SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
, - SUPPORT Summary of a systematic review | print this article |
Health insurance refers to a health financing mechanism that involves the pooling of eligible, individual contributions in order to cover all or part of the cost of certain health services for all those who are insured. Health insurance scheme coverage in low- and middle-income countries (LMICs) is low, especially among vulnerable populations such as children. Consequently, thousands of children suffer and die from preventable and treatable diseases in these settings. Outreach strategies for increasing health insurance coverage for eligible children may include increasing awareness of schemes and benefits, modifying enrolment, and improving insurance schemes management and organisation.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Health insurance can improve access to health care for the insured population and protect it from the burden of unexpected healthcare costs. However, coverage is often low amongst those people most in need of protection, especially in low- and middle-income countries. Strategies for increasing insurance coverage can be adopted during the design of the insurance scheme or added during implementation. Strategies for improving scheme designs include modifying eligibility criteria, making premiums [more?] affordable, and improving healthcare delivery. Strategies for improving programme implementation (also known as ‘outreach strategies’) include increasing awareness of schemes and benefits, modifying enrolment criteria, and improving the management and organisation of insurance schemes.
This summary is based on a Cochrane Review by Meng and colleagues, which assessed the effectiveness of outreach strategies for expanding insurance coverage for children. Meng and colleagues did not review how the design of health insurance schemes could influence coverage.
| Review Objectives: To assess the effectiveness of outreach strategies for expanding insurance coverage of children who are eligible for health insurance schemes | ||
| / | What the review authors searched for | What the review authors found |
|---|---|---|
| Interventions | Randomised controlled trials, controlled clinical trials, controlled before-and-after studies and interrupted time series |
1 randomised controlled trial and 1 controlled clinical trial |
| Participants | Children and young people eligible for any kind of health insurance scheme but not enrolled |
674 children aged 18 years or younger recruited from 2 minority communities (1 study) or the emergency departments of 4 inner-city hospitals (1 study); both in the United States of America (USA) |
| Settings | Not pre-specified |
USA (2 studies) |
| Outcomes |
Primary outcomes: Enrolment of eligible children into health insurance pro-grammes
Secondary outcomes: Health service utili-sation, health status, satisfaction of chil-dren and their parents, costs, adverse effects
|
Enrolment of children into health insurance (2 studies), maintaining enrolment of children in in-surance schemes (1 study), mean time to obtain insurance (1 study), parental satisfaction with proc-ess of enrolment (1 study) |
| Date of most recent search:January 2010 | ||
| Limitations:A good quality systematic review with only minor limitations | ||
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The review included 2 controlled trials, both from the USA. One enrolled 275 children in an urban Latino American community. The other recruited 399 children visiting the Emergency Department of 4 inner-city hospitals in 4 American cities.
One RCT assessed the effect of using community-based trained case managers to provide information on programme eligibility, assist families with completing insurance applications, act as family liaisons with insurance schemes, and assist in maintaining insurance coverage. The RCT showed that this strategy probably:
Awarenesss and application support compared with no intervention |
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| Patient or population: Children with no health insurance Settings: USA (urban Latino American community in Boston) Intervention: Awareness and application support, for 11 months Comparison:No intervention |
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| Outcomes | Comparative risks* |
Relative effect (95% CI) |
No of Participants (studies) |
Quality of the evidence (GRADE) |
Comments | |
|
Without intervention |
With awareness and application support |
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| Enrolment into insurance |
574 per 1,000 |
964 per 1,000 (827 to 1,000) |
RR 1.68 |
257 (1 study) |
|
RR calculation based on number of events imputed from percentage and number of participants meas-ured |
|
Continue en-rolment
|
303 per 1,000 |
785 per 1,000 (591 to 1,000) |
RR 2.59 (1.95 to 3.44) |
257 (1 study) |
|
Same comment as above |
|
Mean time to obtain insur-ance |
134.8 Days |
47.30 lower (73.98 to 20.62 lower) |
MD -47.30 (-73.98 to -20.62) |
200 (1 study)
|
|
Outcome only measured based on children who obtained insurance |
| CI: Confidence interval; RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see explanations) | ||||||
| 1 No information on method of randomization is provided. Allocation concealment is unclear. Blinding is not documented for the intervention or outcome. 2 Estimate from only one study with few events. Very wide confidence interval consistent with either important harms or important benefits from the therapy |
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