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The impact of subsidized private health insurance and health facility upgrades on healthcare utilization and spending in rural Nigeria

  • Emily Gustafsson-Wright
  • Gosia Popławska
  • Zlata Tanović
  • Jacques van der Gaag
Research Article

Abstract

This paper analyzes the quantitative impact of an intervention that provides subsidized low-cost private health insurance together with health facility upgrades in Nigeria. The evaluation, which measures impact on healthcare utilization and spending, is based on a quasi-experimental design and utilizes three population-based household surveys over a 4-year period. After 4 years, the intervention increased healthcare use by 25.2 percentage points in the treatment area overall and by 17.7 percentage points among the insured. Utilization of modern healthcare facilities increased after 4 years by 20.4 percentage points in the treatment area and by 18.4 percentage points among the insured due to the intervention. After 2 years of program implementation, the intervention reduced healthcare spending by 51% compared with baseline, while after 4 years, spending resumed to pre-intervention levels.

Keywords

Health insurance Financial risk Nigeria Impact evaluation 

JEL Classification

I1 I3 

References

  1. Acharya, A., Vellakka, S., Taylor, F., Masset, E., Satija, A., Burke, M., & Ebrahim, S. (2013). The impact of health insurance schemes for the informal sector in low and middle income countries: a systematic review. World Bank Policy Research Working Paper 6324.Google Scholar
  2. Bernal, N., Miguel, C., & Klein T. (2015). The effects of access to health insurance for informally employed individuals in Peru. Netspar discussion paper series, DP 02/2015-023.Google Scholar
  3. Brals, D., Aderibigbe, S., Wit, F., van Ophem, J., van der List, M., Osagbemi, G., Hendriks, M., Akande, T., van Hensbroek, M., & Schultsz, C. (2017). The effect of health insurance and health facility-upgrades on hospital deliveries in rural Nigeria: A controlled interrupted time-series study. Health Policy and Planning, 32(7), 990–1001.Google Scholar
  4. Burger, R., Burger, R. P., & Smith, A. (2015). Does insurance affect health care utilization if the health system is polarized? Evidence from a South African natural experiment. NEUCD conference, Brown University.Google Scholar
  5. Cameron, A. C., Gelbach, J. B., & Miller, D. L. (2008). Bootstrap-based improvements for inference with clustered errors. The Review of Economics and Statistics, 90(3), 414–427.CrossRefGoogle Scholar
  6. Chen, L., Yip, W., Chang, M., Lin, H., Lee, S., Chiu, Y., et al. (2007). The effects of Taiwan’s National Health Insurance on access and health status of the elderly. Health Economics, 16, 223–42.CrossRefPubMedGoogle Scholar
  7. Cheng, L., Liu, H., Zhang, Y., Shen, K., & Zeng, Y. (2015). The impact of health insurance on health outcomes and spending of the elderly: Evidence from China’s New Cooperative Medical Scheme. Health Economics, 24(6), 672–691.CrossRefPubMedGoogle Scholar
  8. Cragg, J. G. (1971). Some statistical models for limited dependent variables with application to the demand for durable goods. Econometrica, 39(5), 829–844.CrossRefGoogle Scholar
  9. Dehejia, R., & Wahba, S. (2002). Propensity score-matching methods for nonexperimental causal studies. The Review of Economics and Statistics, 84(1), 151–161.CrossRefGoogle Scholar
  10. Fan, V., Karan, A., & Mahal, A. (2012). State health insurance and out-of-pocket health expenditures in Andhra Pradesh, India. International Journal for Health Care Finance and Economics, 12(3), 189–215.CrossRefGoogle Scholar
  11. Finkelstein, A., Taubman, S., Wright, B., Bernstein, M., Gruber, J., Newhouse, J. P., Allen, H., Baicker, K., & Oregon Health Study Group (2012). The Oregon Health Insurance Experiment: Evidence from the First Year. The Quarterly Journal of Economics, 127(3), 1057–1106.Google Scholar
  12. Giedion, U., Alfonso, E., & Diaz, Y. (2007). Measuring the impact of mandatory health insurance on access and utilization: The case of the Colombian Contributory Regime. Washington D.C.: Brookings Institution.Google Scholar
  13. Giedion, U., Alfonso, E., & Diaz, Y. (2013). The impact of universal coverage schemes in the developing world; A review of the existing evidence. The World Bank, UNICO studies, series 25, January 2013.Google Scholar
  14. Gomez, G. B., Foster, N., Brals, D., Nelissen, H. E., Bolarinwa, O. A., Hendriks, M. E., et al. (2015). Improving maternal care through a state-wide health insurance program: A cost and cost-effectiveness study in rural Nigeria. PLoS ONE, 10(9), e0139048.CrossRefPubMedPubMedCentralGoogle Scholar
