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Ten years on and major pitfalls still hindering Ghana’s National Health Insurance Scheme

As the Government of Ghana gears up its plans to celebrate the 10th anniversary of its now internationally famed National Health Insurance Scheme, Ghana’s Universal Access to Healthcare Campaign today launch our own assessment of progress to date. Our new paper explains how 65% of the population is still paying out-of-pocket in the old ‘cash and carry’ system and that at the current rate of progress UHC will not be achieved until at least the year 2076. Our campaign argues that progress will continue to stall as long as the NHIS structure excludes the very people it seeks to protect through overly-burdensome and unworkable insurance premiums.

Next week Ghana’s National Health Insurance Authority (NHIA) will host a three day International conference in Accra with the theme: “Towards Universal Health Coverage: Increasing Enrolment whilst Ensuring Sustainability”.  The conference will attract Universal Health Coverage (UHC) practitioners, academia, policy makers, NGOs and CSOs in their numbers, and seeks to examine the successes and challenges of the NHIS, and elicit feedback and proposals for reform.

While the Universal Access to Healthcare Campaign (UAHCC ) welcomes the anniversary event, we are concerned that inherent pitfalls of the NHIS have been consistently left on the sideline over the past decade and if unadressed will stifle any prospect the NHIS has of achieving UHC in the near future. The UAHCC will convey this position at the anniversary conference, where we have been invited to participate in a panel discussion, but also in our own civil society forum today to which government officials and donor agency staff have been invited.

The paper launched today acknowledges some strengths of the scheme including its generous benefits package, comprehensive level of care and treatment coverage and relatively broad range of exemption categories. However, these strengths are only relevant to NHIS active members. The UAHCC calls on the Government of Ghana to act on the glaring short falls of the scheme including:

  • Lack of coverage and access to service: in 2012, only 35% of the population was recorded as being active NHIS subscribers – a less than 2% increase from 2010.  The NHIS is therefore irrelevant to the 65% of the population who still pay out-of-pocket in the burdensome and inequitable “cash and carry” system.  At the current rate of progress Ghana will not achieve UHC until 2076!
  • Exclusion of poor and low-income earners: a growing body of evidence shows that premium payments are beyond the means of a large portion of informal sector workers and constitute a significant barrier to joining the NHIS.  The rich are twice as likely to join and benefit from the scheme as the poor. The value of the premiums is in serious question – while constituting a massive obstacle to progress on UHC they constitute less than 5% of the total annual inflow to the NHIA.  There must be a shift in focus from extracting premium contributions from people who are evidently too poor to pay, to prioritising spending on health, for example through a reduction of inefficiencies and improvements to general progressive taxation.
  • Unsustainable and inequitable financial model: the NHIS was created with a solid financial base, however by 2011 it was facing a deficit of more than GHC 47.3 million.  This is due in part to large scale inefficiencies and cost escalation in the system and the continued belief that financial sustainability will be solved by increased enrollment of members from the informal sector.  More effort must be focused on identifying alternative sources of financing by tackling service provider fraud and corruption, reducing funding leakages and waste across the health system and by instituting progressive reforms to taxation.

 

 

Sidua Hor is coordinator for the Ghana Universal Access to Healthcare Campaign Coalition

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Universal Health Coverage: key to the success of the World Bank’s new vision

“We must be the generation that delivers universal health coverage.” – WBG President Jim Yong Kim in a speech to the World Health Assembly, May 2013

As the World Bank Group’s Annual Meetings come to Washington this weekend, there is much talk of President Jim Yong Kim’s new strategy to achieve the institution’s updated vision: to end extreme poverty by 2030 and promote “shared prosperity,” Bank-speak for reducing inequality.

We would argue that pursuing Universal Health Coverage (UHC) – alongside robust investments in other aspects of human development – must be utterly central to the Bank’s strategy to achieve its two goals.  While Dr. Kim’s Annual Meetings opener speech last week touched on the importance of health (and education) in achieving its goals, human development is not articulated as a central component of the Bank’s new strategy to achieve the goals, which its Board will be approving on Saturday.

The Bank says this is because the strategy is meant to describe an overall approach rather than privileging any particular sector.  That may be, but it is hard to see how the Bank’s two goals can be met without a clear vision for how the fruits of economic growth can be equitably shared through transformative essential public services. We hope to see this change as the implementation details of the strategy become clearer.

