Encouraging Health Insurance for the Informal Sector: A Cluster Randomized Experiment in Vietnam

Selection and behavioral responses of health insurance subsidies in the long run: Evidence from a field experiment in Ghana

We study the effects of a health insurance subsidy in Ghana, where mandates are not enforceable. We randomly provide different levels of subsidy (1/3, 2/3, and full) and evaluate the impact at 7 months and 3 years after the intervention. We find that a one-time subsidy increased insurance enrollment for all groups in both the short and long runs, but health care utilization in the long run increased only for the partial subsidy group. We find supportive evidence that ex-post behavioral responses rather than ex-ante selective enrollment explain the long-run health care utilization results.

Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance

BACKGROUND

Vietnam's primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process.

METHODS

A mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated.

RESULTS

We attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers.

CONCLUSIONS

Significant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases.

Extending universal health coverage to informal workers: A systematic review of health financing schemes in low- and middle-income countries in Southeast Asia

Achieving universal health coverage (UHC) is a priority of most low- and middle-income countries, reflecting governments' commitments to improved population health. However, high levels of informal employment in many countries create challenges to progress toward UHC, with governments struggling to extend access and financial protection to informal workers. One region characterized by a high prevalence of informal employment is Southeast Asia. Focusing on this region, we systematically reviewed and synthesized published evidence of health financing schemes implemented to extend UHC to informal workers. Following PRISMA guidelines, we systematically searched for both peer-reviewed articles and reports in the grey literature. We appraised study quality using the Joanna Briggs Institute checklists for systematic reviews. We synthesized extracted data using thematic analysis based on a common conceptual framework for analyzing health financing schemes, and we categorized the effect of these schemes on progress towards UHC along the dimensions of financial protection, population coverage, and service access. Findings suggest that countries have taken a variety of approaches to extend UHC to informal workers and implemented schemes with different revenue raising, pooling, and purchasing provisions. Population coverage rates differed across health financing schemes; those with explicit political commitments toward UHC that adopted universalist approaches reached the highest coverage of informal workers. Results for financial protection indicators were mixed, though indicated overall downward trends in out-of-pocket expenditures, catastrophic health expenditure, and impoverishment. Publications generally reported increased utilization rates through the introduced health financing schemes. Overall, this review supports the existing evidence base that predominant reliance on general revenues with full subsidies for and mandatory coverage of informal workers are promising directions for reform. Importantly, the paper extends existing research by offering countries committed to progressively realizing UHC around the world a relevant updated resource, mapping evidence-informed approaches toward accelerated progress on the UHC goals.

Addiction to a bad idea, especially in low- and middle-income countries: Contributory health insurance

Despite limited evidence of successful development and implementation of contributory health insurance and low and middle income countries, many countries are in the process implementing such schemes. This commentary summarizes all available evidence on the limitations of contributory health insurance including the lack of good theoretical underpinning and the considerable evidence of inequity and fragmentation created by such schemes. Moreover, the initiation of a contributory health insurance scheme has not been found to increase revenues to the health sector or help health countries achieve universal health coverage. Low and middle income countries can improve equity and efficiency of the health sector by replacing out-of-pocket spending with pre-paid pooling mechanisms, but that is best done through budget transfers and not by contributory insurance that links payment to sub-population entitlements.

The effect of community engagement on healthcare utilization and health insurance enrollment in Ghana: Results from a randomized experiment

Health insurance enrollment in many Sub-Saharan African countries is low, even with highly subsidized premiums and exemptions for vulnerable populations. One possible explanation is low service quality, which results in a low valuation of health insurance. Using a randomized control trial in 64 primary health care facilities in Ghana, this study assesses the impact of a community engagement intervention designed to improve the quality of healthcare and health insurance services on households living nearby the facilities. Although the intervention improved the medical-technical quality of health services, our results show that households' subjective perceptions of the quality of healthcare and insurance services did not increase. Nevertheless, the likelihood of illness and concomitant healthcare utilization reduced, and especially households who were not insured at baseline were more likely to enroll in health insurance. The results show that solely increasing the technical quality of care is not sufficient to increase households' subjective assessments of healthcare quality. Still, improving technical quality can directly contribute to health outcomes and further increase health insurance coverage, especially among the previously uninsured.

Utilization of elderly health promotion services during COVID 19 in Iran: A cross-sectional study

BACKGROUND

The outbreak of COVID-19 pandemic has made it difficult for older adults to utilize ordinary elder services. This cross-sectional study investigated the status of feeling the need, seek, and utilization of health promotion services among older adults in Ardabil, Iran, covered by the country's comprehensive health system during the pandemic.

