Comfort Alison B, Peterson Lauren A, Hatt Laurel E
J Health Popul Nutr. 2013 Dec;31(4 Suppl 2):81-105.
Financial barriers can affect timely access to maternal health services. Health insurance can influence the use and quality of these services and potentially improve maternal and neonatal health outcomes. We conducted a systematic review of the evidence on health insurance and its effects on the use and provision of maternal health services and on maternal and neonatal health outcomes in middle- and low-income countries. Studies were identified through a literature search in key databases and consultation with experts in healthcare financing and maternal health. Twenty-nine articles met the review criteria of focusing on health insurance and its effect on the use or quality of maternal health services, or maternal and neonatal health outcomes. Sixteen studies assessed demand-side effects of insurance, eight focused on supply-side effects, and the remainder addressed both. Geographically, the studies provided evidence from sub-Saharan Africa (n = 11), Asia (n = 9), Latin America (n = 8), and Turkey. The studies included examples from national or social insurance schemes (n = 7), government-run public health insurance schemes (n = 4), community-based health insurance schemes (n = 11), and private insurance (n = 3). Half of the studies used econometric analyses while the remaining provided descriptive statistics or qualitative results. There is relatively consistent evidence that health insurance is positively correlated with the use of maternal health services. Only four studies used methods that can establish this causal relationship. Six studies presented suggestive evidence of over-provision of caesarean sections in response to providers' payment incentives through health insurance. Few studies focused on the relationship between health insurance and the quality of maternal health services or maternal and neonatal health outcomes. The available evidence on the quality and health outcomes is inconclusive, given the differences in measurement, contradictory findings, and statistical limitations. Consistent with economic theories, the studies identified a positive relationship between health insurance and the use of maternal health services. However, more rigorous causal methods are needed to identify the extent to which the use of these services increases among the insured. Better measurement of quality and the use of cross-country analyses would solidify the evidence on the impact of insurance on the quality of maternal health services and maternal and neonatal health outcomes.
经济障碍会影响及时获得孕产妇保健服务。医疗保险会影响这些服务的使用和质量，并有可能改善孕产妇和新生儿的健康结局。我们对低收入和中等收入国家医疗保险及其对孕产妇保健服务的使用、提供以及孕产妇和新生儿健康结局影响的证据进行了系统综述。通过在主要数据库中进行文献检索以及与医疗保健筹资和孕产妇保健领域的专家进行磋商来确定研究。29篇文章符合综述标准，即关注医疗保险及其对孕产妇保健服务的使用或质量，或孕产妇和新生儿健康结局的影响。16项研究评估了保险的需求侧效应，8项关注供给侧效应，其余的则兼顾两者。在地域上，这些研究提供了来自撒哈拉以南非洲（n = 11）、亚洲（n = 9）、拉丁美洲（n = 8）和土耳其的证据。这些研究包括来自国家或社会保险计划（n = 7）、政府运营的公共医疗保险计划（n = 4）、社区医疗保险计划（n = 11）和私人保险（n = 3）的例子。一半的研究使用了计量经济学分析，其余的则提供了描述性统计数据或定性结果。有相对一致的证据表明医疗保险与孕产妇保健服务的使用呈正相关。只有四项研究使用了能够确立这种因果关系的方法。六项研究提供了提示性证据，表明由于医疗保险提供的支付激励措施，剖宫产存在过度提供的情况。很少有研究关注医疗保险与孕产妇保健服务质量或孕产妇和新生儿健康结局之间的关系。鉴于测量方法的差异、相互矛盾的研究结果以及统计局限性，关于质量和健康结局的现有证据尚无定论。与经济理论一致，这些研究确定了医疗保险与孕产妇保健服务的使用之间存在正相关关系。然而，需要更严格的因果方法来确定参保人群中这些服务的使用增加的程度。对质量进行更好的测量以及采用跨国分析将巩固关于保险对孕产妇保健服务质量以及孕产妇和新生儿健康结局影响的证据。
