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Table 5 Methodological details and key findings of the included studies

From: The role of micro health insurance in providing financial risk protection in developing countries- a systematic review

S. No.

Citation

WHO region

Objective of the study

Country/Target population

Name of MHI Scheme

Study design, sampling technique, evaluation design

Measure of financial protection

Key findings/Outcomes

1

Hamid SA, Roberts J, Mosley P. Can micro health insurance reduce poverty? Evidence from Bangladesh. Journal of Risk and Insurance. 2011 Mar 1;78(1):57–82.

Asia

To assess whether the addition of MHI to the microcredit programs of GB has an effect on poverty

Bangladesh/Poor households

Grameen Bank MHI

Cross sectional,

Multistage sampling,

Comparison between program and control areas

Poverty

1. Household income,

2. Household non income assets,

3. Food sufficiency

4. Probability of being above or below the poverty line

Positive association found between MHI and household income, ownership of assets, food sufficiency and poverty reduction. Result was statistically significant for food sufficiency only

2

Yip W, Hsiao WC. Non-evidence-based policy: how effective is China's new cooperative medical scheme in reducing medical impoverishment? Social science & medicine. 2009 Jan 31;68(2):201–9.

To assess the effectiveness of the NCMS model in reducing medical impoverishment

China/Rural population

New Cooperative Medical Scheme (NCMS)

Comparison study,

Convenience sampling,

Comparison between two study (insurance) groups

Poverty

NCMS reduced poverty headcount by 3.5-3.9 %

The RMHC would reduce poverty by 8.3-13.1 %

3

Hou Z, Van de Poel E, Van Doorslaer E, Yu B, Meng Q. Effects of NCMS on access to care and financial protection in China. Health economics. 2014 Aug 1;23(8):917-34

To identify the impact of NCMS on access to care and financial protection by exploiting the variation in NCMS design across counties.

Cross sectional,

Simple random sampling,

Calculation of scheme generosity based on (i) the copayment; (ii) the reimbursement rate; and (iii) the ceiling.

OOP expenditure

No effects found on spending in the full sample, but conditional upon use,

NCMS reduces the share of OOP spending for an outpatient visit and increases OOP spending per inpatient stay (among users)

Total spending per hospitalization had increased (among users)

4

Cheung D, Padieu Y. Heterogeneity of the effects of health insurance on household savings: Evidence from rural China. World Development. 2015 Feb 28;66:84–103.

To explore the heterogeneity of the impact of NCMS on household savings across income groups in rural China.

Cross sectional

Purposive sampling,

Comparison between income quartiles, Propensity Score Matching

Household savings

Higher middle-income participants deplete their savings significantly compared to non-participant households.

This difference suggests a decrease in savings secondary to reduction of household patrimony.

Higher middle-income participants save less than non-participants.

There was no impact of the health care scheme on the poorest and richest households.

5

Sun Q, Liu X, Meng Q, Tang S, Yu B, Tolhurst R. Evaluating the financial protection of patients with chronic disease by health insurance in rural China. International Journal for Equity in Health. 2009;8:42. doi:10.1186/1475-9276-8-42.

To investigate the extent to which patients suffering from chronic disease in rural China face catastrophic expenditure on healthcare, and how far the New Co-operative Medical Insurance Scheme (NCMS) offers them financial protection against this.

China/Rural households with chronic illness patients

Cross Sectional,

Multistage sampling: County: Township: Village: Household,

Comparison between insured and non insured

CHE

Between 8 and 11 % of non-NCMS members and 13 % of NCMS members did not seek any medical care for chronic illness.

A greater proportion of NCMS members in the poorest quintile faced CHE as compared to those in the richest quintile

Overall a slightly higher proportion of non-NCMS members than NCMS member households faced CHE but the difference was not statistically significant.

6

Wagstaff A, Lindelow M, Jun G, Ling X, Juncheng Q. Extending health insurance to the rural population: An impact evaluation of China's new cooperative medical scheme. Journal of health economics. 2009 Jan 31;28(1):1–9.

To assess the impacts on township health centers and county hospitals in all 189 counties. To investigate the issue of how the characteristics of different NCMS schemes—their generosity and which services are reimbursable—affect their impact.

China/Rural households

Cross Sectional,

Multi-stage stratified random sampling,

Comparison between insured and non insured,

Propensity score matching

OOP

CHE

The overall household OOP spending on health care does not appear to have been reduced by NCMS.

