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

Abstract

Summaryobjectives 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.

Perceptions of Care, Socio-Demographic Characteristics and Health Care Utilisation among Health Insurance users in Ghana

“…This indicates financial difficulty in terms of registering under NHIS together with failure to meet clients' expectation about service quality at the various facilities contributed to the decision not to utilize health care with their NHIS cards; however, this does not significantly determine utilisation of health care with NHIS card. The findings corroborate (Boateng and Awunyor-Vitor, 2013) that income levels and poverty did not significantly influence health care access with NHIS card and contrast the positions of Jehu-Appiah (Aryeetey et al, 2010;Basaza et al, 2004) and WHO (2010).…”

“…Again in this study, those residing in rural parts of the study setting were not likely to access healthcare with NHIS. This is supported by recent empirical evidence which reveals that the NHIS is falling short of its equity goals, with lower enrolment among the poor (Sarpong et al, 2010;Asante and Aikins, 2008;Aryeetey et al, 2010;.…”

“…The findings from Aryeetey et al (2010) cross sectional study of a sample population of 13, 867 individuals, with an average of 25 years and children under 18 years representing 49% of the sample, show that despite the fact that 67% of all individuals were in some form of employment, education which was measured by total years of schooling was low at a mean of 7 years whiles the mean monthly individual income was GH¢43.70 (US$29). This amount is thrice of what is required to renew NHIS membership.…”

Chronic non-communicable diseases and the challenge of universal health coverage: insights from community-based cardiovascular disease research in urban poor communities in Accra, Ghana

“…By 2010, only 34% of Ghanaians had subscribed to the scheme. There have been challenges in increasing subscriber numbers, targeting the poor for exemptions, and ensuring that healthcare provider costs are controlled [12-14]. Currently there are NHIS pilots underway that seek to improve cost containment and control cost escalation by sharing risk between schemes, healthcare providers and subscribers.…”

Ethical considerations related to participation and partnership: an investigation of stakeholders’ perceptions of an action-research project on user fee removal for the poorest in Burkina Faso

“…Where user fee abolition is intended to target the most vulnerable, a particular challenge is raised: how to define and identify who should qualify in a context of widespread poverty [7]. This is an important question for policy-makers seeking to address a major health equity gap [8]. …”