title: The impact of health insurance in Africa and Asia: a systematic review.
abstract: OBJECTIVE
  To evaluate the impact of health insurance on resource mobilization, financial protection, service utilization, quality of care, social inclusion and community empowerment in low- and lower-middle-income countries in Africa and Asia.
  
  
  METHODS
  A systematic search for randomized controlled trials, quasi-experimental and observational studies published before the end of 2011 was conducted in 20 literature databases, reference lists of relevant studies, web sites and the grey literature. Study quality was assessed with a quality grading protocol.
  
  
  RESULTS
  Inclusion criteria were met by 159 studies - 68 in Africa and 91 in Asia. Most African studies reported on community-based health insurance (CBHI) and were of relatively high quality; social health insurance (SHI) studies were mostly Asian and of medium quality. Only one Asian study dealt with private health insurance (PHI). Most studies were observational; four had randomized controls and 20 had a quasi-experimental design. Financial protection, utilization and social inclusion were far more common subjects than resource mobilization, quality of care or community empowerment. Strong evidence shows that CBHI and SHI improve service utilization and protect members financially by reducing their out-of-pocket expenditure, and that CBHI improves resource mobilization too. Weak evidence points to a positive effect of both SHI and CBHI on quality of care and social inclusion. The effect of SHI and CBHI on community empowerment is inconclusive. Findings for PHI are inconclusive in all domains because of insufficient studies.
  
  
  CONCLUSIONS
  Health insurance offers some protection against the detrimental effects of user fees and a promising avenue towards universal health-care coverage.
authors.affiliation: Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500HB Nijmegen, Netherlands. e.spaan@elg.umcn.nl
authors.forename: Ernst
authors.initials: E
authors.lastname: Spaan
authors.forename: Judith
authors.initials: J
authors.lastname: Mathijssen
authors.forename: Noor
authors.initials: N
authors.lastname: Tromp
authors.forename: Florence
authors.initials: F
authors.lastname: McBain
authors.forename: Arthur
authors.initials: A
authors.lastname: ten Have
authors.forename: Rob
authors.initials: R
authors.lastname: Baltussen
mesh_terms: D000349:Africa; D001208:Asia; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D054624:Health Status Disparities; D006801:Humans; D007348:Insurance, Health / Q000191:economics / Q000639:trends*; D011209:Power, Psychological; D011787:Quality of Health Care / Q000191:economics / Q000639:trends*; D012923:Social Class