Can health insurance protect against out-of-pocket and catastrophic expenditures and also support poverty reduction? Evidence from Ghana's National Health Insurance Scheme.

BACKGROUND: Ghana since 2004, begun implementation of a National Health Insurance Scheme (NHIS) to minimize financial barriers to health care at point of use of service. Usually health insurance is expected to offer financial protection to households. This study aims to analyze the effect health insurance on household out-of-pocket expenditure (OOPE), catastrophic expenditure (CE) and poverty. METHODS: We conducted two repeated household surveys in two regions of Ghana in 2009 and 2011. We first analyzed the effect of OOPE on poverty by estimating poverty headcount before and after OOPE were incurred. We also employed probit models and use of instrumental variables to analyze the effect of health insurance on OOPE, CE and poverty. RESULTS: Our findings showed that between 7-18 % of insured households incurred CE as a result of OOPE whereas this was between 29-36 % for uninsured households. In addition, between 3-5 % of both insured and uninsured households fell into poverty due to OOPE. Our regression analyses revealed that health insurance enrolment reduced OOPE by 86 % and protected households against CE and poverty by 3.0 % and 7.5 % respectively. CONCLUSION: This study provides evidence that high OOPE leads to CE and poverty in Ghana but enrolment into the NHIS reduces OOPE, provides financial protection against CE and reduces poverty. These findings support the pro-poor policy objective of Ghana's National Health Insurance Scheme and holds relevance to other low and middle income countries implementing or aiming to implement insurance schemes.

Ownership and technical efficiency of hospitals: evidence from Ghana using data envelopment analysis.

BACKGROUND: In order to measure and analyse the technical efficiency of district hospitals in Ghana, the specific objectives of this study were to (a) estimate the relative technical and scale efficiency of government, mission, private and quasi-government district hospitals in Ghana in 2005; (b) estimate the magnitudes of output increases and/or input reductions that would have been required to make relatively inefficient hospitals more efficient; and (c) use Tobit regression analysis to estimate the impact of ownership on hospital efficiency. METHODS: In the first stage, we used data envelopment analysis (DEA) to estimate the efficiency of 128 hospitals comprising of 73 government hospitals, 42 mission hospitals, 7 quasi-government hospitals and 6 private hospitals. In the second stage, the estimated DEA efficiency scores are regressed against hospital ownership variable using a Tobit model. This was a retrospective study. RESULTS: In our DEA analysis, using the variable returns to scale model, out of 128 district hospitals, 31 (24.0%) were 100% efficient, 25 (19.5%) were very close to being efficient with efficiency scores ranging from 70% to 99.9% and 71 (56.2%) had efficiency scores below 50%. The lowest-performing hospitals had efficiency scores ranging from 21% to 30%.Quasi-government hospitals had the highest mean efficiency score (83.9%) followed by public hospitals (70.4%), mission hospitals (68.6%) and private hospitals (55.8%). However, public hospitals also got the lowest mean technical efficiency scores (27.4%), implying they have some of the most inefficient hospitals.Regarding regional performance, Northern region hospitals had the highest mean efficiency score (83.0%) and Volta Region hospitals had the lowest mean score (43.0%).From our Tobit regression, we found out that while quasi-government ownership is positively associated with hospital technical efficiency, private ownership negatively affects hospital efficiency. CONCLUSIONS: It would be prudent for policy-makers to examine the least efficient hospitals to correct widespread inefficiency. This would include reconsidering the number of hospitals and their distribution, improving efficiency and reducing duplication by closing or scaling down hospitals with efficiency scores below a certain threshold. For private hospitals with inefficiency related to large size, there is a need to break down such hospitals into manageable sizes.

Community concepts of poverty: an application to premium exemptions in Ghana's National Health Insurance Scheme.

BACKGROUND: Poverty is multi dimensional. Beyond the quantitative and tangible issues related to inadequate income it also has equally important social, more intangible and difficult if not impossible to quantify dimensions. In 2009, we explored these social and relativist dimension of poverty in five communities in the South of Ghana with differing socio economic characteristics to inform the development and implementation of policies and programs to identify and target the poor for premium exemptions under Ghana's National Health Insurance Scheme. METHODS: We employed participatory wealth ranking (PWR) a qualitative tool for the exploration of community concepts, identification and ranking of households into socioeconomic groups. Key informants within the community ranked households into wealth categories after discussing in detail concepts and indicators of poverty. RESULTS: Community defined indicators of poverty covered themes related to type of employment, educational attainment of children, food availability, physical appearance, housing conditions, asset ownership, health seeking behavior, social exclusion and marginalization. The poverty indicators discussed shared commonalities but contrasted in the patterns of ranking per community. CONCLUSION: The in-depth nature of the PWR process precludes it from being used for identification of the poor on a large national scale in a program such as the NHIS. However, PWR can provide valuable qualitative input to enrich discussions, development and implementation of policies, programs and tools for large scale interventions and targeting of the poor for social welfare programs such as premium exemption for health care.

