Health insurance can improve access to health care and protect the insured population from the burden of healthcare costs. However, in most low- and middle-income countries, and in some high-income countries that have not achieved universal coverage of health insurance, a lack of health insurance coverage is still a policy problem. In these countries, children make up one of the groups with a higher risk of health problems, and a lower likelihood of being insured. It has also been found that even if there is a well-designed health insurance programme, all eligible children might not join it. We did our Cochrane review to find ways to improve this, but found little reliable evidence (1).
Many children are uninsured because their parents don't know of the existence of the relevant health insurance, or are not aware of their eligibility for exemption from premiums. The complexity of the application process can also be a barrier. We began our research with a scoping review in 2008, to help us to explore all interventions used to expand coverage of existing health insurance programmes. This scoping review also revealed that restricting our Cochrane review to children would not mean that we would miss potentially useful evidence in other populations – expanding our criteria to other populations would not have identified any additional reliable evidence. We found that the eligible interventions for our review mainly included raising awareness of insurance programmes, improving or simplifying application and enrolment procedures, and improving the capacity of insurers.
We defined these interventions as “outreach strategies” and sought to evaluate their effectiveness for expanding children's health insurance coverage. However, we found very few studies. We were able to include only two studies, both from the United States, evaluating two different outreach interventions. One randomized trial evaluated case managers who provide information about health insurance and help with the application. This trial included observations for 257 children and found that children with case managers were about 1.7 times more likely to be enrolled into insurance than children without help from case managers (2). There was also a quasi-randomized trial with 223 participants testing the handing out of application materials in the emergency departments of hospitals. This showed that children who received the application materials were about 1.5 times more likely to be insured than the other children (3).
Although these two interventions look promising for health systems similar to that in the United States, their effectiveness in other counties, especially resource poor settings with different health insurance schemes is unknown. We found no reliable studies evaluating other outreach strategies or studies from other countries. In fact, although we did identify a further 23 studies evaluating outreach interventions to expand health insurance coverage in children, most of these had to be excluded because they were retrospective, observational studies analyzing existing data, with a risk of bias that was too high. Our work shows how well-designed experimental studies are rare in the evaluation of health system level interventions. We have suggested some of the studies that are needed in our review.