Amy Dao

Department of Sociomedical Sciences

Columbia University (E-mail: [email protected])
Mark Nichter
School of Anthropology
University of Arizona, Tucson

The Social Life of Health Insurance in Low- to

Middle-income Countries: An Anthropological
Research Agenda
The following article identifies new areas for engaged medical anthropological re-
search on health insurance in low- and middle-income countries (LMICs). Based
on a review of the literature and pilot research, we identify gaps in how insurance
is understood, administered, used, and abused. We provide a historical overview
of insurance as an emerging global health panacea and then offer brief assessments
of three high-profile attempts to provide universal health coverage. Considerable
research on health insurance in LMICs has been quantitative and focused on a
limited set of outcomes. To advance the field, we identify eight productive areas
for future ethnographic research that will add depth to our understanding of the
social life and impact of health insurance in LMICs. Anthropologists can provide
unique insights into shifting health and financial practices that accompany insurance
coverage, while documenting insurance programs as they evolve and respond to con-
tingencies. [health insurance, anthropology, health reform, global health, universal
health coverage]

Introduction
Despite the establishment of health as a fundamental human right and the promo-
tion of primary health care for all under the Declaration of Alma Ata in 1978,
global economic recession through the 1980s resulted in a decline in state-based
health spending. Market-oriented reforms, including structural adjustment policies
(SAPs) across Africa, Asia, and Latin America (Logie 1993), not only cut public ex-
penditures for health but increasingly shifted the responsibility for financing health
care onto individuals and the private sector (McIntyre 2008). The introduction of
user fees at the point of service proved particularly detrimental for the poor (Janes
2006; Pfeiffer and Chapman 2010; Wu and Ramesh 2009). Ultimately, core eco-
nomic principles such as efficiency and cost effectiveness were adopted in favor of

MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 00, Issue 0, pp. 1–22, ISSN 0745-5194,
online ISSN 1548-1387.  C 2015 by the American Anthropological Association. All rights

reserved. DOI: 10.1111/maq.12191

1
2 Medical Anthropology Quarterly

the “health for all” statement of Alma Ata in determining health agendas and subse-
quent health reforms (Janes 2008). More recently, however, widespread recognition
of SAPs’ failure has led to renewed interests about how to address health inequities
through financial reform under policies for universal health coverage (UHC) (WHO
2010a).
The World Health Organization (WHO) defines UHC as “ensuring that all peo-
ple can use the promotive, preventative, curative and rehabilitative health services
they need, of sufficient quality to be effective, while ensuring that the use of these
services does not expose the user to financial hardship” (WHO 2012). The concept
has garnered attention from international development agencies in unprecedented
ways: from the director-general of WHO, who sees UHC as “the single most pow-
erful concept that public health has to offer” (Chan 2012) to the president of the
World Bank, who identified UHC as a key strategy to foster immediate, long-term
economic growth (Kim 2014). Some have gone so far as to describe financing re-
form in the service of UHC as a third health transition following public health
improvements in the 18th–20th centuries and epidemiological transition in the
20th–21st centuries (Rodin and de Ferranti 2012). For such a transition to take
place, low- and middle-income countries (LMICs) that currently lack the capacity
to deliver medicines and services to their populations require innovative approaches
to strengthening health systems (Adam et al. 2012; Hafner and Shiffman 2013)
that demand multidisciplinary health policy and systems research (HSPR)1 (Gilson
2012). Within the policy-maker’s imagination, UHC holds the promise of being
a panacea for many issues plaguing health care. Yet the term’s ambiguity has led
many to question how it will be enacted. Thus, to derive benefits from UHC-related
initiatives more holistic approaches are required that will bridge the gap between
insurance coverage and effective delivery of care.
Issues about how best to develop, implement, and evaluate UHC policies and
mechanisms like health insurance invite both applied anthropological research and
critique. We see HSPR and implementation science as allied programs sharing crit-
ical medical anthropology’s concern for distributive justice in reducing health dis-
parities (Gilson 2012; Gilson et al. 2011; Heurtin-Roberts 2014). Our intent in this
article is to introduce and encourage further anthropological research on the roll
out and impact of health care financing programs in LMICs.
We begin by describing three system-wide2 strategies being implemented in
LMICs to achieve universal coverage: tax-based financing, social health insur-
ance, and community-based health insurance. Next, we note how health service
researchers from multiple disciplines have assessed insurance programs introduced
in LMICs. Drawing on a review of existing studies on insurance in LMICs compiled
by the critical anthropology of global health special interest group3 and our own
pilot research in India and Vietnam, we identify high priority topics for anthro-
pological inquiry. Most research on insurance to date has been survey driven and
quantitative, but there is growing receptivity to qualitative research and anthropo-
logical approaches (Gilson 2012). We make a case for ethnographic research on the
“social life” of health insurance programs as a means of adding breadth and depth
to existing studies of health insurance implementation.
 The Social Life of Health Insurance in LMICs 3

Financing Plans for Universal and Community-based Coverage

Health policy and systems researchers conceptualize the health sector as a system
of different components that function together for the provision of care.4 One
critical component is financing, which refers to the mechanisms by which money is
mobilized, accumulated, and allocated to meet the health needs of both individuals
and groups.5 Financing affects access to and equity of care because it determines
the availability of money, who controls funds, who bears financial burdens, risk
pooling capacities, and control of health care costs. Throughout this article, we
take financing as our starting point to illuminate how decisions in this sector touch
on three other components: payment, involving all the details of how providers are
paid, incentives, and so on; organization, the structure of the health system and the
division of labor of institutions within it; and behavior, the habits and actions of
patients, providers, and regulators within the health system (Roberts et al. 2003).
We present a heuristic typology of national and community-based health insurance
plans below and follow the typology with country case studies chosen to illustrate
that, in practice, several elements from these different plans can appear within one
LMIC context6 (Kutzin 2012).

Tax-based Financing
Run by the national government, tax-based financing or general revenue financing
systems7 collect money through general taxation of the entire population, often
based on income (Savedoff 2004). Subsequently, money collected enters a large
“risk pool” in which the financial risks are shared among the contributors, which
allows for cross-subsidization across populations. As a progressive form of health
financing, health care access is theoretically open to all regardless of the ability
to pay. However, this method of financing comes with a formidable set of chal-
lenges. Funds initially enter the general government budget, from where it is then
distributed. During the allocation process, the funds are subject to political manipu-
lation, as politicians and interest groups influence the amount that will be dedicated
to health care. Low-income countries often lack the taxable population base and
institutional capacity to enforce effective tax collection, allowing informal and pri-
vate sector employees to slip through the cracks in terms of contribution. LMICs
may depend on regressive forms of taxation such as import/export duties, luxury or
“sin” taxes, and sales taxes more generally for contribution.

Tax-based Financing in Thailand. Under Thailand’s tax-based financing

plan, initially called the “30 Baht Health Scheme” in 2001, patients were charged
a supplementary user fee of no more than 30 baht ($1 USD in 2001) for services
and medications. Within four years, registration for health insurance increased from
40% of the population in 2001 to 95.6% in 2004, of which 13.6 million people were
previously uninsured (Damrongplasit and Melnick 2009). After achieving universal
coverage in 2006, copayments were abolished and Thailand shifted its financing to
progressive taxation, a policy whereby the rich contributed a greater share to the
plan than the poor. Pro-poor policies also decreased the incidence of catastrophic
health spending (Somkotra and Lagrada 2008).
4 Medical Anthropology Quarterly

Increased coverage has not, however, resulted in horizontal equity in service

provision. Analysis of clinic-based data indicates higher usage of local primary
health facilities by lower income groups (including the previously uninsured) and
higher usage of provincial hospitals and private clinics by higher income groups
(Yiengprugsawan 2011). This raises concerns about the “inverse equity hypothesis,”
in which “the availability of good medical care tends to vary inversely with the need
for it in the population served” (Hart 1971). Providers reported that health facilities
were unprepared to meet the new demands that came with newly covered patients,
while patients complained about the quality of care received (Boonmongkon et al.
2002). Questions have also been rasied as to whether tax revenues will be able
to sustain present and mounting levels of care and demand for medications in the
post-universal coverage era (Thoresen and Fielding 2011).

