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Insurance as an instrument of financial security in addressing mental illness among agricultural workers in the LMICs

Introduction: Agriculture is a high-risk occupation globally, with risk intensities being higher in low-and middle-income countries (LMICs). Formal risk-mitigation instruments are absent in LMICs. Prevalence of financial insecurity often acts as a prominent stressor predisposing to various mental illnesses among the agrarian workers in LMICs. Aims: We review the existing scientific evidence from LMICs on the role of insurance in improving the mental health of rural workers. Our research identifies the different insurance interventions available for agrarian or rural workers in LMICs, and review their effectiveness - overall and across sub-groups in preventing the development of mental illnesses or reducing existing ones. Methodology: Our review included both peer and non-peer-reviewed literature. We involved people with lived experience (PWLE) that included farmers, workers, NGOs and health workers, policy researchers etc. with experiences from India, Bangladesh, Nepal, Peru, and South Africa. Inputs from PWLE helped in defining our key concepts for the study and in curating a list of keywords for literature search. We identified 79 articles of which we reviewed 47 articles that reported effectiveness of financial interventions, primarily Cash transfer (CT), Pension and Health insurance, Workfare and Microfinance on the mental health of rural workers in LMICs. A cash transfer (CT) is a direct transfer payment of money to an eligible person. Unlike Unconditional CT (UCT), conditional CT (CCT) are conditional upon completing specific actions beyond being eligible for CT such as sending children to school or making regular health visits. Microfinance is provision of banking service to individuals or groups who otherwise would have no access to financial services. Workfare program require participants to perform usually public-service work to receive payment. Insights from PWLE: We learned from PWLE that it is hard to distinguish between self and wage employment as workers are engaged in multiple livelihood activities, and similarly between rural and urban workers due to seasonal migration. Workers continue to work in old age as there is no concept of retirement. PWLE reported that public assistance program whether they supplement income or consumption are beneficial. Access to low cost credit enhances financial security as most workers operate in highly credit-constrained environments. Key findings: (i) Pension and health insurance led to a significant reduction in symptoms of depression and anxiety among workers, particularly among the elderly. (ii) Workfare participation led to a reduction in depression among women by increasing income security. However, in addition to financial security, non-pecuniary benefits of employment were also observed among the unemployed refugee men. (iii) CT led to a reduction in suicides among farmers during adverse income shocks, and in general improved mental health of recipients. However, when the recipients perceived CT as stigmatizing or perceived the compliance condition (as in CCT) as an additional burden, the effects of CT on mental health were negative. (iv) Microfinance schemes had mixed effects on mental health of the participants, primarily women. While it led to a reduction in depression and anxiety, loan repayment was often reported to be stressful. Recommendation for practice: Mental health should be incorporated as an additional welfare parameter in the cost-benefit analysis of policy evaluation as evidence suggest that higher income or consumption do not necessarily improve mental health. While pension and health insurance can bring in positive changes in mental health of workers, CT and microfinance schemes are no silver bullets for improving psychological well-being. CT and microfinance interventions can have an adverse effect on mental health of recipients which depend upon their design and delivery. Recommendation for research: We believe that lack of mental health data largely inhibits evidence-based research on mental health. For example, we did not find any study that evaluated agricultural insurance or price support scheme in spite of these having existed in LMICs for some time now. Evaluation of existing insurance interventions on parameters of mental health is only possible if data collection on mental health variables are encouraged.