What thresholds can be used?

Universal Health Protection 53 ANNEX I: Country cases A.I.1 Africa Ghana Sources: 1 UNDESA: World Population Prospects, 2012. 2 UNDATA, 2011. 3 UNDP: Human Development Indicators, 2011. 4 WHO: Global Health Observatory, 201011. 5 Calculation based on data of Annex III In recent years Ghana has seen significant progress in economic and social development: over the past decade its GDP per capita more than tripled and poverty fell from 39.5 per cent in 1998 to 28.5 per cent in 2006 UNDATA, 2012; Ghana Statistical Service, 2008. Redistributive factors such as land ownership, and increased access to education and health care played an important role in the process of economic growth and poverty reduction ILO, 2013b. The National Health Service in Ghana came into existence in 1957, offering entitlement to free public health care to all members of the population. Lack of financial sustainability forced Ghana to revise the system and introduce co-payments in 1985. In 1992, a new reform followed, introducing the “cash-and-carry” system, in which care was provided only after an initial payment. The result of the reforms was that health services became less affordable and thus less accessible, especially for the poorest members of the population ILO, 2008. In order to make health care more accessible for all members of its population, Ghana implemented a National Health Insurance Scheme NHIS in 2005. Ever since, it has made significant progress towards achieving universal coverage. The greatest virtue of the NHIS is its risk-pooling mechanism and the resulting reduction of the individual burden of health-care costs. Since the introduction of the NHIS, health financing has been evolving from community-based health insurance plans to a system of district mutual health insurance schemes mutuelles de santé Schieber et al., 2012. The current system is coordinated by the National Health Insurance Council. Its Health Insurance Fund receives funding from contributions paid to the Social Security and National Insurance Trust, the health insurance levy, grants, donations and other sources as Table A.1 Ghana: Selected development and social health protection indicators - Total population: 24.26 million 1 - GDP per capita: US1,570 2 - HDI: 0.558 [Rank: 135] 3 - Per capita total expenditures on health as a of GDP: 4.8 4 - Deficit of legal coverage as of population: 26.1 5 - OOP in per cent of THE: 29.1 5 - Per cent of population not covered due to financial resources deficit: 77.7 5 - Staff Access Deficit of population not covered due to lack of professional health staff: 74.1 5 - Maternal mortality rate per 10,000 live births: 35.0 5,4 54 Universal Health Protection well as voluntary contributions from informal-economy workers ILO, 2008. Funds are allocated to district mutual health insurance schemes offering essential health-care benefits as defined in the National Health Insurance Act NHIA. The NHIA stipulates coverage for all persons residing in Ghana, including vulnerable groups such as children, pensioners, the elderly and others, many of whom were not covered previously. The number of beneficiaries has thus increased significantly in the past few years, contributing considerably to decreasing health-related impoverishment. During the process of the extending coverage in health protection, the ILO provided support in monitoring the performance of health insurance and health system budgeting aimed at effective financial governance ILO, 2013b. With regard to changes in Ghana’s health-care financing between 1995 and 2009, the following observations can be made: total health expenditure increased; the composition of total health expenditure THE changed, with the share of public expenditure increasing significantly figure A.1; and OOP has been at or slightly above the average for countries with comparable levels of development, indicating flaws in financial protection Schieber et al., 2012. Figure A.1. Ghana: Changes in composition of health expenditure, 1995 and 2009 Source: Schieber at al., 2012. Ghana is one of the few countries in sub-Saharan Africa to earmark financing for universal health coverage, provide coverage for its vulnerable population groups and extend coverage by transitioning its existing community health insurance schemes into a national health insurance programme. Ghana is thus viewed as an example for other countries in the region. Nevertheless, criticism – for instance, regarding the system’s financial sustainability – has also been voiced Schieber et al., 2012. When analysing access deficits using ILO indicators and related thresholds, there is still significant scope for improvement: The deficit in legal coverage amounts to 26.1 per cent. This implies that the implementation of the National Health Insurance Act, in spite of its efforts to increase coverage to all in need including vulnerable groups, has not resulted in extending coverage to the entire population. Ghana needs to scale up its efforts in taking a rights-based approach towards social protection in health. 10 20 30 40 50 60 1995 2009 T H E i n U S , b y s o u rc e Private OOP Public