The Progressivity of the Ghanaian National Health Insurance Scheme and the Implications for Achieving Universal Coverage

1. Eugenia Amporfu Kwame Nkrumah University of Science and Technology The Progressivity of the Ghanaian National Health Insurance Scheme and the Implications for Achieving Universal Coverage

2. Universal coverage is achieved in a health system when all residents of an economy are able to have access to adequate healthcare at affordable prices (Currin and James, 2004). Requirements: adequate healthcare healthcare financing system that ensures affordability to care regardless of ability to pay. **

3. Types of equity in HC financing • Horizontal Equity: people of the same ability to pay make the same contribution • Vertical equity: People of unequal ability to pay make appropriately dissimilar payment for health care – progressivity of HC financing

4. Why Equity of healthcare? • The ethical justification for equalizing access to health care is health equalizing • Why is health equalizing important? • Necessary for individual to flourish as a human being (Wagstaff and Doorslaer, 2000)

5. Policy makers find it justifiable to link payment of healthcare with its ability to pay because • Healthcare payments are involuntary item of expenditure which is caused by an unwanted health shock and that society as a whole is willing to share in absorbing the burden (Wagstaff, ___).

6. The Ghanaian National Insurance Scheme (NHIS) was introduced in 2003 to make healthcare affordable to all regardless of ability to pay • Premium range: 7.20 – 48.00 GHc to ensure equity • Vertical equity • The purpose of this study is to measure the progressivity of the NHIS

7. NHIS registered members 2009 • Informal adults – 29.4 • SSNIT contributors – 6.1 • SSNIT pensioners – 0.5 • Pregnant women 5.5 • Indigents – 2.3 • Children less than 18 – 49.4 • Adults aged 70 and above – 6.75

8. Coverage by region • Ashanti region – 70.77 • Greater Accra region 40.3 – lowest in the country

9. Sources of financing in the NHIS • There are five sources: 2009 • Premium 19.4% • Non SSNIT contributors: 15.6% • SSNIT contributors 3.8% • NHI levy 61.0% • Investment income 17% • Sector budget support 2.3% • Other income 0.2%

10. NHI levy – borne by all residents: registered and unregistered • Premium – out of pocket payment, important for universal coverage.

11. Assessing the Progressivity • 1. Examine the share of premium in ATP • 2. Compare shares of premiums payments of proportions of the members ranked by ATP with their share of ATP: i.e. compare concentration curves with the Lorenz curve. • Criterion: if L(p) = L(ATP) -> equity • if L(p) < L(ATP) -> Progressive • if L(p) > L(ATP) -> Regressive

12. Measuring Progressivity • The Kakwani Index – measures the degree of proportionality (progressivity). • The computation: πK = C – G • Simpler method:

13. Where σR2 = the variance of R • R = the fractional ranking of premium • hi = the premium paid • ɳ = the mean of premiums paid • yi = the ATP • µ = the mean of ATP

14. Useful for comparison • Gender • Location • Education • Marital Status

15. Data Description • Survey data used: Kumasi and Accra • Sample size 1080

16. Results

17. Results: L(p) vs L(ATP)

18. Results: L(p), L(oop) vs L(ATP)

19. Regression Results

20. Conclusion • Premiums are regressive • Disproportionate contribution by the poor • The degree of regressivity is higher • in Kumasi than Accra • HH with tertiary education • HH with Secondary education • HH is married • Not affected by gender of HH

21. Implication for universal coverage • Kumasi has a higher patronage than Accra • The educated are more likely to value health and hence less likely to drop out. • The married?

22. Policy recommendations • Need to increase the cap on premium to increase the amount paid by the rich. • Marital status could be taken into account when setting premiums • Minimize the variation of progressivity across regions.

23. Thank you for your attention