Achieving universal health care coverage: Current debates in Ghana on covering those outside the formal sector

BMC International Health and Human Rights

Di McIntyre¹  Gilbert Abotisem Abiiro¹ 

[1] Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, 7925, South Africa

关键词: Ghana;    One-time premium payment;    Tax funding;    Those outside formal sector employment;    Policy options;    Policy objective;    National health insurance;    Universal health care coverage;   

Others  :  855491
DOI  :  10.1186/1472-698X-12-25

 received in 2012-01-06, accepted in 2012-10-27,  发布年份 2012

【 摘 要 】

Background

Globally, extending financial protection and equitable access to health services to those outside the formal sector employment is a major challenge for achieving universal coverage. While some favour contributory schemes, others have embraced tax-funded health service cover for those outside the formal sector. This paper critically examines the issue of how to cover those outside the formal sector through the lens of stakeholder views on the proposed one-time premium payment (OTPP) policy in Ghana.

Discussion

Ghana in 2004 implemented a National Health Insurance Scheme, based on a contributory model where service benefits are restricted to those who contribute (with some groups exempted from contributing), as the policy direction for moving towards universal coverage. In 2008, the OTPP system was proposed as an alternative way of ensuring coverage for those outside formal sector employment. There are divergent stakeholder views with regard to the meaning of the one-time premium and how it will be financed and sustained. Our stakeholder interviews indicate that the underlying issue being debated is whether the current contributory NHIS model for those outside the formal employment sector should be maintained or whether services for this group should be tax funded. However, the advantages and disadvantages of these alternatives are not being explored in an explicit or systematic way and are obscured by the considerable confusion about the likely design of the OTPP policy. We attempt to contribute to the broader debate about how best to fund coverage for those outside the formal sector by unpacking some of these issues and pointing to the empirical evidence needed to shed even further light on appropriate funding mechanisms for universal health systems.

Summary

The Ghanaian debate on OTPP is related to one of the most important challenges facing low- and middle-income countries seeking to achieve a universal health care system. It is critical that there is more extensive debate on the advantages and disadvantages of alternative funding mechanisms, supported by a solid evidence base, and with the policy objective of universal coverage providing the guiding light.

