Expanding health insurance coverage in vulnerable groups: a systematic review of options

Abstract

Vulnerable groups are often not covered by health insurance schemes. Strategies to extend coverage in these groups will help to address inequity. We used the existing literature to summarize the options for expanding health insurance coverage, describe which countries have tried these strategies, and identify and describe evaluation studies. We included any report of a policy or strategy to expand health insurance coverage and any evaluation and economic modelling studies. Vulnerable populations were defined as children, the elderly, women, low-income individuals, rural population, racial or ethnic minorities, immigrants, and those with disability or chronic diseases. Forty-five databases were searched for relevant documents. The authors applied inclusion criteria, and extracted data using pre-coded forms, on contents of health insurance schemes or programmes, and used the framework approach to establish categories. Of the 21,528 articles screened, 86 documents were finally included. Descriptions about the USA dominated (72), with only five from Africa, six from Asia and two from South America. We identified six main categories: (1) changing eligibility criteria of health insurance; (2) increasing public awareness; (3) making the premium more affordable; (4) innovative enrollment strategies; (5) improving health care delivery; and (6) improving management and organization of the insurance schemes. All six categories were found in the literature about schemes in the USA, and schemes often included components from each category. Strategies in developing countries were much more limited in their scope. Evaluation studies numbered 25, of which the majority were of time series design. All studies found that the expansion strategies were effective, as assessed by the author(s). In countries expanding coverage, the categories identified from the literature can help policy makers consider their options, implement strategies where it is common sense to do so and establish appropriate implementation monitoring.

Analysing the Influence of Health Insurance Status on Peoples’ Health Seeking Behaviour in Rural Ghana

“…Promoting and improving the services of the National Health Insurance Scheme is a very effective strategy to improve healthcare consumption by the rural people. This finding supports similar studies in Ahafo Ano South District in Ghana [21], slum areas in Accra [6, 7, 9, 25], and South Korea [26, 27] that people with health insurance cover utilize healthcare services more than those with no health insurance cover.…”

“…Access to health insurance thus comes up a game changer to significantly improve utilization of healthcare by providing financial protection against disastrous out-of-pocket healthcare expenditures. The literature establishes direct linkages between health insurance coverage and cost and actual usage of healthcare [6–9]. However, health insurance as a health financing option is poorly implemented in Sub-Saharan Africa [6, 10], and Ghana's recent “moderately successful” experience is held up as a model not only for the region, but also on the global arena.…”

Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition

“…50 Such initiatives seem to improve coverage in some but not all instances, 50 although substantial increases in access to facility-based births have been noted in low-income and middleincome countries. 37 …”

Examining the association between exposure to mass media and health insurance enrolment in Ghana

“…Yet, in the case of the NHIS, there is no study that has looked at how mass media exposure could play a role in promoting enrolment into the scheme. In many developed and developing countries, mass media campaigns through television, radio, print media, and the internet are considered useful in changing health behaviors and shaping attitudes towards health policy . For example, Kimani et al found that, in Kenya, women with higher exposure to print media, radio, and television are more likely to purchase health insurance than otherwise.…”