Essays on health insurance for universal health coverage in low-and middle-income countries

Abstract

This thesis contributes to the understanding of health insurance in low-and middle-income countries (LMIC) via four distinct essays. The focus is on the impact of health insurance on mental health and nutrition outcomes of social health insurance/national health insurance (SHI/NHI), equity and gender differences in community based health insurance (CBHI) payments and the willingness to pay for CBHI. Chapter 1 uses cross-section data from Ghana to explore whether health insurance affects psychological distress. Instrumental variables and propensity score matching methods are used in the analysis. The results suggest that health insurance improves psychological health. Chapter 2 uses longitudinal data from Indonesia to study the effect of health insurance for the poor on body mass index (BMI) and haemoglobin levels. A fixed-effects estimator with and without matching is employed. In general, the results show that health insurance has some negative effects on BMI but not on haemoglobin levels. Moving away from SHI/NHI, Chapters 3 and 4 focus on CBHI in Rwanda and Malawi, respectively. Chapter 3 analyses socioeconomic inequality in CBHI payments in Rwanda using repeated cross-section data. This chapter uses concentration indices, Kakwani indices, and unconditional quantile decomposition methods. The findings suggest that a flat-rate system of health insurance premium payment is more inequitable than the tiered system in which people pay based on community-defined socioeconomic status. Furthermore, female-headed households pay lower health insurance premiums. Chapter 4 uses primary data to examine the factors that affect willingness to pay for CBHI in rural Malawi. The chapter uses quantitative and qualitative data analysis methods. The results show that most people are willing to join and pay for CBHI using fiat money as opposed to commodity money. Furthermore, those who are enrolled in social cash transfer programmes are willing to spend less