1. 2008 Citizens Assessment of the NHIS Africa Workshop on Health Insurance Accra, 22 September 2009

2. Presentation titlePage 2 2 Human Resource Development The key policy interventions prioritised under this thematic area include: Education; Training and skills development; Access to health care; Malaria control; HIV/AIDS prevention and treatment; Safe water and Sanitation; Population management; and Housing and slum upgrading.

3. Presentation titlePage 3 Strategy for Improved Access to Health Care Bridge equity gaps in access to quality health care and nutrition services: Including developing health infrastructure in favour of deprived communities; Ensure Sustainable Health Care Financing Arrangements That Protect the Poor: Including accelerating the implementation of the National Health insurance, Strengthening the exemption policy to enhance access of poor and vulnerable groups to healthcare; Strengthening Efficiency in Service Delivery: Including providing incentive schemes to support the retention and redistribution of trained health personnel;

4. Presentation titlePage 4 Objectives of Study General objective The goal of this study is to ascertain whether NHIS provides effective healthcare financial arrangements for the poor. Specific objectives 1. To obtain feedback from citizens about how the NHIS is performing from perspective of the local communities. 2. To determine whether the NHIS is achieving its goal of ensuring equitable access to quality basic health care to all residents (including vulnerable and excluded) in Ghana. 3. To gain insights into how to bridge the equity gaps in access to quality healthcare services.

5. Presentation titlePage 5 Study analyzed the effects of NHIS on: Financial protection against the cost of illness; Access by households to affordable health care; Behaviour of health workers and health seekers; Incidence of ailment or injury; Publicity/coverage of the NHIS and how it is understood by beneficiaries and prospective beneficiaries; and Issues related to the process of registration and after registration.

6. Presentation titlePage 6 Methodology National representative survey of about 1,988 households 1,000 exit polls conducted from 100 health service facilities from the districts that the household survey was undertaken. Health care providers and scheme managers interviewed 87 health care providers; and 58 scheme managers in the selected districts

7. Presentation titlePage 7 Results and key findings Results are weighted to enable regional representation but not district representation Datasets are available from NDPC for further analysis Discussions are organized in 3 sections Demand issues Effects on access to health care Citizens perception on the schemes performance

8. Presentation titlePage 8 Findings – demand issues 2 aspects of demand for NHIS are discussed overall uptake in terms of individuals across various localities and attributes of citizens uptake in terms of households in different socio-economic settings Issues on registration and renewal, and how demand is related to operational challenges are also discussed

9. Presentation titlePage 9 Findings – demand issues Overall uptake of NHIS Data show an appreciable level of registration under the scheme About 56 percent (55.6%) of Ghanaians have registered Some have registered but do not hold valid NHIS cards for a number of reasons that will be discussed later Fig. 1: Individual registration

10. Presentation titlePage 10 Findings – demand issues the data reveals that nearly one-third of households in Ghana have registered all their members a little over a quarter have registered some members of their households whilst a large proportion of them continue to remain outside the scheme Fig. 2: Household registration

11. Presentation titlePage 11 Findings – demand issues The picture from urban and rural areas The proportion of individuals registered under the scheme is higher in the urban areas than in the rural areas. The uptake is about 10% more in urban areas (53.6%) than the uptake in rural areas. Gender and NHIS status More females have registered with the NHIS than males. For example close to 50% of females (49.7%) are NHIS registrants with valid cards as compared to 45.9% of males that hold valid cards. Females form nearly 53.4% of registered members. The policy for maternal health partly explains the differences

12. Presentation titlePage 12 Findings – demand issues Age and NHIS status About two-thirds (64.6%) of persons aged 70 years and above are registered members of NHIS with valid cards. This means that more will have to be done to enable the rest to take advantage of exemptions provided for the group. Representation of persons aged 18 – 69 (46.7%) in the NHIS may have led to the exclusion of over 40% of children (43.5%) from the scheme. It is also observed from the results that the higher the number of children, the higher the proportion of households that do selective registration. The danger of selecting bad risk individuals is real and hence serious drain on schemes resources cannot be avoided.

13. Presentation titlePage 13 Fig. 3: Individual membership of NHIS by age group (%)

14. Presentation titlePage 14 Fig. 5: Individual membership of NHIS by sector of employment (%) There is a significant number of formal sector workers (32.3%) who do not hold valid NHIS cards. Reasons assigned to this relate to the need for top-up schemes. This raises the need to intensify recent attempts to offer such schemes by the private sector. Given that less than 10% of the labour force is engaged in the formal sector, the schemes sustainability with regards to contribution from beneficiaries depends on the enrolment of informal sector workers.

