1. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Eugenia Amporfu Kwame Nkrumah University of Science and Technology The Progressivity of the Ghanaian National Health Insurance Scheme and the Implications for Achieving Universal Coverage

2. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 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. **

3. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  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 of HC financing Types of equity in HC financing

4. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  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) Why Equity of healthcare?

5. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 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, ___).

6. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 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

7. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Informal adults – 29.4  SSNIT contributors – 6.1  SSNIT pensioners – 0.5  Pregnant women 5.5  Indigents – 2.3  Children less than 18 – 49.4  Adults aged 70 and above – 6.75 NHIS registered members 2009

8. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Ashanti region – 70.77  Greater Accra region 40.3 – lowest in the country Coverage by region

9. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  There are five sources: 2009  Premium 19.4%  Non SSNIT contributors: 15.6%  SSNIT contributors 3.8%  NHI levy 61.0%  Investment income 17%  Sector budget support 2.3%  Other income 0.2% Sources of financing in the NHIS

10. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  NHI levy – borne by all residents: registered and unregistered  Premium – out of pocket payment, important for universal coverage.

11. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  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) Progressive  if L(p) > L(ATP) -> Regressive Assessing the Progressivity

12. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  The Kakwani Index – measures the degree of proportionality (progressivity).  The computation: π K = C – G  Simpler method: Measuring Progressivity

13. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Where σ R 2 = the variance of R  R = the fractional ranking of premium  h i = the premium paid  ɳ = the mean of premiums paid  y i = the ATP  µ = the mean of ATP

14. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Useful for comparison  Gender  Location  Education  Marital Status

15. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Survey data used: Kumasi and Accra  Sample size 1080 Data Description 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)

16. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Results

17. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Results: L(p) vs L(ATP)

18. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 Results: L(p), L(oop) vs L(ATP)

19. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011 P-value Kakwani index for regression without dummies -0.3630.000 Coefficient for control group Kumasi Tertiary Secondary Female Married -.031 -.451 -.196 -.166 -.042 -.104.000.001.004.323.035 Regression Results

20. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  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 Conclusion

21. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Kumasi has a higher patronage than Accra  The educated are more likely to value health and hence less likely to drop out.  The married? Implication for universal coverage

22. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  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. Policy recommendations

23. 2 nd Conference of the African Health Economics and Policy Association (AfHEA) Saly – Senegal, 15 th - 17 th March 2011  Thank you for your attention