People with low incomes often have poor access to health services and limited ability to pay for medical care. For such individuals and households, substantial out-of-pocket healthcare expenditure may have catastrophic financial consequences and worsen poverty. Health insurance schemes are intended to reduce the burden of health costs on individuals and households.
For many people in low-income countries, poverty may both reduce access to healthcare and be worsened by large out-of-pocket payments for healthcare. Poor people include individuals working in the formal sector with low salaries and most of those employed in the informal sector.
Health insurance is a method of reducing the difficulties related to paying for healthcare. The intended impacts of health insurance include improvements in healthcare coverage and health status and reductions in out-of-pocket payments for individuals and households.
Social health insurance (SHI) involves compulsory contributions levied largely on the earnings of formal sector workers and the payment of healthcare providers through an independent mechanism (a health care purchaser).
Community-based health insurance (CHI) are not-for-profit schemes based on voluntary enrolment in which a community (which may be geographic, religious, professional or ethnic) is actively engaged in mobilizing, pooling, and allocating resources for healthcare.
|Review objectives: To systematically examine studies that show the impact of nationally or sub-nationally sponsored health insurance schemes on the poor and near poor.|
|Type of||What the review authors searched for||What the review authors found|
|Study designs & interventions||Randomised trials, non-randomised trials, controlled before-after studies, regression studies and qualitative studies that measured the impact of national health insurance.
||24 studies were included: 4 randomised trials, 10 non-randomised trials and 10 observational studies. 16 studies reported on SHI and 3 on CHI. 19 studies strongly met the review inclusion criteria and 5 partially met the inclusion criteria.|
|Participants||People taking up health insurance.
||People who enrolled in social and community health insurance schemes.
|Settings||Low- and middle-income countries
||Burkina Faso, China (6 studies), Colombia (2 studies), Costa Rica, Egypt, Georgia, India (2 studies), Mexico (3 studies), Nicaragua, Philippines, Tanzania and Vietnam (3 studies). One study was done in Senegal, Mali and Ghana.
|Outcomes||Access or utilisation, healthcare expenditure and health status.
||Access or utilisation, healthcare expenditure and health status.
|Date of most recent search: July 2010|
|Limitations: This is a well-conducted systematic review. However, the methods for assessing the risk of bias of the included studies were unclear.|
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. http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=3346
The review included 24 studies, conducted in low- and middle-income countries. The review did not report quantitative data and therefore the results are reported narratively.
Twenty studies reported on this comparison.
Social health insurance comparaded to no insurance
|People: Poor people including those working in the informal sector
Settings: Low- and middle-income countries (Nicaragua, Mexico, Colombia, Georgia, Ghana, China, Vietnam, Egypt, Indonesia)
Intervention: Social health insurance
Comparison: No health insurance
|Outcomes||Impact||Certainty of the evidence
|Utilisation of health services (use of different types of health facilities including public and private; use of specific health services like diabetes care or prenatal care; visits to physicians; outpatient / inpatient services; use of formal / traditional medicine)||14 studies reported this outcome. Eight studies reported higher utilisation of health services and 5 studies found no increased utilisation among the insured.
|Out-of-pocket expenditure on healthcare services
||14 studies reported this outcome. Seven studies found reduced OOP expenditure among insured participants; 6 studies found little or no changes in expenditure; and 1 study found an increase in expenditure.||Very Low
|Health outcomes (e.g. glucose control in diabetic patients, infant mortality and health status of communities)||Five studies reported this outcome. Three studies found little or no improvement in health outcomes for the insured and 2 studies found improvements in health outcomes.||Very low|
|Equity||Some studies assessed impacts on poorer groups and found mixed results for utilisation of services and out-of-pocket expenditure.||Very Low|
|GRADE: GRADE Working Group grades of evidence (see above and last page)|
These were community-based health insurance programmes, some of which were initiated by the government
of the countries.
Community health insurance compared to no insurance
|People: Poor people including those in the informal sector
Settings: Low- and middle- income countries (Burkina Faso, China and India)
Intervention: Community health insurance
Comparison: No health insurance
|Outcomes||Impact||Quality of the evidence
|Utilisation of health services (use of different types of health facilities including public and private; use of specific health services like diabetes care or pre-natal care; visits to physicians; outpatient / inpatient services; use of formal / traditional medicine)
||All three studies that reported this outcome found higher utilisation of health services among those enrolled in community health insurance schemes.
|Out-of-pocket expenditure on health services||Two studies measured this outcome. A decrease in OOP expenditure was reported for one study while the results of the other study were seen as not valid due to a small sample size.||Very Low|
|Health outcomes (e.g., glucose control in diabetic patients, infant mortality and health status of communities)||One study reported improvements in health outcomes.||Very Low|
|GRADE: GRADE Working Group grades of evidence (see above and last page)
|MONITORING & EVALUATION|
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm
Jehu-Appiah C, Aryeetey G, Spaan E, De Hoop T, Agyepong I, Baltussen R (2011) Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling, who is not and why? Social Science & Medicine 72(2), 157-165.
McIntyre D (2012). Health service financing for universal coverage in east and southern Africa. EQUINET Discussion Paper 95. EQUINET: Harare. http://www.equinetafrica.org/sites/default/files/uploads/documents/Diss_paper_95_UHC_Dec2012.pdf
Sinha T, Ranson M, Chatterjee M, Acharya A, Mills A (2006) Barriers faced by the poor in benefiting from community-based insurance services: lessons learnt from SEWA Insurance, Gujarat. Health Policy and Planning 21: 132-142.
Wagstaff A (2009) Social health insurance re-examined. Health Economics 19: 503-517.
WHO (2010) The world health report: health systems financing: the path to universal coverage. http://www.who.int/whr/2010/en/index.html.
Motaze NV, Wiysonge CS, Centre for Evidence-Based Health care, Stellenbosch University, South Africa.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Donela Besada, Simon Lewin, Cristian Herrera Riquelme
and Andy Oxman. We did not receive any comments from the review authors.
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.
Motaze NV, Wiysonge CS. Do social and community-based health insurance schemes have an impact on the poor and the informal sector in low- and middle-income countries? A SUPPORT Summary of a systematic review. April 2017. www.supportsummaries.org
Evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care
Community health insurance, community-based health insurance, social health insurance, health service utilisation, out-of-pocket payment, informal sector