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. Maria-Luisa Escobar is lead health economist and health systems program leader at the World Bank Institute. Charles C. Griffin is senior adviser in the European and Central Asia regional office of the World Bank. R. Paul Shaw , a former World Bank lead economist, advises the Bill and Melinda Gates Foundation on health economics. The Impact of Health Insurance in Low- and Middle-Income Countries By Maria-Luisa Escobar Charles C. Griffin R. Paul Shaw BROOKINGS INSTITUTION PRESS Copyright © 2010 The Brookings Institution All right reserved. ISBN: 978-0-8157-0546-8 Contents Preface..............................................................................................................................................xiAcknowledgments......................................................................................................................................xiiiChapter 1 Why and How Are We Studying Health Insurance in the Developing World?......................................................................1Chapter 2 A Review of the Evidence...................................................................................................................13Chapter 3 Low-Cost Health Insurance Schemes to Protect the Poor in Namibia...........................................................................33Chapter 4 Ghana's National Health Insurance Scheme...................................................................................................58Chapter 5 Impact of Health Insurance on Access, Use, and Health Status in Costa Rica.................................................................89Chapter 6 Health Insurance and Access to Health Services, Health Services Use, and Health Status in Peru.............................................106Chapter 7 The Impact of Health Insurance on Use, Spending, and Health in Indonesia...................................................................122Chapter 8 The Impact of Rural Mutual Health Care on Health Care Use, Financial Risk Protection, and Health Status in Rural China.....................137Chapter 9 Colombia's Big Bang Health Insurance Reform................................................................................................155Chapter 10 Main Findings, Research Issues, and Policy Implications...................................................................................178Editors and Authors..................................................................................................................................199Index................................................................................................................................................205 Chapter One Why and How Are We Studying Health Insurance in the Developing World? Maria-Luisa Escobar, Charles C. Griffin, and R. Paul Shaw 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