1. For any technical difficulties, please contact Lydia Ndebele (lndebele@worldbank.org )lndebele@worldbank.org We will mute your microphone during the presentations. Send questions and comments to the group via the chat! We will address these during the discussion jointlearningnetwork.org1 Instructions

2. Closing the Gap: Lessons from Africa Health coverage for non-poor informal-sector workers and their families November 5, 2015

3. Agenda jointlearningnetwork.org3 Welcome Introduction Lessons learned – Subsidies – Information – Convenience Discussion

4. Presenters jointlearningnetwork.org4 Jack Langenbrunner, The Bill and Melinda Gates Foundation, USA Collins Akuamoah, National Health Insurance Authority, Ghana Presenters JLN facilitators Marty Makinen, Joint Learning Network, USA Marilyn Heymann, Joint Learning Network, USA

5. Acknowledgements jointlearningnetwork.org5

6. Impetus In October 2013, the Government of Indonesia hosted a High Level Forum on Expanding Coverage to the Informal Sector jointlearningnetwork.org6

7. Introduction

8. “Coverage is often lacking for the non- poor informal- sector workers and their families because of the relative difficulty of identifying and enrolling them and in financing their coverage in an equitable way.” jointlearningnetwork.org8 Introduction

9. We define the non-poor informal sector as those who do not meet the country threshold for poverty status and assumes these four characteristics: 1)absence of formal contracts or protections for employees, 2)irregular income, 3)lack of outside government regulation or taxation, and 4)lack of health coverage through employers. Includes poor, near-poor, and non-poor in both rural and urban areas as well as migrant and temporary workers. Also encompasses the worker and family. jointlearningnetwork.org9

10. Three important factors that influence engagement and participation of the non-poor informal sector in pre-paid health insurance schemes: Subsidies Information Convenience jointlearningnetwork.org10 Introduction

11. Subsidies

12. Funding for social health protection for the non-poor informal sector typically comes from general government revenues— through either full or partial subsidies — or from mandatory or voluntary contributions from enrollees. jointlearningnetwork.org12 BenefitsChallenges Contributory Less burden on the tax base Politically more palatable Population awareness of cost Low coverage Significant transaction costs Tailoring subsidy level Non- contributory High coverage Lower administrative costs Need sufficient funding Need appropriate policy climate Potential reduction in relative size of formal economy

13. Subsidies When direct payments for health insurance are collected from the non-poor informal-sector workers, and particularly the near-poor, the contribution amount is mostly low and (in theory) mandatory. jointlearningnetwork.org13 Country/SchemeEligible GroupsGov’t SubsidyContribution China NRCMS Farmers, rural populations Central gov’t 85% of premium Flat amount, assigned by county South Korea NHI All self-employed populations Partial subsidyApprox. ₩50,513 (USD 45) per household Philippines PhilHealth (1)Sponsored members (2)Informal Economy members (1)Gov’t revenue (2)No subsidy (1)None (2)2,400 PHP or US$52 per family Vietnam SHI Vulnerable populations, informal sector workers Partial subsidy ranges from 30- 100% Income based

14. Background Ghana’s NHIS was established by an Act of Parliament in 2003 (Act 650) in response to challenges posed by “Cash and Carry” system Law reviewed in 2012, NHIS Act 852 A Social Health Protection Policy initiated by Government of Ghana to secure financial risk protection against the cost of healthcare services for all residents in the country. Subsidies - Ghana

15. CategoryPremiumProc. Fee Informal sector Under 18 years 70 years and above SSNIT contributors SSNIT pensioners Indigents Pregnant women LEAP beneficiaries Persons with Mental disorder Exempted from premium payment

16. Subsidies - Ghana CategoryMembershipPercentage Informal3,235,14130.7% SSNIT Contributors371,1873.5% SSNIT Pensioners21,1490.2% Under 18 years4,736,47444.9% 70 years and above380,1573.6% Indigents1,500,32414.2% Police Service7,3760.1% Military4,7170.04% Security Services2,3070.02% Pregnant women registered286,5962.7% Total10,545,428

17. Subsidies - Ghana Target GroupDescription Graduated Premium (Minimum Amount) Very Rich Adults who are employed and able to meet their basic needs and most of their wants GH¢ 48.00 / year USD 12.50 / year Rich Adults who are employed and able to meet their basic needs and some of their wants GH¢ 48.00 / year USD 12.50 / year Middle Income Adults who are employed and able to meet their basic needs. GH¢ 18.00 / year USD 4.69 / year Poor Adults who are unemployed but receive low returns for their efforts and are unable to meet their basic needs GH¢ 7.20 / year USD 1.90/ year Very Poor Adults who are unemployed but receive identifiable and consistent financial support from sources of low income. GH¢ 7.20 / year USD 1.90/ year Core Poor Adults who are unemployed and do not receive any identifiable and constant support from elsewhere for survival. Free

18. Subsidies - Ghana Challenges Difficulty in determining individual incomes No national database to assist in determining appropriate premium High administrative cost to collect premiums o Contribution of premium income to total NHIS revenue is less than 5% Challenges Difficulty in determining individual incomes No national database to assist in determining appropriate premium High administrative cost to collect premiums o Contribution of premium income to total NHIS revenue is less than 5% Solutions Use of geographic targeting / flat premiums Leveraging databases developed by other social welfare groups Solutions Use of geographic targeting / flat premiums Leveraging databases developed by other social welfare groups

19. Information

20. Educating health users about available programs and services — and the processes to use them — is a critical step for all countries working to provide health protection and access to health services. More information may increase willingness for the non-poor informal sector to enroll in health insurance However, education and sensitization efforts may not matter if the quality of health services are poor. jointlearningnetwork.org20

21. Information – Ghana Communication Strategy 1.Community Engagement – Drama on NHIS – Community durbars (meeting with village and chief) – Church / mosque sensitization – Use of mobile van – Gongong or community announcement system 2.Mass communication – Radio announcement, jingles, live talk shows – Television – Newspaper 3.A combination of 1 and 2

22. Information – Ghana Key Messages Conveyed to Informal Sector Members 1.Benefit package contents 2.New biometric membership registration process 3.Procedures for lodging complaints e.g. NHIS call center 4.Penalty for defaulting members 5.Rights and responsibilities of members 6.Credentialed service providers in the district Most of the above information is included in the subscriber manual

23. Convenience

24. Enrollment and Contribution Mechanisms Flexible schedules typically work best Structuring schedules and mechanisms around cycles of workers ensures they can use them However, more flexibility in enrollment and contribution payment options might however also have greater cost implications. jointlearningnetwork.org24

25. Enrolment Procedures Ghana’s NHIS began to use biometric registration in 2014 and is now being rolled out to the 10 th region in Ghana Two approaches to enrolment 1.In-person registration at District Office and other registration points 2.District office staff conduct outreach and registration in communities Convenience - Ghana

26. Subscriber Interview Fill Registration form Make Required Payment Update Basic Data Scan Fingerprints Capture New Photo Preview Details on Screen New Bio Data ? No Yes Print Card Check and Test ID Card Registration using BMS Membership Renewal

27. Solutions Increase outreach Institutional registrations (e.g. churches and mosques) Open more registration points, such as in health facilities Addressing technology issues Convenience - Ghana Challenges Inadequate number of registration kits Lack of connectivity limits site options for registration Technology issues & delays

28. Synthesis

29. Discussion

30. Thank you! jointlearningnetwork.org30 For additional information, please visit www.jointlearningnetwork.org or email Marilyn Heymann (mheymann@r4d.org)www.jointlearningnetwork.orgmheymann@r4d.org