April, 2017 - SUPPORT Summary of a systematic review | print this article |

Do social and community based health insurance schemes have an impact on the poor and the informal sector in low and middle income countries? 9

There has been an increase in caesarean section rates globally. As much as caesarean sections might be life saving, some are unnecessary, they predispose the mother to potential harms, such as haemorrhage, and they have high costs. Non clinical interventions may reduce unnecessary caesarean section. This includes interventions such as providing education to health pro-fessionals and mothers, mandatory second opinions, financial in-terventions, and other guideline implementation strategies.

 

Key messages

 

  • Interventions that may reduce unnecessary caesarean sections include: nurse-led relaxation training, birth preparation classes, education of local opinion leaders, and review of each delivery that does not meet guideline criteria + a 24-hour in house coverage system.
  • A mandatory second opinion and post caesarean section presentation of cases may reduce repeat caesarean section rates.
  • Interventions that may have little or no overall effect on caesarean section rates include: a prenatal education support programme for vaginal birth after caesarean sections, intensive group therapy for women with fear of childbirth, deci-sion aids, a mandatory second opinion and post caesarean section presentation of cases, audit and feedback, childbirth education classes for primary care nurses, changes in fees for vaginal deliveries or caesarean sections, and mandatory peer review.
  • To the extent that reducing unnecessary caesarean sections is a priority, interventions to achieve this goal should be evaluated in randomised trials or interrupted time series studies and the cost effectiveness of effective interventions should be evaluated.

 

 

There has been an increase in caesarean section rates globally. As much as caesarean sections might be life-saving, some are unnecessary, they predispose the mother to potential harms, such as haemorrhage, and they have high costs. Non-clinical interventions may reduce unnecessary caesarean section. This includes interventions such as providing education to health professionals and mothers, mandatory second opinions, financial interventions, and other guideline implementation strategies.

 

Key messages

è Interventions that may reduce unnecessary caesarean sections include: nurse-led relaxation training, birth preparation classes, education of local opinion leaders, and review of each delivery that does not meet guideline criteria + a 24-hour in-house coverage system.

è A mandatory second opinion and post-caesarean section presentation of cases may reduce repeat caesarean section rates.

è Interventions that may have little or no overall effect on caesarean section rates include: a prenatal education support programme for vaginal birth after caesarean sections, intensive group therapy for women with fear of childbirth, decision aids, a mandatory second opinion and post-caesarean section presentation of cases, audit and feedback, childbirth education classes for primary care nurses, changes in fees for vaginal deliveries or caesarean sections, and mandatory peer review.

è To the extent that reducing unnecessary caesarean sections is a priority, interventions to achieve this goal should be evaluated in randomised trials or interrupted time series studies and the cost-effectiveness of effective interventions should be evaluated.


Background

For many people in low income countries, poverty may both reduce access to healthcare and be worsened by large out of pocket payments for healthcare. Poor people include individuals working in the formal sector with low salaries and most of those employed in the informal sector.

Health insurance is a method of reducing the difficulties related to paying for healthcare. The intended impacts of health insurance include improvements in healthcare coverage and health status and reductions in out of pocket payments for individuals and households.

Social health insurance (SHI) involves compulsory contributions levied largely on the earnings of formal sector workers and the payment of healthcare providers  through an independent mechanism (a health care purchaser).

Community based health insurance (CHI) are not for profit schemes based on voluntary enrolment in which a community (which may be geographic, religious, professional or ethnic) is actively engaged in mobilizing, pooling, and allocating resources for healthcare.


 



About the systematic review underlying this summary

What the review authors searched forWhat the review authors found

Review objectives: To systematically examine studies that show the impact of nationally or sub-nationally sponsored health insurance schemes on the poor and near poor.
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, non randomised trials, controlled before after studies, regression studies and qualitative studies that measured the impact of national health insurance.
24 studies were included: 4 randomised tri-als, 10 non-randomised trials and 10 obser-vational studies. 16 studies reported on SHI and 3 on CHI. 19 studies strongly met the review inclusion criteria and 5 partially met the inclusion criteria.
Participants People taking up health insurance.
People who enrolled in social and community health insurance schemes.
Settings Low- and middle-income countries.
Burkina Faso, China (6 studies), Colombia (2 studies), Costa Rica, Egypt, Georgia, India (2 studies), Mexico (3 studies), Nicaragua, Philippines, Tanzania and Vietnam (3 studies). One study was done in Senegal, Mali and Ghana.
Outcomes Access or utilisation, healthcare expenditure and health status. Access or utilisation, healthcare expenditure and health status.
Date of most recent search: July 2010
Limitations: This is a well-conducted systematic review. However, the methods for assessing the risk of bias of the included studies were unclear.

