Encouraging Health Insurance for the Informal Sector: A Cluster Randomized Experiment in Vietnam

Abstract

Subsidized voluntary enrollment in government-run health insurance schemes is often proposed as a way of increasing coverage among informal sector workers and their families. We report the results of a cluster randomized experiment, in which 3000 households in 20 communes in Vietnam were randomly assigned at baseline to a control group or one of three treatments: an information leaflet about Vietnam's government-run scheme and the benefits of health insurance, a voucher entitling eligible household members to 25% off their annual premium, and both. At baseline, the four groups had similar enrollment rates (4%) and were balanced on plausible enrollment determinants. The interventions all had small and insignificant effects (around 1 percentage point or ppt). Among those reporting sickness in the 12 months prior to the baseline survey the subsidy-only intervention raised enrollment by 3.5 ppts (p = 0.08) while the combined intervention raised enrollment by 4.5 ppts (p = 0.02); however, the differences in the effect sizes between the sick and non-sick were just shy of being significant. Our results suggest that information campaigns and subsidies may have limited effects on voluntary health insurance enrollment in Vietnam and that such interventions might exacerbate adverse selection. Copyright © The World Bank Health Economics © 2015 John Wiley & Sons, Ltd.

Expanding social health protection in Cambodia: An assessment of the current coverage potential and gaps, and social equity considerations

“…A study from Viet Nam found enrolment at baseline to be 4 per cent. Information campaigns and the offer of a subsidy only increased enrolment by 1–3.5 per cent with results suggesting that such interventions may exacerbate adverse selection (Wagstaff et al, ). There is strong evidence demonstrating that voluntary health insurance programmes for the non‐poor informal sector have extremely low uptake (Cotlear et al, ).…”

Symposium: Efforts to Extend Effective Coverage in Asia

“…Two randomised experiments conducted in the Philippines (Capuno et al , ) and Vietnam (Wagstaff et al ., ) reveal that substantial premium subsidies had modest, if any, impact on insurance uptake. In Vietnam, despite affordability being reported as the main reason for not purchasing insurance, a 25% subsidy had no effect, even when combined with promotion of the benefits of insurance.…”

Extending health insurance coverage to the informal sector: Lessons from a private micro health insurance scheme in Lagos, Nigeria

“…The MFB felt that the insurance agents slowed down the loan officers, making it difficult for them to maintain their usual schedule. The insurer noted that voluntary enrollment was low and observed potential adverse selection, 2 challenges well documented in the literature . As a result, the partners decided to make insurance enrollment mandatory starting in October 2014.…”

“…Reflecting the global commitment to advance universal health coverage (UHC), a growing number of low‐ and middle‐income countries are implementing health system reforms to reduce financial barriers and increase access to priority health services for all citizens . One major challenge for governments and other stakeholders is how to extend coverage to informal sector workers, who typically make up the majority of the population in these countries . There is a growing body of evidence on demand for health insurance and its effects on access to health services among the informal sector .…”

“…A related body of research has examined supply‐side readiness and the design and financing of health insurance benefit plans . However, fewer studies examine the delivery of health insurance to this target population, particularly in urban settings where social and economic factors differ from the rural areas more frequently documented in the literature …”