Social Health Insurance (SHI)

Like tax-based models, SHI is compulsory, but it generates revenue from employee
payroll taxes (Carrin 2002). These earmarked funds for health care are protected
from political debates over budget allocations. A “quasi-public body” manages
these funds and acts as the purchaser of health goods and services on behalf of those
covered. For the unemployed, children, or those unable to work, a separate fund
must be created to subsidize their health care, which can lead to a two-tiered system
of contributors and non-contributors. Once again, the capacity to collect contribu-
tions for insurance challenges LMICs due to limited resources, infrastructure, and
leadership.

SHI in Vietnam. Initiated in 1992 and supported by WHO and other devel-
opment partners, Vietnam’s social health insurance plan intended to curb out-of-
pocket payments and delayed treatment resulting from health sector deregulation
and privatization after economic liberalization policies were passed (Wagstaff and
Lieberman 2008). In addition to compulsory and voluntary plans, Vietnam’s tax
base–funded Health Care for the Poor (HCFP) demonstrates progressive universal-
ist policies in which “people who are poor gain at least as much as those who are
better off at every step of the way toward universal coverage” (Gwatkin 2011). Re-
searchers found that HCFP increased service utilization and reduced out-of-pocket
expenses within its first two years (Axelson et al. 2009).
Efforts to extend coverage have not proceeded without challenges. Low percep-
tion of service quality explains why only 49% of the population was covered in 2008.
Equity of financing remains limited because less than 20% of private companies,
which tend to pay higher wages, contribute to SHI (Ekman et al. 2008). Although
coverage includes formal sector workers and the poor, the informal and rural sec-
tors have not been incorporated.8 Moreover, a history of unofficial payments to
physicians due to low public wages for physicians, a growing private sector, weak
infrastructure for reimbursement, and established expectations for out-of-pocket
payments compromise the program (Carrin 2002; Ensor 1999).
 The Social Life of Health Insurance in LMICs 5

Community-based Health Insurance (CBHI)

Also known as mutual health organizations, medical aid societies, micro-finance, or
micro-insurance plans, CBHI is a private and voluntary form of prepayment, often
run by a nonprofit entity separate from the national government (Carrin 2003).
CBHI is generally defined as a “mechanism whereby households in the community
(the population in the village, district or other geographical area, or socio-economic
or ethnic population group) finance or co-finance the current and/or capital costs
associated with a given set of health services” and are provided risk pooling services
from a community-based organization to help arrange premium collection and
allocation to administrative and operational parts of health care (Bennett 2004).
Other micro-financing plans include insurance through health facilities similar to
HMOs in Western countries and workplace plans offered by employers who self-
insure.
One advantage of CBHI compared to other plans is its ability to mobilize re-
sources more quickly while also providing some financial protection for its mem-
bers (Preker and Tenkorang 2002). This is especially true in resource-limited settings
that are constrained by insufficient financial, administrative, and human capacity to
operate a plan at the national level. In addition, CBHI can be useful for countries
experiencing political unrest or whose leaders may not be interested in supporting
health policies. However, the fragmentation characteristic of CBHI makes it difficult
to operationalize beyond the community level (WHO 2010c). Establishing provider
payment systems is crucial to CBHI success and sustainability (Robyn et al. 2013),
as misaligned provider incentives under CBHI have contributed to low confidence
in some of the places where CBHI has been implemented such as Burkina Faso (Fink
et al. 2013).

CBHI in Rwanda. Government and international contributions to Rwanda’s

Mutual Health Insurance make it a modified CBHI model. Initiated in 1999 as part
of reconstruction after the 1994 genocide, it covered only 1.2% of the population,
but increased to nearly 44% of the population (4.4 million) by 2005 under 354
different plans (Soors et al. 2010). It now covers 91% of the total population (WHO
2010a). The plan was complemented by massive amounts of external resources
invested into improving the quality of primary health care in Rwanda through pay-
for-performance (P4P) plans promoted internationally by the World Bank, WHO,
and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), among
others. While P4P has received mixed reviews (Magrath and Nichter 2012), it has
fostered impressive shifts in the numbers of people signed up for insurance, reflecting
a boost of confidence in the quality of care in participating clinics.9
Despite high coverage, problems with equitable access, protection, and financing
persist. Regardless of income level, members pay premiums and fixed copayments
for medicines (Twahirwa 2008; Vialle-Valentin 2008). Without funding from in-
ternational donors to help the state create premium exemption programs, the least
wealthy would remain uninsured because CBHI is voluntary (Garrett et al. 2009).
Reliance on out-of-pocket payments not only contributes to inequity between the
insured and uninsured, but constrains utilization of services for both (Schneider and
Hanson 2007).
6 Medical Anthropology Quarterly

Insights from Multidisciplinary Research to Date

Claims that financing reforms will help complex health systems expand accessible
care to all must be substantiated. The fields of economics, health management,
law, political science, public health, and public policy currently dominate health
insurance research in LMICs. In this section, we highlight some of the major lessons
learned about health insurance to date.
1. Universal insurance coverage does not equal financial protection or access to
health care. Despite global endorsement, universal insurance coverage does not guar-
antee financial protection or access to health care due to limits on benefits offered.
Access to drugs is a case in point. Health insurance in India provides affordable
access to inpatient care, but does not cover the costs of drugs that constitute three-
fourths of out-of-pocket health expenditures (Ahlin et al. Forthcoming; Shahrawat
and Rao 2012). Even with insurance, indirect costs such as transportation and
opportunity costs like time away from work can delay treatment by making it dif-
ficult to seek care. As a result, the poor manage as best they can despite misleading
statistics implying improved access to care. For example, despite coverage increases
in China (Xu and Short 2011), self-medication is still seen as most affordable in
terms of time and money (Wen et al. 2011). Programs that provide money for these
hidden costs, called Health Equity Funds, have shown some promise in countries
like Cambodia and Uganda (Meessen et al. 2006). Without deepening coverage to
alleviate significant economic burdens caused by uncovered components of health
care, households may still be pushed into poverty.10
Provision of some modicum of quality health care also eludes universal coverage
efforts. Poor quality medicines and services are often cited in research literature
as a major hurdle. Health insurance may result in poorer quality health care. In
Vietnam and Ghana, insurance users experience longer wait times, mistreatment
by medical personnel, and prescription medicines they deem ineffective (Dalinjong
and Laar 2012; Liu et al. 2012). Many people have little faith in the plan despite
its affordability and they will not access it, believing that good health care requires
paying out of pocket.
2. Compartmentalization and fragmentation negatively affects health care eq-
uity. Public policy researchers identify fragmented and piecemeal approaches to
health care as a primary source of inequity and financial inefficiency. In India,
researchers found that catastrophic spending actually increased among the poor
after health insurance was introduced because the plan was designed to target low-
frequency, high-value hospitalization expenses to contain costs (Selvaraj and Karan
2012). With insurance, private providers found it more lucrative to hospitalize pa-
tients with simple ailments who had previously been treated in outpatient care. The
lack of an overall vision for the health system thus compartmentalized care into
secondary and tertiary level facilities rather than strengthening primary care (Desai
et al. 2014). Also relegated to the background were preventive and promotive health
care at the very time when non-communicable diseases (NCDs), linked to health
and nutritional transition, have been recognized as rising public health threats.
Inequities also arise when fragmentation in financing occurs, such as when revenue
from premiums is allocated to separate risk pools, thus creating difficulty in re-
distributing funds equitably because separate funding pools reduce the possibility
 The Social Life of Health Insurance in LMICs 7

