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Instructions
Closing the Gap: Lessons from AfricaHealth coverage for non-poor informal-sector workers and their families
November 5, 2015
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Agenda
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• Welcome• Introduction • Lessons learned – Subsidies – Information – Convenience
• Discussion
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Presenters
Jack Langenbrunner, The Bill and Melinda Gates Foundation, USACollins Akuamoah, National Health Insurance Authority, Ghana
Presenters
JLN facilitators Marty Makinen, Joint Learning Network , USAMarilyn Heymann, Joint Learning Network , USA
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Acknowledgements
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Impetus
In October 2013, the Government of Indonesia hosted a High Level Forum on Expanding Coverage to the Informal Sector
Introduction
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“Coverage is often lacking for the non-poor informal-sector workers and their families because of the relative difficulty of identifying and enrolling them and in financing their coverage in an equitable way.”
Introduction
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Introduction
We define the non-poor informal sector as those who do not meet the country threshold for poverty status and assumes these four characteristics:
1) absence of formal contracts or protections for employees,2) irregular income, 3) lack of outside government regulation or taxation, and 4) lack of health coverage through employers.
Includes poor, near-poor, and non-poor in both rural and urban areas as well as migrant and temporary workers. Also encompasses the worker and family.
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Three important factors that influence engagement and participation of the non-poor informal sector in pre-paid health insurance schemes: • Subsidies• Information • Convenience
Introduction
Subsidies
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Subsidies
Funding for social health protection for the non-poor informal sector typically comes from general government revenues—through either full or partial subsidies — or from mandatory or voluntary contributions from enrollees.
Benefits Challenges
Contributory • Less burden on the tax base• Politically more palatable• Population awareness of cost
• Low coverage • Significant transaction costs• Tailoring subsidy level
Non-contributory
• High coverage• Lower administrative costs
• Need sufficient funding • Need appropriate policy climate • Potential reduction in relative
size of formal economy
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Subsidies
When direct payments for health insurance are collected from the non-poor informal-sector workers, and particularly the near-poor, the contribution amount is mostly low and (in theory) mandatory.
Country/Scheme Eligible Groups Gov’t Subsidy Contribution
China NRCMS
Farmers, rural populations
Central gov’t 85% of premium
Flat amount, assigned by county
South KoreaNHI
All self-employed populations
Partial subsidy Approx. ₩50,513 (USD 45) per household
PhilippinesPhilHealth
(1) Sponsored members
(2) Informal Economy members
(1) Gov’t revenue(2) No subsidy
(1) None(2) 2,400 PHP or
US$52 per family
VietnamSHI
Vulnerable populations, informal sector workers
Partial subsidy ranges from 30-100%
Income based
Background • Ghana’s NHIS was established by an Act of Parliament in
2003 (Act 650) in response to challenges posed by “Cash and Carry” system
• Law reviewed in 2012, NHIS Act 852
• A Social Health Protection Policy initiated by Government of Ghana to secure financial risk protection against the cost of healthcare services for all residents in the country.
Subsidies - Ghana
Subsidies - Ghana
Category Premium Proc. Fee
Informal sector
Under 18 years
70 years and above
SSNIT contributors
SSNIT pensioners
Indigents
Pregnant women
LEAP beneficiaries
Persons with Mental disorder
Exempted from
premium payment
Subsidies - Ghana
Category Membership Percentage
Informal 3,235,141 30.7%
SSNIT Contributors 371,187 3.5%
SSNIT Pensioners 21,149 0.2%
Under 18 years 4,736,474 44.9%
70 years and above 380,157 3.6%
Indigents 1,500,324 14.2%
Police Service 7,376 0.1%
Military 4,717 0.04%
Security Services 2,307 0.02%
Pregnant women registered 286,596 2.7%
Total 10,545,428
Subsidies - Ghana
Target Group Description Graduated Premium (Minimum Amount)
Very Rich Adults who are employed and able to meet their basic needs and most of their wants
GH¢ 48.00 / yearUSD 12.50 / year
Rich Adults who are employed and able to meet their basic needs and some of their wants
GH¢ 48.00 / yearUSD 12.50 / year
Middle Income Adults who are employed and able to meet their basic needs.
GH¢ 18.00 / yearUSD 4.69 / year
Poor Adults who are unemployed but receive low returns for their efforts and are unable to meet their basic needs
GH¢ 7.20 / yearUSD 1.90/ year
Very Poor Adults who are unemployed but receive identifiable and consistent financial support from sources of low income.
GH¢ 7.20 / yearUSD 1.90/ year
Core Poor Adults who are unemployed and do not receive any identifiable and constant support from elsewhere for survival.
Free
Subsidies - Ghana
Challenges • Difficulty in determining individual incomes• No national database to assist in determining appropriate
premium• High administrative cost to collect premiums
o Contribution of premium income to total NHIS revenue is less than 5%
Solutions • Use of geographic targeting / flat premiums • Leveraging databases developed by other social welfare
groups
Information
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Information
Educating health users about available programs and services — and the processes to use them — is a critical step for all countries working to provide health protection and access to health services.
More information may increase willingness for the non-poor informal sector to enroll in health insurance
However, education and sensitization efforts may not matter if the quality of health services are poor.
Information – Ghana
Communication Strategy
1. Community Engagement – Drama on NHIS– Community durbars (meeting with village and chief)– Church / mosque sensitization– Use of mobile van – Gongong or community announcement system
2. Mass communication – Radio announcement, jingles, live talk shows– Television – Newspaper
3. A combination of 1 and 2
Information – Ghana
Key Messages Conveyed to Informal Sector Members
1. Benefit package contents 2. New biometric membership registration process3. Procedures for lodging complaints e.g. NHIS call center4. Penalty for defaulting members5. Rights and responsibilities of members6. Credentialed service providers in the district
Most of the above information is included in the subscriber manual
Convenience
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Convenience
Enrollment and Contribution Mechanisms • Flexible schedules typically work best• Structuring schedules and mechanisms around cycles of
workers ensures they can use them
However, more flexibility in enrollment and contribution payment options might however also have greater cost implications.
Enrolment Procedures
Ghana’s NHIS began to use biometric registration in 2014 and is now being rolled out to the 10th region in Ghana
Two approaches to enrolment1. In-person registration at District Office and other registration
points 2. District office staff conduct outreach and registration in
communities
Convenience - Ghana
SubscriberInterview
Fill Registrationform
Make Required Payment
Update Basic Data
Scan Fingerprints
Capture New Photo
Preview Details on Screen
New Bio
Data ?
No
Yes
Print Card
Check and TestID Card
Registration using BMS
Membership Renewal
Solutions• Increase outreach
Institutional registrations (e.g. churches and mosques)
Open more registration points, such as in health facilities
• Addressing technology issues
Convenience - Ghana
Challenges • Inadequate number of
registration kits • Lack of connectivity limits
site options for registration• Technology issues & delays
Synthesis
Discussion
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Thank you!
For additional information, please visit www.jointlearningnetwork.org or email Marilyn Heymann ([email protected])