Cost of delivery was reduced by NCMS. Cost of OPD was not reduced. NCMS appears to have resulted in people receiving more expensive health care per visit.

7

Aggarwal A. Impact evaluation of India's ‘Yeshasvini’community-based health insurance programme. Health Economics. 2010 Sep 1;19(S1):5–35./

To evaluate the impact of India’s Yeshasvini community-based health insurance programme on health-care utilization, financial protection, treatment outcomes and economic well-being.

India/Cooperative rural farmers and informal sector workers

Yeshasvini

Cross sectional,

Multi stage random sampling, Comparison between intervention and control groups,

Propensity score matching

Borrowing

Sale of assets

Household Savings

Overall health expenditures

Total borrowings are 36 % and 30 % less for enrollees.

The payments made out of savings, incomes, and other sources, on the other hand, are up to 74 % less for enrollees.

Borrowings and/or asset sales associated with primary health-care use are 61 % lower for the relatively worse-off group among the insured.

Overall health expenditures are 19–20 %

higher for YH enrollees compared with uninsured cooperatives

8

Savitha B, KB K. Microhealth insurance and the risk coping strategies for the management of illness in Karnataka: a case study. The International journal of health planning and management. 2013 Aug 1./

To evaluate the impact of SampoornaSuraksha Program, on risk coping strategies of households faced with medical illness in Karnataka state, India

India/Rural population

Sampoorna Suraksha

Cross sectional descriptive,

Multistage cluster sampling

Borrowing

Household savings

Sale of assets;

A lower percentage of insured individuals (57.2 %) relied on borrowing compared with newly insured (79.5 %) or uninsured individuals (75.2 %) (p < 0.05).

Insured individuals used more savings (32.7 %) than newly insured (24.7 %) (p > 0.05).

Sale of assets was found to be high in insured group than in newly insured but lower than that in uninsured groups (p > 0.05).

The odds of the incidence of borrowing increased by a factor of 4.636 in newly insured and by a factor of 6.407 in uninsured compared with the insured individual

9

Devadasan N, Criel B, Van Damme W, Ranson K, Van der Stuyft P. Indian community health insurance schemes provide partial protection against catastrophic health expenditure. BMC Health Services Research. 2007 Mar 15;7(1):43

To determine whether insured households are protected from catastrophic health expenditure (CHE)

India/ACCORD_ rural population

SEWA- women informal workers

ACCORD & SEWA

Cross sectional,

Desk review of claims register,

Comparison between two health insurance schemes

OOP expenditure

CHE

67 % of ACCORD and 34 % of SEWA members protected from OOP payments

8 % (currently at 3.5 %) at ACCORD and 49 % at SEWA (currently 23 %) would have experienced CHE in the absence of an insurance scheme.

10

Wagstaff A. Health insurance for the poor: initial impacts of Vietnam's health care fund for the poor. World Bank Policy Research Working Paper. 2007 Feb 1(4134).

To estimate the impact of HCFP by comparing out-of-pocket payments and utilization between those covered by HCFP and comparable individuals not covered.

Vietnam/Poor households, households in poor localities, minorities

Health Care Fund for the Poor (HCFP)

Cross Sectional,

Comparison between of insured and uninsured,

Propensity Score Matching

OOP expenditure

HCFP reduces the risk of catastrophic OOP spending.

There was no perceptible impact on (average) OOP spending,

11

Wagstaff A. Estimating health insurance impacts under unobserved heterogeneity: the case of Vietnam's health care fund for the poor. Health economics. 2010 Feb 1;19(2):189–208.

To estimate the impact of Vietnam’s health insurance program for poor households (health care fund for the poor, or HCFP) in a way that is robust to the biases introduced by unobserved heterogeneity.

