtInsurance Status YesNo Number Nkoranza69.031.0 155 Bonsu64.235.8 151 Total66.733.3 306

19. Annual Health Care Costs Table 2: Mean Cost of Health Care per Person per Year US$ Mean Sub DistrictCard Cost Consultatio n cost Medicines CostOther Costs Nkoranza0.62.08.77.3 Bonsu0.40.31.74.1 Total0.51.25.55.7

20. 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/year0.51.50.61.40.8 Consultation2.01.53.01.44.3 Medicines8.71.51.31.418.2 Other Costs0.71.51.11.41.5 Sub total for OPD Services 11.91.517.91.4 25.1

21. Financing by Exemptions Service Mean Annual Cost/ho usehold Amount Bearable by Exemptions only Under Ideal Implementa tion % Financing burden payable by Exemptio ns only Total Amount Bearable by Exemptions Under Ideal Implementa tion % Total Financin g burden payable by Exempti ons Actual Amount Borne by Exemptio ns only currently % Financing burden actually Borne by Exemptio ns only OPD Card 0.8 0.045.07 0.220.90.033.74 Consultatio n 4.3 0.36.81 4.3100.00.122.95 Medicines 18.2 1.910.39 17.696.70.00 Other Services 1.5 0.031.97 0.032.00.031.67 Total 25.1 2.39.09 22.089.10.180.73

22. Financing by Health Insurance Service Mean Annual Cost/hou sehold Amount Bearable by Insurance only Under Ideal Implementatio n % Financin g burden payable by Insuranc e only Total Amount Bearable by Insurance Under Ideal Implementat ion % Total Financin g burden payable by Insuranc e Actual Amount Borne by Insuranc e currently % Financing burden actually Borne by Insurance OPD Card 0.8 0.671.15 0.67 87.000.6685.68 Consultation 4.3 0.00 3.96 93.193.8791.03 Medicines 18.2 0.31.81 16.03 88.1216.0388.12 Other Services 1.5 1.4598.03 14.93 98.031.2382.69 Total 25.1 2.49.59 22.15 89.5721.8188.21

23. Legible coverage - population Max Exemptions Coverage U5 Pop A= 33% B = 0% 0% I nsurance coverage C = 66% D = 0% Health Care ServicesMax

24. Actual coverage - population Max Exemptions Coverage U5 Pop A = 4.8% B = 16.6% I nsurance coverage C = 0% D = 78.6 Health Care ServicesMax

25. Legible coverage - Costs Max Exemptions Coverage U5 Pop A= 9.09% B = 1.34% I nsurance coverage C = 79.98% D = 9.59% Health Care ServicesMax

26. Actual coverage - Costs Max Exemptions Coverage U5 Pop A= 0.73% B = 11.06% I nsurance coverage C = 0% D = 88.21% Health Care ServicesMax

27. 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.

28. 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.