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Impact of national health insurance for the poor and the informal sector in low- and middle-income countries: a systematic review

What do we want to know and why?

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.

The EPPI Centre reference number for this report is 2006.

Acharya A, Vellakkal S, Taylor F, Masset E, Satija A, Burke M and Ebrahim S (2012) Impact of national health insurance for the poor and the informal sector in low- and middle-income countries: a systematic review. London: EPPI Centre, Social Science Research Unit, Institute of Education, University of London.

ISBN: 978-1-907345-34-0

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