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

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1 The Impact of Health Insurance in Low- and Middle-Income Countries Maria-Luisa Escobar Charles C. Griffin R. Paul Shaw EDITORS BROOKINGS INSTITUTION PRESS WASHINGTON, DC

2 Contents Preface xi Acknowledgments xiii Chapter 1 Why and How Are We Studying Health Insurance in the Developing World? Objectives of this study and how it was conducted 4 Country case selection 6... and to the book 11 References 12 Chapter 2 A Review of the Evidence 13 Impact of health insurance on access and use 17 Impact of health insurance on financial protection 19 Impact of health insurance on health status 22 Heterogeneity of health insurance, schemes 25 Moving forward 25 Notes 28 References 29 Studies reviewed but not cited. 31 Chapter 3 Low-Cost Health Insurance Schemes to Protect the Poor in Namibia 33 Health and the health care sector in Namibia 34 Coping with health shocks when uninsured 39 Analysis 41 Scope for targeting 48

.. and to the book 11 References 12 Chapter 2 A Review of the Evidence 13 Impact of health insurance on access and use 17 Impact of health insurance on financial protection 19 Impact of

3 vi Contents Conclusions 51 Notes 56 References 56 Chapter 4 Ghana's National Health Insurance Scheme 58 Ghana's health system 59 Health care financing 59 Early successes and challenges 62 Evaluation of the National Health Insurance Scheme 64 Determinants of enrollment in the National Health Insurance Scheme 65 Effects of National Health Insurance Scheme implementation on health care use and spending 69 Differences in health care use and payment comparing National Health Insurance Scheme-insured and uninsured in Policy implications 78 Challenges for the future 79 Appendix: Details and methods of the evaluation 81 Notes 86 References 87 Chapter 5 Impact of Health Insurance on Access, Use, and Health Status in Costa Rica 89 Main characteristics of the Costa Rican health system 90 Who are the uninsured? 93 What are the determinants of insurance status? 99 Impacts of health insurance 99 Conclusions 102 Appendix: Details of the Estimations 103 Notes 105 Chapter 6 Health Insurance and Access to Health Services, Health Services Use, and Health Status in Peru 106 The Peruvian health sector 106 Health insurance population coverage in the household surveys 109 Descriptive information 109 The effects of Seguro Escolar Gratuito/Seguro Materno Infantil and Seguro Integral de Salud health insurance coverage on health care results using Demographic and Health Survey data 112

spending 69 Differences in health care use and payment comparing National Health Insurance Scheme-insured and uninsured in 2007 76 Policy implications 78 Challenges for the future 79 Appendix:

4 Contents vii Impact of Seguro Integral de Salud health insurance coverage on health care results using ENAHO data 115 Summary and conclusions 117 Appendix: Model Specifications 119 Notes 121 References 121 Chapter 7 The Impact of Health Insurance on Use, Spending, and Health in Indonesia 122 The Indonesian health system 123 Descriptive statistics: the insured and the uninsured 124 Impacts of insurance on adults 125 Impacts of insurance on children 130 Conclusion 134 Notes 136 References 136 Chapter 8 The Impact of Rural Mutual Health Care on Health Care Use, Financial Risk Protection, and Health Status in Rural China 137 Rural health care in China 138 Rural mutual health care 139 Study design and data 143 The enrolled and the nonenrolled 144 Impacts of the Rural Mutual Health Care Scheme 148 Conclusions 150 References 153 Chapter 9 Colombia's Big Bang Health Insurance Reform 155 Main features of the Colombian health sector reform 157 Conceptual framework 159 Health insurance coverage 161 Access and use of services 162 Financial protection 167 Health status 171 Conclusion 173 Notes 175 References 176

Impacts of insurance on adults 125 Impacts of insurance on children 130 Conclusion 134 Notes 136 References 136 Chapter 8 The Impact of Rural Mutual Health Care on Health Care Use, Financial Risk

5 vlii Contents Chapter 10 Main Findings, Research Issues, and, Policy Implications 178 Six general findings 180 Research issues 185 Policy implications 189 Conclusion 197 References 198 ' Editors and Authors 199 Index 205 Boxes 1.1 Impact of health insurance on health-related outcomes in rich countries The key analytical question Robustness of the evidence base Data collection Data and methodology Methodology Data and methodology 154 Figures 5.1 Age structure of the insured and uninsured, Health insurance in Colombia, premiums and benefits plans, Colombia's health system, financial flows, and affiliation The distribution of out-of-pocket spending by households using health services, thousand pesos, Factors diminishing the measured impact of health insurance 186 Tables 1.1 Income and health finance indicators for select country groupings, Indicators for the country cases, Individuals enrolled in a medical aid fund Reported prevalence of chronic disease, acute illness, or injury and incidence of hospitalization among the insured and uninsured (%) Use of health services for acute illness or injury and hospitalization Average per capita annual out-of-pocket health expenditures Average per capita annual out-of-pocket health expenditures for the uninsured, by quintile 40

1 Data collection 35 5.1 Data and methodology 95 7.1 Methodology 124 9.1 Data and methodology 154 Figures 5.1 Age structure of the insured and uninsured, 2006 95 9.

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 EDITORS EDITORS BROOKINGS INSTITUTION PRESS WASHINGTON, DC Copyright 2010 The Brookings