Targeted Micro-Health Insurance in the Department of Nouna, Burkina Faso

TARGETED MICRO-HEALTH INSURANCE IN THE DEPARTMENT OF NOUNA, BURKINA FASO Inaugural-Dissertation zur Erlangung des Doktorgrades des Fachbereichs Wirtschaftswissenschaften der Ruprecht-Karls-UniversitätHeidelberg vorgelegt von Michael Schleicher Heidelberg Juli 2017 dfdfdf **** Dedicated to my Parents **** Acknowledgements I wish to thank Stefan Klonner for his close supervision throughout my PhD. I am grateful for his open door, constant support, encouragement, and advice from which I and my work have benefited tremendously. I also want to thank Axel Dreher for very useful and encouraging comments towards the end of my studies. My appreciation extends to my colleagues from the Institute of Public Health and from the Centre de Recherche en Santéde Nouna without whom this work would be impossible. In particular, I want to thank Rainer Sauerborn for his initiative in establishing the Nouna health research project and for his enthusiasm to collaborate across disciplines. I am thankful to AuréliaSouares for invaluable background information and support in preparing my field visits. The field work would not have been possible without Ali Siéwho welcomed me in Nouna. Furthermore, I am deeply grateful to Athanase Narangoro Pacere for his close and excellent collaboration in the field and beyond. I owe thanks to my colleagues in Heidelberg who created a positive and inspiring research atmosphere. I am very grateful to my family for all the opportunities provided, which eventually allowed me to follow my interests. Finally, I thank my friends and especially Bronja for their support, patience, and guidance on this journey. dfdfdf dfdfdf Contents 1 Introduction 1 2 Empirical Setting 13 2.1 The Local Context.................................... 13 2.2 Targeted Subsidized Health Insurance in Nouna ................... 17 2.3 The Data ......................................... 21 3 Community-based versus Statistical Targeting 27 3.1 Statistical versus Community-Based Poverty Targeting ............... 29 3.2 Empirical Approach ................................... 35 3.3 The Data ......................................... 38 3.4 Results........................................... 41 3.5 Discussion......................................... 53 4 Ethnic Favoritism in Decentralized Targeting 55 4.1 Empirical Approach ................................... 57 4.2 The Data ......................................... 63 4.3 Results........................................... 70 4.4 Robustness Checks.................................... 77 4.5 Discussion......................................... 78 5 Subsidized Health Insurance for the Poor 81 5.1 Empirical Approach ................................... 84 5.2 The Data ......................................... 88 5.3 Results........................................... 89 5.4 Robustness Checks.................................... 99 5.5 Discussion......................................... 103 6 Conclusion 107 Bibliography 114 Appendix 133 dfdfdf List of Figures 1.1 Coverage of social protection and labor programs by region............. 2 2.1 Location of the study site................................ 14 2.2 The survey site...................................... 16 2.3 Histogram of health care facility visits over time ................... 17 2.4 Health insurance demand and wealth before the subsidy intervention . 19 2.5 Three scenarios when applying majority rule among three representatives . 21 2.6 Merging of data sources to construct three final datasets............... 22 3.1 Costs and benefits of statistical and community-based targeting .......... 52 4.1 Average community population shares by sector.................... 64 4.2 Rural and semi-urban communities, ordered by ethnic fractionalization . 71 5.1 First-stage regression................................... 91 5.2 Intent-to-treat effect of majority-eligibility on health insurance enrollment . 92 5.3 Take-up effect along the whole distribution of semi-urban households . 96 5.4 Extrapolation of Engel Curves for semi-urban households .............. 98 5.5 Subsidy-eligibility in 2009 and baseline enrollment in 2007 to 2008 . 101 5.6 Balancing tests for six variables in semi-urban communities in 2009 . 102 Appendix............................................ A.1 Nouna town and its neighborhoods...........................134 A.2 Community-wealth ranking cards............................135 A.3 Health insurance identification card........................... 135 A.4 Sample page of administrative health insurance records . 136 B.1 Histogram and kernel densities of the consumption reference variable . 137 C.1 Fractionalization and economic inequality for semi-urban communities . 155 C.2 Ethnic favoritism in the semi-urban committee decision by community . 