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Background Expanding 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. Methods We 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. Findings 8755 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). Interpretation Increased 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.

Background Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated. Methods A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem. Results Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were “ Training and retention of specialist staff ”, “ Health education/awareness of injury severity ”, “ Geographical coverage of referral trauma centres ”, and “ Lack of protocol for bypass to referral centres ”. The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map. Conclusion Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions.

Objectives This study is the first rigorous evaluation of the impact of Jaminan Kesehatan Nasional (JKN) on improving access to outpatient and inpatient care, utilising longitudinal data from the Indonesian Family Life Survey. Methods Two treatment groups were identified: a contributory group ( N = 982), who paid the premium voluntarily, and a subsidised group ( N = 2503), paid by government. Each group was compared with the uninsured group ( N = 8576). Propensity score matching combined with difference-in-difference approaches was used to estimate the causal effect of the JKN programme. Results The results found that JKN increased the probability of inpatient admission for the contributory and subsidised groups by 8.2% (95% CI 5.9–10.5%) and 1.8% (95% CI 0.7–2.82%), respectively. The contributory group had an increase in probability of an outpatient visit of 7.9% (95% CI 4.3–11.4%). Conclusions The JKN programme has increased the utilisation of outpatient and inpatient care in the contributory group. Those with subsidised insurance have an increase in access to inpatient facilities only, and this is of a smaller magnitude. Hence, while JKN has improved average utilisation, inequity in access to both outpatient and inpatient care may remain. Electronic supplementary material The online version of this article (10.1007/s00038-019-01215-2) contains supplementary material, which is available to authorized users.

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