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van Hees SGM, O'Fallon T, Hofker M, Dekker M, Polack S, Banks LM, Spaan EJAM. Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review. Int J Equity Health 2019; 18:134. [PMID: 31462303 PMCID: PMC6714392 DOI: 10.1186/s12939-019-1040-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/19/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC. METHODS We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care. RESULTS The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments. CONCLUSION Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.
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Affiliation(s)
- Suzanne G M van Hees
- Radboud Institute for Health Sciences (RIHS), Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands.
- Department of Work and Health, HAN University of Applied Sciences, Kapittelweg 33, P.O. Box 6960, 6503GL, Nijmegen, Netherlands.
| | - Timothy O'Fallon
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Marleen Dekker
- African Studies Center, Leiden University, Leiden, The Netherlands
| | - Sarah Polack
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Lena Morgon Banks
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Ernst J A M Spaan
- Radboud Institute for Health Sciences (RIHS), Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
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Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, Adeyi O, Barker P, Daelmans B, Doubova SV, English M, García-Elorrio E, Guanais F, Gureje O, Hirschhorn LR, Jiang L, Kelley E, Lemango ET, Liljestrand J, Malata A, Marchant T, Matsoso MP, Meara JG, Mohanan M, Ndiaye Y, Norheim OF, Reddy KS, Rowe AK, Salomon JA, Thapa G, Twum-Danso NAY, Pate M. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health 2018; 6:e1196-e1252. [PMID: 30196093 PMCID: PMC7734391 DOI: 10.1016/s2214-109x(18)30386-3] [Citation(s) in RCA: 1495] [Impact Index Per Article: 249.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/16/2018] [Accepted: 08/10/2018] [Indexed: 12/19/2022]
Affiliation(s)
| | - Anna D Gage
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Keely Jordan
- New York University College of Global Public Health, New York, NY, USA
| | | | | | | | - Pierre Barker
- Institute for Healthcare Improvement, Cambridge, MA, USA
| | | | | | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | - Oye Gureje
- WHO Collaborating Centre for Research and Training in Mental Health, Neuroscience, Drug and Alcohol Abuse, University of Ibadan, Ibadan, Nigeria
| | - Lisa R Hirschhorn
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lixin Jiang
- National Centre for Cardiovascular Disease, Beijing, China
| | | | | | | | - Address Malata
- Malawi University of Science and Technology, Limbe, Malawi
| | - Tanya Marchant
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - John G Meara
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Manoj Mohanan
- Duke University Sanford School of Public Policy, Durham, NC, USA
| | - Youssoupha Ndiaye
- Ministry of Health and Social Action of the Republic of Senegal, Dakar, Senegal
| | - Ole F Norheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | - Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Gagan Thapa
- Legislature Parliament of Nepal, Kathmandu, Nepal
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Accorsi S, Somigliana E, Farese P, Ademe T, Desta Y, Putoto G, Manenti F. Gender Inequalities in Remote Settings: Analysis of 105,025 Medical Records of a Rural Hospital in Ethiopia (2005-2015). J Community Health 2018; 42:806-812. [PMID: 28303431 DOI: 10.1007/s10900-017-0321-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Gender inequalities in Sub-Saharan Africa are deemed relevant but data to support this view are scanty. Retrospective analysis of a large dataset of 105,025 patients admitted to an Ethiopian rural private, non-for-profit hospital over a 11 years period (2005-2015). Since 2001, the hospital and the local community are involved in a long-term, comprehensive and externally-supported health care intervention. The total number of admissions was higher for females (61.9% of the total) mainly because of the high frequency of admissions for obstetrics conditions. The total male-to-female ratio (M:F) was 0.6. Except for malaria, men had more admissions for the other leading causes, with the highest M:F being found for injuries (2.7) and musculoskeletal diseases (1.7). Overall, excluding admissions for pregnancy-related issues, the M:F was 1.4. The frequency of admissions changed with age and gender. Female admissions prevailed in the reproductive age period (from 15 to 44 years of age) while males admissions prevailed in the younger and older age groups. The case fatality rate was higher for men (M:F = 2.0). The total M:F and the M:F excluding pregnancy-related admissions did not change during the study period. Gender inequalities do exist in rural remote setting but tend to affect women differently during their lifespan. Even if gender inequalities generally favor males, the substantial proportion of admissions for pregnancy-related situations is encouraging.
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Affiliation(s)
- Sandro Accorsi
- Project "Italian Contribution to the Health Sector Development Programme and Contribution to the MDG Fund", Addis Ababa, Ethiopia
| | - Edgardo Somigliana
- Università degli Studi di Milano and Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Via M. Fanti, 6, 20122, Milan, Italy.
| | - Pasquale Farese
- Project "Italian Contribution to the Health Sector Development Programme and Contribution to the MDG Fund", Addis Ababa, Ethiopia
| | | | - Yonas Desta
- St. Luke Catholic Hospital, Wolisso, Ethiopia
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Bosch-Capblanch X, Zuske MK, Auer C. Research on subgroups is not research on equity attributes: Evidence from an overview of systematic reviews on vaccination. Int J Equity Health 2017; 16:95. [PMID: 28592273 PMCID: PMC5463415 DOI: 10.1186/s12939-017-0587-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 05/22/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Equity remains a priority in the international health development agenda. However, major inequities in vaccination coverage jeopardise the achievement of the Sustainable Development Goals. We aim at comprehensively describing how research has addressed equity issues related to vaccination. METHODS We carried out an overview of systematic reviews (SRs) that explicitly explored the effects of interventions to improve vaccination in any context; for any vaccine and, in any language. We followed standard research synthesis methods to systematically search for SR, assess them for inclusion and extracting relevant data, particularly on vaccination related outcomes. To gather evidence on equity issues addressed in the SR, we used the PROGRESS-plus framework. FINDINGS Our search obtained 2,003 hits which resulted in 54 included SRs, published between 1994 and 2014. The quality of SRs was generally poor, with less than half complying with most of the quality criteria. Reported vaccines included, by order of frequency, influenza and Expanded Programme on Immunisation vaccines. The types of interventions more frequently reported were related to vaccination delivery strategies, financial support and information, education and communication. Most of the SRs suggested effects favouring intervention groups as opposed to comparison groups. The most frequently reported equity attribute was 'place of residence' and the least reported equity attributes were sexual orientation and religion. Very few estimates of effects actually measured differences or changes between groups having those attributes and all of them referred to the place of residence. No data was found about reducing equity gaps for vulnerable groups or minorities, or attributes such as sexual orientation, education or specific religious groups. CONCLUSIONS Although research on vulnerable populations as a subgroup is abundant, it fails to report on the interventions that will actually reduce inequities and consider how redistribution of health care resources could shrink the gap between the privileged and most vulnerable groups including minorities. Research, if aiming at being responsive to global health policy trends, needs to report not only on specific attributes but also on how a better redistribution of health care resources could contribute to alleviating the unjust situation of the most vulnerable populations.
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Affiliation(s)
- Xavier Bosch-Capblanch
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002 Basel, Switzerland
- Universität Basel, Petersplatz 1, 4003 Basel, Switzerland
| | - Meike-Kathrin Zuske
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002 Basel, Switzerland
- Universität Basel, Petersplatz 1, 4003 Basel, Switzerland
| | - Christian Auer
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002 Basel, Switzerland
- Universität Basel, Petersplatz 1, 4003 Basel, Switzerland
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