156 D.1 Adverse Selection: Health care utilization among insured households . 160 D.2 Local polynomial regression for health insurance enrollment . 160 dfdfdf List of Tables 2.1 Community-based targeting and community characteristics ............. 24 3.1 Community wealth rankings and community-based targeting: procedural details . 34 3.2 Targeting methods.................................... 36 3.3 Household survey summary statistics.......................... 40 3.4 Targeting errors (in percent) .............................. 42 3.5 Targeting errors by consumption expenditure quantiles ............... 43 3.6 Mean targeting errors for alternative sets of indicators and weights......... 44 3.7 Mean targeting errors and community characteristics................. 46 3.8 Cost-benefit analysis................................... 50 4.1 Community and committee characteristics: ethnicity and religion.......... 65 4.2 Census survey summary statistics by sector and sample specification . 68 4.3 Representatives' characteristics............................. 69 4.4 Test for ethnic and religious favoritism......................... 73 4.5 Additional specifications for ethnic and religious favoritism ............. 76 5.1 Set of outcome variables................................. 87 5.2 Summary statistics.................................... 89 5.3 Intent-to-treat effect of majority-eligibility on enrollment .............. 93 5.4 Different enrollment specifications for semi-urban communities ........... 94 5.5 Selection into health insurance by household member type.............. 95 5.6 'Price test' for adverse selection into health insurance ................ 99 Appendix............................................ B.1 Five statistical targeting indices and their specifications . 138 B.2 Indicators and weights of the econometric PMT index . 139 B.3 Indicators and weights of the asset index........................ 140 B.4 The Poverty Scorecard Index ..............................141 B.5 The Below the Poverty Line Scorecard.........................142 B.6 The Multidimensional Poverty Index..........................143 B.7 Mean targeting error rates, alternative consumption definition . 144 B.8 Differences between pairs of MTEs, Rural Sector ...................145 B.9 Differences between pairs of MTEs, Semi-urban Sector . 146 B.10 Differences between pairs of MTEs, Extremely poor households, Rural Sector . 147 B.11 Differences between pairs of MTEs, Moderately poor households, Rural Sector . 148 B.12 Differences between pairs of MTEs, Around median households, Rural Sector . 149 B.13 Differences between pairs of MTEs, Affluent households, Rural Sector . 150 B.14 Differences between pairs of MTEs, Extremely poor households, Semi-urban Sector 151 B.15 Differences between pairs of MTEs, Moderately poor households, Semi-urban Sector 152 B.16 Differences between pairs of MTEs, Around median households, Semi-urban Sector 153 B.17 Differences between pairs of MTEs, Affluent households, Semi-urban Sector . 154 C.1 Distribution of six ethnic and four religious groups at the community-level . 157 C.2 Numeric values to calculate the distortion due to favoritism . 157 C.3 Robustness checks ....................................158 C.4 Alternative specification for ethnic and religious favoritism . 159 D.1 First-stage regression results............................... 161 D.2 Heterogeneous effects of the subsidy offer with respect to household wealth . 162 D.3 Placebo Test: 2009 eligibility and enrollment in 2007/2008 . 163 D.4 Balancing test with six variables for semi-urban households in 2009 . 164 D.5 Intent-to-treat effect on enrollment with local polynomial regression . 165 dfdfdf dfdfdf dfdfdf Chapter 1 Introduction Social policies that are designed directly to improve the well-being of the poor have become in- creasingly popular throughout the global South (Honorati et al., 2015). International organizations such as the World Bank regard such policies as a key factor to development, as is reflected by their push to increase the number of affordable social protection systems in low-income countries (World Bank, 2012). Similarly, the first goal of the UN's Sustainable Development Goals agenda includes the objective to ensure social protection for the poor and vulnerable and to increase access to basic services.1 Social protection programs −also known as Social Safety Nets− go beyond normal emergency relief and look to to offer individuals effective protection against adverse economic shocks, encourage investments in human capital and improve people's ability to access jobs (Devereux and Sharp, 2006). Hence, social protection programs might work as a valuable complement to income-driven economic development and have the potential to break up poverty traps (Banerjee and Duflo, 2011). Alternatively,

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