The Impact of Health Insurance in Low- and Middle-Income Countries

The Impact of Health Insurance in Low- and Middle-Income Countries

Maria-Luisa Escobar
Charles C. Griffin
R. Paul Shaw
Copyright Date: 2010
Pages: 232
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    The Impact of Health Insurance in Low- and Middle-Income Countries
    Book Description:

    Over the past twenty years, many low- and middle-income countries have experimented with health insurance options. While their plans have varied widely in scale and ambition, their goals are the same: to make health services more affordable through the use of public subsidies while also moving care providers partially or fully into competitive markets.

    Colombia embarked in 1993 on a fifteen-year effort to cover its entire population with insurance, in combination with greater freedom to choose among providers. A decade later Mexico followed suit with a program tailored to its federal system. Several African nations have introduced new programs in the past decade, and many are testing options for reform. For the past twenty years, Eastern Europe has been shifting from government-run care to insurance-based competitive systems, and both China and India have experimental programs to expand coverage. These nations are betting that insurance-based health care financing can increase the accessibility of services, increase providers' productivity, and change the population's health care use patterns, mirroring the development of health systems in most OECD countries.

    Until now, however, we have known little about the actual effects of these dramatic policy changes. Understanding the impact of health insurance-based care is key to the public policy debate of whether to extend insurance to low-income populations -and if so, how to do it -or to serve them through other means.

    Using recent household data, this book presents evidence of the impact of insurance programs in China, Colombia, Costa Rica, Ghana, Indonesia, Namibia, and Peru. The contributors also discuss potential design improvements that could increase impact. They provide innovative insights on improving the evaluation of health insurance reforms and on building a robust knowledge base to guide policy as other countries tackle the health insurance challenge.

    eISBN: 978-0-8157-0561-1
    Subjects: Sociology, Political Science

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-x)
  3. Preface
    (pp. xi-xii)
    Maria-Luisa Escobar, Charles C. Griffin and R. Paul Shaw
  4. Acknowledgments
    (pp. xiii-xiv)
  5. Chapter 1 Why and How Are We Studying Health Insurance in the Developing World?
    (pp. 1-12)
    Maria-Luisa Escobar, Charles C. Griffin and R. Paul Shaw

    More than 2 billion people live in developing countries with health systems afflicted by inefficiency, inequitable access, inadequate funding, and poor quality services. These people account for 92% of global annual deaths from communicable diseases, 68% of deaths from noncommunicable conditions, and 80% of deaths from injuries. The World Health Organization (WHO) estimates that more than 150 million of these people suffer financial catastrophe every year, having to make unexpected out-of-pocket expenditures for expensive emergency care (WHO various years).

    Within countries, the burden of dysfunctional health systems is disproportionately felt by the poorest households. Their access and use of services,...

  6. Chapter 2 A Review of the Evidence
    (pp. 13-32)
    Ursula Giedion and Beatriz Yadira Díaz

    We used a detailed protocol to evaluate the robustness of the available evidence on the impact of health insurance in low- and middle-income countries—on access, use, financial protection, and health status (box 2.1). Of 49 quantitative studies, about half provide reasonably robust evidence. They indicate that health insurance improves access and use, seems to improve financial protection in most cases, but has no conclusive impact on health status. The third result may be related to the difficulties of establishing a causal link between health insurance and currently available information on health status.

    The positive effect of health insurance on...

  7. Chapter 3 Low-Cost Health Insurance Schemes to Protect the Poor in Namibia
    (pp. 33-57)
    Emily Gustafsson-Wright, Wendy Janssens and Jacques van der Gaag

    Investigating alternative mechanisms of health care provision is important for African countries, where the epidemics of HIV/AIDS, tuberculosis, and malaria increase the demands on the health care sector.

    This chapter, using a unique combination of household survey data and a biomedical survey with HIV test data from Greater Windhoek in Namibia, analyzes the extent to which the fairly well developed public health care sector in Namibia offers protection from health shocks to uninsured households. Namibia is in the top tier of African countries in health expenditures. Not only is government health spending high in relative terms at almost 8% of...

  8. Chapter 4 Ghana’s National Health Insurance Scheme
    (pp. 58-88)
    Slavea Chankova, Chris Atim and Laurel Hatt

    In 2003 Ghana introduced a National Health Insurance Scheme (NHIS) that aimed to cover the entire population with affordable access to basic health services within five years. This chapter provides an overview and analysis of the evolution of the NHIS in the first years of its operation, and the results from an impact evaluation on the effect the NHIS has had on use and out-of-pocket expenditures for health care. The evaluation was conducted in two districts in Ghana, using a prepost evaluation design.