【 授权许可】

   
2012 Abiiro and McIntyre; licensee BioMed Central Ltd.

【 参考文献 】

• [1]WHO: Sustainable health financing, universal coverage and social health insurance, Fifty-Eighth World Health Assembly resolutions WHA58.33. World Health Organization, Geneva; 2005.
• [2]WHO: World Health Report 2010, Health systems financing - the path to universal coverage. World Health Organization, Geneva; 2010.
• [3]Carrin G, James C: Reaching universal coverage via social health insurance: key design features in the transition period, DISCUSSION PAPER. World Health Organization, Geneva; 2004. EIP/FER/DP.04.2
• [4]Kutzin J: Myths, instruments, and objectives in health financing and insurance. In Extending social protection in health: Developing countries' experiences, lessons learnt and recommendations. Deutsche Gesellschaft fur Technische Zusammenarbeit (GTZ), Eschborn, Germany; 2007:87-95.
• [5]Tangcharoensathien V, Patcharanarumol WIP, Alijunid SM, Mukti AG, Akkhavong K, Banzon E, Huong DB, Thabrany H, Mills A: Health-financing reforms in southeast Asia: challenges in achieving universal coverage. Lancet 2011, 377:863-873.
• [6]Oxfam: Alliance for Reproductive Health Rights, Essential Service Platform of Ghana, Integrated Social Development Centre. Achieving a Shared Goal: Free Universal Health Care in Ghana. Oxfam International; 2011. Online at: http://www.oxfam.org/sites/www.oxfam.org/files/rr-achieving-shared-goal-healthcare-ghana-090311-en-sum.pdf. webcite Accessed on 24 April, 2011.
• [7]Agyepong IA, Orem JN, Hercot D: When the ‘non‐workable ideological best’ becomes the enemy of the ‘imperfect but workable good. Trop Med Int Health 2011, 16:105-109.
• [8]Abiiro GA, McIntyre D: Universal financial protection through national health insurance: A stakeholder analysis of the proposed one-time premium payment (OTPP) policy in Ghana. Health Policy Plan 2012, 1-16.
• [9]Arhinful DK: The solidarity of self-interest: Social and cultural feasibility of rural health insurance in Ghana. Research Report 71/2003: African Studies Centre, Leiden; 2003.
• [10]Agyepong IA, Adjei S: Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme. Health Policy Plan 2008, 23:150-160.
• [11]The World Bank: World Development Report 1993: Investing in Health. Oxford University Press for the World Bank, New York; 1993.
• [12]Gilson L, Mills A: The political economy of user fees with targeting: developing equitable health financing policy. J Int Dev 1995, 7:369-401.
• [13]Garshong B, Ansah E, Dakpallah G, Huijts I, Adjei S: "We Are Still Paying…” A study on the factors affecting the implementation of the exemptions policy in Ghana. Health Research Unit, Ministry of Health, Ghana; 2001.
• [14]Nyonator F, Diamenu S, Amedo E, Eleeza J: Caring for the health of the poor – Policy versus implementation, a baseline evaluation of exemption practices within health facilities in the Volta region of Ghana. Volta Regional Health Administration, Ghana; 1996.
• [15]Atim C, Grey S, Apoya P, Anie SJ, Aikins M: A survey of health financing schemes in Ghana. PHRplus, Abt Associates for USAID, Bethesda, MD; 2001.
• [16]MOH: National Health Insurance Policy Framework for Ghana. Ministry of Health, Ghana; 2004. Revised edition
• [17]Wahab H: Assessing the implementation of Ghana’s NHIS law. Indiana University, Bloomington; 2008. [Paper prepared for workshop in political theory and policy analysis mini-conference April 26–28, 2008]
• [18]Mills A, Ataguba JE, Akazili J, Borghi J, Garshong B, Makawia S, Mtei G, Harris B, Macha J, Meheus F, McIntyre D: Equity in financing and use of health care in Ghana, South Africa and Tanzania: implications for paths to universal coverage. Lancet 2012.
• [19]NHIA: Delivery on the NHIS Promise of “One-time premium Payment": Financial Sustainability of the NHIS based on recent financial assessment of the NHIS, presentation to stakeholders. The National Health Insurance Authority of Ghana, Elimina; 2010.
• [20]Adjei S, Results for Development Institute: Moving toward universal health coverage. Results for Development Institute with inputs from Sam Adjei, Executive Director, Center for Health and Social Services, Ghana, IV Funding/Results for Development institute, Washington, DC; 2010. [Ghana case-study]
• [21]Gyapong J, Garshong B, Akazili J, Aikins M, Agyepong I, Nyonator F: Critical analysis of Ghana’s health system with a focus on equity challenges and the National Health Insurance, Shield Workpackage1 Report. 2007. Online at: http://heu uct.org.za/research/projects/shield-project/ webcite, accessed 12 April 2011
• [22]Asante F, Aikins M: Does the NHIS cover the poor?. Danida ⁄ Institute of Statistical Social and Economic Research (ISSER), University of Ghana, Legon; 2007.
• [23]MOH: Pulling together, achieving more: Health Sector Programme of Work 2008, Independent Review, draft report. Ministry of Health, Accra; 2009.
• [24]Ansah EK, Narh-Bana S, Asiamah S, Dzordzordzi V, Biantey K, Dickson K, Gyapong JO, Koram KA, Greenwood BM, Mills A, Whitty CJ: Effect of removing direct payment for health care on utilisation and health outcomes in Ghanaian children: A Randomised Controlled Trial. PLoS Med 2009, 6:1549-1277.
• [25]Akazili J: Equity in health care financing in Ghana. University of Cape Town, Cape Town, South Africa; 2010. [PhD Thesis]
• [26]NDC Party Manifesto: A better Ghana, Investing in people, jobs and the economy. National Democratic Congress, Accra; 2008:68.
• [27]Ghanamma website: NHIS’ One-Time Premium -- An Actuarial Estimate. http://www.ghanamma.com/news/2011/04/29/nhis%E2%80%99-one-time-premium-an-actuarial-estimate/ webcite] accessed on 30 April, 2011
• [28]Adu-Gyamerah E: "NHIA IN DANGER IF. 2011. http://tettehamoako.blogspot.com/2010/03/nhia-in-danger-if-1b-march-4-2010.html webcite]. accessed on 5 March, 2011
• [29]Addison T, Osei R: Taxation and Fiscal Reforms in Ghana, Discussion Paper No. 2001/97. Helsinki: UNU/WIDER; 2001. internet publication
• [30]Wagstaff A: Social Health Insurance Re-examined. Health Econ 2010, 19:503-517.
• [31]McIntyre D: Learning from experience: Health care financing in low- and middle-income countries. Global Forum for Health Research, Geneva, Switzerland; 2007.