{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,24]],"date-time":"2026-09-24T23:30:27Z","timestamp":1790292627436,"version":"4.1.0"},"reference-count":59,"publisher":"BMJ","issue":"8","license":[{"start":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T00:00:00Z","timestamp":1785888000000},"content-version":"unspecified","delay-in-days":4,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,7,17]]},"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Out-of-pocket payments remain a major source of healthcare financing in Kenya, yet it is unclear whether health insurance coverage is associated with lower out-of-pocket spending due to non-random enrolment. This study uses coarsened exact matching (CEM) to compare out-of-pocket costs (OOPCs) between insured and uninsured individuals.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design, setting and participants<\/jats:title>\n                    <jats:p>This study used cross-sectional data from the 2022 Kenya Demographic and Health Survey which covered 80\u2009780 household members. Participants with missing or incomplete information on health insurance status and OOPC were excluded from the study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcome measures and analysis<\/jats:title>\n                    <jats:p>The main outcome variable was OOPC, computed from a summation of outpatient and inpatient costs less amounts paid by health insurance. CEM was applied to assess the influence of health insurance coverage on inpatient, outpatient and total healthcare costs. Gross healthcare expenditures (before insurance reimbursement) and net out-of-pocket payments (after insurance reimbursement) were analysed separately to distinguish healthcare utilisation from financial protection, with analyses conducted for different insurance types, including the now-defunct National Hospital Insurance Fund (NHIF), private insurance and community-based health insurance (CBHI).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>In the matched sample, insurance coverage was associated with higher gross inpatient, outpatient and total healthcare expenditures but significantly lower net OOPC for outpatient care (average treatment effect on the treated (ATET) = Kenya Shillings (KES) -5175; 95% CI \u22128755 to \u22121596), and total care (ATET = \u2212KES6680; 95% CI \u221210\u2009486 to \u22122874). The magnitude of financial protection varied by insurance type; private insurance and NHIF were associated with lower net out-of-pocket payments, while CBHI was associated with higher gross and net inpatient OOPC (ATET = KES12889; 95% CI 408 to 25370).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Among the matched insured population, these findings suggest that expanding insurance coverage alone may not be sufficient to achieve financial protection. Differences observed across schemes point to the potential importance of benefit design, reimbursement adequacy and risk pooling, particularly for schemes serving informal and low-income populations.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-111675","type":"journal-article","created":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T11:55:24Z","timestamp":1785930924000},"page":"e111675","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Effects of health insurance on out-of-pocket payments: a coarsened exact matching analysis using Kenya\u2019s 2022 demographic and health survey"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-1482-0730","authenticated-orcid":false,"given":"Denis","family":"Okova","sequence":"first","affiliation":[{"name":"Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akim","family":"Tafadzwa Lukwa","sequence":"additional","affiliation":[{"name":"Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa"},{"name":"Department of Family, Community and Emergency Care (FaCE), Faculty of Health Sciences, University of Cape Town, Cape Town, Western Cape, South Africa"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8768-6014","authenticated-orcid":false,"given":"Robinson","family":"Oyando","sequence":"additional","affiliation":[{"name":"Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edwine","family":"Barasa","sequence":"additional","affiliation":[{"name":"Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya"},{"name":"Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,5]]},"reference":[{"key":"2026090400400683000_16.8.e111675.1","unstructured":"The World Health Report 2010: Health Systems Financing\u2014the Path to Universal Coverage; Geneva World Health Organization; 2010."},{"key":"2026090400400683000_16.8.e111675.2","unstructured":"World Health Organization . Tracking universal health coverage: 2023 global monitoring report. 2023."