for health system-wide income and risk cross-subsidization (WHO 2010b). For ex-
ample, CBHI represents the most fragmented financial plan because it inefficiently
duplicates administrative costs that take away from financing actual care (McIntyre
2008). Ultimately, these narrowly focused approaches miss the fundamental goal of
providing care and financial protection.
3. Universal health coverage requires careful attention towards sustainability and
the role of global institutions. Sustainability refers to the ability for health insurance
plans to maintain fiscal solvency while preserving access and quality of care, however
defined. As noted above, revenue generation is a mounting concern in countries
like Thailand that are committed to universal health care and a set of nationally
established treatment standards. A rise in chronic disease will only exacerbate this
situation. In other contexts, concerns about sustainability in financing are tied to
development aid. In Rwanda, the GFATM helps fund the 1.5 million Rwandans
who cannot afford the CBHI co-pays (Garrett et al. 2009), constituting 53.19%
of Rwanda’s total health expenditures (WHO 2009). In Laos and Cambodia, also
dependent on donor funds, reliability and identification of those eligible pose an
additional challenge (Alkenbrack and Lindelow 2013; Tangcharoensathien et al.
2011). Countries relying heavily on external aid face the challenges of future funding
uncertainty and having to make up shortfalls before being able to sustain services
through insurance contributions (Schieber et al. 2007).

The Social Life of Insurance: Anthropological Contributions and New Areas

for Research
Our use of the term “social life of insurance” refers to a framework for understand-
ing insurance as a commodity whose worth lies both within and beyond its exchange
value (Appadurai 1986). It calls attention to how insurance moves between regis-
ters of value among different stakeholders and at various scales of analysis. It also
encompasses how meaning ascribed to insurance changes over time. The social life
of insurance alerts researchers to the various factors, including the sociocultural,
economic, political, historical, and “glocal” influences (Hill 2011; Kickbusch 1999)
that contribute to the “careers” of insurance plans. In this section, we review rele-
vant anthropological work on health systems and suggest areas demanding further
investigation.
Anthropologists have only recently turned their attention to health financing de-
spite long interest in mutual support and moral economy, informal insurance, and
other community-based risk management arrangements, social capital, and reci-
procity (Bhattamishra and Barrett 2010; Platteau 1997; Popkin 1979; Scott 1977).
In addition to studying local safety nets and mutual aid arrangements, anthropolo-
gists have also contributed to our understanding of how health system viability is
subject to a range of external and internal factors: the influence of supranational
institutions, the terms of development assistance, the global market for medicines,
the capacity of domestic health facilities, and the political circumstances surround-
ing health financing. For example, they have documented the consequences of NGO
involvement on health systems (Fisher 1997; Pfeiffer 2003; Pfeiffer and Nichter
2008) and the impact of structural adjustment on state-sponsored primary care
(Pfeiffer and Chapman 2010), and they have questioned influence of pharmaceutical
8 Medical Anthropology Quarterly

industries in shaping state-sponsored public health agendas in the name of health

equity (Biehl 2007; Iriart et al. 2012).
Others looking at policy have demonstrated how liberal economic reforms re-
sulted in accessible but severely fragmented and limited basic health care (Janes
2004, 2006, 2008). They have also pointed out how policy discourses can exacer-
bate access inequities at the intersections of class and gender (Foley 2009). More
recently, anthropologists directly addressing financing have called for critical exam-
ination of financial incentive policies aimed at achieving better quality of care (Ma-
grath and Nichter 2012), analyzed redefinitions of biomedical citizenship emerging
alongside health insurance implementation (Ellison 2014), and used ethnography
to examine the relationship between health financing and health seeking (Seeberg et
al. 2014).
To further develop health financing as a topic for study, we propose eight avenues
for research that engage our conceptual framework for the social life of health
insurance, which we identified during our own pilot research on private and public
health insurance in southern India (Nichter) and Vietnam (Dao). Together, each
individual topic highlights the multiple levels and vantage points through which
to study health insurance’s social life: We start from the patient perspective, move
into critical constructs such as trust and quality, and then examine the relationships
shaped by insurance. We set forth issues from provider perspectives and finally, we
address issues at the level of the state and policymaking.

Public Response to Health Insurance

One area for anthropologists to begin an investigation of public response to health
insurance plans in LMICs is public understandings of and experiences with local
forms of mutual aid and other types of financing plans offering lines of credit. Two
questions beg examination: (1) Do populations recently exposed to health insur-
ance plans think about them in relation to previous exposure to other forms of
assistance? And (2) Is health insurance responded to differently in contexts where
indigenous forms of mutual aid are well established, such as rotating credit sys-
tems and cooperative societies (Ardener and Burman 1996; Bouman 1995; Mariam
2003)?
In India, experiences with life and car insurance as well as credit and debit cards
appear to influence attitudes toward health insurance. Life insurance is seen by
many as an investment for which a return is expected. A similar logic appears to
underscore how some are looking at health insurance. In cases where one pays into
health insurance, it is considered productive to maximize personal benefits without
regard to risk pooling. In the case of car insurance, the hassle or frustration of filing
claims has led many people to have a negative opinion of insurance, except for
catastrophic events.
Recent experience with credit cards has also influenced understandings of insur-
ance. One key informant, the manager of a small hospital in India, explained how
one of the biggest problems he faces with insured patients is that they tend to treat
insurance more like a credit card than a debit card—i.e., they do not realize they are
spending down a predetermined cap on charges. This widespread misunderstanding
 The Social Life of Health Insurance in LMICs 9

has prompted him to post signage in his office comparing insurance cards to debit
cards.
Research is needed that investigates how concepts of risk, risk sharing, distribu-
tive justice, generalized reciprocity, and hedging against financial catastrophe are
understood and addressed in local worlds. Equally important is how insurance as
both a concept and an institution have been presented to the public by different
stakeholders. Public perceptions of and demand for insurance are not static. They
are sensitive to changing policy, practice, experience, and flows of information.
Pilot research in both India and Vietnam suggests that public perception of health
insurance is being shaped by: (1) stories about insurance and quality of care circulat-
ing within personal networks; (2) rumors about insurance that index larger social
and political issues; (3) media reports that more often report on the sensational
than the mundane; and (4) insurance marketing that has become more proactive in
the last five years. It will be important to explore further what information tends
to undermine or increase confidence in insurance among different segments of the
population, how this knowledge is generated, by whom, and toward what ends.

Who Will Pay for Health Insurance and Why?

