Is Ghana’s pro-poor health insurance scheme really for the poor? Evidence from Northern Ghana

This consensus has prompted interest in investigating alternative health care financing systems such as tax-based financing, social health insurance and community-based health insurance. Consensus is also emerging that achieving the health Millennium Development Goals (MDGs) by 2015 requires sustainable and equitable long-term health system financing strategies to improve access to health care and potentially to reduce morbidity [4]. However, varying definitions of universal coverage are employed in the policy literature. Universal coverage has been defined by WHO as “access to adequate health care for all at an affordable cost”. An influential definition proposed by McIntyre and Thiede [5] has also defined universal coverage as “a health system that provides all citizens with adequate health care, regardless of their employment status or any other factors”. Kutzin notes that universal coverage is not just access, but that effective coverage implies “necessary health care of good quality” [6] Irrespective of the definition used, two key issues are common to all discourse on this topic: equity in access to quality health care and financial risk protection. Achieving universal coverage requires that attention is not only paid to social equity indicators, such as geographical, educational, and cultural barriers, but also to operational constraints to access, such as the quality of care including poor attitude of health staff which discourages the use of health care services particularly by the poor and vulnerable [7],[8] but also to financial arrangements. In fact, all commentators agree that universal coverage is a desirable goal in the health system development goal [9]. “The crucial concept in health financing policy towards universal coverage is that of society financial risk pooling” [10]. However, this aspect appears to be ignored in many policy prescriptions for low income countries [3].

Given the failure of user fees [11], increased reliance on pre-payment mechanisms are critical to the achievement of universal access to health services [12]. Currently, there is growing international attention to the design and implementation of health insurance that is addressing the challenges of improving equity, expanding access, and ensuring quality of care provided by health systems in developing countries [12]. Ghana and several other African countries (e.g. Tanzania, Nigeria, Kenya and South Africa) are implementing (or are planning to implement) mandatory health insurance schemes with the aim of ultimately reaching universal coverage.

Prior to independence in 1957, user charges were instituted in all public health facilities in Ghana. After independence, health services became free to the public and were financed through general tax revenue. However, sustaining the level of financing required to ensure adequate quality of care and coverage of health services became problematic thereafter.

Following the general economic reforms instituted by the World Bank and the International Monetary Fund (IMF) in 1985, the Ghana Ministry of Health (MOH) introduced significant user fees in public health facilities with the aim of recovering at least 15 percent of recurrent operating costs. Though user fees for clients had existed earlier, the amounts paid were minimal and more of a token. The objective of recovering at least 15 percent of recurrent costs was vigorously pursued and met by Ghana [13]. However, access and utilization studies showed a significant reduction in the use of health services, especially in rural areas, after the introduction of user fees [13],[14]. User fees, commonly called the ‘cash and carry’^a system in Ghana, undoubtedly contributed to inequitable health service access and utilization between different socio-economic groups and between poor rural and richer urban dwellers [15],[16].

In response to these complex problems, the Ministry of Health began to consider the feasibility of health insurance as an alternative to user fees in the late 1980s. By the 1990s, a number of pilot schemes were implemented to test the viability and feasibility of this alternative financing arrangement. Some of the pilot schemes that were set up have led to some increases in utilization and access, promoting equity and efficiency in the areas in which these schemes existed [17]. In addition to these government initiated pilot schemes, a number of community-based pre-payment schemes proliferated and by 2002, there were more than 159 mutual health organizations. Despite this expansion, however, their coverage remained at only about 1 percent (220,000) of the population [17].

Due to the consistent evidence attesting to the inequities associated with user fees [18], strong political support for pre-payment health care financing came in 2001 when the government announced the introduction of a national health insurance (NHI) scheme to replace ‘cash and carry’ or user fees at the point of service. This policy was translated into legislation in 2003. The NHI coalesces a single policy from multiple schemes, with a district health insurance (DHI) scheme in each of the country’s over 200 districts, private mutual health insurance schemes and private commercial insurance schemes in order to afford all Ghanaians the opportunity to join a health insurance scheme of their choice. The NHI is aimed at providing access to health care for members without having to pay at the point of use and hence improving the affordability of medical care. Adults (outside the formal sector) pay a yearly minimum subscription of US$8.

A National Health Insurance fund (NHIF) has been set up and is financed through a payroll tax contribution, whereby 2.5 percent of the 17.5 percent of formal sector workers’ Social Security Scheme (SSNIT) contributions is directed towards health insurance. This is augmented by a 2.5 percent value added tax on selected goods and services as well as an annual allocation of central government funds. The NHIF transfers funds to each District Health Insurance Scheme (DHIS) based on the number of SSNIT contributors and indigents in the district [19],[20]. Existing community-based mutual health insurance schemes continue to function, but each such scheme is now required to be licensed by the National Health Insurance Council (NHIC) and only the NHIF is receiving subsidy from the government. However, private schemes can seek to be incorporated into the district schemes created under the law. The law also makes provision for the licensing, regulation, and operation of private commercial schemes that do not receive government subsidies. A relatively comprehensive NHI benefit package for outpatient and inpatient health services has been assembled that includes maternal care services and covers over 90 percent of the health care burden [20].

