Irene Akua Agyepong and Richard Afedi Nagai

1. Irene Akua Agyepong and Richard Afedi Nagai A comparison of user fees plus fee exemptions and health insurance policy effectiveness for children under five in Ghana

2. Objectives To assess effectiveness and reasons for effectiveness or otherwise of the user fee plus exemptions and the health insurance policies in removing the financial access barriers to outpatient clinical care for children under five in Ghana posed by user fees.

3. Conceptual model • HINDERING & ENABLING BENEFICIARY(CLIENT) • FACTORS • Acceptability of the policy & what it offers (benefits) • Access to information about policy • Benefits • How to access the benefits • Direct & indirect costs in accessing benefits POLICY DESIGN POLICY EFFECTIVENESS • HINDERING & ENABLING OPERATIONAL • TRANSLATOR FACTORS • Policy implementation guidelines • Operational translator agenda, needs & interests • Incentives & disincentives for ‘compliance’

4. Ghanaian financing context Tax funded system with free public sector services post independence (1957) User fees with a some fee exemptions 1985 Addition of more fee exemptions programs Under five, AN, elderly 1999 Delivery 2003, 2005 CBI starting 1992 (Nkoranza) Dangme West experiment starting 2000 NHIS 2003

5. Study Area Greater Accra Region 88% urban, high in migration (4.4% growth rate, 2.4% natural increase) Focus on children living in rural and urban poor areas Deprived rural district of subsistence farmers & fishermen (Dangme West) Deprived sub-metropolitan area with mix of indigenous Ga and multi-ethnic migrant settlements (Ashiedu-Keteke)

6. Methods Review of documents Community focus group discussions (3 urban site, 5 rural site) In-depth interviews with public sector facility heads (3/4 rural & 2/2 urban) Structured questionnaire administered to principal childcare takers (300/study site selected by cluster sampling [30*10]) Retrospective analysis of secondary data on public sector outpatient service utilization by insured and uninsured children under five for the period 2000 – 2004

7. Results - Effectiveness Effectiveness measured as % of children using the OPD of public sector facilities who: Got a full exemption from payment of user fees Through the user fees plus exemptions policy Through health insurance Who had to pay user fees despite the existence of the two policies and programs

8. Results - Effectiveness Manual record keeping in the facilities Attendance data kept at OPD records office Financial data in accounts office but with copies of attendance numbers ?from OPD records office. OPD utilization and exemptions financial data from the rural site facilities consistent between OPD records and accounting records. Data in urban site conflicting with numbers of children recorded as exempted higher than numbers of children recorded as having used the OPD. ?poor and unsynchronized record keeping ?deliberate misreporting: Facility management could not explain the discrepancies Insurance started in rural site in 2005 & there were only 27 insured children presenting at OPD

9. Results - Effectiveness Policy introduced in 1999. Operation in rural site started 2000 and in urban site 2002. Reason for different start dates unclear. The estimation of the average claim per child exempted in the sub-metropolitan site facilities showed an unrealistically low average per child exempted in 2002, and a constant low average of about ¢ 5000 (US$ 0.56) in subsequent years. The actual cost of an OPD visit for a child under five during this period was much more Urban facilities management explained that apart from a few children e.g. severely malnourished, they were only exempting children from the consultation fee of ¢ 5000 (US$ 0.56). They paid all other bills Rural site approach was to fully exempt some children and have others fully pay all user fees Insurance started as experiment in rural site in 2000 and data was available for all 5 years

10. Average Exemption claim per child in rural and urban study sites (old cedis)

11. % Children 0-5 covered by different payment mechanisms for primary care in rural district

12. Hindering and Enabling client factors Almost all respondents (rural and urban) knew about exemptions and insurance policies However sometimes vague on the details – especially insurance in the urban area where it was relatively new HOWEVER: Did not ask for an exemption if the staff at the facility did not volunteer one even when they knew of the policy because they were afraid of negative staff reactions

13. Hindering and Enabling client factors Facility user fees were not the only barrier for the poor Quality of care was a concern Geographic access was an issue, but sometimes quality was ranked higher with people bypassing nearer facilities for perceived better quality

14. Hindering and enabling operational translator factors No written guidelines for the exemptions policy Written guidelines available for insurance Long delays in exemptions reimbursement, partial reimbursement Acknowledge negative reactions to clients asking about exemptions and attributed it to the perception that the policy would make them bankrupt if they implemented it to the letter Generally central government appeared to shift the risks of the exemptions scheme to providers Providers reacted to protect their interest by modifying the policy (as described) Insurance was generally working and provider trust that they would be paid at the time of the study (2005/06) Concerning reliabiilty of provider payments, things have changed since – “déjà vu?”

15. Conclusions The user fees plus exemptions policy was not as effective as hoped Among the causes was the failure to provide adequate funds for implementation and the shifting of risk to providers The health insurance policy needs to learn from the failures of the exemptions policy A policy is only as good as its implementation arrangements, and effective policy making power can be diffused between central policy elites who design policies and programs and peripheral operational translators to whom these policies are handed down for implementation

16. Conclusions Unfortunately, central policy elites often go ahead to design policies and accompanying programs and pass them down for implementation on the assumption of a clean dichotomy between policy making which is a central function and implementation which is a peripheral function; without giving adequate attention to the power of peripheral operational translators in policy, and the incentives to make them comply and implement the policy as designed or modify it Some, though not all, of the observed failures of well intentioned policies developed at the central level and passed down for ‘compliance’, without attention to the interests and needs of operational translators may be related to this failure to recognize that operational translators also holds a form of power in effective policy development and implementation

17. Sustainable financing arrangements that effectively protect the vulnerable need more careful multi-factorial thought and analysis in design and implementation than is perhaps realized

18. Thank You