},{"key":"2026090400400683000_16.8.e111675.3","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1080\/23288604.2015.1111288","article-title":"Making Fair Choices on the Path to Universal Health Coverage","volume":"2","author":"Chan","year":"2016","journal-title":"Health Syst Reform"},{"key":"2026090400400683000_16.8.e111675.4","doi-asserted-by":"crossref","unstructured":"Luyten E , Tubeuf S . Equity in healthcare financing: A review of evidence. Health Policy 2025;152. doi:10.1016\/j.healthpol.2024.105218","DOI":"10.1016\/j.healthpol.2024.105218"},{"key":"2026090400400683000_16.8.e111675.5","unstructured":"McIntyre D , Global forum for health research Geneva . Learning from experience: health care financing in low-and middle-income countries. 2007."},{"key":"2026090400400683000_16.8.e111675.6","doi-asserted-by":"crossref","unstructured":"McIntyre D , et al . Challenges in financing universal health coverage in sub-saharan africa, in oxford research encyclopedia of economics and finance. 2018. doi:10.1093\/9780197851418.001.0001","DOI":"10.1093\/acrefore\/9780190625979.013.28"},{"key":"2026090400400683000_16.8.e111675.7","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2020-004712","article-title":"Examining the level and inequality in health insurance coverage in 36 sub-Saharan African countries","volume":"6","author":"Barasa","year":"2021","journal-title":"BMJ Glob Health"},{"key":"2026090400400683000_16.8.e111675.8","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2019.00874"},{"key":"2026090400400683000_16.8.e111675.9","doi-asserted-by":"crossref","DOI":"10.1186\/s12939-023-01923-5","article-title":"Evaluating the effectiveness of the National Health Insurance Fund in providing financial protection to households with hypertension and diabetes patients in Kenya","volume":"22","author":"Oyando","year":"2023","journal-title":"Int J Equity Health"},{"key":"2026090400400683000_16.8.e111675.10","unstructured":"Selvaraj S , Karan AK . Why publicly-financed health insurance schemes are ineffective in providing financial risk protection. Econ Polit Wkly 2012;60\u20138."},{"key":"2026090400400683000_16.8.e111675.11","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhealeco.2008.02.002"},{"key":"2026090400400683000_16.8.e111675.12","doi-asserted-by":"crossref","DOI":"10.1186\/s12939-017-0526-x","article-title":"Assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in Kenya","volume":"16","author":"Barasa","year":"2017","journal-title":"Int J Equity Health"},{"key":"2026090400400683000_16.8.e111675.13","doi-asserted-by":"publisher","DOI":"10.1002\/hpm.2752"},{"key":"2026090400400683000_16.8.e111675.14","doi-asserted-by":"crossref","first-page":"290","DOI":"10.1002\/hpm.2905","article-title":"Patient costs of diabetes mellitus care in public health care facilities in Kenya","volume":"35","author":"Oyando","year":"2020","journal-title":"Int J Health Plann Manage"},{"key":"2026090400400683000_16.8.e111675.15","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2019-001809","article-title":"The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018","volume":"4","author":"Salari","year":"2019","journal-title":"BMJ Glob Health"},{"key":"2026090400400683000_16.8.e111675.16","doi-asserted-by":"publisher","DOI":"10.1093\/heapol\/czs073"},{"key":"2026090400400683000_16.8.e111675.17","unstructured":"Health sector strategic and investment plan II. Nairobi: Ministry of Health Kenya; 2012."},{"key":"2026090400400683000_16.8.e111675.18","unstructured":"Kenya health policy 2014-2030. Ministry of Health; 2014."},{"key":"2026090400400683000_16.8.e111675.19","unstructured":"Ministry of Health . Kenya national health accounts 2016\/17 \u2013 2018\/19. 2021: Nairobi, Kenya. 2021."},{"key":"2026090400400683000_16.8.e111675.20","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-015-0692-8","article-title":"Historical account of the national health insurance formulation in Kenya: experiences from the past decade","volume":"15","author":"Abuya","year":"2015","journal-title":"BMC Health Serv Res"},{"key":"2026090400400683000_16.8.e111675.21","doi-asserted-by":"publisher","DOI":"10.1080\/23288604.2018.1513267"},{"key":"2026090400400683000_16.8.e111675.22","unstructured":"Barasa E , Wambugu J . Report of the Health Financing Reforms Expert Pan For The Transformation and Repositioning of National Hospital Insurance Fund as a Strategic Purchaser of Health Services for the Attainment of Universal Health Coverage by 2022. 2019."},{"key":"2026090400400683000_16.8.e111675.23","unstructured":"KNBS and ICF, Kenya Demographic and Health Survey 2022 . Key indicators report. Nairobi, Kenya, and Rockville, Maryland, USA, 2023."