Irene Akua Agyepong and Richard Afedi Nagai. A comparison of user fees plus fee exemptions and health insurance policy effectiveness for children under five in Ghana. Objectives.
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
To assess effectiveness and reasons for effectiveness or otherwise of the user fee plus exemptions and the health insurance policies in removing the financial access barriers to outpatient clinical care for children under five in Ghana posed by user fees.
Tax funded system with free public sector services post independence (1957)
User fees with a some fee exemptions 1985
Addition of more fee exemptions programs
Under five, AN, elderly 1999
Delivery 2003, 2005
CBI starting 1992 (Nkoranza)
Dangme West experiment starting 2000
Greater Accra Region
88% urban, high in migration (4.4% growth rate, 2.4% natural increase)
Focus on children living in rural and urban poor areas
Deprived rural district of subsistence farmers & fishermen (Dangme West)
Deprived sub-metropolitan area with mix of indigenous Ga and multi-ethnic migrant settlements (Ashiedu-Keteke)
Review of documents
Community focus group discussions (3 urban site, 5 rural site)
In-depth interviews with public sector facility heads (3/4 rural & 2/2 urban)
Structured questionnaire administered to principal childcare takers (300/study site selected by cluster sampling [30*10])
Retrospective analysis of secondary data on public sector outpatient service utilization by insured and uninsured children under five for the period 2000 – 2004
Effectiveness measured as % of children using the OPD of public sector facilities who:
Got a full exemption from payment of user fees
Through the user fees plus exemptions policy
Through health insurance
Who had to pay user fees despite the existence of the two policies and programs
Manual record keeping in the facilities
Attendance data kept at OPD records office
Financial data in accounts office but with copies of attendance numbers ?from OPD records office.
OPD utilization and exemptions financial data from the rural site facilities consistent between OPD records and accounting records.
Data in urban site conflicting with numbers of children recorded as exempted higher than numbers of children recorded as having used the OPD.
?poor and unsynchronized record keeping ?deliberate misreporting:
Facility management could not explain the discrepancies
Insurance started in rural site in 2005 & there were only 27 insured children presenting at OPD
Policy introduced in 1999. Operation in rural site started 2000 and in urban site 2002. Reason for different start dates unclear.
The estimation of the average claim per child exempted in the sub-metropolitan site facilities showed an unrealistically low average per child exempted in 2002, and a constant low average of about ¢ 5000 (US$ 0.56) in subsequent years.
The actual cost of an OPD visit for a child under five during this period was much more
Urban facilities management explained that apart from a few children e.g. severely malnourished, they were only exempting children from the consultation fee of ¢ 5000 (US$ 0.56). They paid all other bills
Rural site approach was to fully exempt some children and have others fully pay all user fees
Insurance started as experiment in rural site in 2000 and data was available for all 5 years
Almost all respondents (rural and urban) knew about exemptions and insurance policies
However sometimes vague on the details – especially insurance in the urban area where it was relatively new
HOWEVER: Did not ask for an exemption if the staff at the facility did not volunteer one even when they knew of the policy because they were afraid of negative staff reactions
Facility user fees were not the only barrier for the poor
Quality of care was a concern
Geographic access was an issue, but sometimes quality was ranked higher with people bypassing nearer facilities for perceived better quality
No written guidelines for the exemptions policy
Written guidelines available for insurance
Long delays in exemptions reimbursement, partial reimbursement
Acknowledge negative reactions to clients asking about exemptions and attributed it to the perception that the policy would make them bankrupt if they implemented it to the letter
Generally central government appeared to shift the risks of the exemptions scheme to providers
Providers reacted to protect their interest by modifying the policy (as described)
Insurance was generally working and provider trust that they would be paid at the time of the study (2005/06)
Concerning reliabiilty of provider payments, things have changed since – “déjà vu?”
The user fees plus exemptions policy was not as effective as hoped
Among the causes was the failure to provide adequate funds for implementation and the shifting of risk to providers
The health insurance policy needs to learn from the failures of the exemptions policy
A policy is only as good as its implementation arrangements, and effective policy making power can be diffused between central policy elites who design policies and programs and peripheral operational translators to whom these policies are handed down for implementation
Unfortunately, central policy elites often go ahead to design policies and accompanying programs and pass them down for implementation on the assumption of a clean dichotomy between policy making which is a central function and implementation which is a peripheral function; without giving adequate attention to the power of peripheral operational translators in policy, and the incentives to make them comply and implement the policy as designed or modify it
Some, though not all, of the observed failures of well intentioned policies developed at the central level and passed down for ‘compliance’, without attention to the interests and needs of operational translators may be related to this failure to recognize that operational translators also holds a form of power in effective policy development and implementation