Something old or something new? Social health insurance in Ghana.
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Witter, S. & Garshong, B. (2009) Something old or something new? Social health insurance in Ghana., BMC International Health and Human Rights, vol. 9, , ,
Background There is considerable interest at present in exploring the potential of social health insurance to increase access to and affordability of health care in Africa. A number of countries are currently experimenting with different approaches. Ghana's National Health Insurance Scheme (NHIS) was passed into law in 2003 but fully implemented from late 2005. It has already reached impressive coverage levels. This article aims to provide a preliminary assessment of the NHIS to date. This can inform the development of the NHIS itself but also other innovations in the region. Methods This article is based on analysis of routine data, on secondary literature and on key informant interviews conducted by the authors with stakeholders at national, regional and district levels over the period of 2005 to 2009. Results In relation to its financing sources, the NHIS is heavily reliant on tax funding for 70-75% of its revenue. This has permitted quick expansion of coverage, partly through the inclusion of large exempted population groups. Card holders increased from 7% of the population in 2005 to 45% in 2008. However, only around a third of these are contributing to the scheme financially. This presents a sustainability problem, in that revenue is de-coupled from the growing membership. In addition, the NHIS offers a broad benefits package, with no co-payments and limited gate-keeping, and also faces cost escalation related to its new payment system and the growing utilisation of members. These features contributed to a growth in distressed schemes and failure to pay outstanding facility claims in 2008. The NHIS has had a considerable impact on the health system as a whole, taking on a growing role in funding curative care. In 2009, it is expected to contribute 41% of the overall resource envelope. However there is evidence that this funding is not additional but has been switched from other funding channels. There are some equity concerns about this, as the new funding source (a VAT-based tax) may be more regressive. In addition, membership of the NHIS at present has a pro-rich bias, and a pro-urban bias in relation to renewals. Only a very small proportion is registered as indigent, and there is some evidence of 'squeezing out' of non-members from health care utilisation. Finally, considerable challenges remain in relation to strengthening the purchasing role of the NHIS, and also settling debates about its structure and accountability. Conclusion Some trade-offs will be necessary between the existing wide benefits package of the NHIS and the laudable desire to reach universal coverage. The overall resource envelope for health is likely to be stable rather than increasing over the medium-term. In the longer term, the investment costs in the NHIS will only be justified if it is able to increase the cost-effectiveness of purchasing and the responsiveness of the system as a whole.It is estimated that in 2000 almost 175 million people, or 2.9% of the world's population, were livingoutside their country of birth, compared to 100 million, or 1.8% of the total population, in 1995.As the global labour market strengthens, it is increasingly highly skilled professionals who aremigrating. Medical practitioners and nurses represent a small proportion of highly skilled workerswho migrate, but the loss of health human resources for developing countries can mean that thecapacity of the health system to deliver health care equitably is compromised. However, data tosupport claims on both the extent and the impact of migration in developing countries is patchyand often anecdotal, based on limited databases with highly inconsistent categories of educationand skills.The aim of this paper is to examine some key issues related to the international migration of healthworkers in order to better understand its impact and to find entry points to developing policyoptions with which migration can be managed.The paper is divided into six sections. In the first, the different types of migration are reviewed.Some global trends are depicted in the second section. Scarcity of data on health worker migrationis one major challenge and this is addressed in section three, which reviews and discusses differentdata sources. The consequences of health worker migration and the financial flows associated withit are presented in section four and five, respectively. To illustrate the main issues addressed in theprevious sections, a case study based mainly on the United Kingdom is presented in section six.This section includes a discussion on policies and ends by addressing the policy options from abroader perspective.