• Geren S Stone, Titus Tarus, Mainard Shikanga, Benson Biwott, Thomas Ngetich, Thomas Andale, Betsy Cheriro, and Wilson Aruasa.
• Department of Medicine, Center for Global Health, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Medicine, Moi University, Eldoret, Kenya; gstone@partners.org.
• Glob Health Action. 2014 Jan 1; 7: 23137.

BackgroundObservational data in the United States suggests that those without health insurance have a higher mortality and worse health outcomes. A linkage between insurance coverage and outcomes in hospitalized patients has yet to be demonstrated in resource-poor settings.MethodsTo determine whether uninsured patients admitted to the public medical wards at a Kenyan referral hospital have any difference in in-hospital mortality rates compared to patients with insurance, we performed a retrospective observational study of all inpatients discharged from the public medical wards at Moi Teaching and Referral Hospital in Eldoret, Kenya, over a 3-month study period from October through December 2012. The primary outcome of interest was in-hospital death, and the primary explanatory variable of interest was health insurance status.ResultsDuring the study period, 201 (21.3%) of 956 patients discharged had insurance. The National Hospital Insurance Fund was the only insurance scheme noted. Overall, 211 patients (22.1%) died. The proportion who died was greater among the uninsured compared to the insured (24.7% vs. 11.4%, Chi-square = 15.6, p<0.001). This equates to an absolute risk reduction of 13.3% (95% CI 7.9-18.7%) and a relative risk reduction of 53.8% (95% CI 30.8-69.2%) of in-hospital mortality with insurance. After adjusting for comorbid illness, employment status, age, HIV status, and gender, the association between insurance status and mortality remained statistically significant (adjusted odds ratio (AOR) = 0.40, 95% CI 0.24-0.66) and similar in magnitude to the association between HIV status and mortality (AOR = 2.45, 95% CI 1.56-3.86).ConclusionsAmong adult patients hospitalized in a public referral hospital in Kenya, insurance coverage was associated with decreased in-hospital mortality. This association was comparable to the relationship between HIV and mortality. Extension of insurance coverage may yield substantial benefits for population health.

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