آیا همسران ادعا را می سازند ؟ توانمندسازی و تأمین منابع مالی کوچک در هند
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|5450||2011||9 صفحه PDF||سفارش دهید||محاسبه نشده|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : World Development, Volume 39, Issue 6, June 2011, Pages 913–921
We study a microfinance program that provides compulsory health insurance to its borrowers and their spouses. We find that non-borrowing spouses are less likely to file insurance claims than those who are borrowing. Further, a man is more likely to use the health insurance acquired through his wife’s loan than is a woman (through her husband’s loan). These patterns suggest that women who do not borrow are disempowered relative to those who do.
Many households in developing countries are especially vulnerable to health risks. For instance, Peters et al. (2002) estimate that a quarter of all Indians that are hospitalized fall below the poverty line as a consequence. In such a situation, the provision of health insurance has huge potential—but also faces at least two constraints. First, the transactions costs of such micro-insurance can be particularly high (Morduch, 2007). Second, women may not utilize health insurance even if they are sick. There is considerable evidence that men and women differ in their health-seeking behavior, that is, in how they perceive their symptoms and translate that perception into treatment based on the social and cultural context (Santow, 1995). One promising approach to deliver health insurance to the poor is in partnership with microfinance institutions. Such programs can save on transactions costs by using their existing rural networks. Further, since a goal of microfinance is to empower women, we might expect that microfinance can reduce the gender disparity in health seeking. Many prominent microfinance institutions in South Asia offer health insurance schemes in conjunction with their loans (Roth, Churchill, & Namerta, 2005). This recent and potentially important development in micro-insurance has been little studied.1 In this paper we study an innovative microfinance institution in India that requires borrowers and their spouses to purchase health insurance when the loan is given. We analyze the claims behavior of borrowers and their spouses, of men, and of women. Our goal is to understand how microfinance, gender, and health insurance interact. The key feature of the program is its group health insurance coverage. Borrowers and their spouses receive the same coverage and pay the same premium regardless of their sex, age, or any medical histories. In other words, the health insurance intervention treats everybody the same—so any differences in claim behavior must be related either to differences in underlying morbidity or to differences in health-seeking behavior. We find that there is a borrower–spouse gap in health insurance utilization—borrowers are twice as likely to file claims as their spouses. We also find a smaller husband–wife gap in health utilization, that is, wives of male borrowers are significantly less likely to file claims than husbands of female borrowers. This borrower–spouse gap and the husband–wife gap persist when we control for gender, age, length of coverage, previous claims, and previous experience and unobserved branch-level differences. While we cannot rule out morbidity explanations for our findings with the available data (i.e., that borrowers are more sickly than spouses, and wives are more sickly than husbands), these results are also suggestive of health-seeking differences. Gender differences in health are related to women’s empowerment within the household in India (Basu, 1992 and Bloom et al., 2001). Women, particularly younger women often do not have much say in their own health decisions in India. Instead, husbands and even mother-in-laws make health care decisions for them. Our results suggest that non-borrowing female spouses are disempowered within the household. Put differently, women who borrow are empowered in their health seeking compared with women who have acquired health insurance through their husbands. These findings are consistent with both selection and/or treatment effects of microfinance on female empowerment. Microfinance institutions may be selecting empowered women as borrowers—and/or they may be making their female borrowers more empowered relative to female non-borrowing spouses. We cannot distinguish between these two possibilities. Our paper contributes to a literature on female empowerment and microfinance (Anderson and Baland, 2002, Mayoux, 1999 and Mayoux, 2001). Female empowerment has been defined and measured in multiple ways in the microfinance literature. Measures include physical mobility of women (Hashemi, Schuler, & Riley, 1996), control over the use of the loan (Goetz & Sen Gupta, 1994), intra-household decision making (Holvoet, 2005), domestic violence (Kim et al., 2007) and contraceptive use (Steele, Amin, & Naved, 2001). We do not measure empowerment directly; instead we use health insurance utilization as an indicator of empowerment. While much of the research on the subject is on the well-known Bangladeshi microfinance programs that typically exclude men, our study looks at a program that includes both men and women. Approximately half the borrowers are male, and half are female. This allows us to contrast the health seeking behavior of men and women borrowers with their male and female spouses. When loans are targeted to women, such a rich comparison is not possible. The outline of the paper is the following: Institutional details, selection issues, description of the data and empirical analysis are in Section 2. Section 3 has discussion of the results where we distinguish between morbidity and health seeking hypotheses. We conclude in Section 4.
نتیجه گیری انگلیسی
In this paper we study how health insurance, gender, and microfinance interact. We find that borrowers are twice as likely to file claims as their spouses. While there is no gender difference in the claims behavior of male and female borrowers, wives of male borrowers are significantly less likely to utilize health insurance than husbands of female borrowers. Our results suggest that either empowered women become borrowers (a selection device) or that microfinance empowers women borrowers (a treatment effect); wives of male borrowers are disempowered by contrast. We outline several potential channels through which empowerment both within the household and in the wider economy can explain our findings. We also find that households that have joined the microfinance program after the coverage was extended are significantly less likely to file claims than pre-existing borrower households. There are both health-seeking and morbidity explanations for this finding. For instance, experience with microfinance programs may make borrower households better informed about insurance coverage—and new loan recipients and their spouses may simply lack this information. Or recent joiners may indeed have lower health risks than pre-existing borrower households, suggesting that adverse selection may be less of a concern in these markets. We leave a fuller exploration of adverse selection in this insurance market to future research. Finally, the low claims-to-coverage ratio is intriguing. One possibility is that morbidity (or awareness of morbidity) in rural India is low. Another is that the process of filing claims is unfamiliar to rural households. Alternatively, credit constraints may prevent a client from spending on medical care before being reimbursed.