Motivations for and against joining different health financing programs need to be
examined both in terms of pragmatic and social relational considerations. Health
service researchers have focused on the pragmatic issues that influence the weighing
of costs and benefits. Anthropologists can assist them to better appreciate indirect
costs and opportunity costs, issues related to time and convenience, and differ-
ences in motivation between those who join insurance programs as a safety net for
catastrophic health events and those who do so to secure more affordable routine
care. With anthropological input, more fine-grained analyses of market segmenta-
tion can be developed.
Studies in Ghana have reported, but not explained, significant differences in
enrollment and renewal of health insurance based on factors such as gender, mar-
ital status, religion, ethnicity, class, and perception of health status (Boateng and
Awunyor-Vitor 2013; Dixon et al. 2013). Future research can further investigate
these differences in how insurance is valued by men and women of different age
cohorts, ethnic and religious groups, and the like. In India, for example, will lower
class women support the idea of paying into community-based insurance plans as a
means of investing scarce resources that might otherwise be spent by husbands for
personal reasons—a motivation reported in the case of rotating savings and credit
plans (Anderson and Baland 2002)? And will insurance reduce gender-related health
care rationing inequities, given that uninsured poor women in India are less likely
to be treated for illnesses than men (Iyer et al. 2007)?
Social relations have been insufficiently studied as a factor influencing health
insurance subscription in LMICs. Insurance is as much about the politics and
distribution of responsibility as it is about the politics and distribution of risk (Baker
and Simon 2002). As such, insurance indexes the politics of responsibility not only
at the level of the state and its obligations to citizens, but also at the community
and household levels. Pilot research in India suggests that among the middle class,
private health (and life) insurance may emerge as an idiom of concern expressing
10 Medical Anthropology Quarterly

care and responsibility within households. Will this become commonplace, and will
community-based insurance for the lower class serve a similar purpose?

Insurance and Health-seeking Behavior

A key area for anthropological contribution is research on whether and how in-
surance coverage influences health-seeking behavior among different segments of
a population. Little research has detailed how households subscribing to different
insurance plans actually use services: for whom, for what, when, and how often? Do
those who have insurance fill a majority of their health care needs at clinics covered
by insurance, or do they continue to engage in preexisting health care–seeking pat-
terns except for particular types of health care needs? Health service researchers we
interviewed identified these issues. Not identified was the way insurance coverage
affects self-treatment, treatment delay, treatment adherence, and preventive health.
Another issue is whether supply-side services covered by insurance influence
demand-side health-seeking behavior. For example, increases in caesarian birth rates
have been linked to higher insurance payment to providers for this procedure in
both LMICs (Bogg et al. 2010; Murray 2000) and higher income countries (Lee
et al. 2004). Demand for cesareans is on the rise in India. To what extent will
they be fostered by insurance coverage, and how much will demand be patient- or
practitioner driven?
Rules governing referral and health system bypassing are two other issues that
may present a challenge to government health insurance programs. Paying out of
pocket as a means to skip directly to tertiary-level care or to attend a hospital not
covered by insurance was a pervasive practice in Vietnam identified by Dao during
preliminary research. At issue is whether insurance leads to more fluid patterns of
referral and better access to valued parts of health care systems or if local populations
find insurance itineraries cumbersome and attempt to bypass them.

Trust
A certain degree of institutional trust is necessary for people to pay into an in-
surance program, raising the need for sustained attention to this concept. How is
institutional trust established above and beyond trust in the advocates of particular
insurance programs? Pilot research in India suggests that trust in insurance pro-
grams may be lost or gained in response to several different factors ranging from
perceptions of quality of care to the social relations of care delivery, expectations
from programs, and perceptions of entitlement to misunderstandings related to filing
insurance claims. Research conducted in Vietnam and other countries often investi-
gates insurance through willingness-to-pay models based on neoclassical economic
theory (Lofgren et al. 2008). However, decision-making is as much an emotional
process—based on impulse, hedging, and desperation—as it is an economic one
(Ergler et al. 2011). Consequently, the standard models often fail to capture other
dimensions that are better articulated through trust.
What has received far less attention is the process of trust building by lo-
cal organizations that sponsor insurance plans (Ahuja and Narang 2005; Bhat
and Saha 2004). Trust in clinics supported by national, state, community, and
 The Social Life of Health Insurance in LMICs 11

NGO-sponsored insurance programs appears to reflect more general levels of public

trust in the funding source and its commitment to particular agendas and particular
population groups. As noted by Mladovsky and Mossialos studying CBHI: “Soli-
darity, trust, extra-community networks, vertical civil society links and state-society
relations at the local level affect the possibility of success of CBHI” (2006:2). Studies
of the “social determinants of insurance” need to pay close attention to the social
life and trajectories of insurance plans. How is trust built by insurance programs
that start off slowly and build a consumer base over time, and what contributes to
loss of trust and popularity of insurance plans? Who is responsible when trust is
lost—marketers, agents, administrators, or health care providers?

Reconceptualizing Quality of Care and Community Efficacy within a Cultural Context

Existing studies of health insurance in both Africa and Asia have tended to pay little
attention to community-based perceptions of quality of care (Spaan et al. 2012).
Quality of care assessments have been largely based on evidence-based medicine
(EBM) criteria, which include the availability of resources, wait times, the qual-
ification of who renders services, and occasionally whether providers speak the
same language or are members of the same ethnic group as patients. Medical an-
thropologists can add further depth to the assessment of quality of care by taking
popular health culture into account. For example, one emerging issue in both India
and Vietnam was patients’ concern about the quality of medication available to
them in clinics covered by government insurance plans. This issue calls attention
to differences in community versus EBM ways of judging quality of care. Previous
anthropological research on pharmaceutical use in India (and many other LMICs)
on subjects ranging from the popularity of injections to perceptions of generic
medications (Nichter and Vuckovic 1994) illustrates differences between patients’
perceived needs and their perceptions of the quality of medicines and medical needs
as determined by EBM. Investigations of medicine perception and preferences raise
fundamental issues about the way quality of care is likely to be judged. It also invites
discussion on how best to educate the public about rational drug use and identify
agents likely to undermine such efforts. In India, such agents included both phar-
maceutical companies and private practitioners with a vested interest in appearing
to offer better quality medication. It is important to note that confidence in prac-
titioners with whom one had an established relationship outweighed both trust in
health messages and medicine brands.

Insurance and Practitioner–Patient Relations

One of the major gaps in the existing literature on health insurance in LMICs is
its lack of attention to practitioner–patient relations. A central research question
that emerged during pilot research in both India and Vietnam was how insurance
plans are likely to affect social norms and customary practice. Insurance plans may
be problematic in places where it has long been customary to gift or indirectly
pay government and indigenous practitioners for services as an incentive for good
care or to forge personal relationships (Datta 2014; Nichter 1983). In places where
this practice is suspended as a matter of policy, will it be seen as undermining
12 Medical Anthropology Quarterly

practitioner–patient relations? In what contexts will such payment be seen as cor-

ruption or continue to be deemed a socially acceptable form of relationship building
(Haller and Shore 2005)?
Another observation made during pilot research in both countries is that social
status is often an important factor in how a patient is treated at a clinic. Research on
how patients with the same insurance benefits, but different social status, are treated
in the same clinic can contribute to anthropological work on medical citizenship
(Wailoo et al. 2006) and structural vulnerability (Quesada et al. 2011).

