Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review

Abstract

Background One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC. Methods We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care. Results The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments. Conclusion Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific. Electronic supplementary material The online version of this article (10.1186/s12939-019-1040-0) contains supplementary material, which is available to authorized users.

Understanding the Problem of Access to Public Health Insurance Schemes among Cross-Border Migrants in Thailand through Systems Thinking

“…On the demand side, the likelihood of migrants buying HICS is shaped by affordability of the insurance, knowledge and awareness about health rights among migrants, and their own health status. Migrants who have not developed any serious diseases are less likely to understand the benefits of being insured [ 31 , 32 ]. These findings were supported by previous literature [ 33 , 34 ], which indicated this as one of barriers of migrants’ access to public health insurance in Thailand.…”

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“…Furthermore, the continuing Covid-19 pandemic has revealed underlying inequalities in access to health care, as it has had a greater impact on lower income groups [11]. Previous studies in Africa and Mexico have evidenced the financial protective effect health insurance schemes may have, particularly for lower income households [12][13][14][15][16]. In this context, we use data on a sample of federal and state workers in Akwa Ibom, Nigeria to examine the relationship between enrolment in a national health insurance scheme and household health expenditures.…”

Health insurance awareness and its uptake in India: a systematic review protocol

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“…2 4 This increases the risk of excluding vulnerable and at-risk population, who cannot afford to pay health insurance premium. 8 Additionally, the older adults, and the individuals with disability and chronic diseases, have less probability of enrolling in health insurance schemes or their specific needs may not be covered under the scheme. 8 The coverage of health insurance policies or programmes in India is improving, however, the publicly funded health insurance schemes are mostly restricted to socioeconomically backward people or government employees.…”

“…7 The Universal Health Coverage (UHC) is embedded within the Sustainable Development Goals (SDGs) and aims 'to ensure healthy lives and promote well-being for all at all ages by 2030'. 8 It includes financial risk protection and equal access to quality essential healthcare services. 8 9 In other terms, UHC encourages equitable healthcare 2 and nations across the world are committed to achieving SDGs through UHC.…”