MATERIALS AND METHODS

This descriptive-analytical and cross-sectional study was conducted on 739 elderly people in Ardabil province. Cluster random sampling method was used for sampling. Data were gathered by referring trained individuals to the place of residence of the selected older adults Questionnaires were consisted of three parts: demographic information, household's economic status, and feeling the need, seek, and utilization from health promotion services. Multivariate logistic regression was used to separately model the need, seeking for, and utilization of health promotion services in STATA ver. 14.

RESULTS

The mean age of the older adults in this study was 68.88 ± 4.72 years. The results indicate that men showed significantly greater need, seek for, and utilization of health promotion services during COVID- 19 than women. According to the results, people over the age of 80 had 4.08 times (95% confidence interval [CI]: 1.99-12.60) more need and utilization of health services than the older adults under 65 years. The results also indicate that use of health promotion services was significantly associated with being married (3.74, 95% CI: 1.22-2.62), having primary insurance and supplementary insurance (1.92, 95% CI: 1.21-3.12), and obesity (2.05, 95% CI: 1.13-3.76) in P < 0.05 level. Based on the results, people with chronic disease and obesity were more likely to utilize health promotion services.

CONCLUSION

Findings suggest that the access and utilization of inpatient and outpatient health services by the elderly in the COVID-19 pandemic has somewhat decreased, which could be due to the fear of the disease being referred to health centers by the elderly. Hence, enabling conditions such as parental health care were major factors affecting health-seeking habits among the Iranian elder population.

How does informal employment affect health and health equity? Emerging gaps in research from a scoping review and modified e-Delphi survey

Introduction

This article reports on the results from a scoping review and a modified e-Delphi survey with experts which aimed to synthesize existing knowledge and identify research gaps on the health and health equity implications of informal employment in both low- and middle-income countries (LMICs) and high-income countries (HICs).

Methods

The scoping review included peer-reviewed articles published online between January 2015 and December 2019 in English. Additionally, a modified e-Delphi survey with experts was conducted to validate our findings from the scoping review and receive feedback on additional research and policy gaps. We drew on micro- and macro-level frameworks on employment relations and health inequities developed by the Employment Conditions Knowledge Network to synthesize and analyze existing literature.

Results

A total of 540 articles were screened, and 57 met the eligibility criteria for this scoping review study, including 36 on micro-level research, 19 on macro-level research, and 13 on policy intervention research. Most of the included studies were conducted in LMICs while the research interest in informal work and health has increased globally. Findings from existing literature on the health and health equity implications of informal employment are mixed: informal employment does not necessarily lead to poorer health outcomes than formal employment. Although all informal workers share some fundamental vulnerabilities, including harmful working conditions and limited access to health and social protections, the related health implications vary according to the sub-groups of workers (e.g., gender) and the country context (e.g., types of welfare state or labour market). In the modified e-Delphi survey, participants showed a high level of agreement on a lack of consensus on the definition of informal employment, the usefulness of the concept of informal employment, the need for more comparative policy research, qualitative health research, and research on the intersection between gender and informal employment.

Conclusions

Our results clearly identify the need for more research to further understand the various mechanisms through which informal employment affects health in different countries and for different groups of informal workers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01684-7.

Increasing Health Insurance Enrollment in Low- and Middle-Income Countries: What Works, What Does Not, and Research Gaps: A Scoping Review

Health insurance programs have the potential to shield individuals in low- and middle-income countries from catastrophic health expenses and reduce their vulnerability to poverty. However, the uptake of insurance programs remains low in these countries. We reviewed existing evidence from experimental studies on approaches that researchers have tested in order to raise the uptake. In the 12 studies we synthesized, educational programs and subsidies were the dominant interventions. Consistent with findings from previous studies on other health products, subsidies were effective in raising the uptake of insurance programs in many contexts. Conversely, education interventions—in their current forms—were largely ineffective, although they bolstered the effect of subsidies. Other strategies, such as the use of microfinance institutions and social networks for outreach and enrollment, showed mixed results. Additional research is needed on effective approaches to raise the uptake of insurance programs, including tools from behavioral economics that have shown promise in other areas of health behavior.

Persistent effects of temporary incentives: Evidence from a nationwide health insurance experiment

Temporary incentives are offered in anticipation of persistent effects that are seldom estimated. We use a nationwide randomized experiment in the Philippines to estimate effects of two incentives for health insurance three years after their withdrawal. We find that both temporary incentives had persistent effects on enrollment. A premium subsidy had a small but highly persistent effect. Application assistance offered to those initially unresponsive to the subsidy had a much larger but less persistent effect. The subsidy persuaded those with higher initial stated willingness to pay to enroll and keep enrolling. The offer of application assistance to initial non-compliers with the subsidy achieved a larger immediate effect by drawing in those who stated they valued insurance less and were less likely to re-enroll when the incentives were withdrawn.

