using willingness to pay data to inform the design of health insurance for the poor: evidence from...
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Using willingness to pay data to inform the design of health insurance for the poor: evidence from micro-
lending clients in Lagos, NigeriaNovember 1, 2012
Global Symposium on Health Systems Research
Payal HathiAyodeji Ajiboye
Abt Associates, Inc.
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Background• Lack of access to health insurance can lead individuals to
forgo seeking care or to incur significant out-of-pocket expenses
• Limited access to health insurance in developing countries, particularly among informal sector workers
• PATHS2 (DfID-funded Abt Associates project) is working to expand coverage of health insurance among informal sector workers – Establishing links between Health Maintenance Organizations
(HMOs) and Micro-Finance Banks (MFBs) in Lagos State, Nigeria
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PPPHI Network
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Willingness to pay study
• The purpose of the study was to understand:– Clients’ interest in health insurance and willingness
to pay for it– Clients’ and their households’ demographic and
socio-economic characteristics– Health seeking behavior and health expenses– Knowledge and prior experience with of health
insuranceOverall, aim of study was to inform design and implementation of insurance package
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Baseline characteristicsDemographic indicators
Spouse of HH head 73%Female 90%Age 39HH size 5Ever attended school 90%Primary school 25%Secondary school 54%Married 94%Own small business 77%Savings account 99%Total savings 26,329 Naira (168 USD) Current outstanding loan 66%Total loan amount 37,945 Naira (242 USD)
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HEALTH INDICATORS
Health event in last month (in HH) 14%Health event in last month (among clients) 8%Type of provider
OPD only 61%IPD only 9%OPD & IPD 1%No provider 30%
Average cost of treatment OPD visit (Naira) 5,088 Naira (32 USD)
IPD visit (Naira) 8,262 Naira (53 USD)
KNOWLEDGE/EXPERIENCE WITH HEALTH INS.
Clients who had ever heard of insurance 40%Clients who have heard of health insurance 13%Clients who have ever used health insurance 2%
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Outpatient only Childbirth only Inpatient & Outpatient
Inpatient only Pharmaceuticals only
0%
5%
10%
15%
20%
25%
30% 28%
20%19% 18%
17%
Most preferred insurance package
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Package preference breakdown
• Age: The childbirth package is most popular among those aged 16-29 and 30-39. In all other age groups, the outpatient package is most popular
• Wealth: Across all asset quintiles, the outpatient package is most preferred
• Health events: Those with 0-2 health events most preferred the outpatient package. Those with 3+ health events most preferred the outpatient + inpatient package
• Location: In both urban and peri-urban areas, the outpatient package was most preferred, while in rural areas, the childbirth package was most preferred
• Gender: Women most prefer the outpatient package, followed by the childbirth package. Men most prefer the outpatient + inpatient package, followed by the childbirth package.
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Childbirth Pharmaceuticals only
Inpatient only Inpatient & Outpatient
Outpatient only0
200
400
600
800
1,000
1,200
972843 820 801
695
Average willingness to pay by type of coverage (Naira)
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WTP for health insurance relative to health expenditure and total consumption
• On average, clients spend 2.85% of monthly consumption on health events.
• Given clients’ WTP 813 Naira per month for health insurance, they are willing to spend more than 10% of monthly consumption on health insurance.
• Clients are willing to pay almost 4 times their monthly spending on health to purchase insurance.
Monthly consumption
(n = 1,239)
Monthly health
expenditure (n = 1,239)
HE/Total Consumption
WTP for 1st choice
package (n = 1,117)
WTP/TC per respondent
WTP/HE per respondent
TOTAL 7,720 220 2.85% 813 10.53% 3.70
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Incentives for enrollment
• Most popular incentives to motivate enrollment:– Education about health insurance (58%)– Free health check-up (53%)– Premium reduction (41%)– Other goods: cookware (39%), airtime (36%), bed nets (33%)– Rewards program for health visit (35%) or food (32%)
• Small presents that clients would like to be offered:– Household needs (75%)
• Large electrical appliances (33%), cash (14%), car (8%)
– Loan (8%)
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Informing insurance product design
• Marketing about health insurance is critical given low knowledge and exposure
• Marketing and distribution adapted to demographics
• Overall interest in health insurance, particularly outpatient coverage
• Relatively high WTP for insurance• Premium financing• Transportation and cash support integration• Incentives for take-up
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Follow-up research
Even when insurance coverage is offered at an “affordable” price with desirable benefits, there may still be low take-up
Purpose of follow-up study:• Evaluate the role of different “nudges” and their
effect on insurance take-up• Evaluate the impact of insurance coverage on access
to care, financial risk protection, health outcomes, and willingness to renew insurance
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Methodological approach
• Select 1 MFB/HMO pair where new health insurance package will be offered
• Randomize the offer of incentives linked to insurance take-up– Group 1: nudge 1 (airtime?)– Group 2: nudge 2 (price reduction?)– Group 3: nudge 3 (in-depth marketing)– Group 4: offer insurance but no nudge
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Methodological approach• RCT design to evaluate impact of different nudges on
take-up of health insurance• Randomized encouragement design to identify impact
of health insurance on key outcomes of interest– Cannot withhold insurance offer or mandate take-up– Use nudges to differentially incentivize take-up
• Treatment group = all individuals eligible for nudges• Control group = individuals offered insurance with no nudge
– Compare differences in outcomes between those who take-up insurance as a result of nudge, and those who do not take-up insurance in the control group
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THANK YOU