Impact of Insurance on Providers

In principal, well-designed health insurance systems discipline all stakeholders so the
afflicted and those at risk use insurance appropriately, health care providers prac-
tice EBM in a cost-effective manner, and insurers protect against catastrophic health
spending while remaining financially solvent. In practice, this has been difficult to
achieve. Pilot research in India suggests that the theory of moral hazard may prove
useful in assessing a wide array of problems that arise when one or more stakehold-
ers “game” insurance utilization in self-serving ways that threaten the integrity of
an insurance system. Moral hazard (Stone 2011), applied in the present context,
characterizes situations in which having insurance affects health care behavior on
the part of both health care recipients and providers. These behavioral changes can
manifest in a variety of ways, ranging from how people utilize health services to the
health risks people take knowing they will receive care later. In India, it has been
reported that insured patients receive extra or unnecessary health services because
the patient does not bear the full economic cost of the bill. This over-consumption
of services, often at the advice of practitioners, drains the shared pool of resources
and drives up the costs of health care. Health providers and clever administrators
attempting to maximize profits often game the system. For example, those responsi-
ble for clinic management may seek financial advantage through such acts as over,
under, and creative diagnosis; the liberal ordering of tests; and the inappropriate
dispensing of medicines to max out or work within insurance benefit caps (Tiwari
2012). To date, medical lobby groups have fought hard against insurance company
attempts to establish standard reimbursement limits for different types of medical
problems and procedures.
Future studies should consider both provider motivation and consumer response
to gaming behavior. During field research in India, Nichter found that members
of insurance plans were unbothered by tests suspected to be unnecessary and, in
fact, linked them to high-quality care and personal benefit. If and when insurance
industry and public policy–driven discourse directs attention to the moral hazard
of gaming the insurance system, what effect will this have on perceptions of re-
sponsibility and health citizenship in both the general and health care provider
community?
We could find no ethnographic studies in LMICs that have investigated the
impact of insurance plans on the ethos of hospitals and health centers and the
motivation of clinic staff. Key issues that beg consideration include not just gaming
the system, but response to strategies employed to improve quality of care under
health insurance plans. Research will be needed about how these programs affect
 The Social Life of Health Insurance in LMICs 13

clinician motivation and clinic teamwork in the short and long term, and what
forms of recognition are likely to motivate health staff in the face of increased
workloads and greater oversight of their activities resulting from insurance
plans.
Studying up: Institutions, Decisions-makers, and Benefits Offered
Anthropologists can draw on organizational ethnography, implementation science,
and policy research when investigating the “organizational life” of insurance pro-
grams and reasons behind policy decisions (Cefkin 2011; Nambiar 2013; Shore
et al. 2011). How are insurance benefits and coverage options decided on and what
do they reveal about cultural values? Given the double burden of communicable
diseases and NCDs that characterizes health transition in LMICs, hard decisions
lie ahead for decision-makers related to resource allocation to rapidly rising patient
populations like diabetes patients, ageing populations, women beyond coverage of
reproductive health, and mental health.11 In addition, mental health is well docu-
mented as a global health problem too often deemed peripheral by planners and
international donors who mistakenly assume that mental health is not a priority for
poor people in less-resourced countries (Desjarlais et al. 1996; Patel 2012; Üstün and
Kessler 2002). Will actuarial planning refocus attention on mental health, and intro-
duce mental health services in primary health care settings? If so, will this result in
the pharmaceuticalization of psychosocial problems (Bell and Figert 2012; Busfield
2010), given a paucity of trained mental health staff, the tendency of busy doctors
to overmedicate, and the influence of the pharmaceutical industry? Ultimately, what
types of data and assumptions will be used to justify decisions made and what role
will special interest groups play in framing health problems as priorities worthy of
insurance coverage?
As a horizontal approach aimed at strengthening health systems, UHC draws
attention to relationships with the state and its governing institutions. How do state
policies alter arrangements for health care provision, and in what ways do new
regulations reshape relationships to the state? For example, the major social trans-
formations in Vietnam and China during the past century generated shifts in health
care provisions and financing. The decentralization of government welfare practices
in the 1980s fundamentally altered the role of government from provider to financier
of health that resulted in increasing and inequitable out-of-pocket payments. Both
countries are now using health insurance to refocus state efforts to manage this
split between government and providers. This history offers an interesting starting
point for investigating the politics surrounding the management and organization
of health care as well as the changing relationships to the state under new modes
of health care provision. Issues relating to the social life of health insurance can
include the blurring of the public/private realm, the materiality of bureaucracy, and
medical citizenship.

Conclusion
In many LMICs, the lion’s share of health care is paid for out of pocket and to
private health care providers, which is a major cause of household impoverishment
14 Medical Anthropology Quarterly

and precludes many from seeking health care in a timely fashion. Health insurance is
being promoted as a means to reduce both health care barriers and financial burden
through risk pooling. Public and practitioner response to health insurance rollouts,
the degree to which the policies live up to their objectives, and how recipients
make use of insurance calls for multidisciplinary research that is attentive to all
stakeholders and triangulates ethnographic data with more population-based data
being produced by our colleagues.
Our aims in this article have been to foster interest in an anthropology of health
care financing in LMICs and to suggest productive directions for engaged anthropo-
logical research on health insurance that are at once critical and constructive. The
emerging field of HPSR has welcomed anthropological input and it is now up to us
to formulate a research agenda that embraces the perspectives of both an anthro-
pology “in health financing” and an anthropology “of health financing.” A positive
step in this direction would be ethnographies of the social and organizational life of
insurance programs that are attentive to biopolitical issues driving insurance policy
decisions, program implementation and their impact on health disparities, as well as
distributive justice. A question to revisit often is: How does current health insurance
practice reflect fundamental ideas about citizen rights and state obligations? Asking
this question will lead us to consider not only programs that exist, but also the
politics of the possible.

Notes
Acknowledgments. This article builds on the “Takes a Stand” Health Insurance
Reform initiative engaged by the Critical Anthropology of Global Health study
group. We thank Craig Janes, Jessica Mulligan, Sarah Horton, Priscilla Magrath,
Tanja Ahlin, and three anonymous reviewers from MAQ for providing insightful
feedback on this article.

1. HPSR integrates multidisciplinary methods to investigate the organization of LMICs

in achieving collective health goals. The HPSR approach is question- and problem-focused
while encouraging a range of research strategies from economics, sociology, anthropology,
political science, public health, and epidemiology (Gilson 2012).
2. Other important, yet non-system-wide financing programs include voucher plans
such as health equity funds (Hardeman et al. 2004; Noirhomme et al. 2007), conditional
cash transfers (Lagarde et al. 2007), and exemption policies (Witter et al. 2007).
3. See Health Insurance Task Force bibliographies: http://www.medanthro.net/policy/
prior-statements/health-insurance-reform/
4. See “Health Systems Building Blocks” (WHO 2010a) and “Health Systems Control
Knobs” (Roberts et al. 2003) for details and typology.
5. Other important issues that we cannot cover due to space limitations are the effects of
financing on division of labor, the capacity and style of plan management, and institutional
set-up.
6. Though beyond the scope of this article, the experiences of developing health insur-
ance in high-income countries such as South Korea, France, the United Kingdom, Germany,
and Sweden would provide an interesting comparison to LMICs.
7. Although tax-based financing is not technically insurance, we included it here because
it is an important mechanism for financing populations, such as the poor or children, who
are not able to pay insurance premiums.
 The Social Life of Health Insurance in LMICs 15

8. The literature refers to this phenomenon as “squeezing in the middle”: the difficulty
in covering the non-poor or the not-so-poor informal sector that exists between the top
layer of formal sector employees and the bottom layer of the poor (Tangcharoensathien
et al. 2011).
9. Participant trust is multifactorial and likely due to a more proactive community
health worker program, increased treatment options for advanced diseases, and increased
access to specialists through new training programs such as the Human Resources for
Health partnership with U.S. medical schools.
10. Mexico’s national health insurance plan, called Seguro Popular, couples the call for
universal coverage with the need to provide social protections of health (Knaul et al. 2012).
11. Between 1995 and 2025, diabetes will increase 170% in LMICs compared to 42%
in high-income nations (Guariguata 2012).

