La couverture sanitaire des pauvres, quelles leçons tirées des expériences internationales pour le RAMED? Expérience de Ghana M. Anthony Gingoung

Socio-Economic Factors World’s second largest producer of cocoa African’s biggest gold miner after SA Oil production at Ghana's offshore Jubilee field began in mid-December, 2010, and is boosting economic growth One of African’s fastest growing economies

National Health Insurance Scheme Pro-poor Policy Programme aimed at providing financial access to basic healthcare to all persons resident in Ghana, especially the poor and the most vulnerable in society Covers about 95% of reported disease conditions in Ghana  In-patients services  Out-patient services  Maternal health services  Emergencies

Membership Category Category PremiumProc. Fee Informal sector Under 18 years 70 years and above SSNIT contributors SSNIT pensioners Pregnant women Indigents LEAP beneficiaries Paying Non-Paying CategoryMembership% of total Informal 3,408, % SSNIT Contributors 360,8603.6% SSNIT Pensioners 24,5400.2% Under 18 years 4,713, % 70 years and above 381,5113.8% Indigents 1,230, % Police Service 7,7900.1% Military 16,2610.2% Other Security Services % Total 10,144, %

NHIS Timeline and Financing National Health Ins. Levy (NHIL) – 2.5% Consumption tax SSNIT – 2.5 percentage points of Social Security Contributions. Premiums from subscribers (ranges from GH¢7.20 to GH¢48.00 ) Funds from Government of Ghana (GoG) allocated by Parliament Returns on investment Sector Budget Support The NHIS was established by an Act of Parliament in 2003 (Act 650) In 2004, L.I 1809 was promulgated to provide regulations for its operations. Revised Law (Act 852) was passed in November 2012 establishing one unitary scheme

Community-based targeting is employed using community members to identify the poor and vulnerable: 1.District Staff liaise with Department of Social Welfare, opinion leaders, and others within their respective areas of operations for list of poor persons in their communities 2. Relying on existing pro-poor social intervention programmes, namely: - Livelihood Empowerment Against Poverty (LEAP) - Orphanages - Leprosaria and inmates in mental homes - Prison inmates (reported to be poor and vulnerable) - Children in government school feeding programme - Children in government school uniform programme 6 Identifying the poor

Enroll all LEAP beneficiaries under the NHIS Livelihood Empowerment Against Poverty (LEAP) Ongoing across the country About 90% enrolled under the NHIS Support the implementation of Common Targeting Mechanism (CTM) Piloted in 10 districts (One per region) Plans are far advanced to increase the number to 50 in 2015 Funding constraint Strategies to increase enrollment of poor (1)

Undertake special registration exercise for the following: Psychiatrict Hospitals Beneficiaries of School Feeding Programmes Beneficiaries of School Uniform Indigent - Mother of twins begging on the street - TB patients - Inmate in Leprosaria who are poor and have no source of income - Persons with no identifiable source of income - Orphans with no support - Differently-able Persons - Prison Inmates - Children in orphanages Strategies to increase enrollment of poor (2)

Evidence on enrollment Current targeting mechanism for reaching the poor has resulted in significant increase in the number of indigents enrolled from 393,453 in 2012 to 1.23m in 2013 representing about 238% increase over the previous year.

Challenges in effective coverage of poor Difficulty reaching out to the poor Hard to reach areas Identification constraints Poor road network Unavailable national database of the poor Difficulty determining the actual population of the poor Unsustainable funding and operational strategy

Way Forward Deepen collaboration with all stakeholders (Department of social welfare, local government, opinion leaders etc) to: Develop guidelines and proxies for targeting and enrolment of the poor and vulnerable under the NHIS Develop register of the poor and vulnerable under the NHIS Ensure consistent funding for identification and registration of the poor and vulnerable

Adaptable Lessons from Ghana’s NHIS Innovative funding: o Earmarked fund – NHIL (2.5% VAT) o 2.5 percentage points of 18.5% Social Security Contributions o Informal sector contributions Promotion of acceptability through community ownership using district based sub-schemes Non-partisan political will of Government and entire population Comprehensive Accreditation system o Public, Private & Mission facilities o Assess staffing, management systems (including quality and safety) o Health care delivery systems and processes o Well accepted due to participation by all stakeholders Involvement of both public and private health care providers

A mix of provider payment mechanisms (i) Fee for Service (ii)The Ghana DRG system (iii) Capitation (Pilot state) NHIS medicine List derived from Ministry of Health (MOH) Essential Medicines List Clinical audit for the promotion of quality and cost containment Broad involvement of providers in the development of NHIS systems Call Centre Annual stakeholder meetings Adaptable Lessons from Ghana’s NHIS (2)