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 ( 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.