The National Health Insurance Programme in Ghana and Household Access to Medicines

1. The National Health Insurance Programme in Ghana and Household Access to Medicines Arhinful, Daniel Kojo (1); d'Almeida, Selassi A (2); Annan, Edith Andrews (2) darhinful@noguchi.mimcom.org 1: Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana; 2: WHO Country Office, Accra, Ghana

2. Background & Setting • The lack of access to essential medicines and health care in developing countries is one of the most pressing global health issues. • Health insurance is increasingly seen as an important alternative financing mechanism for health care in developing countries, and has the potential to increase utilization and better protect people against (catastrophic) health expenses. • In Ghana, a National Health Insurance Scheme (NHIS) became operational in 2004 through an Act of parliament (ACT) passed in 2003. • The national health insurance scheme enjoys high public acceptance and as at December 2009, an estimated 13 million or 65 percent of the population has ever registered with the scheme.

3. Study Questions & Aims • Study Question? • Has health insurance in Ghana led to increased access to health care services? How does it affect utilization of medicines and health care in general? • Main Aim • To collect data on household expenditure in health care for subscribers and non-subscribers of health insurance in Ghana and give an idea of the proportion of the population with access to affordable essential medicines on a sustainable basis. • The specific objective was to examine differences in household health care services utilization: • between insured households and non insured households of the national health insurance scheme and; • between subscribers of the national health insurance and private health insurance subscribers in Ghana

4. Methods 1 • Carried alongside WHO household Survey in 2008 • The survey tools were thus administered in six regions selected "survey areas" based on a combination of purposive and random sampling. • The survey was thus conducted in six regions: Greater Accra region, BrongAhafo region, Central Region, Volta Region, Upper West region and Western region as shown in the adjacent map

5. Country Profile: Demographic and Socioeconomic Indicators • Map of Ghana Showing study areas Population, mortality, fertility Population, total (millions) = 23.351 Population < 15 years (% of total population) = 39.0 Population > 60 years (% of total population) = 6.0 Urban population (% of total population) = 50.0 Birth rate (births per 1,000 population) = 30.8 Death rate (deaths per 1,000 population) = 9.0 Fertility rate, total (births per woman) = 3.9 Economic status GNI per capita (local cur.) = GhC 892.62 GDP growth (annual %) = 6.3 Population living < PPP int. $1 a day (%) = 30.0 Income share held by lowest 20% (%) = 5.6 Education and literacy Adult literacy rate, 15+ years (% of total population) = 65.0 Primary school enrolment rate, males (% of male population) = 73.0 Primary school enrolment rate, females (% of female population) = 71.0

6. Methods 2 • Study Population • In each survey area, sample of reference facilities comprising main public regional hospital and five additional public health care facilities per survey area • Survey tools targeted 30 households located in the vicinity of each reference public health care facility systematically chosen according to their distance from the reference facility: a third of • Altogether, 1020 households were interviewed in the six regions of Ghana by means of a short structured paper questionnaire. • Data entry was performed with EpiData software and analysis with SPSS and Excel.

7. Results 1 • Health Insurance Coverage • No. of Households interviewed = 1020 • No. of Households with at least one member covered by Health Insurance = 732 • % Households with at least one member covered by Health Insurance = 71.8% • The high insurance coverage is a likely function of the close proximity of households to health facilities

8. Results 2 • A little over half (51.8%) of the 732 households with at least one member covered by health insurance reported payments for administrative cost and premium for national health insurance in the last 12 months of the study. The median expenditure was GH¢20 and the mean was GH¢25.5. • Expenditure on private health insurance premium was reported by only 1.9% of insured households. • The findings show the relative wide coverage of national health insurance compared to private insurance.

9. Results 3 • Household Expenditure on Therapeutic appliances and ITNs • Just 2.8% (29) of all households surveyed reported some payments on therapeutic appliances such as glasses, hearing aids, orthopaedics and prosthetics appliances as well as impregnated treated nets in the last 3 months. • 25 out of the 29 who spent on therapeutic appliances were insured. • Similarly 81.8 % of 110 respondents reporting utilizing ITNs were insured. • The findings suggest that the insured have better access to catastrophic health expenditures.

10. Results 4 • Therapy of resort for out-patient care • 37.16% (379) of all households utilized various sources of treatments such as hospitals and health centres, clinics pharmacy and chemical sellers shops. • 53.56% of the 379 also sought complementary treatment • Hospitals and clinics remain the most popular first source of therapy for both the insured (94.2%) and non-insured (88.3%) but the non-insured (44.4%) tend to use chemical sellers and pharmacies as popular sources of complementary care compared to the insured (27.1) who tend to substitute more of that with alternate care.

11. Results 5: Facility Admission by Insurance Status • Only 63 representing 6.2% of all households surveyed reported facility admissions for at least 24 hours. • The ratio of the insured to non-insured being on admission was in the region of 7.8 to 2.1. • The difference was statistically significant [Chi-square = X2 = 11.6, p = 0.001] as table 8 below indicates.

12. Summary • What do we know? • Proximity or geographical access to health facility is a likely determinant to household enrolment in insurance but additional analysis need to be carried out to confirm that. • Introduction of health insurance has led to increased access to health care for majority of households. • The insured are able to meet essential health care and have better access to medicines for over 90% of health conditions as evidenced by reported OPD and hospitalization. • The insured are more able to meet catastrophic health care needs as evidenced in their expenditure on therapeutic appliances and ITNs • The insured have better options for their health care as indicated by therapy of resorts., and are also able because through access

13. Conclusions • Lessons • This is a one off study so the data does not tell us the trend in utilization patterns for health insurance and medicines use behaviour but nevertheless provides very useful baseline results on the demand/user side for assessing future trends. • Policy Implications: • The pattern of health seeking and utilization for both OPD and hospital admission of the insured certainly has cost implications for the scheme and justifies the need for gate keeping mechanisms to prevent moral hazard. In such schemes • Future Research? • What is the basis upon which insurance clients make choices for health care? • To what extent does insurance status influence health seeking behaviour of consumers.