 

Acharya A, Vellakkal S, Taylor F, Masset E, Satija A, Burke M and Ebrahim S (2012). Impact of national health insurance for the poor and the informal sector in low- and middle-income countries: a systematic review. London EPPI-Centre, Social Science Research Unit, institute of Education, University of London. http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=3346

Summary of findings

The review included 24 studies, conducted in low- and middle-income countries. The review did not report quantitative data and therefore the results are reported narratively.

 

1) Social health insurance compared to no insurance

Twenty studies reported on this comparison.

  • It is uncertain if social health insurance improves utilisation of health services and health outcomes, or leads to changes in out of pocket expenditure among those insured in low and middle income countries because the certainty of this evidence is very low.
  • It is uncertain if social health insurance improves equity because the certainty of this evidence is very low.

 

Social health insurance compared to no insurance

People:  Poor people including those working in the informal sector
Settings
:  Low and middle income countries (Nicaragua, Mexico, Colombia, Georgia, Ghana, China, Vietnam, Egypt, Indonesia)
Intervention
: Social health insurance
Comparison
: No health insurance
Outcomes Impact Certainty of the evidence
(GRADE)
Utilisation of health services (use of different types of health facilities including public and private; use of specific health services like diabetes care or pre-natal care;  visits to physicians; outpatient / inpatient services; use of formal / traditional medicine).
14 studies reported this outcome. Eight studies reported higher utilisation of health services and 5 studies found no increased utilisation among the insured.

Very low

Out of pocket expenditure on healthcare services 14 studies reported this outcome. Seven studies found reduced OOP expenditure among insured participants; 6 studies found little or no changes in expenditure; and 1 study found an increase in expenditure.

Very low

Health outcomes (e.g. glucose control in diabetic patients, infant mortality and health status of communities) Five studies reported this outcome. Three studies found little or no improvement in health outcomes for the insured and 2 studies found improvements in health outcomes.

Very low

Equity Some studies assessed impacts on poorer groups and found mixed results for utilisation of services and out of pocket expenditure.

Very low

GRADE: GRADE Working Group grades of evidence (see above and last page)

2) Community-based health insurance compared to no insurance

These were community-based health insurance programmes, some of which were initiated by the government of the countries.

  • Community health insurance may increase utilisation of health services. The certainty of this evidence is low.
  • It is uncertain if community health insurance improves health outcomes or decreases out-of-pocket expenditure because the certainty of this evidence is very low.

 

 

Community health insurance compared to no insurance

People:  Poor people including those in the informal sector
Settings
:  High income countries
Intervention
: Community health insurance
Comparison
: No health insurance
Outcomes Impact Certainty of the evidence
(GRADE)
Utilisation of health services (use of different types of health facilities  including public and private; use of specific health services like diabetes care or pre-natal care;  visits to physicians; outpatient / inpatient services; use of formal / traditional medicine).
All three studies that reported this outcome found higher utilisation of health services among those enrolled in community health insurance schemes. 

Low

Out-of-pocket expenditure on health services
 Two studies measured this outcome. A decrease in OOP expenditure was reported for one study while the results of the other study were seen as not valid due to a small sample size.

Very low

Health outcomes  (e.g., glucose control in diabetic patients, infant mortality and health status of communities) One study reported improvements in health outcomes.

Very Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries


Findings Interpretation*
APPLICABILITY
The studies were all carried out in low- and middle-income countries.

The effects of social and community-based health insur-ance schemes are largely uncertain as the certainty of the evidence is very low.

  • Health financing arrangements differ from one country to another and this should be taken into consideration when planning whether and how to implement health insurance schemes. The ease with which different insurance schemes can be implemented, and their impacts, will depend on a range of factors including the nature of the economy (whether most people are employed by the public or private sectors), the size of the formal work-force, collection mechanisms, risk pooling, and co-payments that might be incurred.
  • The acceptability to stakeholders (healthcare users, healthcare providers, professional organisations, policy makers, health delivery organisations) of different insurance schemes needs to be considered in each setting.
  •  


EQUITY

The studies examined the effects of insurance schemes among largely poorer people and those in the informal sector.

