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01.12.2018 | Systematic review | Ausgabe 1/2018 Open Access

International Journal for Equity in Health 1/2018

Barriers and facilitators to implementation, uptake and sustainability of community-based health insurance schemes in low- and middle-income countries: a systematic review

Zeitschrift:
International Journal for Equity in Health > Ausgabe 1/2018
Autoren:
Racha Fadlallah, Fadi El-Jardali, Nour Hemadi, Rami Z. Morsi, Clara Abou Abou Samra, Ali Ahmad, Khurram Arif, Lama Hishi, Gladys Honein-AbouHaidar, Elie A. Akl
Wichtige Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1186/​s12939-018-0721-4) contains supplementary material, which is available to authorized users.

Abstract

Background

Community-based health insurance (CBHI) has evolved as an alternative health financing mechanism to out of pocket payments in low- and middle-income countries (LMICs), particularly in areas where government or employer-based health insurance is minimal. This systematic review aimed to assess the barriers and facilitators to implementation, uptake and sustainability of CHBI schemes in LMICs.

Methods

We searched six electronic databases and grey literature. We included both quantitative and qualitative studies written in English language and published after year 1992. Two reviewers worked in duplicate and independently to complete study selection, data abstraction, and assessment of methodological features. We synthesized the findings based on thematic analysis and categorized according to the ecological model into individual, interpersonal, community and systems levels.

Results

Of 15,510 citations, 51 met the eligibility criteria. Individual factors included awareness and understanding of the concept of CBHI, trust in scheme and scheme managers, perceived service quality, and demographic characteristics, which influenced enrollment and sustainability. Interpersonal factors such as household dynamics, other family members enrolled in the scheme, and social solidarity influenced enrollment and renewal of membership. Community-level factors such as culture and community involvement in scheme development influenced enrollment and sustainability of scheme. Systems-level factors encompassed governance, financial and delivery arrangement. Government involvement, accountability of scheme management, and strong policymaker-implementer relation facilitated implementation and sustainability of scheme. Packages that covered outpatient and inpatient care and those tailored to community needs contributed to increased enrollment. Amount and timing of premium collection was reported to negatively influence enrollment while factors reported as threats to sustainability included facility bankruptcy, operating on small budgets, rising healthcare costs, small risk pool, irregular contributions, and overutilization of services. At the delivery level, accessibility of facilities, facility environment, and health personnel influenced enrollment, service utilization and dropout rates.

Conclusion

There are a multitude of interrelated factors at the individual, interpersonal, community and systems levels that drive the implementation, uptake and sustainability of CBHI schemes. We discuss the implications of the findings at the policy and research level.

Trial registration

The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID = CRD42015019812).
Zusatzmaterial
Additional file 1: Search strategy (PDF 163 kb)
12939_2018_721_MOESM1_ESM.pdf
Additional file 2: List of coding themes corresponding to each level of the ecological model (PDF 195 kb)
12939_2018_721_MOESM2_ESM.pdf
Additional file 3: List of the excluded studies with reasons for exclusion. (PDF 381 kb)
12939_2018_721_MOESM3_ESM.pdf
Additional file 4: Overview of the characteristics of each included study (PDF 1046 kb)
12939_2018_721_MOESM4_ESM.pdf
Additional file 5: Quality appraisal of included studies (PDF 697 kb)
12939_2018_721_MOESM5_ESM.pdf
Additional file 6: Detailed findings of studies at the individual, interpersonal, community and systems level (PDF 635 kb)
12939_2018_721_MOESM6_ESM.pdf
Literatur
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