},{"key":"2026090400400683000_16.8.e111675.24","doi-asserted-by":"crossref","DOI":"10.12688\/wellcomeopenres.12656.1","article-title":"Extending voluntary health insurance to the informal sector: experiences and expectations of the informal sector in Kenya","volume":"2","author":"Barasa","year":"2017","journal-title":"Wellcome Open Res"},{"key":"2026090400400683000_16.8.e111675.25","unstructured":"Federation of Kenya Employers . The informal economy in Kenya. 2021. Available: https:\/\/www.ilo.org\/publications\/informal-economy-kenya"},{"key":"2026090400400683000_16.8.e111675.26","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2024-085903","article-title":"Social Health Insurance for Universal Health Coverage in Low and Middle-Income Countries (LMICs): a retrospective policy analysis of attainments, setbacks and equity implications of Kenya\u2019s social health insurance model","volume":"14","author":"Nungo","year":"2024","journal-title":"BMJ Open"},{"key":"2026090400400683000_16.8.e111675.27","doi-asserted-by":"crossref","first-page":"1175","DOI":"10.1111\/tmi.12912","article-title":"Examining levels, distribution and correlates of health insurance coverage in Kenya","volume":"22","author":"Kazungu","year":"2017","journal-title":"Tropical Med Int Health"},{"key":"2026090400400683000_16.8.e111675.28","doi-asserted-by":"publisher","DOI":"10.1186\/1475-9276-13-1"},{"key":"2026090400400683000_16.8.e111675.29","first-page":"76","article-title":"The effect of Ghana\u2019s National Health Insurance Scheme on health care utilisation","volume":"46","author":"Blanchet","year":"2012","journal-title":"Ghana Med J"},{"key":"2026090400400683000_16.8.e111675.30","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0264162","article-title":"Prevalence and factors associated with health insurance coverage in urban sub-Saharan Africa: Multilevel analyses of demographic and health survey data","volume":"17","author":"Amu","year":"2022","journal-title":"PLoS One"},{"key":"2026090400400683000_16.8.e111675.31","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0160479","article-title":"What Factors Affect Voluntary Uptake of Community-Based Health Insurance Schemes in Low- and Middle-Income Countries? A Systematic Review and Meta-Analysis","volume":"11","author":"Dror","year":"2016","journal-title":"PLoS One"},{"key":"2026090400400683000_16.8.e111675.32","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-024-17691-y","article-title":"Determinants of health insurance coverage among women in Mauritania: a multilevel analysis","volume":"24","author":"Dowou","year":"2024","journal-title":"BMC Public Health"},{"key":"2026090400400683000_16.8.e111675.33","doi-asserted-by":"publisher","DOI":"10.1093\/heapol\/czz079"},{"key":"2026090400400683000_16.8.e111675.34","doi-asserted-by":"crossref","first-page":"712","DOI":"10.1057\/gpp.2014.29","article-title":"Health Insurance Coverage Within Households: The Case of Private Health Insurance in South Africa","volume":"39","author":"Govender","year":"2014","journal-title":"Geneva Pap Risk Insur Issues Pract"},{"key":"2026090400400683000_16.8.e111675.35","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1057\/gpp.2012.35","article-title":"The Impact of Health Insurance on Health-care Utilisation and Out-of-Pocket Payments in South Africa","volume":"37","author":"Ataguba","year":"2012","journal-title":"Geneva Pap Risk Insur Issues Pract"},{"key":"2026090400400683000_16.8.e111675.36","doi-asserted-by":"publisher","DOI":"10.1057\/s41599-021-00772-3"},{"key":"2026090400400683000_16.8.e111675.37","doi-asserted-by":"publisher","DOI":"10.1177\/1536867X0900900402"},{"key":"2026090400400683000_16.8.e111675.38","doi-asserted-by":"crossref","first-page":"939","DOI":"10.2217\/cer-2021-0069","article-title":"Propensity score matching versus coarsened exact matching in observational comparative effectiveness research","volume":"10","author":"Guy","year":"2021","journal-title":"J Comp Eff Res"},{"key":"2026090400400683000_16.8.e111675.39","doi-asserted-by":"publisher","DOI":"10.3982\/ECTA11293"},{"key":"2026090400400683000_16.8.e111675.40","doi-asserted-by":"publisher","DOI":"10.1111\/j.1467-6419.2007.00527.x"},{"key":"2026090400400683000_16.8.e111675.41","doi-asserted-by":"publisher","DOI":"10.1093\/pan\/mpr013"},{"key":"2026090400400683000_16.8.e111675.42","doi-asserted-by":"crossref","first-page":"38","DOI":"10.22367\/jem.2022.44.03","article-title":"Health insurance and Out of Pocket health care expenditure in Kenya","volume":"44","author":"Kamba","year":"2022","journal-title":"JEM"},{"key":"2026090400400683000_16.8.e111675.43","doi-asserted-by":"crossref","DOI":"10.1186\/s13561-023-00454-7","article-title":"The impact of health insurance enrollment on health outcomes in Kenya","volume":"13","author":"Mugo","year":"2023","journal-title":"Health Econ Rev"},{"key":"2026090400400683000_16.8.e111675.44","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0219731","article-title":"The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: