title: Costs, equity, efficiency and feasibility of identifying the poor in Ghana's National Health Insurance Scheme: empirical analysis of various strategies.
abstract: OBJECTIVE
  To analyse the costs and evaluate the equity, efficiency and feasibility of four strategies to identify poor households for premium exemptions in Ghana's National Health Insurance Scheme (NHIS): means testing (MT), proxy means testing (PMT), participatory wealth ranking (PWR) and geographic targeting (GT) in urban, rural and semi-urban settings in Ghana.
  
  
  METHODS
  We conducted the study in 145-147 households per setting with MT as our gold standard strategy. We estimated total costs that included costs of household surveys and cost of premiums paid to the poor, efficiency (cost per poor person identified), equity (number of true poor excluded) and the administrative feasibility of implementation.
  
  
  RESULTS
  The cost of exempting one poor individual ranged from US$15.87 to US$95.44; exclusion of the poor ranged between 0% and 73%. MT was most efficient and equitable in rural and urban settings with low-poverty incidence; GT was efficient and equitable in the semi-urban setting with high-poverty incidence. PMT and PWR were less equitable and inefficient although feasible in some settings.
  
  
  CONCLUSIONS
  We recommend MT as optimal strategy in low-poverty urban and rural settings and GT as optimal strategy in high-poverty semi-urban setting. The study is relevant to other social and developmental programmes that require identification and exemptions of the poor in low-income countries.
authors.affiliation: Department of Primary and Community Care, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands. cecearyeetey@yahoo.co.uk
authors.forename: Genevieve Cecilia
authors.initials: GC
authors.lastname: Aryeetey
authors.forename: Caroline
authors.initials: C
authors.lastname: Jehu-Appiah
authors.forename: Ernst
authors.initials: E
authors.lastname: Spaan
authors.forename: Irene
authors.initials: I
authors.lastname: Agyepong
authors.forename: Rob
authors.initials: R
authors.lastname: Baltussen
mesh_terms: D003365:Costs and Cost Analysis; D003625:Data Collection / Q000191:economics; D003695:Delivery of Health Care / Q000191:economics*; D004526:Efficiency; D004608:Eligibility Determination / Q000191:economics / Q000592:standards; D005191:Family Characteristics; D005869:Ghana; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D008489:Medical Indigency; D009313:National Health Programs; D011203:Poverty; D011635:Public Health Administration; D012946:Social Welfare; D019472:Universal Health Insurance