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Do social and community-based health insurance schemes have an impact on the poor and the informal sector in low- and middle-income countries?

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.

 

Key messages

 

  • Community health insurance may increase utilisation of health services but it is uncertain if it improves health outcomes or changes out-of-pocket expenditure among those insured in low-income countries
  • It is uncertain if social health insurance improves utilisation of health services and health outcomes, leads to changes in out-of-pocket expenditure or improves equity among those insured in low-income countries
  • Most of the included studies were conducted in low- and middle-income countries in Latin America, Asia and Africa

 

 

 


Who is this summary for?

People making decisions about implementation of social and community health insurance schemes in low- and middle-income countries.

This summary includes:

  • Key findings from research based on a systematic review
  • Considerations about the relevance of this research for low income countries

Not included:

  • Recommendations
  • Additional evidence not included in the systematic review
  • Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

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

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

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.

 

 

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.



About the systematic review underlying this summary

About the systematic review underlying this summary

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

About the certainty of the 
evidence (GRADE)


High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.


Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.


Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.


Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

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.

 

1) Social health insurance compared to no insurance

Twenty studies reported on this comparison.

 

  • It is uncertain if social health insurance improves utilisation of health services and health outcomes, or leads to changes in out-of-pocket expenditure among those insured in low- and middle-income countries because the certainty of this evidence is very low.
  • It is uncertain if social health insurance improves equity because the certainty of this evidence is very low.

 

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
(GRADE)
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.
 Very Low
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)

2) Community-based health insurance compared to no insurance

These were community-based health insurance programmes, some of which were initiated by the government

of the countries.

 

  • Community health insurance may increase utilisation of health services. The certainty of this evidence is low.
  • It is uncertain if community health insurance improves health outcomes or decreases out-of-pocket expenditure because the certainty of this evidence is very low.

 

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
(GRADE)
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. 
 Low
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) 

 



 

 

 

 

 

 

Relevance of the review for low-income countries

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
  • The studies were all carried out in low- and middle-income countries.

 

  • The effects of social and community-based health insurance schemes are largely uncertain as the certainty of the evidence is very low.
  • Health financing arrangements differ from one country to another and this should be taken into consideration when planning whether and how to implement health insurance schemes. The ease with which different insurance schemes can be implemented, and their impacts, will depend on a range of factors including the nature of the economy (whether most people are employed by the public or private sectors), the size of the formal work-force, collection mechanisms, risk pooling, and co-payments that might be incurred.
  • The acceptability to stakeholders (healthcare users, healthcare providers, professional organisations, policy makers, health delivery organisations) of different insurance schemes needs to be considered in each setting.
EQUITY
  • The studies examined the effects of insurance schemes among largely poorer people and those in the informal sector
  • It is uncertain if social health insurance improves equity because the certainty of evidence is very low
  • Disadvantaged groups who have limited financial resources and often greater healthcare needs could benefit from social and community health insurance that reduces out-of-pocket payments for healthcare. However, most of the included studies were not designed to address this question and did not report outcomes among poorer groups separately from the rest of the study population.
  • A number of groups may be disadvantaged in terms of access to healthcare, including poorer people as well as people living with physical and mental impairments. The needs of all these groups should be considered when planning insurance schemes - ideally insurance mechanisms should aim to be progressive and ensure cross-subsidization from richer to poorer groups.
ECONOMIC CONSIDERATIONS
  • Out-of-pocket spending was addressed by some studies but no long-term economic data were identified
  • There are important economic consequences of rolling out insurance schemes that cover a large proportion of the population. Spreading the burden of health costs across the population will entail payment from those who are able to afford these, with smaller or no payments from individuals with little or no earnings. Payments for the latter group may need to be subsidized by the government.
  • Making health insurance more widely available may increase utilisation of health services by those who are insured. How to assess and manage this, including ensuring that service use is appropriate, needs to be considered by those developing and implementing these schemes.
MONITORING & EVALUATION
  • The studies included in this review did not address all of the key outcomes relevant to understanding the effects of social and community-based health insurance schemes implemented in low-income countries

 

  • Outcomes such as healthcare expenditure, equity, access to care, quality of care and health outcomes (like disease morbidity and mortality) need to be monitored in order to evaluate the effectiveness of insurance schemes. This monitoring should be continuous and should be of sufficiently robust to enable informed decisions and adjustments to be carried out.
*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

 


 

 

Additional information

Related literature

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.

 

This summary was prepared by

Motaze NV, Wiysonge CS, Centre for Evidence-Based Health care, Stellenbosch University, South Africa.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

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.

 

This review should be cited as

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 summary should be cited as

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

 

Keywords

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

 

 

 

 



About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

To receive e-mail notices of new SUPPORT summaries or provide feedback on this summary, go to: www.supportsummaries.org/contact

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