Against a background where Out-of-Pocket (OOP) payments currently account for over 45 percent of health care financing in Ghana [3],[21], under the NHI the government is seeking to provide quality, accessible, efficient and equitable health services to about 60 percent of all Ghanaians by 2015 and subsequently to obtain universal coverage throughout the country [20]. The current (2012) coverage rate by the scheme has enrolled about 33 percent population, with wide regional variation. Ghana’s ambitious, yet innovative, initiative has elements in common with the health insurance reforms introduced in Thailand [22]. Despite these common features, however, there are widespread concerns about the sustainability of the comprehensive and attractive benefit package covered by the NHI and concerns as well about how equity can be enhanced in ways that introduce a progressive payment regime. As the international community watches with interest Ghana’s giant step toward universal health insurance, there is a need for substantive research aimed at strengthening the design and implementation of the scheme to enhance its progress to universal access through equitable health care financing.

The NHIS is intended to be a pro-poor initiative with a graduated premium payment that is based on socio-economic status, but in reality, premium payments are generally flat due to the practical difficulty in classifying subscribers according to their relative socio-economic status. Planners have attempted to create a scheme for the NHIS that ensures financial protection to the vulnerable including women and children, thereby contributing to the achievement of maternal and child health MDG goals 4 and 5. The analysis that follows explores the extent to which the proposed pro-poor health insurance scheme is actually covering the poor and vulnerable in Ghana’s most impoverished region.

Upper East Region is one of the ten regions in the country. It is located in the north-eastern corner of the country between longitude 00 and 10 West and latitudes 100 30″N and 110 N and bordered by Burkina Faso to the north, Togo to the east, to the west by Sissala District in the Upper West Region and to the south by the West-Mamprusi District in the Northern Region (Figure 1). The vegetation of the area is primarily arid savanna grassland with a single growing season. The capital town of the region is Bolgatanga. The total land area is about 8,842 sq km, which translates into 2.7 per cent of the total land area of the country. The major ethnic groups are the Nankani, Bimoba, Bissa, Buli, Frafra, Kantosi, Kassena and Kusasi. The region currently has 11 districts. However, at the time of conducting the baseline survey of the GEHIP project, there were nine districts out of which 7 were study areas of the Ghana Essential Health Intervention Project (GEHIP). The region’s economy is dominated by subsistence agriculture, primarily cattle rearing and the cultivation of cereals like millet, sorghum and rice. The major religions in the area include African animism, Christianity and Islam. With regards to health care, the region has one regional referral hospital and five district hospitals. Apart from government health facilities, there are a few private facilities operated mainly by Christian missionary organizations [23].

Data for the study come from the GEHIP baseline survey. GEHIP is an intervention study that seeks to test the hypothesis that strengthening district health systems will accelerate progress with MDG 4 and 5. In other words strengthening the key pillars of the health system which include human resource, information management, supply of essential medicines, resource management, leadership and governance and health care financing, could improve MDG 4. The interventions is implemented in three districts (Bongo, Builsa and Garu-Tempane) in the Upper East Region with four other districts (Bolgatanga, Bawku-East, Bawku-West and Talensi-Nabdan) being control areas. Whilst the intervention is being rolled-out by the regional health directorate the baseline and endline surveys which were factored into project were sub-contracted to the Navrongo Health Research Centre. The survey collected data on 5511 women dispersed across 66 randomly selected census enumeration clusters located in both the intervention and non-intervention districts to establish baseline indicators for the study. Doris Duke Charitable Foundation (DDCF) of the USA is the funding agency for GEHIP and the project is technically assisted by Columbia University Mailman School of Public Health in Collaboration with the Ghana Health Service and the University of Ghana, School of Public Health. The project was ethically approved by the Ghana Health Service Ethics committee and Navrongo Health Research Centre Ethics Review board. The baseline survey asked questions to women of child bearing age (15–49 years) after a written consent was obtained. Information was also collected on the National Health Insurance Scheme. Two key questions were asked and these were: “have you registered as a member of the NHIS” and a follow-up question to those who had registered: “Do you have a valid NHIS card for the 2010/2011”. We took advantage of these questions to assess the coverage of the NHIS by socioeconomic status in the region among women of reproductive age and identified factors affecting enrolment into the scheme since there has been limited comprehensive or wide scale assessment of the NHIS since its inception in 2003/2004.

Out of 5511 women interviewed in the baseline survey, 42 (0.8 percent) had missing values for health insurance status, and were therefore excluded from the analysis. Basic descriptive statistics and logistic regression analysis were employed in this study. Both bivariate and multiple logistic regression models were used to identify factors affecting enrolment into the scheme. The outcome variable was insurance status categorized as 1 if a respondent was registered into the NHIS and had a valid card and 0 otherwise. The explanatory variables controlled for in the multiple regression models include SES, level of education, place of residence, house size, marital status, age of mother, religion and an autonomy variable. Education was categorized into 3 groups: none versus primary/Junior high versus Secondary or tertiary. Age was categorized into 3 groups: 15–17 yr 18–29 yr olds and 30–49 yr olds. The number of children respondents had was broken down into 3 groups -- 0, 1–4 and 5 or more. Occupation was classified by farmer/trader, civil servant and student. With regards to the level of socioeconomic status, the population was categorized into 5 quintiles, quintile 1 being the poorest and quintile 5 being the most prosperous. The socio-economic status indicator was constructed from the asset data using the Principal Component Analysis [24].

The study covered all districts in the Upper East region except two districts (the Kassena-East and West). These two districts are under the demographic surveillance system undertaken by the Navrongo Health Research centre. As to whether the results of the study would have been different if these two districts were added, one cannot tell but given that the region is generally homogenous; the results might not be different. The study did not also capture certain variables (e.g. education of spouses) which could be important.