The scheme itself, as it started, was an attempt to move away from prohibitive user-fees towards a cost-sharing model, where citizens have to enroll by paying an annual premium. One can draw lessons from the research/literature on free distribution v/s cost-sharing.Research findings from field experiments by JPAL/IPA suggests that the benefits of cost-sharing on usage are at best unclear, while they do often tend to result in the a significant drop in demand for these products, leading to the exclusion of those who probably need the product/service the most. This is relevant especially for public health products that have proven positive externalities. Some of these products succeed only if they protect the entire population in a community and in that situation, a cost-sharing model which dampens demand may be an ineffective strategy (even if it increases appropriate usage among those who take-up the product).
The World Bank responds here
Ishac Diwan, the World Bank’s country director for Ghana, says that Oxfam’s 18% coverage figure “is extremely surprising”. All the figures he has seen put it at around 40% to 60%. “If it was 18%, it would be terrible,” he says.
He also denies that the Bank is touting Ghana as an example for the whole of the developing world to follow. In Sierra Leone, for instance, “where some UN people have called for an insurance system, we have been against it”. But, he says, “the health system is something that is extremely defined by globalisation. When nurses and doctors are attracted abroad, adding private sector solutions is really important.” Essentially, insurance schemes which allow the private sector as well as public sector to flourish are good for middle and high income countries, he believes.