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Social Security Health Insurance for the Informal Sector in Nicaragua: A Randomized Evaluation

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Name of the Asset | Social Security Health Insurance for the Informal Sector in Nicaragua: A Randomized Evaluation
Type of Asset | Working Paper
Date | September 2009


There is a growing interest among policymakers and academics regarding the delivery of insurance programs to poor and vulnerable populations throughout the world, as a way of increasing access to priority health services and protecting families from catastrophic health care costs.

This paper evaluates a program in Managua, Nicaragua that randomized incentives to obtain health insurance, enabling an estimation of the causal effects of having insurance among informal sector workers who were previously uninsured. In addition to the quantitative analysis of the demand for and effects of health insurance, the study also conducted a series of focus groups and in-depth interviews to understand uptake of the insurance program and use of health services from a qualitative perspective.

The general findings in this study provide insights on the delivery and effects of voluntary health insurance. The study suggests that streamlined, efficient administrative processes are essential for distribution of insurance to informal workers.  Costs were crucial to signing up for health insurance and retention rates were very low after the expiration of the subsidy.


  • Erica Field, Harvard University
  • Laurel Hatt, PSP-One Project, Abt Associates Inc.
  • Mursaleena Islam, PSP-One Project, Abt Associates Inc.
  • Martha Azuzena González Moncada, ALVA Consultores, Nicaragua
  • Freddy Solís, ALVA Consultores, Nicaragua
  • Rebecca Thornton, University of Michigan

Country and/or Region | Nicaragua
Name of the Program | GDN’s Global Research Project ‘Promoting Innovative Programs from the Developing World: Towards Realizing the Health MDGs in Africa and Asia'
Funder(s) | The Bill & Melinda Gates Foundation, United States

Download the Full Study here

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