References Cited
Adam, T., J. Hsu, D. de Savigny, J. N. Lavis, J. A. Røttingen, and S. Bennett
2012 Evaluating Health Systems Strengthening Interventions in Low-income and
Middle-income Countries: Are We Asking the Right Questions? Health Policy and
Planning 27:iv9–iv19.
Ahlin, T., M. Nichter, and G. Pillai
Forthcoming Health Insurance in India: What We Know and Why Ethnographic Re-
search Is Needed. Submitted for publication.
Ahuja, R., and A. Narang
2005 Emerging Trends in Health Insurance for Low-income Groups. Economic and
Political Weekly 40:4151–4157.
Alkenbrack, S., and M. Lindelow
2013 The Impact of Community-based Health Insurance on Utilization and Out-
of-pocket Expenditures in Lao People’s Democratic Republic. Health Economics.
doi:10.1002/hec.3023.
Anderson, S., and J.-M. Baland
2002 The Economics of Roscas and Intra-household Resource Allocation. The Quarterly
Journal of Economics 117:963–995.
Appadurai, A.
1986 The Social Life of Things: Commodities in Cultural Perspective. Cambridge: Cam-
bridge University Press.
Ardener, S., and S. Burman
1996 Money-go-rounds: The Importance of ROSCAs for Women. Oxford: Berg
Publishers.
Axelson, H., S. Bales, P. Duc Minh, B. Ekman, and U.-G. Gerdtham
2009 Health Financing for the Poor Produces Promising Short-term Effects on Utiliza-
tion and Out-of-pocket Expenditure: Evidence from Vietnam. International Jour-
nal for Equity in Health 8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2694203/
(accessed January 4, 2012).
Baker, T., and J. Simon
2002 Embracing Risk: The Changing Culture of Insurance and Responsibility. Chicago:
University of Chicago Press.
Bell, S. E, and A. E. Figert
2012 Medicalization and Pharmaceuticalization at the Intersections: Looking Backward,
Sideways and Forward. Social Science & Medicine 75:775–783.
16 Medical Anthropology Quarterly

Bennett, S.
2004 The Role of Community-based Health Insurance within the Health Care Financing
System: A Framework for Analysis. Health Policy and Planning 19:147–158.
Bhat, R., and S. Saha
2004 Health Insurance: Not a Panacea. Economic and Political Weekly 39:3667–3670.
Bhattamishra, R., and C. B. Barret
2010 Community-based Risk Management Arrangements: A Review. World Develop-
ment 38:923–932.
Biehl, J.
2007 Pharmaceuticalization: AIDS Treatment and Global Health Politics. Anthropo-
logical Quarterly 80:1083–1126.
Boateng, D., and D. Awunyor-Vitor
2013 Health Insurance in Ghana: Evaluation of Policy Holders’ Perceptions and Factors
Influencing Policy Renewal in the Volta Region. International Journal for Equity in
Health 12:50.
Bogg, L., K. Huang, Q. Long, Y. Shen, and E. Hemmink
2010 Dramatic Increase of Cesarean Deliveries in the Midst of Health Reforms in Rural
China. Social Science & Medicine 70:1544–1549.
Boonmongkon, P., M. Nichter, J. Pylypa, N. Sanhajariya, and S. Saitong
2002 Women’s Health in Northeast Thailand: Working at the Interface between the
Local and the Global. Women & Health 35:59–80.
Bouman, F. J. A.
1995 Rotating and Accumulating Savings and Credit Associations: A Development
Perspective. World Development 23:371–384.
Busfield, J.
2010 “A Pill for Every Ill”: Explaining the Expansion in Medicine Use. Social Science
& Medicine 70:934–941.
Carrin, G.
2002 Social Health Insurance in Developing Countries: A Continuing Challenge. Inter-
national Social Security Review 55:57–69.
2003 Community Based Health Insurance Schemes in Developing Countries: Facts,
Problems and Perspectives. Geneva: World Health Organization.
Cefkin, M.
2011 Ethnography and the Corporate Encounter: Reflections on Research in and of
Corporations. Oxford: Berghahn Books.
Chan, M.
2012 Best Days for Public Health Are Ahead of Us, Says WHO Director-General. In
Address to the Sixty-Fifth World Health Assembly. http://www.who.int/dg/speeches/
2012/wha_20120521/en/ (accessed May 21, 2012).
Dalinjong, P. A., and A. S. Laar
2012 The National Health Insurance Scheme: Perceptions and Experiences of Health
Care Providers and Clients in Two Districts of Ghana. Health Economics Review
2:1–13.
Damrongplasit, K., and G. A. Melnick
2009 Early Results from Thailand’s 30 Baht Health Reform: Something to Smile about.
Health Affairs 28:w457–w466.
Datta, S. S.
2014 Corruptionoma: How to Address the Malignant Condition of the Healthcare
System in India? The Health Agenda 2:1–3.
Desai, S., T. Sinha, A. Mahal, and S. Cousens
2014 Understanding CBHI Hospitalisation Patterns: A Comparison of Insured and
Uninsured Women in Gujarat, India. BMC Health Services Research 14:320.
 The Social Life of Health Insurance in LMICs 17

Desjarlais, R., L. Eisenberg, B. Good, and A. Kleinman

1996 World Mental Health: Problems and Priorities in Low-income Countries. Oxford:
Oxford University Press.
Dixon, J., E. Y. Tenkorang, and I. Luginaa
2013 Ghana’s National Health Insurance Scheme: A National Level Investigation of
Members’ Perceptions of Service Provision. BMC International Health and Human
Rights 13:35.
Ekman, B., T. Liem Nguyen, A. Duc Ha, and H. Axelson
2008 Health Insurance Reform in Vietnam: A Review of Recent Developments and
Future Challenges. Health Policy and Planning 23:252–263.
Ellison, J.
2014 First-class Health: Amenity Wards, Health Insurance, and Normalizing Health
Care Inequalities in Tanzania. Medical Anthropology Quarterly 28:162–181.
Ensor, T.
1999 Developing Health Insurance in Transitional Asia. Social Science & Medicine
48:871–879.
Ergler, C. R., P. Sakdapolrak, H.-G. Bohle, and R. A. Kearns
2011 Entitlements to Health Care: Why Is There a Preference for Private Facilities
among Poorer Residents of Chennai, India? Social Science & Medicine 72:327–337.
Fink, G., P. J. Robyn, A. Sié, and R. Sauerbor
2013 Does Health Insurance Improve Health?: Evidence from a Randomized
Community-based Insurance Rollout in Rural Burkina Faso. Journal of Health Eco-
nomics 32:1043–1056.
Fisher, W. F.
1997 Doing Good? The Politics and Antipolitics of NGO Practices. Annual Review of
Anthropology 26:439–464.
Foley, E. E.
2009 The Anti-politics of Health Reform: Household Power Relations and Child Health
in Rural Senegal. Anthropology and Medicine 16:61–71.
Garrett, L., A. Mushtaque, R. Chowdhury, and A. Pablos-Méndez
2009 All for Universal Coverage. The Lancet 347:1294–1299.
Gilson, L.
2012 Health Policy and Systems Research—A Methodology Reader. Alliance for Health
Policy and Systems Research. Geneva: World Health Organization.
Gilson, L., K. Hanson, K. Sheikh, I. A. Agyepong, F. Ssengooba, and S. Bennett
2011 Building the Field of Health Policy and Systems Research: Social Science Matters.
PLoS Med 8:e1001079.
Guariguata, L.
2012 Tracking the Global Epidemic—New Estimates from the IDF Diabetes Atlas Up-
date for 2012. Diabetes Voice 57:12–15.
Gwatkin, D. R.
2011 Universal Health Coverage: Friend or Foe of Health Equity? The Lancet 377:2160–
2161.
Hafner, T., and J. Shiffman
2013 The Emergence of Global Attention to Health Systems Strengthening. Health
Policy and Planning 28:41–50.
Haller, D., and C. Shore
2005 Corruption: Anthropological Perspectives. London: Pluto.
Hardeman, W., W. Van Damme, M. Van Pelt, I. Por, H. Kimvan and B. Meessen
2004 Access to Health Care for All? User Fees plus a Health Equity Fund in Sotnikum,
Cambodia. Health Policy and Planning 19:22–32.
18 Medical Anthropology Quarterly

