Health insurance in Lao PDR: examining enrolment, impacts, and the prospects for expansion

As in many low- and middle-income countries, out-of-pocket payments by households account for a large share of health care spending in Lao PDR. These payments can deter use of services and increase the risk of financial catastrophe and impoverishment. Consequently, the Government of Laos is attempting to expand health insurance and . risk-protection coverage through four different schemes. This thesis examined two of those schemes: community-based health insurance (CBHI) and social health insurance (SHI). Using a conceptual framework that was developed based on the theoretical and empirical literature, three sub-studies were designed and implemented to explore: the determinants of household enrolment in CBHI; the determinants of enrolment of firms in SHI; and the impacts of CBHI enrolment on utilisation and financial protection. Data for the CBHI studies were collected using household and village surveys with 3000 households (14,804 individuals) in 87 villages, and six focus group discussions with members and non-members. In the SHI study, a survey was administered to 130 private firms. The CBHI and SHI studies employed a cross-sectional, case-comparison design and used a variety of econometric and qualitative methods in the analysis, including propensity score matching. The findings from the two enrolment studies identified various factors that drive and hinder enrolment in health insurance. The impact evaluation showed that CBHI had a positive effect on utilisation and financial protection, but given the low coverage of the scheme and low utilisation, the impacts on a population level are negligible. Moreover, the poor are the least likely to enrol and the poor who are enrolled incur higher out-of-pocket expenditures than the uninsured. The policy implications for Laos are discussed in the context of the international debate regarding the potential contributions of CBHI and SHI in national health financing strategies as countries progress towards universal coverage.