Nevertheless, President Kim’s recent speeches and writing provide clues to his vision of the importance of health in reducing poverty and inequality. In a recent article he wrote that “to free the world from extreme poverty by 2030, countries must ensure that all their citizens have access to quality, affordable health services.” At the World Health Assembly in May, he pointed to a hopeful new direction for the Bank by committing to help countries work towards UHC and stating that point-of-service fees are “both unjust and unnecessary.” But will these high level statements really translate to a change in the way the Bank works in countries?

We hope so.  The Bank’s expertise in building health systems can be powerfully harnessed for the cause of UHC, but this means a break from business as usual.  Building health systems isn’t enough; they must be the right kinds of systems — systems that are equitable and truly universal.

Oxfam’s new paper, “Universal Health Coverage: Why health insurance schemes are leaving the poor behind,” examines the conditions necessary for health systems to be equitable and universal.  The paper looks at four key ingredients to successful financing for UHC: removal of direct payments and other financial barriers, compulsory pre-payment, large risk pools, and financing from general revenues to cover the uncovered.  In our analysis, conventional insurance schemes – whether private, community-based or European-style social health insurance – come up short when measured against these criteria.

Since UHC is about access to quality care for everyone regardless of ability to pay, governments must move away from relying on employment-based and contributory insurance models.  Instead, health care must become a right of citizenship (or residency), financed in large part through general government revenues.  As the diverse but successful UHC experiences of Mexico, Thailand, Sri Lanka, Brazil and Kyrgyzstan show, equity must be designed into the system from the beginning, rather than starting with the easiest to reach in the formal sector.

The World Bank Group has a history of promoting health insurance as a financing mechanism to generate revenues in the health sector in environments of fiscal constraints.  Some examples include a recent policy series on private health insurance, previous work in countries such as Ghana, and IFC investments to support insurance schemes in Africa.

But things may be changing at the Bank.  In a series of 22 recently released case studies on UHC, the Bank finds that, across countries, the use of financing from general taxation to expand coverage is an important commonality, and that prioritizing equity is a key lesson.  We also hear the Bank is playing a more constructive role in certain countries to encourage universal system design. And new leadership in the health sector and from the President should be cause for optimism.

A real test of the potency of the new World Bank strategy will be whether the World Bank Group throws its full weight behind equitable, universal health systems – systems that are financed largely through tax-based general revenues and which include all members of society – through its global knowledge products, its policy advice and technical assistance, and through its lending choices.

 

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Health insurance schemes are leaving the poor behind

Manana Mikaberidze, 52, is a doctor from the Gori region of Georgia. There are lots of poor people in the village, and people don'‚t have money to buy medicine. The lucky ones who do have health insurance are able to get free consultations but post treatment and medicines aren'‚t included. Manana often uses her own salary to buy medicines for patients who cannot afford to pay themselves.

In a new report published today, Oxfam is warning that health insurance schemes introduced in the name of universal health coverage (UHC) are excluding the majority of people and leaving the poor behind.

While the new growing momentum for UHC is welcome there is a concern that the mistakes of history could be repeated. The optimism in 1978 following the Alma Ata ‘Health for All’ declaration was quickly replaced by disillusionment as influential donors failed to act on the shared vision of comprehensive universal primary health care.  They financed low cost selective interventions instead. Today, a similar danger exists as we witness a wide range of ‘business as usual’ interventions being rebranded as ‘UHC’ despite them bearing little resemblance to the World Health Organisation’s UHC principles.

This is certainly the case for health financing. Our new report takes a critical look at the almost exclusive focus of some donors and low and middle income countries on contributory insurance schemes as the way to achieve UHC. Such schemes fail to provide coverage for the majority of citizens and serve to divert attention away from needed reforms to national and international tax systems that could raise significant additional revenues for health.

Voluntary insurance – private and community-based – has never worked to achieve UHC yet is still being widely promoted. India’s voluntary RSBY insurance scheme for people below the poverty line is widely praised as a success but offers limited financial protection and has skewed public resources to curative rather than preventative care.

For those who recognise the pitfalls of voluntary schemes, social health insurance (SHI) has emerged as the model of choice. SHI has worked to achieve UHC in a number of high-income countries, but attempts to replicate in poorer countries have proved unsuccessful. In practice SHI schemes usually start with the small number of easy-to-reach formally employed and then struggle to scale up beyond. Premiums are too expensive for most and schemes become de facto voluntary, leading to large scale exclusion. Ten year old national insurance schemes in Tanzania and Ghana cover only 17% and 36% of citizens respectively. Kenya’s National Hospital Insurance Fund – established nearly 50 years ago – today insures just 18 per cent of Kenyans.

