بررسی اثرات بهداشتی از جایگذاری میکرو بیمه سلامت: شواهد از بنگلادش

We examine the impact of Micro Health Insurance placement on health awareness, healthcare utilization, and health status of microcredit members in rural Bangladesh, using data from 329 households in the operating areas of Grameen Bank. The results are based on econometric analysis conditioned on placement of the scheme and show that placement has a positive association with all of the outcomes. The results are statistically significant for health awareness and healthcare utilization, but not for health status and these findings are potentially important for the expansion and replication of Micro Health Insurance.

Microcredit provides collateral free small loans, especially to women, to enable them to develop household-based micro enterprises. A key aim is to break the vicious circle of poverty where low income leads to low saving, therefore low investment, thus low income. The importance of microinsurance emanates from the limitations of conventional loan-based microcredit programs in protecting the poor from all sorts of vulnerabilities. Although microcredit has been shown to generate various beneficial outcomes, there is also evidence that not all sectors of the poor can benefit. One such group is those who experience severe health shocks, which reduce work capacity and investment and require a redirection of resources to the consumption of healthcare. Due to increased evidence that microcredit does not help the poorest poor, welfarists stress the value of adding auxiliary services to improve the effectiveness of the programs (e.g., Bhatt and Tang, 2001, Woller et al., 1999 and Woller and Woodworth, 2001). Insurance can protect vulnerable people from risks and shocks when existing coping strategies fail. However, traditional health insurance markets are almost entirely absent in the rural areas of Bangladesh. There is no social health insurance scheme even in the formal sector, and in addition the government has not been able to meet the healthcare needs of the rural poor (BBS, 2006, IMF, 2005 and NIPORT, 2009). Grameen Bank1 (GB) has played a major role in developing microcredit in Bangladesh. The organization emerged from an action research project by Professor Muhammad Yunus in 1976, examining the possibility of providing banking services for the rural poor. GB as a microfinance institution (MFI) provides a number of services including loans and savings schemes. It added a Micro Health Insurance (MHI) scheme in the late 1990s, in order to protect its clients from health risks with the aim of preventing their economic downfall. Other MFIs have also introduced MHI schemes with similar aims. These schemes may increase the health status of the participating households via increased health awareness and utilization of modern healthcare. Improved health status may lead to higher productivity, higher labor supply, fewer workdays lost, and reduced healthcare expenditure. In addition, if households are insured against health risk, they may invest in high return riskier assets because they do not need to retain cash or to hold highly liquid assets for precautionary purposes. Kochar (2004) finds, from a study in rural Pakistan, that overall savings of households rise in the expectation of future illness of adult males, but investments in productive assets decline. The empirical verification of this issue is important for policy decisions concerning the expansion and replication of MHI schemes. However, to date there has been very little research on the added effects of MHI. Mosley (2003) examined the added effects of the MHI scheme of BRAC2 on outcomes such as assets, household expenditure, current saving, educational expenditure, and education level. However, the study did not explore the impact on health outcomes. The evidence was not conclusive because the study was conducted at a very early stage of program development using a small sample. Other MHI studies have concentrated mainly on health outcomes: healthcare utilization and the equality of access to healthcare in the Philippines (Dror et al., 2006 and Dror et al., 2005); healthcare use and out of pocket expenditure in Senegal (Jutting, 2004); utilization of healthcare and financial protection from health shocks in Tanzania (Msuya, Jutting, & Asfaw, 2007); and cost recovery in Rwanda (Schneider & Hanson, 2007). However, there is no existing evidence regarding the impact of MHI on health outcomes in Bangladesh. This is a serious omission given the size of the microcredit sector in Bangladesh; according to the Palli Karma Sahayak Foundation (http://www.pksf-bd.org) in December 2005, there were about 700 MFIs and 33.17 million microcredit members in Bangladesh. In this paper, we have explored the added effects of MHI on a broad set of health outcomes: health awareness, utilization of modern healthcare, and perceived health status. We use data collected from a primary survey of 329 households in three areas where GB operates microcredit programs. The areas are distinguished according to their experience of MHI: areas with at least 5 years experience of MHI, those with 2 years or less experience, and those where MHI is not available. Our evidence is based on econometric analysis of the impact of placement of MHI. This paper is organized as follows. Section 2 presents a brief description of health, microcredit, and MHI programs in Bangladesh; Section 3 describes the methodology; Section 4 gives the findings; Section 5 provides a discussion on the findings; and Section 6 provides the conclusion.

This study has outlined the mechanisms by which adding MHI to microcredit schemes can contribute to improving health awareness, health-seeking behavior, and health status. We have investigated this in the context of GB, the largest microcredit organization in Bangladesh. Where MHI is available take-up rates are very high and there are large potential spill-over effects, so we have focused on the effects of MHI placement. Our results show a positive association between MHI placement and all of our health outcome measures. The results are statistically significant for the determination of health awareness and seeking formal care, but not for health status. A number of reasons have been suggested for our findings, which include problems in detecting long-term effects with our cross section data as well as shortcomings of the MHI scheme in question, including a lack of proper referral services and the adverse effects of protection against moral hazard. Our findings are potentially important for the expansion or replication of MHI by MFIs in Bangladesh. However, in practice most MFIs do not have the capacity (either managerial or financial) to expand this provision. MHI has been mainly operated in the areas where government healthcare facilities are not functioning well. Thus, one possible solution is for government to contract out its poorly functioning health centers to the existing micro insurers. This could generate a number of benefits including saving the rental or construction costs of new health centers, enhancing the confidence of both clients and health personnel regarding the sustainability of the program, and avoiding inefficient duplication of health service provision.