Reviewing the impact of health insurance

Health insurance schemes, whether private, community-based or national/social schemes, are widespread across low- and middle-income countries. But what evidence do we have that they are effective in these countries? Beyond financial risk protection, and providing adequate service coverage, what other ways might we assess the impact of prepayment schemes on individuals and the health system?

The authors of the study below (refer to the ‘see also’ section at the end of this step) conducted a systematic review on the impact of health insurance on:

1. Resource mobilisation
2. Financial protection
3. Service utilisation
4. Quality of care
5. Social inclusion
6. Community empowerment

in low- and middle-income countries in Asia and Africa.

The impact of different types of health insurance schemes can vary and therefore all three types of pre-payment schemes were included in the review:

• National or Social health insurance (SHI) – mostly Asia (Thailand, Philippines, Vietnam) – 86 of 159 studies
• Community-based health insurance (CBHI) – mostly Africa (Ghana, Rwanda, Senegal, Democratic Republic of Congo) – 80 of 159 studies
• Voluntary private health insurance (PHI) – large scale coverage in Brazil, Chile, Namibia, South Africa – 10 of 159 studies.

Summary of results

In Africa, most studies were from seven countries (DRC, Senegal, Uganda, Rwanda, Tanzania, Ghana and Kenya) and reported primarily on CBHI. In Asia, most studies were from India, China, Thailand, Philippines and Vietnam and reported primarily on SHI.

Out of the six criteria established to assess insurance schemes, most studies reported on the impact of health insurance on financial protection (90 of 159), utilisation (91 of 159) and social inclusion (65 of 159). Fewer studies reported on the impact on resource mobilisation (28 of 159), quality of care (21 of 159) and community empowerment (6 of 159).

Findings on impact were:

• Resource mobilisation: strong evidence on the impact of CBHI on resource mobilisation generally positive, but impact of SHI and PHI inconclusive
• Financial protection: strong evidence that CBHI and SHI provide financial protection by reducing out-of-pocket payments
• Service utilisation: strong evidence that CBHI and SHI increase service utilisation of both inpatient and outpatient care
• Quality of care: weak evidence. CBHI schemes in Kenya, Uganda and Tanzania found increased essential drug availability and shorter waiting times, whereas a study of CBHI in Burundi found preferential treatment for cash paying clients
• Social inclusion: weak evidence that both SHI and CBHI have a positive impact on social inclusion. Thailand and the Philippines have achieved this more successfully by subsidising the poor for enrolment, whereas Cameroon, Guinea and Senegal are countries where this has not been achieved because of the poor’s inability to pay premiums
• Community empowerment: inconclusive evidence because of the lack of studies.

The authors conclude that the evidence clearly shows health insurance is an alternative to user fees as a health financing mechanism and is capable of mitigating the negative effects of user fees on financial protection and utilisation.

It is important to note that only a small proportion of health insurance schemes across Asia and Africa have actually been evaluated for impact and therefore not represented in this review. The impact of health insurance schemes is highly dependent on context and this study does not compare health insurance schemes to tax-based systems or make any conclusions on the optimum type of health financing mechanism.

This review finds that although health insurance schemes (CBHI and SHI) have a positive impact on financial protection and service utilisation, the evidence for a positive impact on improving quality of care or social inclusion is weak.

Why do you think this is the case? Do you think health insurance is a better alternative than progressive taxation (and why do you say so)?

Please comment below.

References

Spaan, E, Mathijssen, J, Tromp, N, McBain, F, Have, AT & Baltussen, R, 2012, ‘The impact of health insurance in Africa and Asia: a systematic review’, Bulletin of the World Health Organization, vol. 90, pp. 685-692.