Hopes that insurance contributions from those outside of formal employment would raise significant additional revenue have also not been realised. In Ghana, premiums paid by the informal sector contribute just five per cent towards the cost of the national scheme. Governments also face huge bills to cover the SHI contributions of their workers. The Government of Tanzania spent $33m on employer contributions in 2009/10; this equated to $83 per employee – six times more than it spent per person, per year on health for the general population.

Instead of importing inappropriate health financing models from high-income countries, our paper recommends that developing country governments look to learn from the increasing number of home-grown UHC success stories in other, more comparable countries.

The countries making most progress towards UHC agree that entitlement to health care should be based on citizenship and/or residency (not employment status or financial contribution) and while specific journeys differ, these countries fall into two broad camps. First there are examples of countries at all income levels, including Sri Lanka, Malaysia, and Brazil, which use tax revenues to fund UHC. A second option increasingly being adopted by another set of successful UHC countries, including Thailand, Mexico, and Kyrgyzstan, is to collect insurance premiums only from those in formal salaried employment, and to pool these where possible with tax revenues to finance health coverage for the entire population. According to WHO, only eight of 49 low-income countries will be in a position to fully finance UHC from domestic resources in 2015 so international aid will continue to play a crucial role.

The focus on health insurance seems to have served as a distraction for the international health community from the key ingredient for all UHC success stories – public financing. Rather than focus efforts on collecting contributions from people who are too poor to pay, governments and donors should look to reform national and international tax systems in order to generate significant and urgently needed revenue for health. Oxfam estimates that strengthening tax administration alone could raise an additional 31 per cent of tax revenue across 52 developing countries, amounting to $269bn in increased domestic resources. Enough to double health budgets in these countries.

The growing momentum for UHC is welcome, exciting, and challenging. However, if we are to heed World Bank President Jim Kim’s warning that UHC could easily become a ‘toothless slogan’, then UHC advocates must stand true to the WHO UHC principles to reduce out of pocket payments, introduce mandatory pre-payment, create large risk pools and scale up public financing to cover those who cannot afford to contribute. To these we add that entitlement to health coverage should be based on citizenship and/or residence, and that progress can only be considered progress if women and men living in poverty benefit at least as much as the better off at every step of the way towards UHC.

 

Oxfam’s report ‘Universal health coverage: why health insurance schemes are leaving the poor behind’ is available to download from www.oxfam.org/uhc

 

Anna Marriott is a Health Policy Advisor for Oxfam and editor of Global Health Check

 

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Universal health coverage, real or selective? Time for global health advocates to unite

About a year ago,  at the AIDS 2012 conference in Washington DC, I wondered why the theme universal health coverage was virtually absent from the conference. It looked as if UNAIDS’ universal test-and-treat strategy and WHO’s universal health coverage plan were designed for two different worlds, as I argued in a blog post then. Such a division of global health advocates was bad news for global health, in my opinion, especially in light of the coming MDG negotiations. We should not count on three or more health-focused MDGs this time.

But I also understood why the AIDS activists at the conference were wary about supporting universal health coverage. The key UN resolutions about universal health coverage – the 2005 World Health Assembly resolution and the 2012 UN General Assembly resolution – hardly mention international responsibility or solidarity. The 2005 WHA Resolution mentions international assistance in its preamble – “Noting that some countries have recently been recipients of large inflows of external funding for health” – while the 2012 UNGA Resolution mentions “universal health coverage on the basis of solidarity at national and international levels”, but none of them admit that real universal health coverage will require considerable levels of international assistance during decades to come. With real universal health coverage, I mean “that people should have access to all the services they need”.

Universal health coverage “developed within the particular epidemiological, economic, socio-cultural, political and structural context of each country in accordance with the principle of national ownership”, as it is formulated in the 2012 UN General Assembly resolution, could mean anything and everything. In low-income countries, it could mean something that looks a lot like selective primary health care, excluding antiretroviral treatment. For AIDS activists, universal health coverage could mean a giant step backwards, so even if I deplored the lack of support for universal health coverage by many of them, I didn’t expect them to change their position.

