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

Preface

xi 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 improving access and care. Low- and middle-income countries continue to limp along with poorly performing public health care delivery systems , which almost all rich countries have abandoned for mixed systems financed through public purchasers or insurers financed predominately from tax revenues. What could be done at the global level to support countries interested in undertaking fundamental reforms in health finance? One obvious candidate is health insurance, which for most low- and middle-­ income countries would be a paradigm-shifting change in the technology of health financing. The first question asked, however, is whether such a change could have demonstrable impacts on the take-up and impact of health services. We know little about this issue because economists’ principal empirical interest in insurance has been its impact on financial risk protection, not on health benefits. This question of insurance as a tool of health policy is the challenge addressed by this book. It is a small first step to explore whether changing the health financing method fully or partly into an insurancebased approach—that is, moving away from the supply side or direct Preface xiiPreface service delivery model that dominates low- and middle-income country health financing­ —can have beneficial effects on health-seeking behavior and, by implication , health status. We did not know what to expect when we set out to find countries, datasets, and analysts to shed light on this question. Our conclusion is that shifting partly or fully to insurance-like financing methods (in which payments are made to providers contingent on providing services to patients) has positive effects on the healthseeking behavior of consumers, at least in the countries covered in this book. Even in a country like Costa Rica, where 80% of the population is covered by insurance and everyone has access to hospital care when they need it (at no cost if they cannot afford it), the uninsured behave differently from the insured. The association of insurance with better health-seeking behavior—and in some cases a clear impact of insurance on better management of a family’s health—is strong enough to encourage more experimentation and policy innovations. In a few cases, particularly China and Peru, it is apparent that insurance also affects provider behavior, although that is not the focus of the book. Moreover, although we also did not expect it, there are lessons in every chapter about the nuts and bolts of design and implementation that illuminate some of the tasks reformers need to do well for a reform to work. Because the hoped-for benefits of insurance depend on how it is designed and who benefits from it, no effort should be spared to get the details right before policy reforms are put in place. The authors of the chapters in this book retrofitted evaluations as best they could. It is surprising to us that evaluation had not been built into all of these insurance reforms from the start. How else can anyone know what is working and what needs to be changed? How else can the progress of the reform against its goals be measured? We do not end this effort with a simple call for more research but with a call for more innovations in health financing policy like those covered in this book. But pairing them with a research agenda by building in evaluation at the start is the only way to improve reforms as learning takes place and impacts become clear. We hope this book encourages health finance policy innovation, more international support for it, more learning, and feedback of that learning into constantly improving policies for better health. Maria-Luisa Escobar Charles C. Griffin R. Paul Shaw ...