EFFECT OF FARMERS’ HEALTH INSURANCE STATUS ON HEALTH CARE CONSUMPTION AND PRODUCTIVITY IN GHANA John A. Boateng Doctoral Colloquium, Dublin November 06,

Background Agriculture contributes on average about 26% to GDP, 37% to export earnings (GSS, 2012). Agric labour force – 55.8% (GLSS 5, 2008). Low labour productivity Health risk associated with agric activities (especially rain harvesting and water storage – breeding ground for mosquitos - a major killer disease in Ghana Results – illness and sometimes death Effects – productivity, income, poverty 2

Background Introduction of National Health Insurance (NHIS) in 2003 to give: Financial protection and access to healthcare services Major Feature: Compulsory insurance which captures the formal sector (25%) of the economy and a Voluntary insurance which also captures the informal sector (75%). – income from the informal sector is difficult to assess. Farmers belong to the informal – incomes are low, not regular and difficult to assess. 3

Background Yet, in Ghana, out-of-pocket expenditure is highest among the poorest sections of the pop (37% of the total health expenditure, twice WHO’s thresholds for adequate financial protection). In these circumstances, poor households are stuck with the choice of whether to enroll or not in a NHIS in order to use health services. 4

Problem statement In most parts of the world, insurance coverage in general is less for those in farming as a major occupation. As a result, some studies done in China, Moldova and United States of America have shown that most rural farmers do not have health insurance (Mao, 2000; Zheng and Zimmer, 2008 & Richardson et al., 2011). Even where they have, farmers have problems accessing affordable health insurance coverage (Zheng and Zimmer, 2008) mainly because of affordability. 5

Problem statement In the context of Sub-Saharan African countries, despite the emergence of health insurance schemes, coverage remains low. It has been estimated that about 1.8% of people in sub- Saharan Africa are covered for health in insurance schemes targeting the informal sector (Leppert et al., 2011). Empirical research conducted in some African countries explains the reasons for the low coverage 6

Problem statement These include: timing of the collection of the premium (Allegri et al., 2006) affordability of premium problem of trust, poor quality of care rigid design in terms of enrolment requirements (Basaza et al., 2008). 7

Problem statement In the context of Ghana, cumulative membership as at 2010 – 18m (75%) of the Ghanaian Pop. (GHIA, 2010) Results – better utilisation of health facilities (NHIA, 2010) Evidence - increased proportion of insured clients reporting at the outpatient department visits (OPD) % (2009) 55.8% (2010) and 82.0% (2011) (GHS, 2011). 8

Problem statement Despite this, empirical evidence shows that the NHIS is falling short of its equity goals, with lower enrolment among the poor (Jehu-Appiah et al., 2011). Affordability of health insurance is a major problem (NDPC, 2008). Out-of- pocket payment for care from informal sources and for uncovered drugs and tests at health facilities (Nguyen et al., 2011) may have a significant deterrent effect on the poor in the use of health services under the NHIS 9

Problem statement Moreover, NHIS coverage is relatively high in districts where the incidence of poverty is high and health-care facilities are located far away from people (Durairaj et al., 2010). there have been instances where renewal of membership has been affected by location and these are peculiar to rural households. out of the cumulative membership of 14.5 million (representing 65% of the population) as at 2009, 32% were able to renew their membership in 2010 and could actually be claimants of the benefits of the health insurance. 10

Problem statement Farmers health insurance coverage and use of healthcare services is very important in the context of agriculture where seasonality of agricultural production normally results in low and irregular income. The possibility is that farmers may not be able to afford and even where they are able to afford and become members, in low income years, they may have to drop their insurance coverage. Coupled with this, is the inadequacy of medical care resources in rural areas (Kuruvilla and Liu, 2007). 11

Problem statement This may result in insufficient healthcare coverage among rural farmers. Consequently, this would have both negative micro and macro-economic effects on farmers and agricultural productivity respectively. 12

Objectives of the study Major objective  To determine the effect of farmers’ health insurance status on healthcare consumption and productivity Specific objectives To determine the factors that affect rural farmers’ decision to enroll and remain in the health insurance scheme; To estimate the effect of rural farmers’ insurance status on healthcare consumption (expenditures and utilization); To determine the effect of health insurance status on farmers’ productivity. To explore the experiences insured farmers go through when seeking for healthcare services under the NHIS. 13

Justification of the study Many recent studies have focused on willingness to pay, demand, implementation, evaluation and equity implications of National Health Insurance in Ghana (Asenso – Boadi, and Coast, 2007; Osei et al., 2007; Sulzbach, 2008; Nketia- Amponsah, 2009; Jehu-Appiah et al., 2011). Little has been said so far on the effect of farmers’ health insurance coverage on healthcare consumption and productivity. This study aims to fill this gap. Bring out strategies that will aim at increasing health insurance coverage among farmers which will potentially improve their health and boost productivity and welfare. 14

Method of data analysis Research Questions Data RequiredSource of Data Instrument to collect data Method of Data Analysis To determine the factors that affect rural farmers’ decision to enroll and remain in the health insurance scheme; Demand and Supply factors including demographic and economic age, marital status etc. Farmers NHIS managers Key informants Questionnaire/ / interviews Logistic Regression Content analysis To estimate the effect of rural farmers’ insurance status on healthcare consumption (expenditures and utilization); Individual, households, and community X’tics, nummber of hospital visits, total health expenditure Farmers QuestionnaireTwo-part model Probit model To determine the effect of health insurance status on farmers’ productivity. Insurance status demographic and economic x’tica age, marital status, farm size, education etc. Insured farmers Uninsured farmers Questionnaire To explore the experiences insured farmers go through when seeking for healthcare services under the NHIS. Problems from registration, to and beyond point of care Insured farmers Health personnel DMHIS managers Personal interviews Personal observation Content Analysis 15

THANK YOU 16