    In its first three years of operation, the NHIS caused an increase in the use of curative...

  9. Chapter 5 Impact of Health Insurance on Access, Use, and Health Status in Costa Rica
    (pp. 89-105)
    James Cercone, Etoile Pinder, Jose Pacheco Jimenez and Rodrigo Briceno

    Costa Rica, as a middle-income country that has largely achieved universal health coverage, allows for analysis of the differences in behavior and care for the small share of citizens who remain uninsured. This chapter sheds light on the impact of being covered by insurance in a country where access is guaranteed even if uninsured and on the costs and benefits of covering the last 10%–20% of the population with insurance or other approaches.

    A country of 4.5 million people, Costa Rica has a per capita gross domestic product (GDP) of US$5,600 (US$10,700 in purchasing power parity terms), and in...

  10. Chapter 6 Health Insurance and Access to Health Services, Health Services Use, and Health Status in Peru
    (pp. 106-121)
    Ricardo Bitrán, Rodrigo Muñoz and Lorena Prieto

    This chapter examines how Peru’s eight-year-old Integral Health Insurance (Seguro Integral de Salud, or SIS) has affected access to health services and out-of-pocket spending by its beneficiaries. We use data from the Demographic and Health Survey (DHS), which contains two crosssectional samples, one for 2000 and another for 2004–07, with a sample spread over five years. We also use data from the National Household Survey (ENAHO), a panel collected over 2002–06.

    Classified by the World Bank as a lower middle-income country in 2008, Peru had per capita gross national income of US$7,950 annually in purchasing power parity terms....

  11. Chapter 7 The Impact of Health Insurance on Use, Spending, and Health in Indonesia
    (pp. 122-136)
    Facundo Cuevas and Susan W. Parker

    Classified by the World Bank as a lower middle-income country, Indonesia had per capita gross national income of US$3,600 in purchasing power parity terms in 2008. With about half the population residing in rural areas, life expectancy remains fairly low—at 69 years for men and 73 years for women—and under-five mortality high—at 41 per 1,000 in 2008. Child vaccination remains far from universal: in 2008, 77% of children had received the full course DPT vaccination (three doses) by their 23rd month, a good metric for the performance of immunization programs. Total health spending was about 2.2% of...

  12. Chapter 8 The Impact of a Social Experiment—Rural Mutual Health Care—on Health Care Use, Financial Risk Protection, and Health Status in Rural China
    (pp. 137-154)
    Winnie Yip and William Hsiao

    In 2002 the Chinese government announced a new national policy for rural health care—the New Cooperative Medical Scheme (NCMS). First rolled out in a small number of pilot counties in 2003 and targeted to cover the entire rural population by 2010, the goals are to improve access to health care and reduce inequality and medical impoverishment. The government has allocated new resources to the scheme, targeting the poor western and central regions. The national policy guidelines for the scheme have only two requirements: voluntary enrollment and priority to cover catastrophic health expenditures. Apart from this, local governments are free...

  13. Chapter 9 Colombia’s Big Bang Health Insurance Reform
    (pp. 155-177)
    Ursula Giedion, Carmen Elisa Flórez, Beatriz Yadira Díaz, Eduardo Alfonso, Renata Pardo and Manuela Villar

    Colombia is one of the few developing countries that have introduced government-subsidized universal health insurance by drastically changing social security schemes and breaking the public sector monopoly. The reforms began in 1993, when approximately 28% of the population was covered by insurance through the traditional Latin American approach of a social security system delivering services directly to the covered population. By 2005 health insurance (with choice of provider) reached more than 70% of the total population and close to 60% of the lowest two income quintiles.

    Recent estimates suggest that insurance coverage reached 86% of the population by the end...

  14. Chapter 10 Main Findings, Research Issues, and Policy Implications
    (pp. 178-198)
    Maria-Luisa Escobar, Charles C. Griffin and R. Paul Shaw

    This book contains rich and varied analyses of the impact of health insurance in different socioeconomic and organizational settings. It begins with a comprehensive literature review that distills findings on prior studies that examine causal effects between health insurance and health outcomes. This is followed by seven country case studies, most of which use advanced statistical techniques and new data sources to shed light on how health insurance improves health outputs and outcomes. This chapter summarizes the main findings, the methodological issues that can understate or diminish the estimated impact of health insurance on health, and the country scenarios that...

  15. Editors and Authors
    (pp. 199-204)
  16. Index
    (pp. 205-222)
  17. Back Matter
    (pp. 223-224)