title: The role of micro health insurance in providing financial risk protection in developing countries--a systematic review.
abstract: BACKGROUND
  Out of pocket payments are the predominant method of financing healthcare in many developing countries, which can result in impoverishment and financial catastrophe for those affected. In 2010, WHO estimated that approximately 100 million people are pushed below the poverty line each year by payments for healthcare. Micro health insurance (MHI) has been used in some countries as means of risk pooling and reducing out of pocket health expenditure. A systematic review was conducted to assess the extent to which MHI has contributed to providing financial risk protection to low-income households in developing countries, and suggest how the findings can be applied in the Pakistani setting.
  
  
  METHODS
  We conducted a systematic search for published literature using the search terms "Community based health insurance AND developing countries", "Micro health insurance AND developing countries", "Mutual health insurance AND developing countries", "mutual OR micro OR community based health insurance" "Health insurance AND impact AND poor" "Health insurance AND financial protection" and "mutual health organizations" on three databases, Pubmed, Google Scholar and Science Direct (Elsevier). Only those records that were published in the last ten years, in English language with their full texts available free of cost, were considered for inclusion in this review. Hand searching was carried out on the reference lists of the retrieved articles and webpages of international organizations like World Bank, World Health Organization and International Labour Organization.
  
  
  RESULTS
  Twenty-three articles were eligible for inclusion in this systematic review (14 from Asia and 9 from Africa). Our analysis shows that MHI, in the majority of cases, has been found to contribute to the financial protection of its beneficiaries, by reducing out of pocket health expenditure, catastrophic health expenditure, total health expenditure, household borrowings and poverty. MHI also had a positive safeguarding effect on household savings, assets and consumption patterns.
  
  
  CONCLUSIONS
  Our review suggests that MHI, targeted at the low-income households and tailored to suit the cultural and geographical structures in the various areas of Pakistan, may contribute towards providing protection to the households from catastrophe and impoverishment resulting from health expenditures. This paper emphasizes the need for further research to fill the knowledge gap that exists about the impact of MHI, using robust study designs and impact indicators.
authors.affiliation: Department of Community Health Sciences, The Aga Khan University, Stadium Road, 74800, Karachi, Pakistan. shifa.hpm12006@student.aku.edu.
authors.forename: Shifa Salman
authors.initials: SS
authors.lastname: Habib
authors.affiliation: Department of Community Health Sciences, The Aga Khan University, Stadium Road, 74800, Karachi, Pakistan.
authors.forename: Shagufta
authors.initials: S
authors.lastname: Perveen
authors.affiliation: School of Nursing & Midwifery, The Aga Khan University, Stadium Road, 74800, Karachi, Pakistan.
authors.forename: Hussain Maqbool Ahmed
authors.initials: HM
authors.lastname: Khuwaja
mesh_terms: D000349:Africa; D001208:Asia; D003695:Delivery of Health Care / Q000191:economics; D003906:Developing Countries; D005191:Family Characteristics; D005382:Financing, Personal / Q000191:economics*; D005102:Health Expenditures / Q000706:statistics & numerical data; D006801:Humans; D007348:Insurance, Health / Q000191:economics / Q000458:organization & administration*; D012306:Risk
keywords: Community based health insurance; Developing countries; Financial protection; Micro health insurance; Mutual health insurance; Mutual health organizations; Pakistan; Systematic review