Policy makers are not blind to evidence

Governance, Health, Methodology

Regular readers of this blog will know that Oxfam has adopted a Global Performance Framework, which, among other things, involves the random selection of samples of closing or sufficiently mature projects under six outcome areas each year and rigorous evaluations of their performance. These are referred to as Effectiveness Reviews. The Universal Access to Health Care Campaign was randomly selected for evaluation in 2012/13 and an effectiveness review – informed by a research protocol based on process tracing, a qualitative research approach used to investigate casual inference – was conducted between December 2012 and March 2013.  Today, Al-hassan Adam – Oxfam GB’s Essential Service Campaign Manager, highlights some of the key findings of the effectiveness review
evaluation.

Ghana’s Health Insurance Scheme is celebrating its 10th year anniversary; this celebration will not be complete without acknowledging the contributions made by civil society through campaigns and advocacy.  

One of the key players was the Universal Access to Health Care Campaign  a collaboration of civil society organisations and networks including Alliance for Reproductive Health Rights (ARHR), the Integrated Social Development Centre (ISODEC) and Oxfam –
which worked towards a collective vision of free, quality and accessible universal health care for all Ghanaians. In 2011 the Campaign launched a report titled
Achieving a shared goal: free universal healthcare in Ghana.   

The report challenged the sustainability of Ghana’s health insurance scheme and, contrary to official reports of 67% coverage by the health insurance scheme, provided evidence that only 18% of Ghanaians might have been enrolled by the health insurance scheme. Despite being met with widespread controversy and a determined backlash from the National Health Insurance Authority (NHIA), among others, following its publication the official coverage figures were lowered from 67% to 34%. The evaluation found
strong evidence to suggest that the NHIA changed its methodology for calculating National Health Insurance Scheme coverage due to the actions of the Campaign, and that this sobering appraisal of the number of Ghanaians who actually benefit from access to free health care was a clear victory for the Campaign.   

‘A key success of the campaign was its ability to mobilise civil society organisations in the health arena.’The evaluation further found that a key success of the Campaign was its ability to mobilise civil society organisations in the health arena around the common goal of free universal health care, with the combined reach of the campaign extending to over 500 organisations working on health-related issues and to all
10 regions of Ghana, taking the place of partners and threatening coalition dynamics.

While the evaluation notes that the Ghanaian Government has not yet embraced the idea of free universal access to healthcare, gaining recognition of the weaknesses of the current model was a significant step towards this, and the impacts of this pivotal joint report are still being felt.

Following the evaluation, in February’s 2013 World Health Organisation/World Bank Ministerial-level Meeting on Universal Health Coverage in Geneva, the campaign had one of its most significant endorsements to date by the Ghanaian government delegate who said: 

“The Oxfam Report…  was actually very helpful and prompted us to revise our figures. We now know that 34% of the population are covered, not 67% as previously thought. In Ghana we are now doing a lot more to improve our monitoring and evaluation and in this way civil society is helping us.”   

The Director of the European Health Observatory at WHO further observed that: 

“The Ghana example is a powerful reminder that while at times it can seem to governments that an active civil society is ‘a pain’, what they do is actually really important. This shows how civil society can play a crucial role in holding government to account.”

And, just five days ago, one of Ghana’s Public Health experts, Professor Irene Agyepong, had this to say about the health insurance scheme:

We do have a sustainability challenge and we do need to seriously address that challenge if we want this scheme to survive.” 

Women queue at Achimota Hospital in Accra, Ghana, to access the free healthcare facilites available for pregnant women. Credit: Abbie Trayler-Smith/PanosThe World Bank has also come to the same conclusion in their 2012 publication Health Financing in Ghana at a Crossroads.

The campaign will now be taken forward by the civil society coalition, with Oxfam GB taking a back seat, supporting efforts to resource and continuing to engage on strategic issues.  And, as the evaluation noted, with renewed focus and commitment from its membership, the Campaign surely has a future in realising its vision

Going forward, one of the main messages of the Campaign is that a better way of sustaining the scheme and increasing access by marginalised people is through increased progressive taxation. Writing this as a Ghanaian, I know the national health insurance scheme has reduced the burden of family health bills when compared to out-of-pocket payment. However, this scheme would better serve Ghanaians if its financing were based on progressive taxation and other public sources of revenue such as corporate income tax, royalties from oil and gas, telecom, timber and
mining
. Relying on premiums is not the solution. They are costly to collect and as the report demonstrated, deny poor people access.

Read more

  • Find out more about our effectiveness reviews
  • Download Achieving a shared goal: free universal healthcare in Ghana
  • Images

    Top: Single mother Joyce with her baby son Prince whom she delivered in the local hospital thanks to the free healthcare provided to pregnant women in Ghana. Credit: Abbie Trayler-Smith/Panos

    Right: Women queue at Achimota Hospital in Accra, Ghana, to access the free healthcare facilites available for pregnant women. Credit: Abbie Trayler-Smith/Panos

Author: Al-hassan Adam
Archive blog. Originally posted on Oxfam Policy & Practice.