Banking on Health Explores Adding Family Planning Services to the Ghana National Health Insurance Scheme
Over the past decade, Ghana has made tremendous strides in economic growth, however, some important health and social indicators have not improved as would be expected. Of particular concern is a decline in maternal health indicators, including an increase in the maternal mortality rate, which threatens to derail the achievement of some of the Millennium Development Goals. It is likely that the increase in maternal mortality is linked in part to a relatively high total fertility rate, which stagnated at 4.4 children per woman between 1998 and 2003 despite a rise in the contraceptive prevalence rate (CPR) from 13 to 19 during the same period (DHS, 2003).
In a Health Summit in April 2008, the Ministry of Health (MoH) and its development partners discussed shortfalls in funding and performance of the national reproductive health and family planning programs. Among other shortfalls, the cost of family planning commodities far exceeded the budget, leaving a funding gap. As one strategy to address this gap, the Banking on Health Project was invited by the Ministry of Health through USAID/Ghana to provide an analysis of the costs and benefits to the National Health Insurance Scheme (NHIS) in adding family planning products and services to the coverage package, to be used by the National Health Insurance Council (NHIC) and the MoH in policy and benefit package deliberations. As part of this analysis, the Banking on Health Project was also asked to examine the potential role of private facilities in offering expanded access to family planning and their access to external financial support (such as commercial loans) for adding these services or products.
The assessment revealed that reproductive health and family planning has slipped as a public health priority in Ghana and these services are increasingly underfunded. Currently, family planning services are not covered as part of the National Health Insurance Scheme, which explicitly excluded these services from the benefits package when it was launched in 2003. Family planning was determined to be an “essential public good”, such as immunization and should be offered “free” through the Ghana Health Service (GHS). However, because constrained budgets fail to cover all basic operational costs at the facility level, in actual practice, almost every public facility and all private facilities charge fees for family planning products.
While family planning is not covered, as of July 1, 2008 the NHIS made all expectant mothers eligible for coverage and as of September 2008 all children under 18 will be eligible for coverage regardless of whether their parents are enrolled. Thus, a woman who registers for health insurance has free antenatal and delivery care and will receive free care for her baby, but must pay a fee to obtain family planning services at the same clinic. Financial incentives now favor more rather than fewer births. Expanded NHIS coverage for pregnant women, makes the medical care costs of additional births zero for women, which provides a marginally positive incentive to increase average total fertility per woman. Lack of NHIS coverage for family planning commodities maintains a positive price for delaying or limiting births, providing a marginally negative incentive to delay or limit births.
Banking on Health conducted a cost benefit analysis of adding coverage of long term and permanent family planning methods, as well as injectable contraceptives, to the NHIS benefits package. The analysis revealed that including family planning would cause a decrease in fertility and would avert births that would otherwise have cost the NHIS considerable expenditures. Adding this benefit would lead to an annual net savings to the NHIS that would increase over time. The size of the net savings depends on a number of variables, which may change over time. According to Banking on Health’s assumptions, if family planning is covered in 2009, by 2011 the NHIS will realize almost C 11 million (US 11 million) in net savings in that year alone. This increases to over C 18 million (US 18 million) in 2017. Based on this analysis, Banking on Health recommended that the NHIS add coverage of the proposed package of family planning services. This recommendation is currently under review.
The Banking on Health assessment also determined that private providers play a significant role within the NHIS, providing approximately one third of all services that are reimbursed and that this role will continue to grow. Many of the private providers that were interviewed believe that adding family planning to the package of covered services will increase use. Banking on Health recommended a number of strategies to strengthen the role of the private health sector within the NHIS.