  15. Grogger, J., Arnold, T., León, A. S., & Ome, A. (2015). Heterogeneity in the effect of public health insurance on catastrophic out-of-pocket health expenditures: The case of Mexico. Health Policy and Planning, 30(5), 593–599.CrossRefPubMedGoogle Scholar
  16. Gustafsson-Wright, E., & Schellekens, O. (2013). Achieving universal health coverage one state at a time: A public–private partnership community-based health insurance model. Brooke Shearer Working Paper. Global Economy and Development. Washington D.C.: Brookings Institution Press.Google Scholar
  17. Hendriks, M. E., Rosendaal, N. T., Wit, F. W., Bolarinwa, O. A., Kramer, B., Brals, D., et al. (2016). Sustained effect of health insurance and facility quality improvement on blood pressure in adults with hypertension in Nigeria: A population-based study. International Journal of Cardiology, 202, 477–484.CrossRefPubMedGoogle Scholar
  18. Hendriks, M. E., Wit, F. W., Akande, T. M., Kramer, B., Osagbemi, G. K., Tanović, Z., et al. (2014). Effect of health insurance and facility quality improvement on blood pressure in adults with hypertension in Nigeria: A population-based study. JAMA Internal Medicine, 174(4), 555–563.CrossRefPubMedGoogle Scholar
  19. Jütting, J. (2004). Do community-based health insurance schemes improve poor people’s access to health care? Evidence from rural Senegal. World Development, 32(2), 273–288.CrossRefGoogle Scholar
  20. Khandker, S., Koolwal, G., & Samad, H. (2010). Handbook on impact evaluation quantitative methods and practices. Washington D.C: The World Bank.Google Scholar
  21. King, G., Gakidou, E., Imai, K., Lakin, J., Moore, R. T., Nall, C., et al. (2009). Public policy for the poor? A randomized assessment of the Mexican universal health insurance programme. The Lancet, 373, 1447–1454.CrossRefGoogle Scholar
  22. Kramer, B. (2017). From awareness to adverse selection: cardiovascular disease risk and health insurance decisions. SSRN Working paper.  https://doi.org/10.2139/ssrn.2636210.
  23. Langedijk-Wilms, A. (2014). Personal communication with PharmAccess Group.Google Scholar
  24. Levine, D., Polimeni, R., & Ramage, I. (2016). Insuring Health or Insuring Wealth? An experimental evaluation of health insurance in rural Cambodia. Journal of Development Economics, 119, 1–15.CrossRefGoogle Scholar
  25. Limwattananon, S., Neelsen, S., O’Donnell, O., Prakongsai, P., Tangcharoensathien, V., Van Doorslaer, E., et al. (2015). Universal coverage with supply-side reform: The impact on medical expenditure risk and utilization in Thailand. Journal of Public Economics, 121, 79–94.CrossRefGoogle Scholar
  26. Lu, C., Chin, B., Lewendowski, J. L., Basinga, P. Hirschorn, L., & Binahgwaho, A. (2012). Towards universal health coverage: An evaluation of of Rwanda Mutuelles in its first eight years. PLOS ONE, 7(6), e39282.Google Scholar
  27. Manning, W.., Newhouse, J., Duan, N., Keeler, E., & Leibowitz, A. (1987). Health insurance and the demand for medical care: Evidence from a randomized experiment. The American Economic Review, 77(3), 251–277.Google Scholar
  28. Mebratie, A., Sparrow, R., Vilma, Z., Abenaw, D., Alemu, G., & Bedi, A. (2013). Impact of Ethiopian pilot community-based health insurance scheme on health-care utilisation: A household panel data analysis. The Lancet, 381, S92.CrossRefGoogle Scholar
  29. Miller, G., Pinto, D., & Vera-Hernández, M. (2013). Risk protection, service use, and health outcomes under Colombia’s health insurance program for the poor. American Economic Journal: Applied Economics, 5(4), 61–91.PubMedGoogle Scholar
  30. Moulton, B. R. (1990). An illustration of a pitfall in estimating the effects of aggregate variables on micro units. The Review of Economics and Statistics, 72(2), 334–338.CrossRefGoogle Scholar
  31. Neyman, J., & Scott, E. L. (1948). Consistent estimates based on partially consistent observations. Econometrica, 16(1), 1–32.CrossRefGoogle Scholar
  32. Palacios, R., Das, J., & Sun, C. (2011). India’s Health Scheme for the Poor. New Delhi, India: Center for Policy Research.Google Scholar
  33. Ravallion, M. (2001). The mystery of vanishing benefits: An introduction to impact evaluation. The World Bank Economic Review, 15(1), 115–140.CrossRefGoogle Scholar
  34. Saleh, K. (2013). The health sector in Ghana: A comprehensive assessment. Washington DC: Directions in Development, Human Development World Bank.Google Scholar