 

  • It is uncertain if social health insurance improves equity because the certainty of evidence is very low.
  •  

Disadvantaged groups who have limited financial resources and often greater healthcare needs could benefit from social and community health insurance that reduces out-of-pocket payments for healthcare. However, most of the included studies were not designed to address this question and did not report outcomes among poorer groups separately from the rest of the study population.

 

  • A number of groups may be disadvantaged in terms of access to healthcare, including poorer people as well as people living with physical and mental impairments. The needs of all these groups should be considered when planning insurance schemes - ideally insurance mechanisms should aim to be progressive and ensure cross-subsidization from richer to poorer groups.
ECONOMIC CONSIDERATIONS
Out-of-pocket spending was addressed by some studies but no long-term economic data were identified.

There are important economic consequences of rolling out insurance schemes that cover a large proportion of the population. Spreading the burden of health costs across the population will entail payment from those who are able to afford these, with smaller or no payments from individuals with little or no earnings. Payments for the latter group may need to be subsidized by the government.

  • Making health insurance more widely available may increase utilisation of health services by those who are insured. How to assess and manage this, including ensuring that service use is appropriate, needs to be considered by those developing and implementing these schemes.
  •  

MONITORING & EVALUATION
The studies included in this review did not address all of the key outcomes relevant to understanding the effects of social and community-based health insurance schemes implemented in low-income countries. Outcomes such as healthcare expenditure, equity, access to care, quality of care and health outcomes (like disease morbidity and mortality) need to be monitored in order to evaluate the effectiveness of insurance schemes. This monitoring should be continuous and should be of sufficiently robust to enable informed decisions and adjustments to be carried out.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

The effects of social and community-based health insurance schemes are largely uncertain as the certainty of the evidence is very low.

w Health financing arrangements differ from one country to another and this should be taken into consideration when planning whether and how to implement health insurance schemes. The ease with which different insurance schemes can be implemented, and their impacts, will depend on a range of factors including the nature of the economy (whether most people are employed by the public or private sectors), the size of the formal workforce, collection mechanisms, risk pooling, and co-payments that might be incurred.

w The acceptability to stakeholders (healthcare users, healthcare providers, professional organisations, policy makers, health delivery organisations) of different insurance schemes needs to be considered in each setting.

Additional information

Related literature

Jehu-Appiah C, Aryeetey G, Spaan E, De Hoop T, Agyepong I, Baltussen R (2011) Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling, who is not and why? Social Science & Medicine 72(2), 157-165.

 

McIntyre D (2012). Health service financing for universal coverage in east and southern Africa. EQUINET Discussion Paper 95. EQUINET: Harare. http://www.equinetafrica.org/sites/default/files/uploads/documents/Diss_paper_95_UHC_Dec2012.pdf

 

Sinha T, Ranson M, Chatterjee M, Acharya A, Mills A (2006) Barriers faced by the poor in benefiting from community-based insurance services: lessons learnt from SEWA Insurance, Gujarat. Health Policy and Planning 21: 132-142.

 

Wagstaff A (2009) Social health insurance re-examined. Health Economics 19: 503-517.

 

WHO (2010) The world health report: health systems financing: the path to universal coverage. http://www.who.int/whr/2010/en/index.html.

 

This summary was prepared by

Motaze NV, Wiysonge CS, Centre for Evidence-Based Health care, Stellenbosch University, South Africa.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Donela Besada, Simon Lewin, Cristian Herrera Riquelme

and Andy Oxman. We did not receive any comments from the review authors.

 

This review should be cited as

Acharya A, Vellakkal S, Taylor F, Masset E, Satija A, Burke M and Ebrahim S (2012). Impact of national

health insurance for the poor and the informal sector in low- and middle-income countries: a systematic

review. London EPPI-Centre, Social Science Research Unit, institute of Education, University of London.

http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=3346.

 

The summary should be cited as

Motaze NV, Wiysonge CS. Do social and community-based health insurance schemes have an impact on the poor and the informal sector in low- and middle-income countries? A SUPPORT Summary of a systematic review. April 2017. www.supportsummaries.org

 

Keywords

Evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care

Community health insurance, community-based health insurance, social health insurance, health service utilisation, out-of-pocket payment, informal sector

 



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