In Appreciation of Adam: Reflections from Friends and Colleagues

Some of Adam Wagstsaff's colleagues and research collaborators submitted short reflections about the different ways Adam made a difference through his amazing research output to health equity and health systems as well as a leader and mentor. The Guest Editors of this Special Issue selected a set of six essays related to dimensions of Adam's contributions.The first contribution highlights his role early on in his career, prior to joining the World Bank, in defining and expanding an important field of research on equity in health ("Adam and Equity," by Eddy van Doorslaer and Owen O'Donnell). The second contribution focuses on Adam's early work on equity and health within the World Bank and his leadership on important initiatives that have had impact far beyond the World Bank ("Adam and Health Equity at the World Bank," by Davidson Gwatkin and Abdo Yazbeck). The next contribution focuses on Adam's deep dive into providing support, through research, for country-specific programs and reforms, with a special focus on some countries in East Asia ("Adam and Country Health System Research," by Magnus Lindelow, Caryn Bredenkamp, Winnie Yip, and Sarah Bales). The next contribution highlights Adam's many ways of contributing to the International Health Economics Association, from the impressive technical contributions to leadership and organizational reform ("Adam and iHEA," by Diane McIntyre). The next to last contribution focuses on Adam's long-term leadership in the research group at the World Bank and the long-lasting influence on integrating the research produced into World Bank operations and creating an environment that rewarded producing evidence for action ("Adam the Research Manager," by Deon Filmer and Damien de Walque). The last contribution pulls on the thread found in many of the earlier ones, mentorship with honesty, directness, caring, commitment, and equity ("Adam the Mentor," by Agnes Couffinhal, Caryn Bredenkamp, and Reem Hafez).

Reforms for financial protection schemes towards universal health coverage, Senegal

Advancing the public health insurance system is one of the key strategies of the Senegalese government for achieving universal health coverage. In 2013, the government launched a universal health financial protection programme, la Couverture Maladie Universelle. One of the programme's aims was to establish a community-based health insurance scheme for the people in the informal sector, who were largely uninsured before 2013. The scheme provides coverage through non-profit community-based organizations and by the end of 2016, 676 organizations had been established across the country. However, the organizations are facing challenges, such as low enrolment rates and low portability of the benefit package. To address the challenges and to improve the governance and operations of the community-based health insurance scheme, the government has since 2018 planned and partly implemented two major reforms. The first reform involves a series of institutional reorganizations to raise the risk pool. These reorganizations consist of transferring the risk pooling and part of the insurance management from the individual organizations to the departmental unions, and transferring the operation and financial responsibility of the free health-care initiatives for vulnerable population to the community-based scheme. The second reform is the introduction of an integrated management information system for efficient and effective data management and operations of the scheme. Here we discuss the current progress and plans for future development of the community-based health insurance scheme, as well as discussing the challenges the government should address in striving towards universal health coverage in the country.

Healthcare Financing in Rural Cameroon

In the global South, low-income populations are faced with frequent health shocks. Formal mechanisms to protect them against these shocks are absent or limited. Thus, what are the mechanisms used by low-income rural populations to finance healthcare? This paper draws on a qualitative study to examine the healthcare financing mechanisms of low-income rural populations in Cameroon. The findings suggest that low-income populations use 13 mechanisms to finance healthcare. Depending on several factors, people may use more than one of these mechanisms. In addition, social factors shape people’s patterns of usage of these mechanisms. Patterns of usage of these mechanisms are embedded in the principle of reciprocity. The notion of reciprocity does seem to discourage people from enrolling in the limited voluntary health insurance programmes which exist in various communities. Newly insured people were more likely to drop out if they did not receive a payout.

Can information increase the understanding and uptake of insurance? Lessons from a randomized experiment in rural Burkina Faso

Community Based Health Insurance Schemes are often confronted to very low uptake. We analyze the impact of a randomized information package on the understanding and adoption of Community Based Health Insurance in Burkina Faso. The sample consists of about 2000 households in the rural community of Ziniaré which we interviewed several times between 2013 and 2016. In contrast to previous studies in the literature, we assess the effects of an intensive information intervention combining tools and repeated interaction instead of only a single event of information provisioning. The information package combines three tools to present different types of information - a brochure presenting factual information, a video presenting a hypothetical health episode and a personalized phone call reminder. The brochure and video are delivered through home visits by specially trained agents. Despite the repeated interaction and the comprehensiveness of the information package, we find only modest improvements in the understanding of insurance principles following our intervention. Investigating treatment heterogeneity, we observe an increase in understanding in poorer households and in households with literate heads. Given the small improvements in insurance knowledge we do not see a significant effect on insurance uptake either. We conclude that information is not enough to increase insurance uptake and discuss the role of other factors that might matter including the political context in which our experiment was implemented.