Household perceptions and their implications for enrollment in the National Health Insurance Scheme in Ghana.

OBJECTIVE: This paper identifies, ranks and compares perceptions of insured and uninsured households in Ghana on health care providers (quality of care, service delivery adequacy, staff attitudes), health insurance schemes (price, benefits and convenience) and community attributes (health 'beliefs and attitudes' and peer pressure). In addition, it explores the association of these perceptions with household decisions to voluntarily enroll and remain in insurance schemes. METHODS: First, data from a household survey of 3301 households and 13,865 individuals were analysed using principal component analysis to evaluate respondents' perceptions. Second, percentages of maximum attainable scores were computed for each cluster of perception factors to rank them according to their relative importance. Third, a multinomial logistic regression was run to determine the association of identified perceptions on enrollment. RESULTS: Our study demonstrates that scheme factors have the strongest association with voluntary enrollment and retention decisions in the National Health Insurance Scheme (NHIS). Specifically these relate to benefits, convenience and price of NHIS. At the same time, while households had positive perceptions with regards to technical quality of care, benefits of NHIS, convenience of NHIS administration and had appropriate community health beliefs and attitudes, they were negative about the price of NHIS, provider attitudes and peer pressure. The uninsured were more negative than the insured about benefits, convenience and price of NHIS. CONCLUSIONS: Perceptions related to providers, schemes and community attributes play an important role, albeit to a varying extent in household decisions to voluntarily enroll and remain enrolled in insurance schemes. Scheme factors are of key importance. Policy makers need to recognize household perceptions as potential barriers or enablers to enrollment and invest in understanding them in their design of interventions to stimulate enrollment.

Costs, equity, efficiency and feasibility of identifying the poor in Ghana's National Health Insurance Scheme: empirical analysis of various strategies.

OBJECTIVES: To analyse the costs and evaluate the equity, efficiency and feasibility of four strategies to identify poor households for premium exemptions in Ghana's National Health Insurance Scheme (NHIS): means testing (MT), proxy means testing (PMT), participatory wealth ranking (PWR) and geographic targeting (GT) in urban, rural and semi-urban settings in Ghana. METHODS: We conducted the study in 145-147 households per setting with MT as our gold standard strategy. We estimated total costs that included costs of household surveys and cost of premiums paid to the poor, efficiency (cost per poor person identified), equity (number of true poor excluded) and the administrative feasibility of implementation. RESULTS: The cost of exempting one poor individual ranged from US$15.87 to US$95.44; exclusion of the poor ranged between 0% and 73%. MT was most efficient and equitable in rural and urban settings with low-poverty incidence; GT was efficient and equitable in the semi-urban setting with high-poverty incidence. PMT and PWR were less equitable and inefficient although feasible in some settings. CONCLUSION: We recommend MT as optimal strategy in low-poverty urban and rural settings and GT as optimal strategy in high-poverty semi-urban setting. The study is relevant to other social and developmental programmes that require identification and exemptions of the poor in low-income countries.

Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling, who is not and why?

To improve equity in the provision of health care and provide risk protection to poor households, low-income countries are increasingly moving to social health insurance. Using data from a household survey of 3301 households conducted in 2009 this study aims to evaluate equity in enrollment in the National Health Insurance Scheme (NHIS) in Ghana and assess determinants of demand across socio-economic groups. Specifically by looking at how different predisposing (age, gender, education, occupation, family size, marital status, peer pressure and health beliefs etc) enabling (income, place of residence) need (health status) and social factors (perceptions) affect household decision to enrol and remain in the NHIS. Equity in enrollment is assessed by comparing enrollment between consumption quintiles. Determinants of enrolling in and dropping out from NHIS are assessed using a multinomial logit model after using PCA to evaluate respondent's perceptions relating to schemes, providers and community health 'beliefs and attitudes'. We find evidence of inequity in enrollment in the NHIS and significant differences in determinants of current and previous enrollment across socio-economic quintiles. Both current and previous enrollment is influenced by predisposing, enabling and social factors. There are, however, clear differences in determinants of enrollment between the rich and the poor. Policy makers need to recognize that extending enrollment will require recognition of all these complex factors in their design of interventions to stimulate enrollment.

Identification of poor households for premium exemptions in Ghana's National Health Insurance Scheme: empirical analysis of three strategies.

