Ethiopian Health Insurance Agency, Addis Ababa, Ethiopia.
Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
Health Policy Plan. 2021 Nov 11;36(10):1705-1714. doi: 10.1093/heapol/czab080.
In the past two decades, community-based Health Insurance (CBHI) is expanding in most of sub-Saharan African countries with the aim of improving equitable access to health services for the informal sector population. However, population enrolment into CBHI and membership renewals thereafter remains stubbornly low. The purpose of this systematic review is to generate an evidence to better understand barriers to uptake of CBHI in sub-Saharan African countries. We systematically searched for relevant studies from databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychInfo, ProQest, Excerpta Medica dataBASE (EMBASE) and Africa-Wide Information. The search strategy combined detailed terms related to (i) CBHI, (ii) enrolment/renewal and (iii) sub-Saharan African countries. A narrative synthesis of findings was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol for this systematic review was registered with International Prospective Register of Systematic Reviews (PROSPERO) (ref: CRD42020183959). The database search identified 4055 potential references from which 15 articles reporting on 17 studies met the eligibility criteria. The findings revealed that barriers to uptake of CBHI in sub-Saharan Africa were multidimensional in nature. Lack of awareness about the importance of health insurance, socio-economic factors, health beliefs, lack of trust towards scheme management, poor quality of health services, perceived health status and limited health benefit entitlements were reported as barriers that affect enrolments into CBHI and membership renewals. The methodological quality of studies included in this review has been found to be mostly suboptimal. The overall findings of this systematic review identified major barriers of CBHI uptake in sub-Saharan African countries which may help policymakers to make evidence-informed decisions. Findings of this review also highlighted that further research with a robust methodological quality, depth and breadth is needed to help better understand the factors that limit CBHI uptake at individual, societal and structural levels in sub-Saharan Africa.
在过去的二十年中，社区医疗保险（CBHI）在撒哈拉以南非洲的大多数国家得到了扩展，旨在改善非正规部门人口获得卫生服务的公平性。然而，人口入保和续保率仍然很低。本系统评价的目的是提供证据，以更好地了解撒哈拉以南非洲国家中 CBHI 参保的障碍。我们系统地从以下数据库中搜索了相关研究：PubMed、Scopus、护理学和联合健康文献累积索引（CINAHL）、心理信息、ProQest、Excerpta Medica dataBASE（EMBASE）和非洲广泛信息。搜索策略结合了与（i）CBHI、（ii）入保/续保和（iii）撒哈拉以南非洲国家相关的详细术语。根据系统评价和荟萃分析的首选报告项目（PRISMA）指南，对研究结果进行了叙述性综合。本系统评价的方案已在国际前瞻性系统评价注册库（PROSPERO）（参考号：CRD42020183959）中进行了注册。数据库搜索从 4055 条潜在参考文献中确定了 15 篇文章，其中 17 项研究符合纳入标准。研究结果表明，撒哈拉以南非洲地区 CBHI 参保的障碍具有多维度的性质。缺乏对健康保险重要性的认识、社会经济因素、健康信念、对计划管理的不信任、卫生服务质量差、感知健康状况和有限的健康福利权益被认为是影响 CBHI 参保和续保的障碍。本评价纳入研究的方法学质量大多不尽人意。本系统评价的总体结果确定了撒哈拉以南非洲国家 CBHI 参保的主要障碍，这可能有助于决策者做出基于证据的决策。本评价的结果还强调，需要进一步开展具有稳健方法学质量、深度和广度的研究，以帮助更好地了解限制撒哈拉以南非洲个人、社会和结构层面 CBHI 参保的因素。
