title: Voluntary Health Insurance expenditure in low- and middle-income countries: Exploring trends during 1995-2012 and policy implications for progress towards universal health coverage.
abstract: BACKGROUND
  Most low- and middle-income countries (LMIC) rely significantly on private health expenditure in the form of out-of-pocket payments (OOP) and voluntary health insurance (VHI). This paper assesses VHI expenditure trends in LMIC and explores possible explanations. This illuminates challenges deriving from changes in VHI expenditure as countries aim to progress equitably towards universal health coverage (UHC).
  
  
  METHODS
  Health expenditure data was retrieved from the WHO Global Health Expenditure Database to calculate VHI, OOP and general government health (GGHE) expenditure as a share of total health expenditure (THE) for the period of 1995-2012. A literature analysis offered potential reasons for trends in countries and regions.
  
  
  RESULTS
  In 2012, VHI as a percentage of THE (abbreviated as VHI%) was below 1 % in 49 out of 138 LMIC. Twenty-seven countries had no or more than five years of data missing. VHI% ranged from 1 to 5 % in 39 LMIC and was above 5 % in 23 LMIC. There is an upwards average trend in VHI% across all regions. However, increases in VHI% cannot be consistently linked with OOP falling or being redirected into private prepayment. There are various countries which exhibit rising VHI alongside a rise in OOP and fall in GGHE, which is a less desirable path in order to equitably progress towards UHC.
  
  
  CONCLUSIONS
  Reasons for the VHI expenditure trends across LMIC include: external influences; government policies on the role of VHI and its regulation; and willingness and ability of the population to enrol in VHI schemes. Many countries have paid insufficient attention to the potentially risky role of VHI for equitable progress towards UHC. Expanding VHI markets bear the risk of increasing fragmentation and inequities. To avoid this, health financing strategies need to be clear regarding the role given to VHI on the path towards UHC.
authors.affiliation: Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
authors.forename: Luisa M
authors.initials: LM
authors.lastname: Pettigrew
authors.affiliation: Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. mathaueri@who.int.|Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva, Switzerland. mathaueri@who.int.
authors.forename: Inke
authors.initials: I
authors.lastname: Mathauer
mesh_terms: D003906:Developing Countries; D005102:Health Expenditures / Q000592:standards / Q000639:trends; D006291:Health Policy / Q000639:trends*; D006801:Humans; D007348:Insurance, Health / Q000191:economics* / Q000639:trends; D012648:Self Care / Q000379:methods; D019472:Universal Health Insurance / Q000639:trends*
keywords: Health expenditure; Low- and middle-income countries; Private health insurance; Universal health coverage; Voluntary health insurance