We cannot verify your location
Browse Book and Journal Content on Project MUSE

The Impact of Health Insurance in Low- And Middle-Income Countries

edited by Maria-Luisa Escobar, Charles C. Griffin, and R. Paul Shaw

Publication Year: 2010

Over the past twenty years, many low- and middle-income countries have experimented with health insurance options. While their plans have varied widely in scale and ambition, their goals are the same: to make health services more affordable through the use of public subsidies while also moving care providers partially or fully into competitive markets.

Colombia embarked in 1993 on a fifteen-year effort to cover its entire population with insurance, in combination with greater freedom to choose among providers. A decade later Mexico followed suit with a program tailored to its federal system. Several African nations have introduced new programs in the past decade, and many are testing options for reform. For the past twenty years, Eastern Europe has been shifting from government-run care to insurance-based competitive systems, and both China and India have experimental programs to expand coverage. These nations are betting that insurance-based health care financing can increase the accessibility of services, increase providers' productivity, and change the population's health care use patterns, mirroring the development of health systems in most OECD countries.

Until now, however, we have known little about the actual effects of these dramatic policy changes. Understanding the impact of health insurance–based care is key to the public policy debate of whether to extend insurance to low-income populations —and if so, how to do it —or to serve them through other means.

Using recent household data, this book presents evidence of the impact of insurance programs in China, Colombia, Costa Rica, Ghana, Indonesia, Namibia, and Peru. The contributors also discuss potential design improvements that could increase impact. They provide innovative insights on improving the evaluation of health insurance reforms and on building a robust knowledge base to guide policy as other countries tackle the health insurance challenge.

Published by: Brookings Institution Press

Front Cover

pdf iconDownload PDF (490.0 KB)

Copyright Information

pdf iconDownload PDF (33.6 KB)
pp. iv

Table of Contents

pdf iconDownload PDF (44.8 KB)
pp. v-x

read more


pdf iconDownload PDF (31.5 KB)
pp. xi-xii

While the underinvestment in health technology for poorer countries has become glaringly obvious and is starting to be rectified, health care financing has been an area of neglect. Yet in richer countries, public policy in health focuses almost exclusively on financing and incentive issues—and much progress has been made by those countries in ...

read more


pdf iconDownload PDF (32.4 KB)
pp. xiii-xiv

Each chapter was written by a team whom we challenged to do their best to understand the impact of health insurance reforms using available household data and their knowledge of health policy in the country they were working on. We have been impressed by their resourcefulness in securing data and finding creative ways to address econometric ...

read more

Chapter 1: Why and How Are We Studying Health Insurance in the Developing World?

pdf iconDownload PDF (116.4 KB)
pp. 1-12

More than 2 billion people live in developing countries with health systems afflicted by inefficiency, inequitable access, inadequate funding, and poor quality services. These people account for 92% of global annual deaths from communicable diseases, 68% of deaths from noncommunicable conditions, and 80% of deaths from injuries. The World ...

read more

Chapter 2: A Review of the Evidence

pdf iconDownload PDF (161.3 KB)
pp. 13-32

We used a detailed protocol to evaluate the robustness of the available evidence on the impact of health insurance in low- and middle-income countries—on access, use, financial protection, and health status (box 2.1). Of 49 quantitative studies, about half provide reasonably robust evidence. They indicate that health insurance improves access and use ...

read more

Chapter 3: Low-Cost Health Insurance Schemes to Protect the Poor in Namibia

pdf iconDownload PDF (200.5 KB)
pp. 33-57

Investigating alternative mechanisms of health care provision is important for African countries, where the epidemics of HIV/AIDS, tuberculosis, and malaria increase the demands on the health care sector. This chapter, using a unique combination of household survey data and a biomedical survey with HIV test data from Greater Windhoek in ...

read more

Chapter 4: Ghana's National Health Insurance Scheme

pdf iconDownload PDF (222.9 KB)
pp. 58-88

In 2003 Ghana introduced a National Health Insurance Scheme (NHIS) that aimed to cover the entire population with affordable access to basic health services within five years. This chapter provides an overview and analysis of the evolution of the NHIS in the first years of its operation, and the results from an impact evaluation on the effect the ...

read more

Chapter 5: Impact of Health Insurance on Access, Use, and Health Status in Costa Rica

pdf iconDownload PDF (186.0 KB)
pp. 89-105

Costa Rica, as a middle-income country that has largely achieved universal health coverage, allows for analysis of the differences in behavior and care for the small share of citizens who remain uninsured. This chapter sheds light on the impact of being covered by insurance in a country where access is guaranteed even if uninsured and on the costs ...

read more

Chapter 6: Health Insurance and Access to Health Services, Health Services Use, and Health Status in Peru

pdf iconDownload PDF (149.7 KB)
pp. 106-121

This chapter examines how Peru’s eight-year-old Integral Health Insurance (Seguro Integral de Salud, or SIS) has affected access to health services and out-of-pocket spending by its beneficiaries. We use data from the Demographic and Health Survey (DHS), which contains two cross-sectional samples, one for 2000 and another for 2004–07, with a sample ...

read more

Chapter 7: The Impact of Health Insurance on Use, Spending, and Health in Indonesia

pdf iconDownload PDF (136.5 KB)
pp. 122-136

Classified by the World Bank as a lower middle-income country, Indonesia had per capita gross national income of US$3,600 in purchasing power parity terms in 2008. With about half the population residing in rural areas, life expectancy remains fairly low—at 69 years for men and 73 years for women—and under-five mortality high—at 41 per 1,000 ...

read more

Chapter 8: The Impact of a Social Experiment--Rural Mutual Health Care--on Health Care Use, Financial Risk Protection, and Health Status in Rural China

pdf iconDownload PDF (158.9 KB)
pp. 137-154

In 2002 the Chinese government announced a new national policy for rural health care—the New Cooperative Medical Scheme (NCMS). First rolled out in a small number of pilot counties in 2003 and targeted to cover the entire rural population by 2010, the goals are to improve access to health care and reduce inequality and medical impoverishment ...

read more

Chapter 9: Colombia's Big Bang Health Insurance Reform

pdf iconDownload PDF (262.7 KB)
pp. 155-177

Colombia is one of the few developing countries that have introduced government-subsidized universal health insurance by drastically changing social security schemes and breaking the public sector monopoly. The reforms began in 1993, when approximately 28% of the population was covered by insurance through the traditional Latin American ...

read more

Chapter 10: Main Findings, Research Issues, and Policy Implications

pdf iconDownload PDF (208.5 KB)
pp. 178-198

This book contains rich and varied analyses of the impact of health insurance in different socioeconomic and organizational settings. It begins with a comprehensive literature review that distills findings on prior studies that examine causal effects between health insurance and health outcomes. This is followed by seven country case studies, most of ...

Editors and Authors

pdf iconDownload PDF (85.4 KB)
pp. 199-204


pdf iconDownload PDF (135.9 KB)
pp. 205-221

Back Cover

pdf iconDownload PDF (119.6 KB)

E-ISBN-13: 9780815705611
E-ISBN-10: 0815705611

Page Count: 232
Publication Year: 2010