Department of Clinical Sciences, Lund University, Jan Waldenströms Gata, 35205 02, Malmö, Sweden.
Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium.
BMC Health Serv Res. 2024 Apr 5;24(1):432. doi: 10.1186/s12913-024-10815-5.
Low- and middle-income countries have committed to achieving universal health coverage (UHC) as a means to enhance access to services and improve financial protection. One of the key health financing reforms to achieve UHC is the introduction or expansion of health insurance to enhance access to basic health services, including maternal and reproductive health care. However, there is a paucity of evidence of the extent to which these reforms have had impact on the main policy objectives of enhancing service utilization and financial protection. The aim of this systematic review is to assess the existing evidence on the causal impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries.
The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search included six databases: Medline, Embase, Web of Science, Cochrane, CINAHL, and Scopus as of 23rd May 2023. The keywords included health insurance, impact, utilisation, financial protection, and maternal and reproductive health. The search was followed by independent title and abstract screening and full text review by two reviewers using the Covidence software. Studies published in English since 2010, which reported on the impact of health insurance on maternal and reproductive health utilisation and or financial protection were included in the review. The ROBINS-I tool was used to assess the quality of the included studies.
A total of 17 studies fulfilled the inclusion criteria. The majority of the studies (82.4%, n = 14) were nationally representative. Most studies found that health insurance had a significant positive impact on having at least four antenatal care (ANC) visits, delivery at a health facility and having a delivery assisted by a skilled attendant with average treatment effects ranging from 0.02 to 0.11, 0.03 to 0.34 and 0.03 to 0.23 respectively. There was no evidence that health insurance had increased postnatal care, access to contraception and financial protection for maternal and reproductive health services. Various maternal and reproductive health indicators were reported in studies. ANC had the greatest number of reported indicators (n = 10), followed by financial protection (n = 6), postnatal care (n = 5), and delivery care (n = 4). The overall quality of the evidence was moderate based on the risk of bias assessment.
The introduction or expansion of various types of health insurance can be a useful intervention to improve ANC (receiving at least four ANC visits) and delivery care (delivery at health facility and delivery assisted by skilled birth attendant) service utilization in low- and lower-middle-income countries. Implementation of health insurance could enable countries' progress towards UHC and reduce maternal mortality. However, more research using rigorous impact evaluation methods is needed to investigate the causal impact of health insurance coverage on postnatal care utilization, contraceptive use and financial protection both in the general population and by socioeconomic status.
This study was registered with Prospero (CRD42021285776).
中低收入国家已承诺实现全民健康覆盖，以此作为增强服务获取和改善财务保护的手段。实现全民健康覆盖的一项关键卫生筹资改革是引入或扩大医疗保险，以增强获取基本卫生服务的机会，包括孕产妇和生殖保健服务。然而，关于这些改革对增强服务利用和财务保护这两个主要政策目标产生影响的程度，证据十分有限。本系统评价旨在评估医疗保险对中低收入国家孕产妇和生殖健康服务利用和财务保护的因果影响的现有证据。
本评价遵循系统评价和荟萃分析的首选报告项目（PRISMA）指南。检索了 6 个数据库：截至 2023 年 5 月 23 日的 Medline、Embase、Web of Science、Cochrane、CINAHL 和 Scopus。关键词包括医疗保险、影响、利用、财务保护和孕产妇及生殖健康。在 Covidence 软件中，两名评审员独立进行标题和摘要筛选以及全文审查。自 2010 年以来以英文发表、报告医疗保险对孕产妇和生殖健康利用和/或财务保护影响的研究被纳入本评价。使用 ROBINS-I 工具评估纳入研究的质量。
共有 17 项研究符合纳入标准。大多数研究（82.4%，n=14）为全国代表性研究。大多数研究发现，医疗保险对至少接受 4 次产前检查（ANC）、在卫生机构分娩和由熟练助产士接生的分娩有显著的积极影响，平均处理效应分别为 0.02 至 0.11、0.03 至 0.34 和 0.03 至 0.23。没有证据表明医疗保险增加了产后护理、获得避孕措施和孕产妇及生殖健康服务的财务保护。各项孕产妇和生殖健康指标在研究中均有报道。ANC 的报告指标最多（n=10），其次是财务保护（n=6）、产后护理（n=5）和分娩护理（n=4）。基于偏倚风险评估，证据的总体质量为中等。
在中低收入国家，引入或扩大各类医疗保险可以成为改善 ANC（接受至少 4 次 ANC 检查）和分娩护理（在卫生机构分娩和由熟练助产士接生）服务利用的有用干预措施。实施医疗保险可以使各国朝着全民健康覆盖的方向取得进展，并降低孕产妇死亡率。然而，需要使用更严格的影响评估方法进行更多研究，以调查医疗保险覆盖范围对一般人群和按社会经济地位划分的产后护理利用、避孕措施使用和财务保护的因果影响。
本研究已在 PROSPERO 注册（CRD42021285776）。
