Underutilization of Social Insurance among the Poor: Evidence from the Philippines

Abstract

BackgroundMany developing countries promote social health insurance as a means to eliminate unmet health needs. However, this strategy may be ineffective if there are barriers to fully utilizing insurance.MethodsWe analyzed the utilization of social health insurance in 30 hospital districts in the central regions of the Philippines between 2003 and 2007. Data for the study came from the Quality Improvement Demonstration Study (QIDS) and included detailed patient information from exit interviews of children under 5 years of age conducted in seven waves among public hospital districts located in the four central regions of the Philippines. These data were used to estimate and identify predictors of underutilization of insurance benefits - defined as the likelihood of not filing claims despite having legitimate insurance coverage - using logistic regression.ResultsMultivariate analyses using QIDS data from 2004 to 2007 reveal that underutilization averaged about 15% throughout the study period. Underutilization, however, declined over time. Among insured hospitalized children, increasing length of stay in the hospital and mother's education, were associated with less underutilization. Being in a QIDS intervention site was also associated with less underutilization and partially accounts for the downward trend in underutilization over time.DiscussionThe surprisingly high level of insurance underutilization by insured patients in the QIDS sites undermines the potentially positive impact of social health insurance on the health of the marginalized. In the Philippines, where the largest burden of health care spending falls on households, underutilization suggests ineffective distribution of public funds, failing to reach a significant proportion of households which are by and large poor. Interventions that improve benefit awareness may combat the problem of underutilization and should be the focus of further research in this area.

The Impact of Healthcare Insurance on the Utilisation of Facility-Based Delivery for Childbirth in the Philippines

“…This outcome was particularly significant when looking at women from poor or rural households. Earlier studies have argued that insurance coverage, particularly amongst the poor, was yet to translate into access to services due to various factors including the community’s lack of awareness of the rights to access health services [7, 46]. In contrast, our results suggest that insurance coverage for women in poor and rural households is possibly leading to an increasing demand for services and higher probabilities of FBD.…”

The role of national health insurance for achieving UHC in the Philippines: a mixed methods analysis

“…An older study from the Philippines [22] looked at the use of insurance in children under 5 years of age and found an overall under-utilization of about 15%, in particular associated with less-educated mothers and beneficiaries with shorter length of stay. These findings were corroborated by Faraon and colleagues [23], who showed the effect of gender, income status and type of membership (probably reflecting socio-economic characteristics) on frequency of use, and reported the lack of knowledge on how to file claims and on the benefit catalogue as significant predictors of under-utilization.…”

Evidence of a causal link between health outcomes, insurance coverage, and a policy to expand access: experimental data from children in the Philippines

“…Another behavioral response confounding health insurance effects is provider-initiated moral hazard, where increased insurance coverage may only translate into higher mark-ups, not additional services or higher quality of care needed to secure health improvements (Gertler and Solon, 2002). Also, when insurance premiums are highly subsidized and the cost to an individual of enrolling into an insurance program is marginal, there could be little incentive for the insured to gather the information needed to optimize use of insurance benefits (Quimbo et al, 2008). All of these point to the possibility that health insurance could affect health (e.g., through the traditional utilization channel); health could affect health insurance (e.g., the case of adverse selection); or health could be affected by a variable that is correlated with health insurance (e.g., higher prices which in turn impedes utilization or better awareness) (Levy and Meltzer, 2001).…”