Does health insurance improve health? Evidence from a randomized community-based insurance rollout in rural Burkina Faso

From 2004 to 2006, a community-based health insurance (CBI) scheme was rolled out in Nouna District, Burkina Faso, with the objective of improving access to health services and population health. We explore the random timing of the insurance rollout generated by the stepped wedge cluster-randomized design to evaluate the welfare and health impact of the insurance program. Our results suggest that the insurance had limited effects on average out-of-pocket expenditures in the target areas, but substantially reduced the likelihood of catastrophic health expenditure. The introduction of the insurance scheme did not have any effect on health outcomes for children and young adults, but appears to have increased mortality among individuals aged 65 and older. The negative health effects of the program appear to be primarily driven by the adverse provider incentives generated by the scheme and the resulting decline in the quality of care received by patients. © 2013 Elsevier B.V.