Assessing the multiple dimensions of coverage and access

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 Universal Health Protection 55 Ghana faces considerable shortages in the health workforce: 74.1 per cent of the population has no access to health services, due to the country’s limited density of qualified health workers. The relative deficit in per capita health spending is almost 18.4 per cent, indicating that the quality of health care may be insufficient. OOP expenditure as a percentage of THE is at 29.1 per cent. In spite of progress with regard to maternal mortality over the past two decades, which has decreased from 580 to 350 deaths per 100,000 live births since 1990, Ghana will not be able to meet the MDG target of reducing maternal mortality by three-quarters by 2015. Additional challenges faced by Ghana relate above all to extending social protection in health to the informal economy and persons living in rural areas. Rwanda Sources: 1 UNDESA: World Population Prospects, 2012. 2 UNDATA, 2011. 3 UNDP: Human Development Indicators, 2011. 4 WHO: Global Health Observatory, 201011. 5 Calculations based on data of Annex III Since its civil war ended in 1994, Rwanda has achieved significant development progress. Its economic growth in the past decades has resulted in significant poverty reduction and progress towards the MDGs. Its development strategy focuses on equitable, efficient and effective pro-poor service delivery. Currently, Rwanda’s GDP growth is 7.9 per cent and it is among the most stable countries in the African continent World Bank, 2013. From 1995 to 2011 total health expenditure as a percentage of GDP increased from 4.5 to 10.8 per cent. Total expenditure multiplied by five during this period, while OOP as a share of it decreased from 26.3 to 22.2 per cent WHO Global Health Observatory, 2011. The ILO estimates that in 2011 approximately 91 per cent of the population was covered by some form of health insurance. Formal-sector employees are covered by different health insurance schemes dependent on their status. The Rwanda Health Insurance Scheme La Rwandaise d’assurance de maladie, RAMA covers civil servants and other public-sector employees. RAMA was founded in Table A.2 Rwanda: Selected development and social health protection indicators - Total population: 10.84 million 1 - GDP per capita: US583 2 - HDI: 0.434 [Rank: 167] 3 - Total expenditures on health as a of GDP: 10.8 4 - Deficit of legal health coverage as of population: 9.0 5 - OOP in per cent of THE: 21.4 5 - Per cent of population not covered due to financial resources deficit: 79.4 5 - Staff Access Deficit of population not covered due to lack of professional health staff: 84 5 - Maternal mortality ratio: 34.0 5