, - SUPPORT Summary of a systematic review | print this article |

Which outreach strategies increase health insurance coverage for children?

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.


Key messages

  • Awareness and application support, probably
    • Increases the enrolment of children in health insurance schemes
    • Leads to the continuous enrolment of children in health insurance schemes
    • Decreases the mean time taken to obtain health insurance for children, and
    • Leads to parental satisfaction with the process of enrolment
  • Handing out application forms in emergency department of hospitals
    • Probably increases the enrolment of children in health insurance schemes
  • Only two studies conducted in high-income countries were included in the review. Rigorous studies are needed that evaluate the effects and costs of different outreach strate-gies in different countries for expanding the health insurance coverage of children
  • In the interim, the use of the outreach strategies assessed in this review (or any other strategy) for increasing health in-surance coverage in LMICs should be accompanied by a rigorous monitoring and evaluation framework



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.

About the systematic review underlying this summary

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)

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
Meng Q, Yuan B, Jia L,Wang J, Garner P. Outreach strategies for expanding health insurance coverage in children. Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.:CD008194. DOI:10.1002/14651858.CD008194.pub2.

Summary of findings

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.


1) Awareness and application support

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:


  • Increases the enrolment of children in health insurance schemes
  • Leads to the maintenance of enrolment in health insurance schemes
  • Decreases the mean time taken to obtain insurance for chil-dren, and
  • Leads to parental satisfaction with the process of enrolment


Awarenesss and application support compared with no intervention

Patient or population:  Children with no health insurance
:  USA (urban Latino American community in Boston)
: Awareness and application support, for 11 months
:No intervention
Outcomes Comparative risks*
Relative effect
(95% CI)
No of Participants
Quality of the evidence

Without intervention

With awareness and application support
Enrolment into insurance
574 per 1,000

964 per 1,000

(827 to 1,000)

RR 1.68
(1.44to 1.96)


(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)


(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)



(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





Relevance of the review for low-income countries

Additional information