Costs, equity, efficiency and feasibility of identifying the poor in Ghana’s National Health Insurance Scheme: empirical analysis of various strategies

• Published in: Tropical medicine & international health 2012-01, Vol.17 (1), p.43-51
• Main Authors: Aryeetey, Genevieve Cecilia, Jehu‐Appiah, Caroline, Spaan, Ernst, Agyepong, Irene, Baltussen, Rob
• Format: Article
• Language: English
• Subjects: assurance maladie; Biological and medical sciences; Costes; costs; Costs and Cost Analysis; coûts; Data Collection - economics; Delivery of Health Care - economics; efficacité; Efficiency; eficiencia; Eligibility Determination - economics; Eligibility Determination - standards; Equidad; equity; Exemptions; faisabilité; Family Characteristics; Feasibility; General aspects; Ghana; Health economics; health insurance; Health Services Accessibility - economics; Humans; Insurance premiums; Low income groups; Medical Indigency; Medical sciences; National health insurance; National Health Programs; Poverty; Public Health Administration; seguro sanitario; Social Welfare; Universal Coverage; viabilidad; équité
• ISSN: 1360-2276; 1365-3156
• DOI: 10.1111/j.1365-3156.2011.02886.x

Objectives  To analyse the costs and evaluate the equity, efficiency and feasibility of four strategies to identify poor households for premium exemptions in Ghana’s National Health Insurance Scheme (NHIS): means testing (MT), proxy means testing (PMT), participatory wealth ranking (PWR) and geographic targeting (GT) in urban, rural and semi‐urban settings in Ghana. Methods  We conducted the study in 145–147 households per setting with MT as our gold standard strategy. We estimated total costs that included costs of household surveys and cost of premiums paid to the poor, efficiency (cost per poor person identified), equity (number of true poor excluded) and the administrative feasibility of implementation. Results  The cost of exempting one poor individual ranged from US$15.87 to US$95.44; exclusion of the poor ranged between 0% and 73%. MT was most efficient and equitable in rural and urban settings with low‐poverty incidence; GT was efficient and equitable in the semi‐urban setting with high‐poverty incidence. PMT and PWR were less equitable and inefficient although feasible in some settings. Conclusion  We recommend MT as optimal strategy in low‐poverty urban and rural settings and GT as optimal strategy in high‐poverty semi‐urban setting. The study is relevant to other social and developmental programmes that require identification and exemptions of the poor in low‐income countries. Objectifs:  Analyser les coûts et évaluer l’équité, l’efficacité et la faisabilité, de quatre stratégies pour l’identification des ménages pauvres éligibles pour les plus importantes exonérations dans le système national d’assurance santé au Ghana (SNIS): l’évaluation des moyens (MT), l’évaluation des indicateurs de moyens (PMT), le classement par richesse participative (CRP) et le ciblage géographique (GT), en milieu urbain, rural et semi‐urbain au Ghana. Méthodes:  Nous avons réalisé l’étude sur 145 à 147 ménages par contexte en utilisant MT comme stratégie de référence. Nous avons estimé les coûts totaux, qui comprennent les coûts des enquêtes auprès des ménages et le coût des primes payées aux pauvres, l’efficacité (coût par personne pauvre identifiée), l’équité (nombre de vrais pauvres exclus) et la faisabilité administrative pour l’implémentation. Résultats:  Le coût pour exempter une personne pauvre variait de 15,87$à 95,44 $ américains; l’exclusion des pauvres variait entre 0% et 73%. MT a été plus efficace et équitable dans les milieux ruraux et urbains avec une f