Utilization of public health care by people with private health insurance: a systematic review and meta-analysis

The impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries: a systematic review of the evidence

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

TRIAL REGISTRATION

This study was registered with Prospero (CRD42021285776).

Effect of supplementary private health insurance on inpatient utilisation: Evidence from Malaysia

Supplementary private health insurance (PHI) provides better access to healthcare, improves health outcomes, potentially lowers the costs for health systems and supports the social security system. Improperly regulated PHI, however, may aggravate inequity of access towards preferential care and encourage moral hazard among PHI purchasers, altering the health-seeking behaviour, which is often observed through the pattern of health care utilisation. We investigated the effect of PHI ownership on private inpatient care utilisation, its frequency of admission and length of stay by conducting secondary data analysis of the Malaysian National Health Morbidity Survey (NHMS) 2015 data, a nationally representative community health survey. Malaysian adults 18 years of age and above who utilised inpatient healthcare facilities were included. In this cross-sectional study, we addressed the endogeneity effect of health insurance by employing instrumental variable estimation and a two-stage residual inclusion analysis. We found a significant increase in private inpatient utilisation among those who owned PHI compared to those who did not (β = 4.39, p < 0.001). There was no significant difference in the frequency of admission and length of stay. The increase in private inpatient utilisation among PHI owners may reflect the demand for timely care and hospitality provided by the private sector, potentially exacerbating the moral hazard behaviour among PHI owners. Further exploration of this issue could impact future healthcare systems financing designs and PHI regulation.

WITHDRAWN: The effect of commercial health insurance and health policy incentives on health risk assessment of residents

Ahead of Print article withdrawn by publisher.

Health Insurance Ownership and Quality of Computed Tomography Requests: Experience from a Peripheral Referral Hospital in Cameroon

BACKGROUND

Health insurance ownership facilitates access and minimizes financial hardship after utilization of healthcare services such as computed tomography (CT). Understanding the rational utilization of CT by people with health insurance can help optimize the scheme and provide baseline information for a national universal health coverage program.

OBJECTIVE

To assess the relationship between health insurance ownership and the appropriateness of requests for CT in a peripheral referral hospital in Cameroon.

METHODS

A survey of CT users was conducted during which information on health insurance ownership was collected and the request forms for CT assessed for appropriateness using the American College of Radiologists (ACR) Appropriateness Criteria®.

RESULTS

We consecutively enrolled 372 participants of which 167 (45%) were females. The median age (range) was 52 (18-92) years. Thirty-eight out of 370 participants reported having health insurance (10.3%; 95% confidence interval (CI): 7.2%-13.4%). Twenty-nine out of 352 CT scan requests (8.2%; 95% CI: 5.3-11.0) were judged to be "inappropriate." The proportion of inappropriate scan requests was higher amongst people with health insurance compared to those without health insurance (18.4% vs. 7.0%; χ 2 = 5.8; p=0.02). In the logistic regression analysis, health insurance ownership was associated to the appropriateness of CT requests in the univariate analysis only (OR = 0.33; 95% CI: 0.13-0.84; p=0.020).

CONCLUSIONS

Inappropriate requests for CT were low but nevertheless associated to health insurance ownership. The continuous sensitization and training of physicians would help minimize potential wasteful utilization of resources.