Health insurance coverage in low-income and middle-income countries: progress made to date and related changes in private and public health expenditure

Abstract

Introduction: Several low-income and middle-income countries (LMICs) have implemented health insurance programmes to foster accessibility to healthcare and reduce catastrophic household health expenditure. However, there is little information regarding the population coverage of health insurance schemes in LMICs and on the relationship between coverage and health expenditure. This study used open-access data to assess the level of health insurance coverage in LMICs and its relationship with health expenditure.

Methods: We searched for health insurance data for all LMICs and combined this with health expenditure data. We used descriptive statistics to explore levels of and trends in health insurance coverage over time. We then used linear regression models to investigate the relationship between health insurance coverage and sources of health expenditure and catastrophic household health expenditure.

Results: We found health insurance data for 100 LMICs and combined this with overall health expenditure data for 99 countries and household health expenditure data for 89 countries. Mean health insurance coverage was 31.1% (range: 0%-98.7%), with wide variations across country-income groups. Average health insurance coverage was 7.9% in low-income countries, 27.3% in lower middle-income countries and 52.5% in upper middle-income countries. We did not find any association between health insurance coverage and health expenditure overall, though coverage was positively associated with public health spending. Additionally, health insurance coverage was not associated with levels of or reductions in catastrophic household health expenditure or impoverishment due to health expenditure.

Conclusion: These findings indicate that LMICs continue to have low levels of health insurance coverage and that health insurance may not necessarily reduce household health expenditure. However, the lack of regular estimates of health insurance coverage in LMICs does not allow us to draw solid conclusions on the relationship between health insurance coverage and health expenditure.

Keywords: Health economics; Health insurance; Health systems.

Figure 1

Proportion of population covered by health insurance by World Bank country income group (A) and continent (B) (n=100).

Figure 2

Total current health expenditure as a portion of country gross domestic product (GDP) relative to proportion of the population covered by health insurance (n=99).

Figure 3

The proportions of total current health expenditure accounted for by government expenditure, private expenditure and external expenditure (n=99).

Figure 4

Scatter plots of country-level health insurance coverage in relation to the proportion of the population spending more than 10% (A) and 25% (B) of household income on health (n=89). Scatter plots of country-level health insurance coverage in relation to the proportion of the population pushed below $1.90/day poverty line (C) and $3.20/day poverty line (D) as a result of household expenditure on healthcare services (n=85). Note the varying scales of the y-axes.

Figure 5

Scatter plots showing the change in country-level health insurance coverage between observation years in relation to the proportion of health expenditure accounted for by government expenditure (A), private expenditure (B) and out-of-pocket expenditure (C) (n=25). For legend of country abbreviations, see online supplemental appendix I. GDP, gross domestic product.