The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: A systematic review.

Darius Erlangga,Marc Suhrcke,Shehzad Ali,Karen Bloor,Sandra C Buttigieg

doi:10.1371/journal.pone.0219731

Darius Erlangga, Marc Suhrcke + Show 3 more

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https://doi.org/10.1371/journal.pone.0219731

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Abstract

BackgroundExpanding public health insurance seeks to attain several desirable objectives, including increasing access to healthcare services, reducing the risk of catastrophic healthcare expenditures, and improving health outcomes. The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years.MethodsWe reviewed systematically empirical studies published from July 2010 to September 2016 using Medline, Embase, Econlit, CINAHL Plus via EBSCO, and Web of Science and grey literature databases. No language restrictions were applied. Our focus was on both randomised and observational studies, particularly those including explicitly attempts to tackle selection bias in estimating the treatment effect of health insurance. The main outcomes are: (1) utilisation of health services, (2) financial protection for the target population, and (3) changes in health status.Findings8755 abstracts and 118 full-text articles were assessed. Sixty-eight studies met the inclusion criteria including six randomised studies, reflecting a substantial increase in the quantity and quality of research output compared to the time period before 2010. Overall, health insurance schemes in low- and middle-income countries (LMICs) have been found to improve access to health care as measured by increased utilisation of health care facilities (32 out of 40 studies). There also appeared to be a favourable effect on financial protection (26 out of 46 studies), although several studies indicated otherwise. There is moderate evidence that health insurance schemes improve the health of the insured (9 out of 12 studies).InterpretationIncreased health insurance coverage generally appears to increase access to health care facilities, improve financial protection and improve health status, although findings are not totally consistent. Understanding the drivers of differences in the outcomes of insurance reforms is critical to inform future implementations of publicly funded health insurance to achieve the broader goal of universal health coverage.

Highlights

In recent decades, achieving universal health coverage (UHC) has been a major health policy focus globally.[1,2,3] UHC entitles all people to access healthcare services through publicly organised risk pooling,[4] safeguarding against the risk of catastrophic healthcare expenditures.[5]
We recognise the heterogeneity of insurance schemes implemented in Low- and middle-income countries (LMICs) and do not attempt to generalise findings, but we aim to explore
Our findings showed that only three papers between 2010 and 2016 were able to conduct a randomised study to evaluate the impact of health insurance programmes in developing countries, community-based health insurance (CBHI) [38,75,103]

Summary

Introduction

In recent decades, achieving universal health coverage (UHC) has been a major health policy focus globally.[1,2,3] UHC entitles all people to access healthcare services through publicly organised risk pooling,[4] safeguarding against the risk of catastrophic healthcare expenditures.[5]. Introducing and increasing the coverage of publicly organised and financed health insurance is widely seen as the most promising way of achieving UHC,[9,10] since private insurance is mostly unaffordable for the poor.[11] Historically, social health insurance, tax-based insurance, or a mix of the two have been the dominant health insurance models amongst high income countries and some LMICs, including Brazil, Colombia, Costa Rica, Mexico, and Thailand.[12] This is partly influenced by the size of the formal sector economy from which taxes and payroll contributions can be collected. The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years

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