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Evaluating the Impact of National Health Insurance in Ghana

Evaluating the Impact of National Health Insurance in Ghana . Sara Sulzbach, MPH Health Systems 20/20. October 29, 2008. Acknowledgements. Abt Associates: Slavea Chankova, Laurel Hatt, Karen Finnegan Ghana Health Service/Health Research Unit: Dr. John Gyapong, Bertha Garshong

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Evaluating the Impact of National Health Insurance in Ghana

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  1. Evaluating the Impact of National Health Insurance in Ghana Sara Sulzbach, MPH Health Systems 20/20 October 29, 2008

  2. Acknowledgements • Abt Associates: Slavea Chankova, Laurel Hatt, Karen Finnegan • Ghana Health Service/Health Research Unit: Dr. John Gyapong, Bertha Garshong • USAID: Yogesh Rajkotia, Karen Cavenaugh

  3. Health Financing in Ghana • At independence in 1957, public health services were free • In 1970s introduced nominal fees to due to insufficient financing • 1980s instituted ‘cash and carry’ system of user fees; restricted access to health care • Community health insurance schemes emerged in 1990s, replacing user fees with modest premiums • Such schemes grew to 159 by 2002, but only covered 1% of the population

  4. National Health Insurance • National Health Insurance (NHI) passed in 2003 • District-level health insurance in accordance with national guidelines • Goal: equitable and universal access to health care for all Ghanaians • Financing: 2.5% levy on all goods and services, social security contributions, annual premiums • Coverage (as of December 2007): 42% of population insured; 55% registered

  5. National Health Insurance Benefit structure • Adults pay annual premium of 72,000 Cedis ($9) each • All dependents covered • Exemptions for elderly and indigent Benefits package • Inpatient • Outpatient • Essential drugs • Maternity (ANC and delivery) • Emergency care • Eye care

  6. Study Objectives • Examine changes in insurance enrollment since implementation • Determine effect of enrollment on • Health seeking behavior • Out-of-pocket expenditures

  7. Methodology – Study Design • Cross-sectional surveys • Household in 2 districts: Nkoranza and Offinso • Patient exit in 6 districts: Nkoranza, Offinso, Savelugu, Ajumako, Kwahu South, Ahanta West • Baseline in 2004; endline in 2007 • In-depth interviews with district scheme managers • Service statistics at district health facilities

  8. Methodology – Analysis Policy impacts • Pre-post comparisons to measure changes in insurance coverage, utilization, and expenditures Individual insurance effects • Propensity score matching (PSM) to measure individual impact of insurance on these outcomes and reduce selection bias

  9. Sample Characteristics

  10. Pre-Post Results: Increase in Wealth Status from Baseline to Endline Distribution of Wealth Quintiles: Baseline and Endline

  11. Pre-Post Results: Heads of households more likely to enroll

  12. Pre-Post Results: At endline, ill respondents more likely to seek formal care

  13. Pre-Post Results: No difference in maternal care seeking

  14. Pre-Post Results: Significant decreases in expenditures

  15. Determinants of insurance enrollment

  16. Additional Determinants of Individual Enrollment: Endline • Membership in community solidarity organization • Member of Akan ethnic group • Presence of chronic health condition

  17. Preliminary PSM Results:Insured more likely to seek curative care Differences in curative care seeking: insured vs. uninsured

  18. Preliminary PSM Results:Insured more likely to receive maternity care Differences in maternal care seeking: insured vs. uninsured

  19. Preliminary PSM Results:Insured pay less for health services Differences in OOPs: insured vs. uninsured

  20. Policy Implications • Exemptions for the poorest groups need to be strengthened; strong wealth effects observed for enrollment • Insurance is very effective at reducing OOP expenditures for curative and maternal care • Insurance is less effective at increasing rates of facility deliveries

  21. Recent Policy Changes and Proposals • Maternal health coverage: effective July 1, 2008 • De-coupling dependent minors from parent enrollment: effective September 2008 • Proposal to include family planning products and services in benefits package: TBD

  22. Exempting the poor District scheme manager on exemption policy: “When you go to a community, you will realize that they are all farmers. You can’t determine the income level at the end of the day so how do you determine the poor, the poorer and, the poorest in that community? Why not ask everybody to pay the same premium? Yaa, so we have decided that they should all pay the same.”

  23. Thank you Reports related to this presentation are available at www.HS2020.org

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