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Adverse Selection in Community Based Health Insurance among Informal Workers in Bangladesh: An EQ-5D Assessment

Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, SE-171 77 Stockholm, Sweden
Department of Management Science, University of Strathclyde, Glasgow G1 1XQ, UK
Faculty of Health, Deakin University, Melbourne, VIC 3125, Australia
Department of Agriculture Economics, Purdue University, IN 47907, USA
Centre for Health Economics, University of York, York YO10 5DD, UK
Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2018, 15(2), 242;
Received: 15 November 2017 / Revised: 4 January 2018 / Accepted: 29 January 2018 / Published: 31 January 2018
(This article belongs to the Special Issue Insurance and Health)
PDF [633 KB, uploaded 31 January 2018]


Community-based Health Insurance (CBHI) schemes are recommended for providing financial risk protection to low-income informal workers in Bangladesh. We assessed the problem of adverse selection in a pilot CBHI scheme in this context. In total, 1292 (646 insured and 646 uninsured) respondents were surveyed using the Bengali version of the EuroQuol-5 dimensions (EQ-5D) questionnaire for assessing their health status. The EQ-5D scores were estimated using available regional tariffs. Multiple logistic regression was applied for predicting the association between health status and CBHI scheme enrolment. A higher number of insured reported problems in mobility (7.3%; p = 0.002); self-care (7.1%; p = 0.000) and pain and discomfort (7.7%; p = 0.005) than uninsured. The average EQ-5D score was significantly lower among the insured (0.704) compared to the uninsured (0.749). The regression analysis showed that those who had a problem in mobility (m 1.25–2.17); self-care (OR = 2.29; 95% CI: 1.62–3.25) and pain and discomfort (OR = 1.43; 95% CI: 1.13–1.81) were more likely to join the scheme. Individuals with higher EQ-5D scores (OR = 0.46; 95% CI: 0.31–0.69) were less likely to enroll in the scheme. Given that adverse selection was evident in the pilot CBHI scheme, there should be consideration of this problem when planning scale-up of these kind of schemes. View Full-Text
Keywords: adverse selection; community based health insurance; EQ-5D adverse selection; community based health insurance; EQ-5D

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Ahmed, S.; Sarker, A.R.; Sultana, M.; Chakrovorty, S.; Hasan, M.Z.; Mirelman, A.J.; Khan, J.A.M. Adverse Selection in Community Based Health Insurance among Informal Workers in Bangladesh: An EQ-5D Assessment. Int. J. Environ. Res. Public Health 2018, 15, 242.

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