OBJECTIVES: To evaluate the effectiveness of three alternative strategies to identify poor households: means testing (MT), proxy means testing (PMT) and participatory wealth ranking (PWR) in urban, rural and semi-urban settings in Ghana. The primary motivation was to inform implementation of the National Health Insurance policy of premium exemptions for the poorest households. METHODS: Survey of 145-147 households per setting to collect data on consumption expenditure to estimate MT measures and of household assets to estimate PMT measures. We organized focus group discussions to derive PWR measures. We compared errors of inclusion and exclusion of PMT and PWR relative to MT, the latter being considered the gold standard measure to identify poor households. RESULTS: Compared to MT, the errors of exclusion and inclusion of PMT ranged between 0.46-0.63 and 0.21-0.36, respectively, and of PWR between 0.03-0.73 and 0.17-0.60, respectively, depending on the setting. CONCLUSION: Proxy means testing and PWR have considerable errors of exclusion and inclusion in comparison with MT. PWR is a subjective measure of poverty and has appeal because it reflects community's perceptions on poverty. However, as its definition of the poor varies across settings, its acceptability as a uniform strategy to identify the poor in Ghana may be questionable. PMT and MT are potential strategies to identify the poor, and their relative societal attractiveness should be judged in a broader economic analysis. This study also holds relevance to other programmes that require identification of the poor in low-income countries.

Efficiency, equity and feasibility of strategies to identify the poor: an application to premium exemptions under National Health Insurance in Ghana.

OBJECTIVES: This paper outlines the potential strategies to identify the poor, and assesses their feasibility, efficiency and equity. Analyses are illustrated for the case of premium exemptions under National Health Insurance (NHI) in Ghana. METHODS: A literature search in Medline search was performed to identify strategies to identify the poor. Models were developed including information on demography and poverty, and costs and errors of in- and exclusion of these strategies in two regions in Ghana. RESULTS: Proxy means testing (PMT), participatory welfare ranking (PWR), and geographic targeting (GT) are potentially useful strategies to identify the poor, and vary in terms of their efficiency, equity and feasibility. Costs to exempt one poor individual range between US$11.63 and US$66.67, and strategies may exclude up to 25% of the poor. Feasibility of strategies is dependent on their aptness in rural/urban settings, and administrative capacity to implement. A decision framework summarizes the above information to guide policy making. CONCLUSIONS: We recommend PMT as an optimal strategy in relative low poverty incidence urbanized settings, PWR as an optimal strategy in relative low poverty incidence rural settings, and GT as an optimal strategy in high incidence poverty settings. This paper holds important lessons not only for NHI in Ghana but also for other countries implementing exemption policies.

Using data envelopment analysis to measure the extent of technical efficiency of public health centres in Ghana.

BACKGROUND: Data Envelopment Analysis (DEA) has been used to analyze the efficiency of the health sector in the developed world for sometime now. However, in developing economies and particularly in Africa only a few studies have applied DEA in measuring the efficiency of their health care systems. METHODS: This study uses the DEA method, to calculate the technical efficiency of 89 randomly sampled health centers in Ghana. The aim was to determine the degree of efficiency of health centers and recommend performance targets for the inefficient facilities. RESULTS: The findings showed that 65% of health centers were technically inefficient and so were using resources that they did not actually need. CONCLUSION: The results broadly point to grave inefficiency in the health care delivery system of public health centers and that significant amounts of resources could be saved if measures were put in place to curb the waste.

Balancing equity and efficiency in health priorities in Ghana: the use of multicriteria decision analysis.

OBJECTIVES: To guide the Ministry of Health in Ghana in the priority setting of interventions by quantifying the trade-off between equity, efficiency, and other societal concerns in health. METHODS: The study applied a multicriteria decision analytical framework. A focus group of seven policymakers identified the relevant criteria for priority setting and 63 policymakers participated in a discrete choice experiment to weigh their relative importance. Regression analysis was used to rank order a set of health interventions on the basis of these criteria and associated weights. RESULTS: Policymakers in Ghana consider targeting of vulnerable populations and cost-effectiveness as the most important criteria for priority setting of interventions, followed by severity of disease, number of beneficiaries, and diseases of the poor. This translates into a general preference for interventions in child health, reproductive health, and communicable diseases. CONCLUSION: Study results correspond with the overall vision of the Ministry of Health in Ghana, and are instrumental in the assessment of present and future investments in health. Multicriteria decision analysis contributes to transparency and accountability in policymaking.

Malnutrition and the disproportional burden on the poor: the case of Ghana.

BACKGROUND: Malnutrition is a major public health and development concern in the developing world and in poor communities within these regions. Understanding the nature and determinants of socioeconomic inequality in malnutrition is essential in contemplating the health of populations in developing countries and in targeting resources appropriately to raise the health of the poor and most vulnerable groups. METHODS: This paper uses a concentration index to summarize inequality in children's height-for-age z-scores in Ghana across the entire socioeconomic distribution and decomposes this inequality into different contributing factors. Data is used from the Ghana 2003 Demographic and Health Survey. RESULTS: The results show that malnutrition is related to poverty, maternal education, health care and family planning and regional characteristics. Socioeconomic inequality in malnutrition is mainly associated with poverty, health care use and regional disparities. Although average malnutrition is higher using the new growth standards recently released by the World Health Organization, socioeconomic inequality and the associated factors are robust to the change of reference population. CONCLUSION: Child malnutrition in Ghana is a multisectoral problem. The factors associated with average malnutrition rates are not necessarily the same as those associated with socioeconomic inequality in malnutrition.