Hart, J. T.
1971 The Inverse Care Law. The Lancet 297:405–412.
Heurtin-Roberts, S.
2014 But Will It Work here? Anthropology and Implementation Science. Anthropology
News. http://www.anthropology-news.org/index.php/2014/03/07/but-will-it-work-
here/ (accessed May 29, 2014).
Hill, P. S.
2011 Understanding Global Health Governance as a Complex Adaptive System. Global
Public Health 6:593–605.
Iriart, C., T. Franco, and E. E. Merhy
2012 Health Sector Reform after Managed Care Era: The Role of the Pharmaceu-
tical Industry. http://www.medanthro.net/research/cagh/insurancestatements/Iriart,
%20Franco,%20Merhy%20(pharmaceuticals).pdf (accessed January 3, 2013).
Iyer, A., G. Sen, and A. George
2007 The Dynamics of Gender and Class in Access to Health Care: Evidence from Rural
Karnataka, India. International Journal of Health Services 37:537–554.
Janes, C.
2004 Free Markets and Dead Mothers: The Social Ecology of Maternal Mortality in
Post-socialist Mongolia. Medical Anthropology Quarterly 18:230–257.
2006 Poor Medicine for Poor People? Assessing the Impact of Neoliberal Reform on
Health Care Equity in a Post-socialist Context. Global Public Health 1:5–30.
2008 An Ethnographic Evaluation of Post–Alma Ata Health System Reforms in Mongo-
lia: Lessons for Addressing Health Inequities in Poor Communities. In Anthropology
in Public Health: Bridging Differences in Culture and Society. R. A Hahn and M.
Inhorn, Eds. Pp. 652–680. Oxford: Oxford University Press.
Kickbusch, I.
1999 Global +Local = Glocal Public Health. Journal of Epidemiology and Community
Health 53:451–452.
Kim, J. Y.
2014 Speech by World Bank Group President Jim Yong Kim on Universal Health
Coverage in Emerging Economies at the Center for Strategic and International Stud-
ies Conference on Universal Health Coverage in Emerging Economies in Wash-
ington, DC. http://www.worldbank.org/en/news/speech/2014/01/14/speech-world-
bank-group-president-jim-yong-kim-health-emerging-economies (accessed January
14, 2014).
Knaul, F. M., E. González-Pier, O. Gómez-Dantés, D. Garcı́a-Junco, H. Arreola-Ornelas,
M. Barraza-Lloréns, R. Sandoval, F. Caballero, M. Hernández-Avila, M. Juan,
D. Kershenobich, G. Nigenda, E. Ruelas, J. Sepúlveda, R. Tapia, G. Soberón, S.
Chertorivski, and J. Frenk
2012 The Quest for Universal Health Coverage: Achieving Social Protection for All in
Mexico. The Lancet 380:1259–1279.
Kutzin, J.
2012 Anything Goes on the Path to Universal Health Coverage? No. Bulletin of World
Health Organization 90:867–868.
Lagarde, M., A. Haines, and N. Palmer
2007 Conditional Cash Transfers for Improving Uptake of Health Interventions in Low-
and Middle-income Countries: A Systematic Review. JAMA 298:1900–1910.
Lee, S.-I., Y.-H. Khang, and M.-S. Lee
2004 Women’s Attitudes toward Mode of Delivery in South Korea—a Society with
High Cesarean Section Rates. Birth 31:108–116.
 The Social Life of Health Insurance in LMICs 19

Liu, X., S. Tang, B. Yu, N. Khanh Phuong, F. Yan, D. Duc Thien, and R. Tolhurst
2012 Can Rural Health Insurance Improve Equity in Health Care Utilization? A Com-
parison between China and Vietnam. International Journal for Equity in Health
11:1–10.
Lofgren, C., N. X. Thanh, N. T. K. Chuc, A. Emmelin, and L. Lindholm
2008 People’s Willingness to Pay for Health Insurance in Rural Vietnam. Cost Effec-
tiveness and Resource Allocation 6:1–16.
Logie, D. E.
1993 Structural Adjustment: The Wrong Prescription for Africa? British Medical Journal
307:41–44.
Magrath, P., and M. Nichter
2012 Paying for Performance and the Social Relations of Health Care Provision: An
Anthropological Perspective. Social Science & Medicine 75:1778–1785.
Mariam, D. H.
2003 Indigenous Social Insurance as an Alternative Financing Mechanism for Health
Care in Ethiopia (the Case of Eders). Social Science & Medicine 56:1719–1726.
McIntyre, D.
2008 Beyond Fragmentation and towards Universal Coverage: Insights from Ghana,
South Africa and the United Republic of Tanzania. Bulletin of World Health Orga-
nization 86:871.
Meessen, B., W. Van Damme, C. K. Tashobya, and A. Tibouti
2006 Poverty and User Fees for Public Health Care in Low-income Countries: Lessons
from Uganda and Cambodia. Lancet 368:2253–2257.
Mladovsky, P., and E. Mossialos
2006 A Conceptual Framework for Community-based Health Insurance in Low-income
Countries: Social Capital and Economic Development. LSE Health Working Pa-
pers, 2/2006. London: LSE Health, London School of Economics and Political
Science.
Murray, S. F.
2000 Relation between Private Health Insurance and High Rates of Caesarean Section in
Chile: Qualitative and Quantitative Study. British Medical Journal 321:1501–1505.
Nambiar, D.
2013 India’s “Tryst” with Universal Health Coverage: Reflections on Ethnography in
Indian Health Policymaking. Social Science & Medicine 99:135–142.
Nichter, M.
1983 Paying for What Ails You: Sociocultural Issues Influencing the Ways and Means
of Therapy Payment in South India. Social Science & Medicine 17:957–965.
Nichter, M., and N. Vuckovic
1994 Agenda for an Anthropology of Pharmaceutical Practice. Social Science &
Medicine 39:1509–1525.
Noirhomme, M., B. Meessen, F. Griffiths, P. Ir, B. Jacobs, R. Thor, B. Criel, and W. Van
Damme
2007 Improving Access to Hospital Care for the Poor: Comparative Analysis of Four
Health Equity Funds in Cambodia. Health Policy and Planning 22:246–262.
Patel, V.
2012 Global Mental Health: From Science to Action. Harvard Review of Psychiatry
20:6–12.
Pfeiffer, J.
2003 International NGOs and Primary Health Care in Mozambique: The Need for a
New Model of Collaboration. Social Science & Medicine 56:725–738.
20 Medical Anthropology Quarterly

