LUXEMBOURG/ACCRA - The Director of Nsawam District Hospital in Ghana sees around twenty women a year dying of post-partum haemorrhaging - a comparatively easily treated condition. "They put off coming to the hospital because they are afraid they will not be able to pay the bill. So by the time they do come it's too late and we can't save them", he says.

The situation is repeated for dozens of conditions and thousands of people in Ghana. "Access to and use of health facilities has been low and declining, particularly since a shift some twenty years ago from a universally accessible national health service to the introduction of user fees", says Fiona Kilpatrick, Project Coordinator of the Global Social Trust.

A survey conducted by the Ghana Statistical Service in 1998 suggests that only around 43.8 per cent of those who were ill had consulted a medical practitioner. This trend can be linked, at least in part, to the increasing health care user fees over recent years. Provision of health care has in recent years been based on a pay-as-you-go system known as "cash and carry": the Government meets around 80 per cent of the fees for public healthcare, and the remainder is paid by the end user at the time of use. "But the problem is that the vast majority of people in Ghana cannot afford to pay their 20 per cent share…", says Kilpatrick.

For over twenty years, successive governments have recognized the unsatisfactory nature of this system, which acts as a disincentive to use of healthcare facilities, excludes the poorest and limits access generally. The Government has now passed legislation to introduce a national health insurance system to replace user fees. It is particularly concerned with ensuring access for the poor in Ghana.

"However, an ILO survey in two districts of Ghana found that 45 per cent of those who would like to join existing mutual health insurance organizations could not afford the premium", says Kilpatrick.

The ILO has therefore been working with the Ghanaian Ministry of Health and the Dangme West Health Insurance Administration in the Greater Accra region to find community-based ways of identifying those in most need and supporting their access to health insurance by subsidizing their premiums.

The Global Social Trust funding will help the Government of Ghana establish a means of targeting the poor for support, and will provide key information on numbers involved and utilization of health services to help the development of long-term planning and sustainable financing of the new national health insurance system.

The concept is simple. Individuals in the industrialized economies - who are benefiting from reliable social security arrangements - contribute a modest monthly sum (around € 5) as additional voluntary social insurance contribution into a trust fund. The funds collected are used to support the extension of social security systems in developing countries.

The financial commitment from the host government - Ghana in this case - gradually increases over a number of years until the new system is fully-funded by the host government on a sustainable basis. The Trust is not designed to fund national social security schemes on an open-ended basis, but to kick-start the extension of existing schemes. It offers support to governments over a fixed period of time during which those governments can adjust their expenditure and forward plans in order to take over the financing of the social protection in the long term.

The challenge was to put the concept into practice, both through collecting contributions and identifying effective ways of distributing the funds. In Luxembourg, the largest trade union confederation, the OGB-L, and the Government have agreed to work with the ILO to pilot the collection of contributions. The resulting trust funds will be used to support a new national health insurance system in Ghana.

Immediate access to health care is key to reducing poverty

Project activities have started in Dangme West, a primarily rural district, with a population of around 110,000 people. Fewer than half have access to a safe water supply or toilet facilities, with obvious consequences for their health status. Only 13,000 were covered by the health insurance scheme. The health insurance premium is around US$3 per person per year, with reductions for children under five.

A series of workshops with community leaders and social development workers, and health insurance registrars established that in almost all the communities, people "knew" who the poor were. The Health Insurance Administration drew on this knowledge to put together a list of potential beneficiaries, which identified some 2,500 households (around 10,000) people. A process of cross-checking and verification reduced this number to 1,600 households/8,000 people who were then invited to join the health insurance scheme. They were offered a 75 per cent discount on the premium. At the end of the first round of registration, some 4,000 people had taken up the offer, and the remainder expected to be able to do so in the second year.

A full pilot funded from the Global Social Trust is now planned for a further ten districts in Ghana, reaching up to 100,000 people. The project is not only helping poor people get immediate access to health insurance, the information collected in Dangme West is being used to develop a process to identify the poor in other districts through a combination of community knowledge and objective assessment.

"Improving health is one key to reducing poverty, and this partnership between the people of Luxembourg and the people of Ghana will help the poorest to get the basic healthcare they need. It also brings two countries together in social solidarity", says Michael Cichon, Head of the ILO's Social Security Financial, Actuarial and Statistical Services.

The Global Social Trust initiative is part of a wider campaign of the ILO to encourage countries to extend social security to more of their citizens. Noting that four out of five people in the world lack basic social security coverage, the ILO launched a " Global Campaign on Social Security and Coverage for All" in June 2003.

The campaign seeks to develop a broad partnership involving international organizations, donor countries, social security institutions and civil society organizations. This renewed commitment to social protection has led to the development of the innovative concept for a Global Social Trust by the ILO's International Financial and Actuarial Service. This is part of a continuing effort to explore new ways of mobilizing international financing to support the development of national social protection systems.