This paper explores whether health insurance coverage or improved quality at the hospital level protect better against out-of-pocket payments. Using data from a randomized policy experiment in the Philippines, we found that interventions to expand insurance coverage and improve provider quality both had an impact on out-of-pocket payments. The sample consists of 3121 child-patient patient observations across 30 hospitals either at baseline in 2003/04 or at the follow-up in 2007/08. Compared to controls, interventions that expanded insurance and provided performance-based provider payments to improve quality both resulted in a decline in out-of-pocket spending (21% decline, p-value = 0.061; and 24% decline, p-value = 0.017, respectively). With lower out-of-pocket payments for hospital care, monthly household spending on personal hygiene rose by 0.9 (p-value = 0.026) and 0.6 US$ (p-value = 0.098) under the expanded insurance and provider payment interventions, respectively, amounting to roughly a 40–60% increase relative to the controls. With the current surge for health insurance expansion in developing countries, our study suggests paying increased and possibly, equal attention to supply-side interventions will have similar impacts with operational simplicity and greater provider accountability.

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Keywords Health care quality, Health insurance, Out-of-pocket payments, Philippines, RCT, Universal health coverage
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Journal Social Science & Medicine
Wagner, N, Quimbo, S. (Stella), Shimkhada, R. (Riti), & Peabody, J. (John). (2018). Does health insurance coverage or improved quality protect better against out-of-pocket payments? Experimental evidence from the Philippines. Social Science & Medicine, 204, 51–58. doi:10.1016/j.socscimed.2018.03.024