Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon.
Int J Equity Health. 2018 Jan 29;17(1):13. doi: 10.1186/s12939-018-0721-4.
Community-based health insurance (CBHI) has evolved as an alternative health financing mechanism to out of pocket payments in low- and middle-income countries (LMICs), particularly in areas where government or employer-based health insurance is minimal. This systematic review aimed to assess the barriers and facilitators to implementation, uptake and sustainability of CHBI schemes in LMICs.
We searched six electronic databases and grey literature. We included both quantitative and qualitative studies written in English language and published after year 1992. Two reviewers worked in duplicate and independently to complete study selection, data abstraction, and assessment of methodological features. We synthesized the findings based on thematic analysis and categorized according to the ecological model into individual, interpersonal, community and systems levels.
Of 15,510 citations, 51 met the eligibility criteria. Individual factors included awareness and understanding of the concept of CBHI, trust in scheme and scheme managers, perceived service quality, and demographic characteristics, which influenced enrollment and sustainability. Interpersonal factors such as household dynamics, other family members enrolled in the scheme, and social solidarity influenced enrollment and renewal of membership. Community-level factors such as culture and community involvement in scheme development influenced enrollment and sustainability of scheme. Systems-level factors encompassed governance, financial and delivery arrangement. Government involvement, accountability of scheme management, and strong policymaker-implementer relation facilitated implementation and sustainability of scheme. Packages that covered outpatient and inpatient care and those tailored to community needs contributed to increased enrollment. Amount and timing of premium collection was reported to negatively influence enrollment while factors reported as threats to sustainability included facility bankruptcy, operating on small budgets, rising healthcare costs, small risk pool, irregular contributions, and overutilization of services. At the delivery level, accessibility of facilities, facility environment, and health personnel influenced enrollment, service utilization and dropout rates.
There are a multitude of interrelated factors at the individual, interpersonal, community and systems levels that drive the implementation, uptake and sustainability of CBHI schemes. We discuss the implications of the findings at the policy and research level.
The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID = CRD42015019812 ).
社区健康保险（CBHI）作为一种替代自费支付的医疗融资机制，在中低收入国家（LMICs）得到了发展，尤其是在政府或雇主提供的医疗保险微乎其微的地区。本系统评价旨在评估 LMICs 中 CBHI 计划实施、采用和可持续性的障碍和促进因素。
我们检索了六个电子数据库和灰色文献。我们纳入了 1992 年以后以英文发表的定量和定性研究。两名审查员重复且独立地完成了研究选择、数据提取和方法特征评估。我们根据主题分析综合了研究结果，并根据生态模型分为个人、人际、社区和系统层面进行分类。
在 15510 条引文中，有 51 条符合入选标准。个人因素包括对 CBHI 概念的认识和理解、对计划和计划管理者的信任、对服务质量的感知以及人口统计学特征，这些因素影响了参保和可持续性。人际因素，如家庭动态、其他家庭成员参加该计划以及社会团结，影响了参保和续保。社区层面的因素，如文化和社区对计划发展的参与，影响了计划的参保和可持续性。系统层面的因素包括治理、财务和交付安排。政府参与、计划管理的问责制以及强有力的政策制定者-执行者关系促进了计划的实施和可持续性。涵盖门诊和住院治疗的方案以及针对社区需求定制的方案，有助于增加参保人数。保费的金额和收取时间被报道会对参保产生负面影响，而被报道为可持续性威胁的因素包括设施破产、运营预算小、医疗成本上升、风险池小、缴费不规律以及服务过度利用。在交付层面，设施的可及性、设施环境和卫生人员影响了参保、服务利用和辍学率。
在个人、人际、社区和系统层面上，有许多相互关联的因素推动了 CBHI 计划的实施、采用和可持续性。我们在政策和研究层面讨论了这些发现的意义。
本综述方案在 PROSPERO 国际前瞻性系统评价注册库（ID=CRD42015019812）中注册。