But I was proven wrong by the International HIV/AIDS Alliance that came out with a statement in support of “universal health coverage, including universal access to HIV prevention, treatment, care and support and universal access to sexual and reproductive health services via a rights-based approach” first, and for universal health coverage as a “key mechanism for achieving the health goal” more recently. The words that matter are “rights-based approach”, as universal health coverage anchored in the right to health requires at least comprehensive primary health care, with duty-based international assistance to countries that are unable to provide comprehensive primary health care without assistance.

Wishful thinking? The UN Sustainable Development Solutions Network (UNSDSN) doesn’t think so. A few days ago, it presented a draft report on health financing in the sustainable development framework, inviting everyone to comment before October 15, 2013. There’s a comment form to be used, but the UNSDSN will forgive me for using a different channel. The draft report proposes targets for “Public health care expenditure as a percent of GDP (Gross Domestic Product)” – 3% of GDP in low income countries; 3.5% in lower middle income countries; 4% in upper middle income countries; 5% in high income countries – and also for “ODA (Official Development Assistance) for health as percent of GNI (Gross National Income) – Minimum of 0.1% of GNI in high-income countries. When these percentages are applied to present GDP levels of all countries of the world, allocating international assistance on the basis of ‘poorest countries first’, universal health coverage at a minimum value of 50 US dollars per person per year becomes possible. That is still cheap, but it should allow financing comprehensive primary health care, including antiretroviral treatment.

The UNSDSN proposal will meet resistance, and not only from high-income countries, which are being expected to double their international assistance for health – from about 0.05% to 0.1% of GDP (from 5 cent to 10 cent out of every 100 dollars). The net ‘cost’ of this proposal will be higher for low income countries, which are being expected to increase their public health care expenditure from domestic resources with at least 1% of GDP – from the present level of 2% of GDP to 3% of GDP, see World Health Statistics 2013, page 140.*

Not feasible? Well, that was also said when antiretroviral treatment was started in low income countries, or when user fees were removed. If all global health advocates unite, it is possible.

You have until October 15 to express your support for #RealUHC here. And on Twitter, of course. And elsewhere.

 

* If you want to look it up, don’t get confused by the ‘total expenditure on health as percentage of GDP’ column. Total health expenditure combines government and private (including out of pocket expenditure), but the UNSDSN proposal of 3% of GDP for low income countries is about government health expenditure only. In low income countries, the average total health expenditure amounted to 5.3% of GDP (in 2010). Government expenditure made up only 38.5% of this figure in the same year meaning that government expenditure on health, on average,  amounted to 2% of GDP – the UNSDSN wants that to increase to 3% of GDP.

 

Gorik is a human rights lawyer, researcher at the Institute of Tropical Medicine, Antwerp, and adjunct professor of law at Georgetown University, Washington DC.

 

 

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Health for All in India: Public, not “packaged”

As world leaders prepare to gather for the 66th World Health Assembly on May 20, social movements are questioning the market-friendly version of universal health coverage (UHC) it is promoting.

One organization, Jan Swasthya Abhiyan (JSA), is denouncing India’s emulation of this UHC strategy, as contained in the country’s 12th Five Year Plan, which uncritically endorses the private medical sector and focuses on health insurance schemesIn a recent paper JSA proposes an alternative UHC model.

 

Public financing for whom?

In the past five years there has been an impressive roll out of government-funded insurance schemes in India that are supposed to improve the country’s public health system. In theory, treatment covered under these schemes can be provided by any accredited facility. But in practice the majority of providers are found in the largely unregulated private sector which already accounts for 80% of outpatient and 60% of in-patient care according to the National Sample Survey Organisation (NSSO), making India one of the most privatized systems in the world. India’s healthcare system is increasingly dominated by big hospitals chains (e.g. Apollo Hospitals) with an infamous track record of expensive services and unethical practices. As it is, health insurance schemes mostly channel public monies for private profitFor example, from 2007 to 2013 the state of Andhra Pradesh allocated a total Rs.47.23 billion to facilities accredited under the Arogyasri scheme, of which Rs.36.52 billion went to private facilities.

 

Getting it right

Health is a right, and priorities should be based on citizens’ needs. What the majority of Indians lack is comprehensive primary care, but current health insurance “packages” only insure beneficiaries for ailments that require hospitalization. They cover a very small portion of the burden of disease, excluding out-patient treatments for tuberculosis, diabetes, hypertension, heart conditions, and cancer among others. Evidence from the first such scheme in India – Arogyasri – suggests that it consumed 25% of the state’s health budget but addressed only 2% of the burden of disease.

