Systematic Review of national health insurance for the poor and informal sector in LMICs

Systematic Review:   Impact of national health insurance for the poor and the informal sector in low- and middle-income countries.


Full Report here.





Abstract

What do we want to know?

Moving away from out-of-pocket (OOP) payments for healthcare at the time of use
to prepayment through health insurance (HI) is an important step towards averting
financial hardships associated with paying for health services. Social health
insurance (SHI) is mandated for those employed in many developed countries
where employment and wage rates are high; this service is extended to those
unemployed through subsidy. In low- and middle-income countries (LMICs) some
version of SHI has been offered to those in the informal labour sector, who may
well comprise the majority of the workforce. We carried out a systematic review of
studies reporting on the impact of health insurance schemes that are intended to
benefit the poor, mostly employed in the informal sector, in LMICs at a national
level, or have the potential to be scaled up to be delivered to a large population.

Who wants to know and why?

Our findings will help policy makers to learn what lessons the implementation of
such insurance suggests in terms of welfare enhancement to those who currently
undertake out-of-pocket health expenditure, which often exacerbates their already
meagre material living conditions. The information in this document will help
reshape existing programmes, and assess the need for expanding and introducing HI
programmes for the poor and those in the informal sector. We further aim to
influence future effort in examining the impact of health insurance by detailing
appropriate methods that have succeeded in identifying the impact of insurance,
given the mechanism through which schemes were offered.

What did we find?

Our systematic review showed inconclusive evidence. Low enrolment is commonly
observed in many of the insurance schemes we examined. Many health system
factors may play a role in explaining low enrolment; studies did not explore supply
factors. We do not observe a pattern regarding enrolment and outcome: for
example, high enrolment is not correlated with better outcomes. There is some
evidence that health insurance may prevent high levels of expenditure. From those
studies reporting on whether or not the impact on the subgroup of insured that
were poorer was more noticeable, we find that the impact was smaller for the
poorer population. That is, the insured poor may be undertaking higher OOP
expenditure than those who are not insured.

What are the implications?

Greater effort needs to be undertaken to study the health-seeking behaviour of
those insured and those uninsured in LMICs.

How did we get these results?


We give results from 34 studies that report the impact of health insurance for the
poor using quantitative methods. We found no qualitative studies. We emphasise
the results from those studies that made a significant effort to use statistical
methods currently prevalent in the economics literature on impact evaluation.