The Impact of Health Insurance Schemes for the Informal Sector in Low- and Middle-Income Countries: A Systematic Review

Abstract

This paper summarizes the literature on the impact of state subsidized or social health insurance schemes that have been offered, mostly on a voluntary basis, to the informal sector in low-and middle-income countries. A substantial number of papers provide estimations of average treatment on the treated effect for insured persons. We summarize papers that correct for the problem of self-selection into insurance and papers that estimate the average intention to treat effect. Summarizing the literature was difficult because of the lack of (1) uniformity in the use of meaningful definitions of outcomes that indicate welfare improvements and (2) clarity in the consideration of selection issues. We find the uptake of insurance schemes, in many cases, to be less than expected. In general, we find no strong evidence of an impact on utilization, protection from financial risk, and health status. However, a few insurance schemes afford significant protection from high levels of out-of-pocket expenditures. In these cases, however, the impact on the poor is weaker. More information is needed to understand the reasons for low enrollment and to explain the limited impact of health insurance among the insured.

Households’ Willingness to Pay for Health Microinsurance and its Impact on Actual Take-up: Results from a Field Experiment in Senegal

“…It has been shown that the cost of major illness may lead to impoverishment (see, among others, Wagstaff [2007] and Wagstaff and van Doorslaer [2003]). This is particularly the case for the most vulnerable categories in society; workers in the informal sector and rural areas are less likely to be involved in mandatory social security schemes, as is often the case for public servants and workers in the formal private sector (see Acharya et al [2013] and Ekman [2004] for reviews).…”

Understanding CBHI hospitalisation patterns: a comparison of insured and uninsured women in Gujarat, India

“…Based on our findings, morbidity patterns and outpatient care were similar up until the point of hospitalisation – but there is no indication of whether higher inpatient admission results in better long term health. Thus far, evaluations of CBHI as well as larger social insurance schemes have focused on the quantitative increase in utilisation and financial security afforded by coverage, with limited assessment of the associated effects on health [2,3,12]. Encouragingly, a recent study in Burkina Faso has investigated the association of CBHI coverage with mortality outcomes [45].…”

“…According to findings from a systematic review in 2009 that covered 31 studies and 118 schemes, and an earlier review of 12 schemes in Asia and Africa, there is strong evidence that CBHI schemes can decrease out of pocket spending on health care [2,3] A large proportion of schemes in low-income settings cover only inpatient hospitalisation expenses, and CBHI coverage has been associated with increased hospitalisation in a number of studies [4-9]. However, health systems issues such as poor quality of services and lack of patient empowerment remain barriers to increased treatment-seeking [10,11], while low enrolment limits coverage of CBHIs and similar voluntary schemes [12]. Despite these weaknesses, CBHIs continue to be implemented in many low-income countries, as a potential tool to improve access and financial security [1].…”

Does Social Health Insurance Reduce Financial Burden? Panel Data Evidence from India

“…Given the large share of OOP payments in health care in India, RSBY is considered a very innovative scheme that relies on providing cashless health services to the beneficiary households without any paperwork with the use of smart cards (more details are provided in section 1.1) with only a marginal enrollment/renewal cost of 30 Indian Rupees (INR) (about $0.5) per year. 1 It covers up to five members of family. As of November, 2012, 33.19 million 1 The World Bank hailed RSBY as a model of good design and implementation with important lessons for other programs in India.…”

“…1 It covers up to five members of family. As of November, 2012, 33.19 million 1 The World Bank hailed RSBY as a model of good design and implementation with important lessons for other programs in India. http://pib.nic.in/newsite/efeatures.aspx?relid=69262 1 BPL families were enrolled in RSBY, and an estimated 165.9 million persons were a part of "BPL-families-with-a-RSBY-card" (Ministry of Labour and Employment, 2012).…”