بیمه سلامت و دیگر خطر راهبردهای مقابله در اوگاندا: مورد میکرو مراقبت بیمه در شرکت با مسئولیت محدود

To reduce the burden of health expenditures in developing countries, health-insurance schemes have become popular and now feature prominently in poverty-reduction strategies. There is, however, limited empirical evidence on the effect of such schemes on the livelihoods of clients, especially regarding household strategies to finance medical expenditures. This paper explores the relationship between health insurance and other risk-coping strategies used to finance medical expenditures in Uganda. Insurance is associated with a lower frequency of asset sales but not with lower incidences of borrowing. The amount of money borrowed or generated through the sales of assets is lower for insured households.

Achieving the Millennium Development Goals (MDGs) remains an important global challenge. Better protection for the poor against health risks is crucial in this endeavor and micro or community-based health-insurance schemes are being advanced as a means to reduce and stabilize the costs of treatment, increase access to health care and to reduce the use of costly risk-coping strategies (ILO, 2008, IFC, 2009 and WHO, 2006). Previous studies have shown how insurance increases health-seeking behavior and reduces out-of-pocket (OOP) expenditures for medical treatment. Possible reductions in the use of other coping strategies, as an indirect effect of health insurance, have not been addressed in much detail. Based on data from specific areas in Uganda, this paper explores the relationship between health insurance and the use of other strategies to finance health care. Illness is a significant risk for people in developing countries (see, e.g., Dekker, 2004, Dercon et al., 2005 and Leliveld, 2006) and can have considerable short-term financial effects on the household affected. Illness is likely to reduce a household’s income if people are not able to work and may also result in additional expenditures to cover costs of treatment. As it is not uncommon for people to lack the cash to pay for medical fees (Asenso-Okyere, Anum, Osei-Akoto, & Adukonu, 1998), people may forego treatment, with potentially detrimental effects for their long-term health. Alternatively, households use costly risk-coping strategies to pay for medical care: they reduce spending on basic needs, sell household or productive assets or borrow money. In a study of coping strategies in Uganda, Leliveld (2006) reported how households sold land, cattle, or goats or used their savings to respond to (long-term) illness. Such strategies are expensive and may endanger the future economic status of the household by depleting its finances through indebtedness and its future income-generating capacity by selling productive assets (Scheil-Adlung, Carrin, Jütting, & Xu, 2006). This, in return, will increase the risk of ending up or being trapped in poverty. Bogale, Mariamand, and Ali (2005) and Krishna et al. (2006) demonstrate how the costs of illness contribute significantly to the impoverishment of households in rural Ethiopia and Uganda, respectively. In this context, reducing the financial burden of health care, for example, by having health insurance, allows earlier medical treatment and enhances a household’s long-term welfare as it may well shorten the duration of an illness, reduce the number of workdays lost, and improve productivity at work through having better health (Jutting, 2004 and Young et al., 2006). More indirectly, when households are better protected against high medical costs, they are less likely to have to rely on other risk-coping strategies and may be able to accumulate savings and assets, thus improving their general welfare. In line with these arguments, policy debates have placed a great deal of emphasis on the development of health-insurance products for the poor. In the past two decades, hundreds of small schemes have been implemented across the globe (Bennett, Creese, & Monash, 1998) but, to date, profound empirical evidence of the effects of health insurance is still limited (Ekman, 2004, Jutting, 2005, Young et al., 2006 and Scheil-Adlung et al., 2006). Many studies describe the institutional underpinnings and the performance of the provider (see, e.g., Atim and Sock, 2000 and McCord, 2000) or discuss the potential contribution of micro insurance for financing health systems (Dror et al., 2005).1 Some have documented the impact of insurance schemes on health expenditure and treatment-seeking behavior and have found that health insurance increases health-care utilization (Ekman, 2004, Preker et al., 2001 and Schneider and Hanson, 2006). Jutting, 2004 and Jowett et al., 2003 and Ranson (2002) have all reported reduced levels of OOP payments for medical treatment as a result of insurance. Information on the relationship between insurance and the use of other coping strategies is scantier. Apart from a descriptive comparison of the incidence of risk-coping strategies in the context of three different health-insurance schemes (Scheil-Adlung et al., 2006), the relationship between health insurance and the sale of assets or borrowing money to pay for medical expenses has not been tested statistically and remains unsubstantiated.2 Based on household-level data collected in five rural and two urban communities in Uganda where the private health-insurance provider Microcare Insurance Ltd. (Microcare) operates, this paper considers the relationship between insurance and OOP expenditures, and then addresses the correlation of insurance and the incidences and value of asset sales and loans. We have found that health insurance is associated with lower OOP expenditure on health and with less use of other risk-coping strategies. This association between health insurance and other risk-coping strategies calls for additional empirical work on the relationship between insurance, risk-coping, and poverty. If reductions in other coping strategies can indeed be attributed to health-insurance schemes and this is found in a wider range of schemes, health insurance can be seen as relevant beyond its direct effects on health-seeking behavior and reduced health expenditures, and has important indirect effects on household well-being too. This paper is organized as follows. Section 2 describes the operation of the health-insurance scheme and this is followed by a description of the data in Section 3. Section 4 discusses the empirical strategy, including the hypotheses, the methodology used, potential sources of bias, and some descriptive statistics. Section 5 presents the results of the analyses. Section 6 discusses the implications of our results, while Section 7 draws some conclusions.

Health-insurance schemes have been advanced over the past decades as an appropriate instrument in reducing the impact of health risks in developing countries and in poverty-reduction strategies in general. Protection against high, unexpected medical costs through health insurance is hypothesized to reduce OOP health expenditures and the use of other (costly) risk-coping strategies such as borrowing money and the sale of assets. Although several empirical studies have indeed confirmed a reduction in health expenditures, the hypothesized change in risk-coping behavior still remained unsubstantiated. Based on a survey in five rural and two urban communities in Uganda, this study has addressed the relationship between insurance and OOP health expenditures and the use and proceeds of other risk-coping strategies. In line with the hypothesis and empirical results obtained in other contexts, we found that insurance reduces OOP expenditures on health care (including the health-insurance premium). We also showed that insured households sell assets less frequently and, when they do, the value of the assets sold per illness is lower than the sums achieved by uninsured households. At the same time, insured and uninsured households borrow money equally, but those insured borrowed less money per illness compared to uninsured households, potentially influencing a household’s level of indebtedness. The findings presented here imply that health insurance cannot offer households full protection against the direct financial effects of health risks. The availability of cash to meet, for example, transport costs, user fees, exclusions from the health package or the health-insurance premium, remains problematic and is an important reason for household borrowing (or the selling of assets). At the same time, finding a lower incidence of asset sales for insured respondents tentatively suggests that health insurance can make a positive contribution to reducing other risk-coping strategies and thereby to improving a household’s well-being more generally. Given the potential sources of bias in our sample, this study should be replicated in a representative sample and different contexts to ascertain whether this relationship can indeed be attributed to health insurance and how the results are affected by the set-up and context of Microcare’s schemes.