Efficiency, equity and feasibility of strategies to identify the poor: An application to premium exemptions under National Health Insurance in Ghana

Objectives: This paper outlines the potential strategies to identify the poor, and assesses their feasibility, efficiency and equity. Analyses are illustrated for the case of premium exemptions under National Health Insurance (NHI) in Ghana. Methods: A literature search in Medline search was performed to identify strategies to identify the poor. Models were developed including information on demography and poverty, and costs and errors of in- and exclusion of these strategies in two regions in Ghana. Results: Proxy means testing (PMT), participatory welfare ranking (PWR), and geographic targeting (GT) are potentially useful strategies to identify the poor, and vary in terms of their efficiency, equity and feasibility. Costs to exempt one poor individual range between US$11.63 and US$66.67, and strategies may exclude up to 25% of the poor. Feasibility of strategies is dependent on their aptness in rural/urban settings, and administrative capacity to implement. A decision framework summarizes the above information to guide policy making. Conclusions: We recommend PMT as an optimal strategy in relative low poverty incidence urbanized settings, PWR as an optimal strategy in relative low poverty incidence rural settings, and GT as an optimal strategy in high incidence poverty settings. This paper holds important lessons not only for NHI in Ghana but also for other countries implementing exemption policies. (C) 2009 Elsevier Ireland Ltd. All rights reserved.