The impact of health insurance in Africa and Asia

Health insurance is attracting more and more attention in lowand middle-income countries as a means for improving health care utilization and protecting households against impoverishment from out-of-pocket expenditures.

The health financing mechanism was developed to counteract the detrimental effects of user fees introduced in the 1980s, which now appear to inhibit heath care utilization, particularly for marginalized populations, and to sometimes lead to catastrophic health expenditures.

The World Health Organization (WHO) considers health insurance a promising means for achieving universal health-care coverage. Various types of health insurance are available. National or social health insurance (SHI) is based on individuals’ mandatory enrolment.

Several low- and middle-income countries, including the Philippines, Thailand and Viet Nam, are establishing SHI.

Voluntary insurance mechanisms include private health insurance (PHI), which is implemented on a large scale in countries like Brazil, Chile, Namibia and South Africa, and community-based health insurance (CBHI), now available in countries like the Democratic Republic of the Congo, Ghana, Rwanda and Senegal.

The various types of health insurance have different impacts on the populations they serve. For example, PHI is said to mainly serve the affluent segments of a population, but CBHI is often put forward as a health financing mechanism that can especially benefit the poor.

Countries wishing to introduce health insurance schemes into their health systems should be aware of how their impact varies. The impact of health insurance in low-and-middleincome countries has unfortunately been documented only partially.

Previous reviews have evaluated the performance of CBHI in terms of enrolment, financial management and sustainability.

A recent review provides an overview of the scope and origin of CHI in low- and middle-income countries, with a particular focus on China, Ghana, India, Mali, Rwanda and Senegal, and also assesses CHI’s performance in terms of population coverage, range of services included and reimbursement rate.

The authors concluded that the picture in Africa and Asia is very patchy, with large heterogeneity in institutional designs and organizational models and enormous variation in population coverage, services covered and costs achieved.

No systematic reviews are available on the impact of SHI and PHI, which limits a direct comparison of their options and limitations. Also, health insurance is known to have effects on domains beyond those reported in existing reviews, such as social inclusion.

Furthermore, most reviews available on the rapid development of health insurance in low- and middle-income countries are somewhat outdated. To address the gaps described, this paper provides an up-to-date review of the impact of SHI, PHI and CBHI on a comprehensive set of domains.

Following the conceptual framework by Preker & Carrin, we evaluate whether the different types of health insurance can:

mobilize resources, i.e. generate sufficient and stable resources for adequate functioning of health services;
provide financial protection to clients against catastrophic health expenditures;
improve utilization of health-care services by all socioeconomic groups;
improve health care quality;
improve social inclusion, i.e. the provision of health services in alignment with the needs of various population groups, especially the poor and vulnerable; and
improve community empowerment, i.e. involvement of the community in the organization of health services. Our review covers all low and lower-middle-income countries in Africa and Asia.

1. Methods

We carried out a systematic review of studies on the impact of SHI, PHI and CBHI in Africa and Asia that were published any year up to the end of 2011. Our search strategy is described in Box 1. Studies were included if they:

were randomized controlled trials, cohort, case-control or cross-sectional studies, or qualitative descriptive case studies;
studied the impact of health insurance on resource mobilization, service utilization, quality of care, financial protection, social inclusion or community empowerment;
were carried out in a low- or lower-middleincome country either in 1987 or in 2007, to allow for changes in countries’ income status over time21 (Appendix A, available at: http://www.niche1.nl/ publications); and
were written in English, French, Spanish or Portuguese. Studies were excluded if they:

were policy reviews, opinion pieces, editorials, letters to the editor, commentaries or conference abstracts;
originated from a country on the American continent or
were duplicate references from different databases.

Two pairs of independent reviewers (ES and NT, JM and FM) screened all titles and abstracts of the initially identified studies to determine if they satisfied the inclusion criteria. Any disagreement was resolved through consensus.

Full text articles were retrieved for the selected titles. Reference lists of the retrieved articles, as well as previous review articles, were searched for additional publications (referred to as “snowballing”).

Data extraction

The reviewers used a data collection form to extract the relevant information from the selected studies from Africa (ES and NT) and Asia (JM and FM).

The data collection form included questions on qualitative aspects of the studies (such as date of publication, design, geographical origin and setting), health insurance scheme characteristics (such as type of scheme, starting year and target group), study characteristics (such as study design and period), and information on the reported impact domains, including reported strengths and weaknesses of schemes and main study conclusions.

Reviewers graded the impact according to the following categories: positive effect (A); negative effect (B); no effect (C); inconclusive or not assessed.

Quality evaluation

The pairs of reviewers evaluated the quality of the included studies using a quality-grading protocol adapted from existing protocols known as the HIP study Review Protocol on Health Insurance.

The protocol, which is available from the corresponding author on request, covers 19 indicators to assess rigour, bias, validity and generalizability of the studies, type of study (qualitative; quantitative), whether research question(s), concepts, methods, sampling, and data eliciting are adequately described, and whether the robustness of presented data and results is critically examined.

For each item 0–2 points are given and these are added up to get an overall quality score (ranging from 0 to 38 points). Studies were categorized as low quality (0–14 points), medium quality (15–29) or high quality (≥30).

One in five studies was randomly selected for assessment by a second reviewer. Any disagreements on the quality evaluation between the pairs of reviewers were resolved through consensus.

Impact judgements

We formulated overall judgements on the impact of SHI, PHI and CBHI on the various domains if at least 10 studies of medium or better quality were performed in those domains.

We judged the evidence as strongly positive if A÷(A+B+C) ≥ 60%; weakly positive if A÷(A+B+C)≥ 30% and <60%; strongly negative if B ÷ (A + B + C) ≥ 60%; weakly negative if B÷ (A+B+C) ≥ 30% and < 60%; and inconclusive otherwise. We adhered to PRISMA guidelines for the conduct of systematic reviews.

2. Results

From the initial search for peer-reviewed articles based on title (8689 references), 8459 references were excluded and 230 full text references were retained for further scrutiny.

Detailed inspection of abstracts and texts resulted in 159 Still, other schemes in countries such as Rwanda and Uganda showed weak financial sustainability because of low renewal rates, high claims-to-revenue ratios and high operational costs.

There is no conclusive evidence that SHI or PHI affects, positively or negatively, resource mobilization for health.

There is, however, strong evidence that CBHI and SHI provide financial protection for their members in terms of reducing their out-of-pocket expenditures, and that they improve utilization of inpatient and outpatient services.

Weak evidence suggests that both SHI and CBHI have a positive impact on the quality of care. To illustrate this, CBHI schemes in Kenya, Uganda and the United Republic of Tanzania were found to improve service quality in health facilities, increase essential drug availability and shorten waiting times.

Another study on a CBHI scheme in Burundi reported that health workers discriminated against card holders and provided preferential treatment to patients paying in cash.

There is weak evidence that both SHI and CBHI have a positive impact on social inclusion as indicated by enrolment and utilization patterns among vulnerable groups.

Health insurance schemes undertake various initiatives to reach the vulnerable segments of the populations, such as discount cards, exemption schemes or free enrolment for vulnerable populations.

For example, targeted policies of the National Health Insurance Program in the Philippines and the Thai universal coverage scheme increased the number of insured indigents and poor.

In other countries, social inclusion is not achieved to the same extent, and in Cameroon, Guinea and Senegal, to name a few examples, premiums that the poor cannot afford are reportedly the main reason.

Both SHI and CBHI yield inconclusive findings on community empowerment, primarily because very few studies have been carried out. Findings for PHI are inconclusive on all domains because of insufficient studies.

Location: Indonesia