1. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I BearingPoint I Bitrán y Asociados I BRAC University I Broad Branch Associates I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health Evaluating the Impact of National Health Insurance in Ghana Sara Sulzbach, MPH Health Systems 20/20 October 29, 2008

2. Acknowledgements Abt Associates: Slavea Chankova, Laurel Hatt, Karen Finnegan Ghana Health Service/Health Research Unit: Dr. John Gyapong, Bertha Garshong USAID: Yogesh Rajkotia, Karen Cavenaugh

3. Health Financing in Ghana At independence in 1957, public health services were free In 1970s introduced nominal fees to due to insufficient financing 1980s instituted cash and carry system of user fees; restricted access to health care Community health insurance schemes emerged in 1990s, replacing user fees with modest premiums Such schemes grew to 159 by 2002, but only covered 1% of the population

4. National Health Insurance National Health Insurance (NHI) passed in 2003 District-level health insurance in accordance with national guidelines Goal: equitable and universal access to health care for all Ghanaians Financing: 2.5% levy on all goods and services, social security contributions, annual premiums Coverage (as of December 2007): 42% of population insured; 55% registered

5. National Health Insurance Benefit structure Adults pay annual premium of 72,000 Cedis ($9) each All dependents covered Exemptions for elderly and indigent Benefits package Inpatient Outpatient Essential drugs Maternity (ANC and delivery) Emergency care Eye care

6. Study Objectives Examine changes in insurance enrollment since implementation Determine effect of enrollment on Health seeking behavior Out-of-pocket expenditures

7. Methodology – Study Design Cross-sectional surveys Household in 2 districts: Nkoranza and Offinso Patient exit in 6 districts: Nkoranza, Offinso, Savelugu, Ajumako, Kwahu South, Ahanta West Baseline in 2004; endline in 2007 In-depth interviews with district scheme managers Service statistics at district health facilities

8. Methodology – Analysis Policy impacts Pre-post comparisons to measure changes in insurance coverage, utilization, and expenditures Individual insurance effects Propensity score matching (PSM) to measure individual impact of insurance on these outcomes and reduce selection bias

9. Sample Characteristics NkoranzaOffinso HouseholdsBaselineFollow-upBaselineFollow-up Insured620617-632 Uninsured687636499637 Individuals Insured31082869-2113 Uninsured3539296328193814 Individuals ill or injured in past 2 weeks 287 (4.6%) 248 (4.3%) 128 (4.4%) 184 (3.1%) Individuals hospitalized in past year 119 (2.3%) 118 (2.0%) 84 (3.2%) 129 (2.2%) Women who delivered in past year209 (11.4%) 17691 (14%) 143

10. Pre-Post Results: Increase in Wealth Status from Baseline to Endline Distribution of Wealth Quintiles: Baseline and Endline

11. Pre-Post Results: Heads of households more likely to enroll

12. Pre-Post Results: At endline, ill respondents more likely to seek formal care

13. Pre-Post Results: No difference in maternal care seeking

14. Pre-Post Results: Significant decreases in expenditures

15. Determinants of insurance enrollment Baseline (MHO scheme)Endline (NHI scheme) Older women and older menWomen of all ages, older men Households with 3-5 members Households with household heads that are: female older more highly educated from wealthier quintiles

16. Additional Determinants of Individual Enrollment: Endline Membership in community solidarity organization Member of Akan ethnic group Presence of chronic health condition

17. Preliminary PSM Results: Insured more likely to seek curative care Differences in curative care seeking: insured vs. uninsured

18. Preliminary PSM Results: Insured more likely to receive maternity care Differences in maternal care seeking: insured vs. uninsured

19. Preliminary PSM Results: Insured pay less for health services Differences in OOPs: insured vs. uninsured

20. Policy Implications Exemptions for the poorest groups need to be strengthened; strong wealth effects observed for enrollment Insurance is very effective at reducing OOP expenditures for curative and maternal care Insurance is less effective at increasing rates of facility deliveries

21. Recent Policy Changes and Proposals Maternal health coverage: effective July 1, 2008 De-coupling dependent minors from parent enrollment: effective September 2008 Proposal to include family planning products and services in benefits package: TBD

22. Exempting the poor District scheme manager on exemption policy: When you go to a community, you will realize that they are all farmers. You can t determine the income level at the end of the day so how do you determine the poor, the poorer and, the poorest in that community? Why not ask everybody to pay the same premium? Yaa, so we have decided that they should all pay the same.

23. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I BearingPoint I Bitrán y Asociados I BRAC University I Broad Branch Associates I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health Thank you Reports related to this presentation are available at www.HS2020.org