Pfeiffer, J., and R. Chapman

2010 Anthropological Perspectives on Structural Adjustment and Public Health. Annual
Review of Anthropology 39:149–165.
Pfeiffer, J., and M. Nichter
2008 What Can Critical Medical Anthropology Contribute to Global Health? Medical
Anthropology Quarterly 22:410–415.
Platteau, J.-P.
1997 Mutual Insurance as an Elusive Concept in Traditional Rural Communities. The
Journal of Development Studies 33:764–796.
Popkin, S. L.
1979 The Rational Peasant: The Political Economy of Rural Society in Vietnam. Berke-
ley: University of California Press.
Preker, A. S., G. Carrin, D. Dror, M. Jakab, W. Hsiao, and D. Arhin-Tenkorang
2002 Effectiveness of Community Health Financing in Meeting the Cost of Illness.
Bulletin of the World Health Organization 80:143–150.
Quesada, J., L. Kain Hart, and P. Bourgois
2011 Structural Vulnerability and Health: Latino Migrant Laborers in the United States.
Medical Anthropology 30:339–362.
Roberts, M., W. Hsiao, P. Berman, and M. Reich
2003 Getting Health Reform Right: A Guide to Improving Performance and Equity: A
Guide to Improving Performance and Equity. Oxford: Oxford University Press.
Robyn, P. J., R. Sauerborn, and T. Bärnighausen
2013 Provider Payment in Community-based Health Insurance Schemes in Developing
Countries: A Systematic Review. Health Policy and Planning 28:111–122.
Rodin, J., and D. de Ferranti
2012 Universal Health Coverage: The Third Global Health Transition? The Lancet
380:861–862.
Savedoff, W.
2004 Tax-based Financing for Health Systems: Options and Experiences. Geneva: World
Health Organization.
Schieber, G. J., P. Gottret, L. K. Fleisher, and A. A. Leive
2007 Financing Global Health: Mission Unaccomplished. Health Affairs 26:921–934.
Schneider, P., and K. Hanson
2007 The Impact of Micro Health Insurance on Rwandan Health Centre Costs. Health
Policy and Planning 22:40–48.
Scott, J. C.
1977 The Moral Economy of the Peasant: Rebellion and Subsistence in Southeast Asia.
New Haven: Yale University Press.
Seeberg, J., S. Pannarunothai, R. S. Padmawati, L. Trisnantoro, N. Barua, and C. S. Pandav
2014 Treatment Seeking and Health Financing in Selected Poor Urban Neighbourhoods
in India, Indonesia and Thailand. Social Science & Medicine 102:49–57.
Selvaraj, S., and A. K. Karan
2012 Why Publicly-financed Health Insurance Schemes Are Ineffective in Providing
Financial Risk Protection. Economic and Political Weekly 47:60–68.
Shahrawat, R., and K. D Rao
2012 Insured yet Vulnerable: Out-of-pocket Payments and India’s Poor. Health Policy
and Planning 27:213–221.
Shore, C., S. Wright, and D. Però
2011 Policy Worlds: Anthropology and the Analysis of Contemporary Power. New
York: Berghahn Books.
 The Social Life of Health Insurance in LMICs 21

Somkotra, T., and L. P. Lagrada

2008 Payments for Health Care and Its Effect on Catastrophe and Impoverishment:
Experience from the Transition to Universal Coverage in Thailand. Social Science &
Medicine 67:2027–2035.
Soors, W., N. Devadasan, V. Durairaj, and B. Criel
2010 Community Health Insurance and Universal Coverage: Multiple Paths, Many
Rivers to Cross. World Health Report (2010) Background Paper, No 48:52–57.
Spaan, E., J. Mathijssen, N. Tromp, F. McBain, A. ten Have, and R. Baltussen
2012 The Impact of Health Insurance in Africa and Asia: A Systematic Review. Bulletin
of World Health Organization 90:685–692.
Stone, D.
2011 Behind the Jargon: Moral Hazard. Journal of Health Politics, Policy and Law
36:887–896.
Tangcharoensathien, V., W. Patcharanarumol, P. Ir, S. M. Aljunid, A. G. Mukti, K.
Akkhavong, E. Banzon, D. B. Huong, H. Thabrany, and A. Mills
2011 Health-financing Reforms in Southeast Asia: Challenges in Achieving Universal
Coverage. The Lancet 377:863–873.
Thoresen, S. H., and A. Fielding
2011 Universal Health Care in Thailand: Concerns among the Health Care Workforce.
Health Policy 99:17–22.
Tiwari, D.
2012 Private Hospitals Perform Fake Surgeries to Claim Thousands in Insurance
Cover. The Economic Times. http://articles.economictimes.indiatimes.com/2012--
10--24/news/34708046_1_rsby-private-hospitals-labour-ministry (accessed Novem-
ber 12, 2012).
Twahirwa, A.
2008 Sharing the Burden of Sickness: Mutual Health Insurance in Rwanda. Bulletin of
the World Health Organization 86: 823.
Üstün, T. B., and R. C. Kessler
2002 Global Burden of Depressive Disorders: The Issue of Duration. The British Journal
of Psychiatry 181:181–183.
Vialle-Valentin, C. E.
2008 Medicines Coverage and Community-based Health Insurance in Low-income
Countries. Health Research Policy and Systems 6:1–11.
Wagstaff, A., and S. S. Lieberman
2008 Health Financing and Delivery in Vietnam. Washington, DC: World Bank Publi-
cations. https://openknowledge.worldbank.org/handle/10986/2594 License: CC BY
3.0 IGO (accessed January 5, 2012).
Wailoo, K., J. Livingston, and P. J. Guarnaccia
2006 A Death Retold: Jesica Santillan, the Bungled Transplant, and Paradoxes of Med-
ical Citizenship. Chapel Hill: University of North Carolina Press.
Wen, Y., E. Lieber, D. Wan, and Y. Hong
2011 A Qualitative Study about Self-medication in the Community among Market
Vendors in Fuzhou, China. Health & Social Care in the Community 19:504–513.
Witter, S., D. K. Arhinful, A. Kusi, and S. Zakariah-Akoto
2007 The Experience of Ghana in Implementing a User Fee Exemption Policy to Provide
Free Delivery Care. Reproductive Health Matters 15:61–71.
World Health Organization (WHO)
2009 WHO Global Health Observatory Data Repository. http://apps.who.int/nha/
database/Select/Indicators/en (accessed January 4, 2012).
22 Medical Anthropology Quarterly

2010a Health Systems Financing: The Path to Universal Coverage. The World Health
Report. Geneva: World Health Organization.
2010b Monitoring the Building Blocks of Health Systems: A Handbook of Indicators
and Their Measurement Strategies. Geneva: World Health Organization.
2010c Fragmentation in Pooling Arrangements. Technical Brief Series—Brief No. 5.
The World Health Report. Geneva: World Health Organization.
2012 Health Financing for Universal Health Coverage. What Is Universal Health Cov-
erage? http://www.who.int/health_financing/universal_coverage_definition/en/ (ac-
cessed January 3, 2012).
Wu, X., and M. Ramesh
2009 Health Care Reforms in Developing Asia: Propositions and Realities. Development
and Change 40:531–549.
Xu, H., and S. Short
2011 Health Insurance Coverage Rates in 9 Provinces in China Doubled from 1997 to
2006, with a Dramatic Rural Upswing. Health Affairs 30:2419–2426.
Yiengprugsawan, V.
2011 Explanation of Inequality in Utilization of Ambulatory Care before and after
Universal Health Insurance in Thailand. Health Policy and Planning 26:105–114.