  35. Smith, K., & Sulzbach, S. (2008). Community-based health insurance and access to maternal health services: Evidence from three West African countries. Social Science and Medicine, 66, 2460–2473.CrossRefPubMedGoogle Scholar
  36. Sparrow, R., Suryahadi, A., & Widyanti, W. (2013). Social health insurance for the poor: Targeting and impact of Indonesia’s Askeskin programme. Social Science and Medicine, 96, 264–271.CrossRefPubMedGoogle Scholar
  37. The World Bank Databank. (2010). Maternal mortality ratio (modeled estimate, per 100,000 live births). Retrieved on 17 June 2013. http://data.worldbank.org/indicator/SH.STA.MMRT.
  38. The World Bank Databank. (2013). Health expenditure per capita (current US$) and Health expenditure, public (% of total health expenditure). Retrieved on 6 June 2015. http://data.worldbank.org/indicator/SH.XPD.PCAP/countries/NG?display=graph.
  39. The World Bank Databank: Health Nutrition and Population Statistics. (2010). Adults (age 15+) and children (0–14 years) with HIV. Retrieved on 17 June 2013. http://databank.worldbank.org/data/views/reports/tableview.aspx.
  40. Thornton, R., Hatt, L., Field, E., Islam, M., Diaz, F., & Gonzalez, M. (2010). Social security health insurance for the informal sector in Nicaragua: A randomized evaluation. Health Economics, 19, 181–206.CrossRefPubMedGoogle Scholar
  41. Trujillo, A., Portillo, J., & Vernon, J. (2005). The impact of subsidized health insurance for the poor: Evaluating the Colombian experience using propensity score matching. International Journal of Health Care Finance and Economics, 5, 211–239.CrossRefPubMedGoogle Scholar
  42. van der Gaag, J., & Stimac, V. (2012). How can we increase resources for health care in developing countries? Is (subsidized) voluntary health insurance the answer? Health Economics, 21, 55–61.CrossRefPubMedGoogle Scholar
  43. Wagstaff, A. (2010). Estimating health insurance impacts under unobserved heterogeneity: The case of Vietnam’s health care fund for the poor. Health Economics, 19(2), 189–208.CrossRefPubMedGoogle Scholar
  44. Wagstaff, A., & Lindelow, M. (2008). Can insurance increase financial risk? The curious case of health insurance in China. Journal of Health Economics, 27, 990–1005.CrossRefPubMedGoogle Scholar
  45. Wagstaff, A., Lindelow, M., Jun, G., Ling, X., & Juncheng, Q. (2009). Extending health insurance to the rural population: an impact evaluation of China’s New Cooperative Medical Scheme. Journal of Health Economics, 28(1), 1–19.Google Scholar
  46. Wagstaff, A., & Moreno-Serra, R. (2007). Europe and Central Asia’s great post-communist social health insurance experiment: Impacts on health sector and labor market outcomes. Washington, D.C.: World Bank Policy Research Working Paper 4371.Google Scholar
  47. Wagstaff, A., & Pradhan, M. (2005). Health insurance impact on health and nonmedical consumption in a developing country. Washington, D.C.: World Bank Policy Research Working Paper No. 3563.Google Scholar
  48. Wagstaff, A., & Yu, S. (2007). Do health sector reforms have their intended impacts? The World Bank’s Health VIII project in Gansu province China. Journal of Health Economics, 26(07), 505–535.CrossRefPubMedGoogle Scholar
  49. World Health Organization. (2011). The Abuja declaration: Ten years on. Geneva: World Health Organization.Google Scholar
  50. World Health Organization Global Health Observatory Data Repository. (2012). General government expenditure on health as a percentage of total government expenditure. Retrieved on 4 June 2015. http://apps.who.int/gho/data/view.main.HEALTHEXPRATIONGA?lang=en.
  51. Yilma, Z., Mebratie, A., Sparrow, R., Dekker, M., Alemu, G., & Bedi, A. (2015). Impact of Ethiopia’s Community Based Health Insurance on Household Economic Welfare. The World Bank Economic Review, 29(Supple 1), 1–10.Google Scholar
  52. Yip, W., & Hsiao, W. (2008). The impact of rural mutual health care on access to care: Evaluation of a social experiment in rural China. Harvard School of Public Health Working Paper.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2017

Authors and Affiliations

  • Emily Gustafsson-Wright
    • 1
  • Gosia Popławska
    • 2
  • Zlata Tanović
    • 3
    • 4
  • Jacques van der Gaag
    • 1
    • 5
  1. 1.Brookings InstitutionWashingtonUSA
  2. 2.Department of Primary Health Care, Center for Health Service Economics and OrganisationUniversity of OxfordOxfordUK
  3. 3.Vrije University (VU)AmsterdamThe Netherlands
  4. 4.Amsterdam Institute for International DevelopmentAmsterdamThe Netherlands
  5. 5.Department of Economics and BusinessUniversity of AmsterdamAmsterdamThe Netherlands

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