Impact of national health insurance for the poor and the informal sector in low- and middle-income countries

Moving away from out-of-pocket (OOP) payments for healthcare at the time of use to prepayment through health insurance (HI) is an important step towards averting financial hardships associated with paying for health services. In low- and middle-income countries (LMICs) some version of Social Health Insurance (SHI) has been offered to those in the informal labour sector, who may well comprise the majority of the workforce.

The authors of this document carried out a systematic review of studies reporting on the impact of health insurance schemes that are intended to benefit the poor, mostly employed in the informal sector, in LMICs at a national level, or have the potential to be scaled up to be delivered to a large population. Specifically, they assessed the impact of social health insurance schemes on health care utilisation, health outcomes and healthcare payments among low- and middleincome people in developing country settings. They also examined insurance uptake.

They found that:

• low enrolment is commonly observed in many of the insurance schemes examined
• no pattern was observed regarding enrolment and outcome: for example, high enrolment is not correlated with better outcomes
• there is some evidence that health insurance may prevent high levels of expenditure
• the insured poor may be undertaking higher OOP expenditure than those who are not insured.

The document concludes that there is no strong evidence to support widespread scaling up of social health insurance schemes as a means of increasing financial protection from health shocks or of improving access to health care. The health insurance schemes must be designed to be more comprehensive in order to ensure that the beneficiaries attain desirable levels of healthcare utilisation and have higher financial protection. At the same time, the non-financial barriers to access to healthcare, such as
awareness and distance to healthcare facilities, must be minimised.