15. Presentation titlePage 15 Fig. 6:Individual NHIS membership by socio-economic group (%) There is a direct relationship between the proportion registered under the NHIS and socio-economic status. Less than 4 in every 10 people from the poorest 20% of Ghanaians are covered. This demands policy attention to address the significant number of poor individuals who are excluded from the scheme.

16. Presentation titlePage 16 Fig 7. Household NHIS membership by socio-economic group (%) The relationship is not very clear among households that register some members and leave some out of the scheme. This implies that selection of individuals into the scheme is common among all types of households, irrespective of socio-economic status.

17. Presentation titlePage 17 Table 1: Reasons for non-registration (% of non-registered individuals) Reasons assigned for non-registration relate to: Affordability (more for poor households); and Health needs (more for the richer 40%). The second reason reinforces the need for top-up schemes.

18. Presentation titlePage 18 Table 2: Reasons for non-renewal (% of those with expired cards) Reasons assigned for non-renewal relate to: Affordability (more for poor households); Registration process (rises with socio-economic status); and Non-use of previous card.

19. Presentation titlePage 19 Health care providers consulted for health care: The data suggest that a significantly higher proportion of insured households consult quality/skilled health providers than the non- insured. As many as 11% of uninsured did not consult a health provider even though they reported sick. Of those who consult medical doctors the NHIS was the main source of payment of the bills for more than 80% of households in Ghana. Effects on access to health care in Ghana

20. Presentation titlePage 20 Table 3: NHIS membership status and health care providers consulted for general health care within the last 4 weeks The proportion of those who consult skilled health care providers for general health conditions has risen from 45% to about 62% between 2005 and 2008, with the implementation of the scheme.

21. Presentation titlePage 21 Fig. 8:Main source of payment for general health care within the last 4 weeks by household NHIS status

22. Presentation titlePage 22 Table 4: NHIS membership status and health care providers consulted for deliveries within the last 12 months The proportion of those who consult skilled health care providers for deliveries has risen from 50% to about 71% between 2006 and 2008. Many factors could account for this but one cannot rule out the role of the scheme.

23. Presentation titlePage 23 Delivery of social services, e.g. education and health, is largely influenced by the accountability relationships across the delivery chain: not just resource constraint problem but also one where accountability relationships are weak More resources dont necessarily mean better service Strength of voice Client power

24. Presentation titlePage 24 With the exception of drugs not covered by the scheme, citizens are generally satisfied with what is provided by the NHIS Close to 70% of Ghanaians indicate the need for the inclusion of drugs not covered by the scheme. This is particularly high in the Eastern, Ashanti and Volta regions. 91.8%, 86.6% and 82.3% of the people interviewed in these three regions respectively indicate the need for these additional drugs to be added. Citizens perceptions on the performance of NHIS

25. Presentation titlePage 25 Fig. 10: Percent of respondents expressing the need for additional services by NHIS status – Household Survey

26. Presentation titlePage 26 Perception on the effects of NHIS on quality of health care An important concern in health care management is often how to maintain quality of service as demand increases There is a high indication that with the introduction of NHIS, the number of people who visit health care facilities will increase substantially thereby putting pressure on the existing facilities of health. This can certainly compromise the quality of health care services if the increase is not matched proportionately by increases in personnel and infrastructure. The performance of the scheme will then depend very much on whether or not the NHIS card bearing members are getting better health care than non-holders.

27. Presentation titlePage 27 Perception on the overall performance of NHIS Overall, 53.9% of Ghanaians are satisfied with the performance of the NHIS and 27.9% are very satisfied. 11% of Ghanaians are not satisfied with the scheme with just 1% expressing strong dissatisfaction with the scheme. These concerns are corroborated by other findings during interviews with scheme managers and providers

28. Presentation titlePage 28 Box 1: Concerns raised by scheme managers

29. Presentation titlePage 29 Box 2: Concerns raised by service providers

30. Presentation titlePage 30 Recommendations The exemption policy needs further improvement to adequately serve the health needs of the poor. Other social interventions provided by faith-based organisations, NGOs and others should incorporate sustained NHIS registration as part of their assistance. The schemes should endeavour to sustain and strengthen their communication mechanisms. Recent interventions to offer schemes that appear to be more attractive to high income groups (top-up schemes) are encouraged. NHIA will have to continue its efforts to de-politicise structures in the various regions and strengthen its neutral hold on issues so as to ensure sustainability of the scheme.

31. Presentation titlePage 31 Thank you