Identification of the poor for premium exemptions under national health insurance in Ghana: A review of feasible approaches, costs and policy trade offs

Presenter:

Abstract

Objectives: Since Ghana passed a National Health Insurance (NHI) law in 2003 she has struggled with adequate enrolment among the poor. This is related to difficulties in identifying the poor and uncertainties as to the trade off between equity and costs of different approaches. This paper reviews literature on feasible approaches to identify the poor for insurance premium exemptions and estimated the costs and trade-offs between equity and affordability.

Methods: Medline was used for a literature search on experiences with identification and targeting of the poor. From over 215 articles, 62 were selected for inclusion in our analysis, supplemented by snowballing techniques, contacting of individual authors, and grey literature searches. Costing models were developed to estimate the cost for implementation of approaches in all regions and districts in Ghana. Welfare losses associated with excluding the poor, and welfare gains associated with including non-poor were also estimated.

Results: Our results show that Geographic Targeting, Proxy Means Testing and Participatory Welfare Ranking are, all feasible approaches for identification of the poor in Ghana. However their costs and errors of exclusion vary. The selection of an optimal approach is dependent on the context e.g. poverty incidence, population and the trade off between societal and policy maker concerns about costs, capacity to administer and equity.

Conclusions: This paper generates evidence to inform national health insurance policy and provides lessons for other developing countries struggling with issues around health financial protection for the poor through premium exemptions as part of health insurance or user fee exemptions.