Extending health insurance coverage to the informal sector: Lessons from a private micro health insurance scheme in Lagos, Nigeria

BACKGROUND

As a growing number of low- and middle-income countries commit to achieving universal health coverage, one key challenge is how to extend coverage to informal sector workers. Micro health insurance (MHI) provides a potential model to finance health services for this population. This study presents lessons from a pilot study of a mandatory MHI plan offered by a private insurance company and distributed through a microfinance bank to urban, informal sector workers in Lagos, Nigeria.

METHODS

Study methods included a survey of microfinance clients, key informant interviews, and a review of administrative records.

RESULTS

Demographic, health care seeking, and willingness-to-pay data suggested that microfinance clients, particularly women, could benefit from a comprehensive MHI plan that improved access to health care and reduced out-of-pocket spending on health services. However, administrative data revealed declining enrollment, and key informant interviews further suggested low use of the health insurance plan. Key implementation challenges, including changes to mandatory enrollment requirements, insufficient client education and marketing, misaligned incentives, and weak back-office systems, undermined enrollment and use of the plan.

CONCLUSIONS

Mandatory MHI plans, intended to mitigate adverse selection and facilitate private insurers' entry into new markets, present challenges for covering informal sector workers, including when distributed through agents such as a microfinance bank. Properly aligning the incentives of the insurer and the agent are critical to effectively distribute and service insurance. Further, an urban environment presents unique challenges for distributing MHI, addressing client perceptions of health insurance, and meeting their health care needs.

Subsidized health insurance coverage of people in the informal sector and vulnerable population groups: trends in institutional design in Asia

BACKGROUND

Many low- and middle-income countries with a social health insurance system face challenges on their road towards universal health coverage (UHC), especially for people in the informal sector and vulnerable population groups or the informally employed. One way to address this is to subsidize their contributions through general government revenue transfers to the health insurance fund. This paper provides an overview of such health financing arrangements in Asian low- and middle-income countries. The purpose is to assess the institutional design features of government subsidized health insurance type arrangements for vulnerable and informally employed population groups and to explore how these features contribute to UHC progress.

METHODS

This regional study is based on a literature search to collect country information on the specific institutional design features of such subsidization arrangements and data related to UHC progress indicators, i.e. population coverage, financial protection and access to care. The institutional design analysis focuses on eligibility rules, targeting and enrolment procedures; financing arrangements; the pooling architecture; and benefit entitlements.

RESULTS

Such financing arrangements currently exist in 8 countries with a total of 14 subsidization schemes. The most frequent groups covered are the poor, older persons and children. Membership in these arrangements is mostly mandatory as is full subsidization. An integrated pool for both the subsidized and the contributors exists in half of the countries, which is one of the most decisive features for equitable access and financial protection. Nonetheless, in most schemes, utilization rates of the subsidized are higher compared to the uninsured, but still lower compared to insured formal sector employees. Total population coverage rates, as well as a higher share of the subsidized in the total insured population are related with broader eligibility criteria.

CONCLUSIONS

Overall, government subsidized health insurance type arrangements can be effective mechanism to help countries progress towards UHC, yet there is potential to improve on institutional design features as well as implementation.

Effects of Price, Information, and Transactions Cost Interventions to Raise Voluntary Enrollment in a Social Health Insurance Scheme: A Randomized Experiment in the Philippines

A cluster randomized experiment was undertaken testing two sets of interventions encouraging enrollment in the Individually Paying Program (IPP), the voluntary component of the Philippines' social health insurance program. In early 2011, 1037 unenrolled IPP-eligible families in 179 randomly selected intervention municipalities were given an information kit and offered a 50% premium subsidy valid until the end of 2011; 383 IPP-eligible families in 64 control municipalities were not. In February 2012, the 787 families in the intervention sites who were still IPP-eligible but had not enrolled had their vouchers extended, were resent the enrollment kits and received SMS reminders. Half the group also received a 'handholding' intervention: in the endline interview, the enumerator offered to help complete the enrollment form, deliver it to the insurer's office in the provincial capital, and mail the membership cards. The main intervention raised the enrollment rate by 3 percentage points (ppts) (p = 0.11), with an 8 ppt larger effect (p < 0.01) among city-dwellers, consistent with travel time to the insurance office affecting enrollment. The handholding intervention raised enrollment by 29 ppts (p < 0.01), with a smaller effect (p < 0.01) among city-dwellers, likely because of shorter travel times, and higher education levels facilitating unaided completion of the enrollment form. Copyright © The World Bank Health Economics © 2015 John Wiley & Sons, Ltd.