Cross Sectional,

Comparison between insured and uninsured,

Triple differencing with matching

OOP expenditure

HCFP appears to have reduced OOP spending on health care considerably,

A significant impact on OOP spending is not evident in a single difference, i.e. comparing spending in 2006 across the treated and control groups. It is evident in a double difference – i.e. comparing the 2004–2006 change across the two groups

12

Pham T, Pham TL. Does microinsurance help the poor? Evidence from the targeted health microinsurance program in Vietnam 2004–2008. International Labor Organization. 2012 Feb. Research paper No. 11

To assess whether HCFP program improves health care seeking behavior of the poor with respect to access to health care, OOP spending, and preventive care behavior;

Cross sectional,

Stratified random cluster sampling,

Impact Evaluation: using impact measures of Intention to treat effect, and treatment effect of the treated

OOP expenditure

CHE

MHI reduced the OOP health care expenditure of poor participants, through a price reduction effect.

propensity of having a CHE is lowered by 19 % among insured

13

Alkenbrack S, Lindelow M. The Impact of Community‐Based Health Insurance on Utilization and Out‐of‐Pocket Expenditures in Lao People's Democratic Republic. Health economics. 2013 Dec 1

To estimate the MHI program’s impact on utilization and out-of-pocket expenditures

Lao PDR/Informal workers

CBHI implemented by MoH

Cross sectional,

two-stage cluster sampling,

Comparison between insured and uninsured,

Propensity Score matching

Health expenditures

CHE

CBHI members’ total payments, conditional on any use, were less than those of the uninsured ($62.71 for CBHI versus $98.70 for non-CBHI members).

14.7 % of insured inpatient service users live in households with CHE compared with 27.4 % of uninsured inpatient users

14

Bodhisane S, Pongpanich S. The Impact of Community Based Health Insurance in Enhancing Better Accessibility and Lowering the Chance of Having Financial Catastrophe Due to Health Service Utilization A Case Study of Savannakhet Province, Laos. International Journal of Health Services. 2015 Jul 20:0020731415595609

To determine the role of community-based health insurance in making health care services accessible and in preventing financial catastrophe resulting from personal payment for inpatient services.

Lao PDR/Informal sector

Cross sectional,

simple random sampling ,

Comparison between insured and uninsured

CHE

There was no difference in terms of probability of financial catastrophe from health service utilization between insured and uninsured households.

Insurance status does not significantly improve accessibility and financial protection against CHE

15

Franco LM, Diop FP, Burgert CR, Kelley AG, Makinen M, Simpara CH. Effects of mutual health organizations on use of priority health-care services in urban and rural Mali: a case–control study. Bulletin of the World Health Organization. 2008 Nov;86(11):830–8./

Africa

To examine the effects of a community-based mutual health organization (MHO) on utilization of priority health services, financial protection of its members and inclusion of the poor and other target groups.

Mali/Informal sector

4 MHOs

Case control,

Simple random sampling, Desk review,

Comparison between member and non-member households

Health expenditures

OOP expenditure

Lower household health expenditures

as a percentage of overall cash

consumption and lower OOP

payments for fever treatments were reported among the insured.

Health expenditure out of total cash is 5.6 to 6.4 in MHO members and 6.2 to 8.9 % in non members

16

Dercon S, Gunning JW, Zeitlin A, Lombardini S. The impact of a health insurance programme: Evidence from a randomized controlled trial in Kenya. Research Paper. 2012 Nov(24)./

To investigate the impact of Bimaya Jamali health insurance on health care utilization and health care outcomes, and a variety of outcomes not directly related to health.

Kenya/Informal sector/tea farmers

Wananchi Savings and Credit Cooperative Society/Bimaya Jamali

Randomized Controlled Trial

Health expenditures 

Borrowing

Household consumption

Positive impact of MHI was reported on

1. Net health expenditures

2. Informal borrowing for medical costs

3. Food consumption

4. Non-food consumption

5. Overall consumption

17

Parmar D, Reinhold S, Souares A, Savadogo G, Sauerborn R. Does Community-Based Health Insurance Protect Household Assets? Evidence from Rural Africa. Health services research. 2012 Apr 1;47(2):819–39./

To evaluate whether community-based health insurance (CBHI) protects household assets in rural Burkina Faso, Africa

Burkina Faso/Rural population

Assurance Maladie à Base Communautaire

Randomized controlled trial

Random sampling

Household assets

MHI seemed to protect and increase household assets

7 % increase in 2006 and 16 % increase in 2007 was recorded.

18

Haddad S, Ridde V, Yacoubou I, Mák G, Gbetié M. An evaluation of the outcomes of mutual health organizations in Benin.

To evaluate the benefits attributable to membership in a mutual health organization in a rural region of Benin.

