Flourence Marine, Jarawan Eva, Boiangiu Mara, El Yamani Fatima El Kadiri
Department of Global Health, Georgetown University, Washington, District of Columbia, United States of America.
Health, Nutrition & Population Global Practice, The World Bank Group, Washington, District of Columbia, United States of America.
PLOS Glob Public Health. 2025 Jan 9;5(1):e0003651. doi: 10.1371/journal.pgph.0003651. eCollection 2025.
Universal Health Coverage (UHC) aims to provide access to quality health services to all while avoiding financial hardship. Strategies can include establishing a national health insurance scheme (NHIS). However, variations in the progress exist among countries with an NHIS. This study assesses strategies adopted in low- and lower-middle-income countries (LLMICs) with an NHIS to expand UHC. The research entailed a descriptive, qualitative review of the literature on LLMICs that have implemented an NHIS. PRISMA guidelines were used to identify studies and reports. A total of 569 texts were identified from 4 databases. A total of 78 texts were included, spanning 7 countries from Sub-Saharan Africa and 4 from Asia. The search was conducted in March 2023 and updated in April 2024. An analytical framework was used to systematically collect, analyze, and synthesize key features to review healthcare financing mechanisms and coverage dimensions. Countries generate revenue through various public and private means, including taxes, premiums, and out-of-pocket payments. Some have consolidated revenue streams into a single pool for efficiency, while others maintain separate pools. Healthcare services are procured from public and private providers, differing by country. Fee-for-service is the prevalent payment method, but capitation systems have been attempted to control expenses. Population coverage depends on whether enrollment in an NHIS is mandatory or voluntary and on its enforcement. Service provision can be comprehensive and universal or can vary with specific schemes. Mechanisms to avoid financial hardship can involve premium exemptions or subsidies. Progressing toward UHC requires addressing issues of financial sustainability, cost-containment, enrollment expansion, financial protection, and health equity. While policy options are context-specific, this review showcased experiences for other LLMICs committed to UHC with an NHIS. Recommendations on health financing include increasing the allocation of tax revenues to the insurance scheme, merging risk pools, and adopting strategic purchasing.
全民健康覆盖（UHC）旨在为所有人提供获得优质医疗服务的机会，同时避免经济困难。策略可以包括建立国家健康保险计划（NHIS）。然而，拥有NHIS的国家在进展方面存在差异。本研究评估了拥有NHIS的低收入和中低收入国家（LLMICs）为扩大UHC而采取的策略。该研究对已实施NHIS的LLMICs的文献进行了描述性的定性综述。采用PRISMA指南来识别研究和报告。从4个数据库中总共识别出569篇文本。总共纳入了78篇文本，涵盖撒哈拉以南非洲的7个国家和亚洲的4个国家。搜索于2023年3月进行，并于2024年4月更新。使用一个分析框架来系统地收集、分析和综合关键特征，以审查医疗保健融资机制和覆盖范围维度。各国通过各种公共和私人手段创收，包括税收、保费和自付费用。一些国家为了提高效率将收入流合并到一个单一的资金池中，而另一些国家则维持单独的资金池。医疗保健服务从公共和私人提供者处采购，因国家而异。按服务收费是普遍的支付方式，但也尝试过人头费制度来控制费用。人口覆盖率取决于NHIS的参保是强制性的还是自愿的以及其执行情况。服务提供可以是全面和普遍的，也可以因具体计划而异。避免经济困难的机制可以包括保费豁免或补贴。向UHC迈进需要解决财务可持续性、成本控制、参保扩大、财务保护和健康公平等问题。虽然政策选择因具体情况而异，但本综述展示了其他致力于通过NHIS实现UHC的LLMICs的经验。关于卫生融资的建议包括增加对保险计划的税收分配、合并风险池以及采用战略采购。
