1. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I BearingPoint I Bitrán y Asociados I BRAC University I Broad Branch Associates I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health Risk Pooling to Achieve Universal Coverage: Ghana s National Health Insurance Scheme Slavea Chankova

2. I. BACKGROUND

3. Introduction: Health Financing in Ghana At independence in 1957, public health services were free 1970s: nominal fees introduced due to insufficient financing 1980s: more substantial user fees for public health services This restricted access to health care, particularly for the poor 1990s: community-based health insurance schemes emerged, replacing user fees with modest premiums Rapid growth of schemes from 3 in 1999 to 258 in 2003 But only covered about 2% of the population

4. The National Health Insurance Scheme (NHIS) Established by legislation in 2003 Goal: equitable and universal access to health care Coverage reached 66% in 2010 Evaluation of NHIS Designed in anticipation of NHIS implementation Collaboration between Health Systems 20/20 project and Health Research Unit - Ghana Health Service

5. Key Features of the NHIS Managed by district-level mutual health insurance schemes Providers: all public health facilities and accredited private providers Benefits: 95% of disease conditions, essential drugs Enrollment Open to all with sliding-scale premium contributions starting at about $5 per adult Premium exemptions for children (under 18), elderly (70+), indigent, and pregnant women (as of 2008)

6. II. EVALUATION DESIGN

7. Evaluation Questions Who has enrolled in the NHIS? Do enrollment rates differ among different socio-economic groups? Is there evidence of adverse selection in NHIS enrollment? How well-targeted have premium exemptions been? What is the impact of the NHIS on the utilization of health services? What is the impact of the NHIS on out-of-pocket expenditures for health care?

8. Evaluation Design Pre-post study design Baseline in September 2004 Endline in September 2007 Implementation of NHIS in study sites started in 2005 Cross-sectional household surveys in 2 districts Nkoranza (had CBHI at baseline) Offinso

9. Study Sample Baseline 2004 Endline 2007 Number of households1,8052,520 Number of individuals9,55411,770 Individuals reporting illness/injury in past 2 weeks 413411 Individuals reporting hospitalization in past 12 months 203208 Women reporting delivery in past 12 months 298312

10. Analytic Methods Pre-post comparison of means for key indicators Regression models Control for differences in socio-economic characteristics between baseline and endline samples Probit and logistic regression models Results were robust to analytic methods

11. III. RESULTS

12. Sample Characteristics Poor rural population General improvements in socio-economic characteristics between 2004 and 2007 Health insurance coverage: Baseline 2004 (Nkoranza CBHI) Endline 2007 (NHIS) Nkoranza35%45% Offinso0%25% Total sample23%35%

13. Who Enrolls in NHIS? Enrollment increases with wealth quintile Poorest are 3 times less likely to enroll compared to the richest

14. Who Enrolls in NHIS? Factors associated with higher likelihood of NHIS enrollment * Richer wealth quintile Education of household head Female headed household Female gender Age: children and the elderly more likely to enroll, compared to 18-49 yr old Self-reported chronic illness At least one household member is part of a community solidarity scheme * Results from multivariate regression (variables with statistically significant coefficients)

15. Targeting of NHIS: Premium Exemptions for Children & Elderly Age-based exemptions have worked as intended But nearly all enrolled (97%) had paid a registration fee

16. Targeting of NHIS: Premium Exemptions for the Poor Exemptions have not benefited primarily those in the lowest wealth quintile

17. Adverse Selection in Enrollment Strong evidence of adverse selection based on health status NHIS-insured almost 3 times as likely to report illness in past 2 weeks, compared to uninsured 55% of those with chronic illness insured, compared to 34% of those without No evidence of self-selection in enrollment related to pregnancy 36% of women with delivery in the past 12 months were insured at time of delivery, compared to 33% of women who did not have a delivery

18. Utilization of Care for Recent Illness or Injury

19. Utilization of Maternal Health Care No significant changes between 2004 and 2007 in proportion of pregnant women receiving key maternal health services

20. Likelihood of OOP Expenditures for Care Significant decrease in probability of incurring OOP expenditures for recent curative care, hospitalization, antenatal care (ANC), and delivery

21. Changes in OOP Expenditures for Care Average expenditures for treatment declined significantly for most services: 41% decrease for curative care (from $2 at baseline) 44% decrease for hospitalization (from $25 at baseline) No significant decrease for ANC (remained at about $3) 30% decrease for delivery (from $8 at baseline) No significant changes in average amount paid by those who had positive OOP expenditures

22. Limitations Results from 2 districts (out of 138) so cannot be generalized to whole country Changes between 2004 and 2007 likely reflect impact of NHIS, but may also be influenced by other factors (e.g. other socioeconomic or policy changes occurring simultaneously) Small samples for some indicators (e.g. hospitalization) limit the ability of the study to detect significant changes

23. IV. CONCLUSIONS & POLICY IMPLICATIONS

24. NHIS Enrollment Age-based exemptions from NHIS premiums for children and the elderly have worked as intended But this may have potential implications for NHIS sustainability Strong wealth effects observed for NHIS enrollment Exemptions for the poorest groups need to be strengthened to ensure equitable enrollment in NHIS Evidence of adverse selection: those with poorer health status are more likely to enroll and more likely to utilize care Implications for DMHIS sustainability

25. Utilization and OOP Expenditures Substantial increase in use of formal medical services for illness; decrease in self-treatment and informal care-seeking However, no improvement in maternal care-seeking Need to explore non-financial barriers for seeking care Insurance has been very effective at reducing out-of-pocket expenditures for curative care and hospitalization, as well as for maternal care

26. Acknowledgements Abt Associates -- Health Systems 20/20: Laurel Hatt, Sara Sulzbach, Hong Wang, Ha Nguyen Ghana Health Service/Health Research Unit: Dr. John Gyapong, Bertha Garshong USAID: Yogesh Rajkotia, Karen Cavenaugh, Mary Ellen Stanton

27. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I BearingPoint I Bitrán y Asociados I BRAC University I Broad Branch Associates I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health Reports related to this presentation are available at: www.HS2020.orgwww.HS2020.org Presentation will be posted at: http://www.abtassociates.com/HSRsymposium http://www.abtassociates.com/HSRsymposium