扩大脆弱人群健康保险覆盖率的策略:描述性系统评价

Strategies for Expanding Health Insurance Coverage for Vulnerable Populations:A Descriptive Systematic Review

目的描述扩大脆弱人群健康保险覆盖率的策略及作者对实施这些策略的评价。方法由主题专家和检索人员讨论并试验后确定检索词,共检索28个电子数据库、12个卫生机构网站、3个灰色文献数据库和搜索引擎Google。纳入所有描述或评价已经实施的扩大脆弱人群健康保险覆盖率策略的文献。用预先设计的数据提取表收集文献内容和有关研究质量的信息,分析和描述提取信息。结果共纳入86篇文献,大多研究来自美国,主要研究人群是儿童。61篇描述策略,25篇评价策略。据卫生筹资机制理论分析,扩大健康保险的策略分为六类,即改变健康保险的入保资格、提高对健康保险的认知度、合理设置保险金水平、改进入保程序、改善卫生服务提供、改善保险的管理和组织。评价策略的研究大部分为回顾性纵向数据分析,仅有两篇为随机对照试验。评价研究的结论是所实施的策略对扩大保险覆盖有正面效应。结论美国等发达国家已实施大量策略用于扩大健康保险覆盖率,发展中国家实施的策略和相关研究均较少,发达国家实施的策略对发展中国家有一定的借鉴意义。纳入文献中有25篇评价策略效果的研究,可做进一步的系统评价,以考察策略对扩大健康保险覆盖率的效果。

Objectives To describe the range of strategies for expanding health insurance coverage for vulnerable population and how the authors have assessed these strategies. Methods Search words were chosen by both health policy experts and search coordinators after discussion and pilot. What was searched included 28 electronic databases, 12 websites of health institutions, 3 grey literature databases and search engine Google. Any report of implemented strategies to expand health insurance coverage for vulnerable population was included. Pre-designed data extraction form was used for collecting strategies and study methods of the included studies. Then the extracted information was analyzed and described. Results A total of 86 studies were included, most of which were the ones in the U.S. and the main targeted population was children. In terms of the study objective, 61 studies aimed to describe strategies and 25 ones are to evaluate effectiveness of the strategies. All strategies could be categorized into 6 groups based on the theoretical framework： changing eligibility criteria of health insurance, increasing awareness, making premium affordable, innovating enrollment approaches, improving health care delivery and strengthening management capacity. Most of the studies evaluating effectiveness were retrospective analysis of longitude data, and there were also two experimental studies. Conclusions The U.S. and other developed countries have implemented a great many strategies for expanding insurance coverage, while few strategies and related studies are found in developing countries. However, developing countries can learn from the developed countries in extending health insurance coverage. The 25 included studies evaluating strategies need further systematic reviews to assess the effectiveness of these strategies.