Benin/Rural low income households

10 MHOs

Cross sectional,

Purposive and convenience sampling;

Document review,

Comparison between intervention and control groups

OOP

MHI significantly reduced hospitalization expenses among members.

Particular benefits to the poor were not proven.

19

Saksena P, Antunes AF, Xu K, Musango L, Carrin G. Mutual health insurance in Rwanda: evidence on access to care and financial risk protection. Health policy. 2011 Mar 31;99(3):203–9./

To examine the effect of mutual health insurance (MHI) on utilization of health services and financial risk protection.

Rwanda/Mainly informal sector

Not mentioned

Cross sectional,

Comparison between insured and uninsured

OOP expenditure

Financial burden

Insured households spent significantly less OOP: only 3.5 % of their CTP compared to 6.6 % for non-insured households.

Households insured with MHI had a lower financial burden, with only 20.1 % of them spending over 10 % compared to 41.6 % for non-insured.

20

Lu C, Chin B, Lewandowski JL, Basinga P, Hirschhorn LR, Hill K, Murray M, Binagwaho A. Towards universal health coverage: an evaluation of Rwanda Mutuelles in its first eight years. PLoS One. 2012 Jun 1;7(6):e39282.

To evaluate the impact of Mutuelles on achieving universal coverage of medical services and financial risk protection in its first eight years of implementation

Rwanda/General Population

Children Under 5 Years

Pregnant women

Mutelles

Cross sectional,

Comparison between insured and uninsured,

Propensity Score matching

OOP expenditure

CHE

The average annual household OOP spending for insured was significantly lower (5,744 RWF) than that of the uninsured households (8,755 RWF).

The percentage of the insured households with CHE (5.1 %) was significantly lower than that (10.5 %) of uninsured households.

21

Kihaule A. Impact of Micro Health Insurance Plans on Protecting Households Against Catastrophic Health Spending in Tanzania. GSTF Journal of Nursing and Health Care (JNHC). 2015 Aug 27;2(2

To analyze whether households’ membership in micro health insurance funds provide them with the protection against catastrophic health spending, when sick.

Tanzania/Rural and urban population

Not mentioned

Cross sectional,

Comparison between insured and uninsured

CHE

OOP expenditure

Insured households were protected against CHE during episodes of illness

Reduction in OOP expenditure among the members was reported

22

Dekker M, Wilms A. Health Insurance and Other Risk-Coping Strategies in Uganda: The Case of Microcare Insurance Ltd. World Development. 2010 Mar 31;38(3):369–78.

To explore the relationship between health insurance and other risk-coping strategies used to finance medical expenditures in Uganda.

Uganda/ Formal and informal sector (study restricted to rural, informal sector population)

Microcare insurance

Cross sectional,

Convenience sampling

OOP expenditure

Sale of assets 

Borrowing

OOP expenditures on health care were significantly higher in the uninsured households: USh 186,640 (US$ 100.88) in last 12 months compared to the insured households USh 83,420 (US$ 45.09). 44 % of the uninsured households and 56 % of those insured had enough cash to pay for health care.

Uninsured households sold assets worth USh 138,940 (US$ 75.10) while insured households sold USh 35,030 (US$ 18.94) worth of assets.

OOP expenditure per illness was USh 31,252 (US$ 16.89) lower for insured households.

Insured borrowed less money per illness (a reduction of USh 42,828 or US$ 23.15).

23

Chankova S, Sulzbach S, Diop F. Impact of mutual health organizations: evidence from West Africa. Health policy and planning. 2008 Jul 1;23(4):264–76.

To add to the limited evidence on the impact of MHOs on utilization and out-of-pocket payments.

Ghana, Mali, Senegal/Households registered and not registered in 3 study sides serving as cases and comparison groups

Ghana: 1 MHO: Nkoranza Health Insurance Scheme Mali:

4 MHOs: Bougoulaville, Wayerma, Kemeni, Blaville Senegal:

27 MHOs—all MHOs in Thies region that had been operational in the 2 years preceding the study

Cross sectional,

Comparison between insured and insured households

OOP expenditure

In Ghana, hospital OOP expenditure averaged US$2 among insured, compared with US$44 for non-beneficiaries. In Senegal, inpatient OOP expenditures was US$61 for MHO members, US$234 for non-members.

There was no difference in OOP expenditures for outpatient care between MHO members and non-members in Ghana, Mali and Senegal