title: Effect of health insurance and facility quality improvement on blood pressure in adults with hypertension in Nigeria: a population-based study. Does the financial protection of health insurance vary across providers? Vietnam's experience. Impact of Community-based Health Insurance on Access and Financial Protection: Evidence from Three Randomized Control Trials in Rural India. Evidence of a causal link between health outcomes, insurance coverage, and a policy to expand access: experimental data from children in the Philippines. Does health insurance improve health?: Evidence from a randomized community-based insurance rollout in rural Burkina Faso. Health insurance and health-seeking behavior: evidence from a randomized community-based insurance rollout in rural Burkina Faso. Does community-based health insurance protect household assets? Evidence from rural Africa.
abstract: IMPORTANCE Hypertension is a major public health problem in sub-Saharan Africa , but the lack of affordable treatment and the poor quality of health care compromise antihypertensive treatment coverage and outcomes . OBJECTIVE To report the effect of a community-based health insurance ( CBHI ) program on blood pressure in adults with hypertension in rural Nigeria . DESIGN , SETTING , AND PARTICIPANTS We compared changes in outcomes from baseline ( 2009 ) between the  CBHI program  area and a control area in 2011 through consecutive household surveys . Households were selected from a stratified r and om sample of geographic areas . Among 3023 community-dwelling adults , all nonpregnant adults ( aged ≥18 years ) with hypertension at baseline were eligible for this study . INTERVENTION Voluntary CBHI covering primary and secondary health care and quality improvement of health care facilities . MAIN OUTCOMES AND MEASURES The difference in change in blood pressure from baseline between the program and the control areas in 2011 , which was estimated using difference-in-differences regression analysis . RESULTS Of 1500 eligible households , 1450 ( 96.7 % ) participated , including 564 adults with hypertension at baseline ( 313 in the program area and 251 in the control area ) . Longitudinal data were available for 413 adults ( 73.2 % ) ( 237 in the program area and 176 in the control area ) . Baseline blood pressure in respondents with hypertension who had incomplete data did not differ between areas . Insurance coverage in the hypertensive population increased from 0 % to 40.1 % in the program area ( n = 237 ) and remained less than 1 % in the control area ( n = 176 ) from 2009 to 2011 . Systolic blood pressure decreased by 10.41 ( 95 % CI , -13.28 to -7.54 ) mm Hg in the program area , constituting a 5.24 ( -9.46 to -1.02)-mm Hg greater reduction compared with the control area ( P = .02 ) , where systolic blood pressure decreased by 5.17 ( -8.29 to -2.05 ) mm Hg . Diastolic blood pressure decreased by 4.27 ( 95 % CI , -5.74 to -2.80 ) mm Hg in the program area , a 2.16 ( -4.27 to -0.05)-mm Hg greater reduction compared with the control area , where diastolic blood pressure decreased by 2.11 ( -3.80 to -0.42 ) mm Hg ( P = .04 ) . CONCLUSIONS AND RELEVANCE Increased access to and improved quality of health care through a CBHI program was associated with a significant decrease in blood pressure in a hypertensive population in rural Nigeria .  Community-based health insurance programs should be included in strategies to combat cardiovascular disease in sub-Saharan Africa Using household panel data from Vietnam , this paper compares out-of-pocket health expenditures on outpatient care at a health facility between insured and uninsured patients as well as across various providers . In the r and om effects model , the estimated coefficient of the insurance status variable suggests that insurance reduces out-of-pocket spending by 24 % for those with the compulsory and voluntary coverage and by about 15 % for those with the health insurance for the poor coverage . However , the modest financial protection of the compulsory and voluntary schemes disappears once we control for time-invariant unobserved individual effects using the fixed effects model . Additional analysis of the interaction terms involving the type of insurance and health facility suggests that the overall insignificant reduction in out-of-pocket expenditures as a result of the insurance schemes masks wide variations in the reduction in out-of-pocket sending across various providers . Insurance reduces out-of-pocket expenditures more for those enrollees using district and higher level public health facilities than those using commune health centers . Compared to the uninsured patients using district hospitals , compulsory and voluntary insurance schemes reduce out-of-pocket expenditures by 40 and 32 % , respectively . However , for contacts at the commune health centers , both the compulsory health scheme and the voluntary health insurance scheme schemes have little influence on out-of-pocket spending while the health insurance scheme for the poor reduces out-of-pocket spending by about 15 % Since the 1990s , community-based health insurance ( CBHI ) schemes have been proposed to reduce the financial consequences of illness and enhance access to healthcare in developing countries . Convincing evidence on the ability of such schemes to meet their objectives is scarce . This paper uses r and omized control trials conducted in rural Uttar Pradesh and Bihar ( India ) to evaluate the effects of three CBHI schemes on healthcare utilization and expenditure .  