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Review of Exemptions (In-depth Review)

Review of Exemptions (In-depth Review). by Moses Aikins, Daniel Kojo Arhinful, K Appiah Denkyirah, Daniel Osei & Kwakye Kontor. Outline of Presentation. Methods Key Findings: Brief history of Exemptions Current Exemption package Financing of Exemptions Exemptions indebtedness

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Review of Exemptions (In-depth Review)

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  1. Review of Exemptions (In-depth Review) by Moses Aikins, Daniel Kojo Arhinful, K Appiah Denkyirah, Daniel Osei & Kwakye Kontor MOH Health Summit, 13 - 17th November 2006

  2. Outline of Presentation • Methods • Key Findings: • Brief history of Exemptions • Current Exemption package • Financing of Exemptions • Exemptions indebtedness • Status of Exemptions • Exemption obstacles • NHIS and exemptions • Challenges and Way Forward • Conclusions MOH Health Summit, 13 - 17th November 2006

  3. Review Methodology • Desk review – Acts, LIs, Documents, reports, claims returns & letters … • Field visits – Central & Eastern Regions • Interviews – National, Regional, District & Facility Levels with Policy makers, Health Providers, CHAG & a Donor MOH Health Summit, 13 - 17th November 2006

  4. Highlights KEY FINDINGS MOH Health Summit, 13 - 17th November 2006

  5. History of Exemptions in Ghana • Acts & Instruments • User fees (Hospital Fee Decree (NLCD 360) - 1969 & Amended in 1970 (Act 387) ~ nominal fees • In 1985 number of exemptions introduced as part of reforms together with user fees ~LI 1313 • Presidential pronouncement 1997 – Paupers, communicable diseases etc ~ Reinforcement MOH Health Summit, 13 - 17th November 2006

  6. History of Exemptions in Ghana • Presidential pronouncement 2003 – Free deliveries • NHIS Exemptions? – Act 650 & LI1809 • “Indirect” –registration of spouses & Chn U18Y; • Direct – Aged & indigents MOH Health Summit, 13 - 17th November 2006

  7. Goal of exemptions • Part of MOH 5POW • Consistent with the GPRS • Fulfills health sector pro-poor agenda • Exemptions Improves Service delivery • Reduces financial access barriers MOH Health Summit, 13 - 17th November 2006

  8. What is the current package? • Specified Diseases & Emergencies • Vulnerable groups i.e. U5Y, Aged & ANC • Free deliveries • Exemptions for paupers and indigents MOH Health Summit, 13 - 17th November 2006

  9. Financing National Exemption Budgets MOH Health Summit, 13 - 17th November 2006

  10. Exemption financing problems 1 • Specified Diseases & Emergencies • Total cost not known? • Central allocations made for procurement • Scope of financing treatment i.e. Leprosy & malaria • Vulnerable groups • Targeting Problem • Inadequate budget MOH Health Summit, 13 - 17th November 2006

  11. Exemption financing problems 2 • Free Deliveries • HIPC allocations and sustainability? • Paupers and indigents • Total cost unknown • Facility budget based on historical allocations • Very little incentive to grant exemptions to poor MOH Health Summit, 13 - 17th November 2006

  12. How much is owed to Exemptions (indebtedness)? MOH Health Summit, 13 - 17th November 2006

  13. Percentage of Claims submitted by Classified Regions, 2002 - 04 MOH Health Summit, 13 - 17th November 2006

  14. Percentage of Reimbursements received by Classified Regions, 2002 - 04 MOH Health Summit, 13 - 17th November 2006

  15. Current Status of Exemptions 1 Field experiences (1): • Specified Diseases and Emergencies • Erratic & running on routine drugs • Last refund in Eastern = Sept 2005 • Central = April 2005 • Vulnerable groups • Erratic and co-payment • ANC • Erratic, routine drugs & 4 visits MOH Health Summit, 13 - 17th November 2006

  16. Current Status of Exemptions 2 Field experiences (2) • Free Deliveries • Eastern Region – Stopped around March 2006 • Central Region – Stopped around August 2005 • Paupers and indigents • Erratic and mostly not granted MOH Health Summit, 13 - 17th November 2006

  17. Key Obstacles of Exemptions 1 • Commitment to exemptions • (budgetary allocation & reimbursements?) • Poor Documentation & Monitoring • Inadequate allocation & Mgmt of Exemption Funds • Referral issues of exemptions MOH Health Summit, 13 - 17th November 2006

  18. Key Obstacles of Exemptions 2 • Blanket exemptions (i.e. deliveries) • Defining & Identifying the Poor • Fraud & Abuse MOH Health Summit, 13 - 17th November 2006

  19. Challenges of Exemptions 1 Provider perspective: • Too broad implementation guidelines - makes targeting difficult and near impossible. • Irregular and inadequate reimbursement of claims. • Delay in reimbursement of claims. • Too much paperwork • Difficulties in the identification of the poor • High moral hazards associated with exemptions MOH Health Summit, 13 - 17th November 2006

  20. Challenges of Exemptions 2 Client perspective: • Less attention • Stigmatization of the Poor • Mistrust of health service MOH Health Summit, 13 - 17th November 2006

  21. Should Exemptions Continue? • YES • - Socially • - Politically • - Both MOH Health Summit, 13 - 17th November 2006

  22. The Way Forward (1): Exemption Lessons from NHIS: • Important to set up a monitoring system for NHIS • Establish confidence in the health system especially among health providers • Ensure adequate and prompt reimbursement • Cost the benefit package in order to enhance sustainability • Provide regular information especially the relationship between the Exemption Policy and NHIS MOH Health Summit, 13 - 17th November 2006

  23. The Way Forward (2): • Exemption Lessons for NHIS: • Improve target & identification of The Poor • Involve communities? • Improve capacity of Dept. of Social Welfare to assist? • For a start use GLSS4 poverty maps MOH Health Summit, 13 - 17th November 2006

  24. The Way Forward (3): • Reformat exemptions • Disease Targeting~ Diseases of high externalities (e.g. TB, Leprosy,Buruli) • Group targeting ~ Children under 5, NHIS • Geographical targeting ~ developmental issue?? • Any decision taken should depend on the smooth implementation of NHIS to absorb the Poor & indigents MOH Health Summit, 13 - 17th November 2006

  25. The Way Forward (4): • ALL exemptions should be integrated into NHIS (with main focus on paupers & indigents) • Financing & sustaining NHIS should be our main concern MOH Health Summit, 13 - 17th November 2006

  26. Conclusions • Implementation and funding are long drawn challenges of exemptions • Sustainability issues important to consider • Commitment to the whole process of exemption & NHIS crucial • No rush decisions MOH Health Summit, 13 - 17th November 2006

  27. Perception of Exemption & NHIS transition environment MOH Health Summit, 13 - 17th November 2006

  28. Thank you ALL for your attention. Stay Blessed. MOH Health Summit, 13 - 17th November 2006

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