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

Abstract

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.

Impact of Health Insurance on Health Care Utilisation and Out-of-Pocket Health Expenditure in Vietnam

“…However, evidence on the effect of HI on OOP reduction is inconsistent [ 14 , 15 , 24 – 26 ]. Many recent studies have shown that HI lowers OOP [ 16 , 26 – 28 ]. However, Liu and Zhao find that the Urban Resident Basic Medical Insurance in China does not reduce OOP [ 18 ].…”

Universal Health Coverage in Marginalized Populations: A Qualitative Evaluation of a Health Reform Implementation in Rural Ecuador

“…14 Another recent review of relevance for this study concluded that there is moderate evidence that new health insurance schemes in LMIC improve the health of the insured. 15 Both reviews point to the importance of studies of implementation of health reforms and financing systems, such as our study.…”

Health shocks, medical insurance and household vulnerability: Evidence from South Africa

“…There is no significant difference in the proportion of sample that experienced health shocks by their medical insurance status. Evidence from literature is mixed in terms of the effect of medical insurance on health status, with a recent review [48] indicating that of the 12 studies: nine studies found a positive effect, one study reported a negative effect, and two studies reported no effect. Therefore the indication that medical insurance does not make a substantial impact on health shock is not contradictory to existing evidence.…”