 

Who inverted the pyramid?

This situation ends up distorting the very structure of the health system by starving primary care facilities to the benefit of more profitable secondary and tertiary care. In 2009-2010, direct national government expenditure on tertiary care was slightly over 20% of total health expenditure, but if one adds spending on the insurance schemes the total would be closer to 37%. In Andhra Pradesh, following the implementation of Arogyasri, the proportion of funds allocated for primary care fell by 14%.

 

A good health system is like a pyramid: the largest numbers should be treated at the primary level where people live and work. We need to flip the inverted pyramid that has been created and offer a new roadmap predicated on public funding and provisioning of a public system that reprioritizes primary health care, and is comprehensive, integrated and accessible to all.

 

Bad medicine

The health insurance schemes in place fail to address another key issue: access to medicines. Paradoxically, India is the largest producer of drugs in the developing world and at the same time the country where the WHO estimates the greatest number can’t afford the medicines they need. Since the Patent Act was amended in 2005, domestic pharmaceutical companies can’t produce cheaper versions of new drugs, which are now sold by multinationals at prices well beyond the reach of most patients. Poor regulations also means more than 50% of the average family spending on medicines is on irrational or unnecessary drugs and diagnostic tests according to the NSSO. Clearly, the pharmaceutical sector must be reigned in, and all essential drugs should be made available, free of cost, at all public facilities.

 

Addressing public health gaps

The task of achieving health for all in India will not be easy. Current public health services are marked by poor access, low quality and limited choice. Besides rampant corruption, poor management results in mismatches between demand and supply of services: facilities aren’t distributed optimally; equipment and funds fall short of requirements and don’t flow efficiently. Labour shortages can be partly explained by disinvestment in medical education and flawed deployment mechanisms. Although programs such as the National Rural Health Mission have made some inroads to improve services, much remains to be done. The problem is largely one of unresponsiveness to citizens coupled with unreliable technical estimates of costs and disease burden, leading to ill-informed prioritization.

 

It is necessary to recast the UHC debate and propose alternatives to strengthen the public health systemto address these problems and to build integrated, comprehensive services with strong mechanisms of accountability. Key to these changes are the following:

  • Earmark adequate financing for the public system that should aim to reach 5% of GDP in the medium term
  • Streamline structures and human resources in facilities to improve efficiency, as well as rationalize costs of care in public facilities
  • Provide more equitable access across rural and urban areas
  • Set standard treatment protocols to ensure quality of care
  • Establish mechanisms to empower communities to hold health authorities accountable

Over the short term, we also need to explore alternate ways of harnessing private resources for public health goals. Given the sheer size of the private sector, it is not possible to entirely ignore it while planning for equitable access to public services. It’s not a monolithic entity either; some segments such as charitable, faith-based and other not-for-profit healthcare facilities that work in less developed parts of the country can fill certain critical gaps in the public system. Under clear terms and conditions, other private providers such as general practitioners or small and medium-sized hospitals could be in-sourced to complement available public health services. Importantly, there should be no transfer of assets and resources into private hands and kickback statutes should be put in place to ensure there are no referrals with conflict of interests.

All the possible mechanisms for harnessing the private sector should be seen as supplementary (and often interim) measures, and not as a substitute for very significant scaling up and strengthening of the public system both in terms of quality and accessibility.

There is a need to reclaim public systems, to strengthen and expand them. Moving toward health for all requires major transformations in health care, but also in a wide range of social determinants of health – food security and nutrition, water supply, sanitation, working conditions, housing, environment, education and more. We need to build broad-based alliances for social change to redefine the relationship between people and their public systems.

 

Amit Sengupta is a Research Associate with the Municipal Services Project and Associate Global Co-ordinator with the People’s Health Movement, a global network of 18 national chapters that includes India’s Jan Swasthya Abhiyanfor which he acts as National Co-convenor.

Madeleine Bélanger Dumontier is Communications Manager for the Municipal Services Project, a global research initiative that explores alternatives to the privatization and commercialization of service provision in the electricity, health, water and sanitation sectors.

Photo: Rajeev Chaudhury

 

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Global Health Check is edited by Anna Marriott, Health Policy Advisor for Oxfam GB, and welcomes contributions from different authors. If you would like to write an article for this site or if you have any queries please contact: amarriott@oxfam.org.uk.