We find that the schemes have no effect on these outcomes . The results suggest that CBHI schemes of the type examined in this paper are unlikely to have a substantial impact on access and financial protection in developing countries . Copyright © 2015 John Wiley & Sons , In this paper , we present evidence on the health effects of a health insurance intervention targeted to poor children using data from a r and omized policy experiment known as the Quality Improvement Demonstration Study . Among study participants , using a difference-in-difference regression model , we estimated a 9 - 12 and 4 - 9 percentage point reduction in the likelihood of wasting and having an infection , respectively , as measured by a common biomarker C-reactive Protein . Interestingly , these benefits were not apparent at the time of discharge ; the beneficial health effects were manifest several weeks after release from the hospital From 2004 to 2006 , a  community-based health insurance ( CBI ) scheme was rolled out in Nouna District , Burkina Faso , with the objective of improving access to health services and population health . We explore the r and om timing of the insurance rollout generated by the stepped wedge cluster-r and omized design to evaluate the welfare and health impact of the insurance program . Our results suggest that the insurance had limited effects on average out-of-pocket expenditures in the target areas , but substantially reduced the likelihood of catastrophic health expenditure . The introduction of the insurance scheme did not have any effect on health outcomes for children and young adults , but appears to have increased mortality among individuals aged 65 and older . The negative health effects of the program appear to be primarily driven by the adverse provider incentives generated by the scheme and the result ing decline in the quality of care received by patients In 2004 , a community-based health insurance ( CBI ) scheme was introduced in Nouna district , Burkina Faso , with the primary objective of improving access to facility-based health services . In order to overcome self- selection issues in the analysis of the behavioral effects of insurance , we combine four waves of the Nouna Health District Household Survey into a panel data set , and use the r and omized timing of insurance rollout to estimate the causal effect of insurance coverage on health-seeking behavior . While we find a generally positive association between CBI affiliation and treatment seeking , we can not reject the null that the introduction of health insurance does not have any effect on treatment seeking in general , and utilization of facility-based professional care , in particular . Low levels of health care provider satisfaction , poor perceived quality of care by enrollees , and ambiguity in the coverage level of the CBI benefit package appear to have contributed to these weak results . Our findings imply that the basic notion of insurance mechanically increasing facility-based professional care is not necessarily true empirically , and likely contingent on a large number of context ual factors affecting health-seeking behavior within households and communities OBJECTIVE To evaluate whether community-based health insurance ( CBHI ) protects household assets in rural Burkina Faso , Africa . DATA SOURCES Data were used from a household panel survey that collected primary data from r and omly selected households , covering 41 villages and one town , during 2004 - 2007(n = 890 ) . STUDY DESIGN The study area was divided into 33 clusters and CBHI was r and omly offered to these clusters during 2004 - 2006 . We applied different strategies to control for selection bias-ordinary least squares with covariates , two-stage least squares with instrumental variable , and fixed-effects models . DATA COLLECTION Household members were interviewed in their local language every year , and information was collected on demographic and socio-economic indicators including ownership of assets , and on self-reported morbidity . PRINCIPAL FINDINGS Fixed-effects and ordinary least squares models showed that CBHI protected household assets during 2004 - 2007 . The two-stage least squares with instrumental variable model showed that CBHI increased household assets during 2004 - 2005 . CONCLUSIONS In this study , we found that CBHI has the potential to not only protect household assets but also increase household assets . However , similar studies from developing countries that evaluate the impact of health insurance on household economic indicators are needed to benchmark these results with other setting
target: INTERPRETATION Increased health insurance coverage generally appears to increase access to health care facilities , improve financial protection and improve health status , although findings are not totally consistent .
background: BACKGROUND Exp and ing public health insurance seeks to attain several desirable objectives , including increasing access to healthcare services , reducing the risk of catastrophic healthcare expenditures , and improving health outcomes .
  The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years .