Project Summary
This project is an evaluation of a pilot project that extended the Nicaraguan Social Security Institute's (INSS) health insurance program to informal sector workers using microfinance institutions (MFIs) as delivery channels. This monitoring and evaluation activity was co-funded by the USAID-funded Private Sector Partnerships-One (PSP-One) project and the Global Development Network (GDN).
By extending the INSS' basic package of services and medications to the informal sector, the program aimed to positively impact health outcomes including family planning and reproductive health (FP/RH), as well as move towards achieving health MDGS related to the reduction of child mortality rates, improved maternal health and reduced incidence of HIV/AIDS and malaria.
Workers engaged in the informal sector, which is made up of microentrepreneurs, independent professionals and contractors, number around 1.2 million in Nicaragua. Our initial survey census of business owners and workers in urban Managua shows that although, in theory all of the informal sector workers have access to public sector services, a large majority, 93 percent, lack health insurance coverage.
Existing synergies between the delivery of financial and health services to clients in the informal sector have made MFIs an increasingly promising and innovative mechanism to extend health services to low-income groups while streamlining administrative costs for premium collection in settings where MFI penetration is high. MFIs can integrate health savings or insurance products into their menu of financial services, which may be particularly important in meeting the needs of women micro-entrepreneurs who manage their family's finances, health and education.
There is little documentation on the effectiveness of health insurance schemes targeting the informal sector regarding ability to cover costs and increase utilization of quality health services. One of the main reasons for this is the difficulty in making causal inferences from cross-sectional or panel studies. Most studies that aim to measure the impact of having health insurance on health outcomes suffer from omitted variable bias. Typically, those who are more likely to be sick will also be more likely to enroll in health insurance programs. Thus comparing outcomes for those with health insurance with those without health insurance is likely to confound these other factors that are correlated with the choice to purchase insurance, although the direction of the bias is ambiguous.
This study, however, introduced an experimental component into the evaluation in which individuals were allocated by lottery, health insurance subsidies of varying amounts, thereby eliminating this selection bias by disproportionately encouraging enrollment among a randomly chosen subset.
In addition, individuals were randomly assigned where to sign up for the insurance: either at the Social Security Institute's health insurance facility, or at participating microfinance institutions. Winning lottery tickets were only validated by the institution that was specified on the ticket. In the case of microfinance institutions, winners could select any one of three participating institutions at various branches. This allows for evaluating the impact of MFIs in delivery of the insurance product without the usual concerns of selection bias.
The baseline study involved a representative sample of approximately 4,000 informal sector workers in Managua, Nicaragua with a follow-up of a subset (2,800) of these workers approximately one year later.
This evaluation project brings together a research team including Barbara Magnoni (EA Consultants), Laurel Hatt (PSP-One, Abt Associates), Rebecca Thornton (University of Michigan), Mursaleena Islam (PSP-One, Abt Associates),Martha Azuzena Gonzalez (ALVA Consultores), Erica Field (Harvard University), and Tania Dmytraczenko (World Bank). Contributions from ALVA Consultores researchers and field staff have been essential to the research.
Documentation and Data
Coming Soon
Baseline Questionnaire (English)
Follow-up Questionnaire (English)
Baseline Questionnaire (Spanish)
Follow-up Questionnaire (Spanish)
Working Papers
Coming Soon
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