Effects of health insurance on out-of-pocket payments: a coarsened exact matching analysis using Kenya’s 2022 demographic and health survey
Denis Okova, Akim Tafadzwa Lukwa, Robinson Oyando, Edwine BarasaObjectives
Out-of-pocket payments remain a major source of healthcare financing in Kenya, yet it is unclear whether health insurance coverage is associated with lower out-of-pocket spending due to non-random enrolment. This study uses coarsened exact matching (CEM) to compare out-of-pocket costs (OOPCs) between insured and uninsured individuals.
Design, setting and participants
This study used cross-sectional data from the 2022 Kenya Demographic and Health Survey which covered 80 780 household members. Participants with missing or incomplete information on health insurance status and OOPC were excluded from the study.
Outcome measures and analysis
The main outcome variable was OOPC, computed from a summation of outpatient and inpatient costs less amounts paid by health insurance. CEM was applied to assess the influence of health insurance coverage on inpatient, outpatient and total healthcare costs. Gross healthcare expenditures (before insurance reimbursement) and net out-of-pocket payments (after insurance reimbursement) were analysed separately to distinguish healthcare utilisation from financial protection, with analyses conducted for different insurance types, including the now-defunct National Hospital Insurance Fund (NHIF), private insurance and community-based health insurance (CBHI).
Results
In the matched sample, insurance coverage was associated with higher gross inpatient, outpatient and total healthcare expenditures but significantly lower net OOPC for outpatient care (average treatment effect on the treated (ATET) = Kenya Shillings (KES) -5175; 95% CI −8755 to −1596), and total care (ATET = −KES6680; 95% CI −10 486 to −2874). The magnitude of financial protection varied by insurance type; private insurance and NHIF were associated with lower net out-of-pocket payments, while CBHI was associated with higher gross and net inpatient OOPC (ATET = KES12889; 95% CI 408 to 25370).
Conclusions
Among the matched insured population, these findings suggest that expanding insurance coverage alone may not be sufficient to achieve financial protection. Differences observed across schemes point to the potential importance of benefit design, reimbursement adequacy and risk pooling, particularly for schemes serving informal and low-income populations.