A systematic review","volume":"14","author":"Erlangga","year":"2019","journal-title":"PLoS One"},{"key":"2026090400400683000_16.8.e111675.45","doi-asserted-by":"publisher","DOI":"10.2471\/BLT.12.102301"},{"key":"2026090400400683000_16.8.e111675.46","doi-asserted-by":"publisher","DOI":"10.1017\/S1744133109004836"},{"key":"2026090400400683000_16.8.e111675.47","doi-asserted-by":"crossref","DOI":"10.1002\/hsr2.1313","article-title":"Invisible illness: The consequences of limited health insurance in Africa","volume":"6","author":"Nicholas","year":"2023","journal-title":"Health Sci Rep"},{"key":"2026090400400683000_16.8.e111675.48","first-page":"443","article-title":"A Narrative Synthesis Review of Out-of-Pocket Payments for Health Services Under Insurance Regimes: A Policy Implementation Gap Hindering Universal Health Coverage in Sub-Saharan Africa","volume":"10","author":"Derkyi-Kwarteng","year":"2021","journal-title":"Int J Health Policy Manag"},{"key":"2026090400400683000_16.8.e111675.49","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1186\/s12962-020-00206-y","article-title":"The effect of medical insurance on catastrophic health expenditure: evidence from China","volume":"18","author":"Sun","year":"2020","journal-title":"Cost Eff Resour Alloc"},{"key":"2026090400400683000_16.8.e111675.50","doi-asserted-by":"crossref","DOI":"10.1186\/s12962-021-00301-8","article-title":"Strategies for reducing out of pocket payments in the health system: a scoping review","volume":"19","author":"Jalali","year":"2021","journal-title":"Cost Eff Resour Alloc"},{"key":"2026090400400683000_16.8.e111675.51","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-022-09019-6","article-title":"The impact of community-based health insurance on health service utilization and financial risk protection in Ethiopia","volume":"23","author":"Alemayehu","year":"2023","journal-title":"BMC Health Serv Res"},{"key":"2026090400400683000_16.8.e111675.52","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-023-09181-5","article-title":"Effect of community-based health insurance on catastrophic health expenditure among chronic disease patients in Asella referral hospital, Southeast Ethiopia: a comparative cross-sectional study","volume":"23","author":"Degefa","year":"2023","journal-title":"BMC Health Serv Res"},{"key":"2026090400400683000_16.8.e111675.53","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0205972","article-title":"The effect of community based health insurance on catastrophic health expenditure in Northeast Ethiopia: A cross sectional study","volume":"13","author":"Mekonen","year":"2018","journal-title":"PLoS One"},{"key":"2026090400400683000_16.8.e111675.54","doi-asserted-by":"crossref","unstructured":"Woldemichael A , Gurara DZ , Shimeles A . Community-Based Health Insurance and Out-of-Pocket Healthcare Spending in Africa: Evidence from Rwanda. SSRN J 2016. doi:10.2139\/ssrn.2776927","DOI":"10.2139\/ssrn.2776927"},{"key":"2026090400400683000_16.8.e111675.55","doi-asserted-by":"publisher","DOI":"10.1093\/heapol\/czh031"},{"key":"2026090400400683000_16.8.e111675.56","doi-asserted-by":"publisher","DOI":"10.1093\/wbro\/lks009"},{"key":"2026090400400683000_16.8.e111675.57","doi-asserted-by":"crossref","unstructured":"Woldemichael A , Gurara D , Shimeles A , et al . The impact of community based health insurance schemes on out-of-pocket healthcare spending: evidence from Rwanda. 2019.1. doi:10.5089\/9781484398074.001","DOI":"10.5089\/9781484398074.001"},{"key":"2026090400400683000_16.8.e111675.58","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1016\/j.worlddev.2018.01.023","article-title":"The political path to universal health coverage: Power, ideas and community-based health insurance in Rwanda","volume":"106","author":"Chemouni","year":"2018","journal-title":"World Dev"},{"key":"2026090400400683000_16.8.e111675.59","doi-asserted-by":"crossref","DOI":"10.1080\/23288604.2019.1619065","article-title":"Is Health Insurance Associated with Health Service Utilization and Economic Burden of Non-Communicable Diseases on Households in Vietnam?","volume":"6","author":"Giang","year":"2020","journal-title":"Health Syst Reform"}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2025-111675","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T07:40:15Z","timestamp":1788507615000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2025-111675"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8]]},"references-count":59,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8,5]]},"published-print":{"date-parts":[[2026,8]]}},"alternative-id":["10.1136\/bmjopen-2025-111675"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2025-111675","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8]]}}}