Willingness-to-Pay for Health Insurance in South Asia: A Systematic Review and Meta-Analysis.

INTRODUCTION

In low- and middle-income countries, healthcare systems rely heavily on out-of-pocket payments, causing financial hardship and limiting access to care. Globally, 800 million people spend over 10% of household income on healthcare, driving 100 million into extreme poverty due to catastrophic health expenditures (CHE). In South Asia, out-of-pocket (OOP) payments remain the primary funding source, with India and Bangladesh reporting significant CHE burdens. Health insurance (HI) can reduce costs, improve access and mitigate CHE, playing a key role in achieving universal health coverage.

OBJECTIVE

We conducted this systematic review and meta-analysis to estimate the proportion of willingness-to-pay (WTP) for HI and to explore the factors generally associated with it.

METHODS

Electronic searches of PubMed, Google Scholar and Bangladesh Journals Online (BanglaJOL), as well as citation tracking, were conducted to identify eligible studies. Study quality was assessed using the Newcastle-Ottawa Scale. Publication bias was evaluated using Egger's test and funnel plots. Leave-one-out sensitivity and subgroup analyses by WTP elicitation method and insurance type were conducted. All analyses were conducted in STATA 19.

RESULTS

We included 17 studies from 5 South Asian countries in the analysis. The pooled proportion of WTP for HI was 0.72 (95% CI: 0.61-0.82), with a 95% prediction interval of 0.20-1.00 and considerable heterogeneity (I 2 = 99.59%, τ 2 = 0.2474). The pooled proportion from Bangladeshi studies was higher than that of Indian studies (0.83 and 0.69, respectively). Leave-one-out estimates ranged from 0.70 to 0.76. Age, sex, level of education, size of the family, socio-economic status, monthly personal income, occupation, family income, healthcare utilisation and healthcare expenditure were generally associated with WTP.

CONCLUSION

Overall, 72% of participants were willing to pay for HI, although substantial heterogeneity was observed across studies. Further robust studies are needed to better characterise WTP for HI in South Asia.