The path to universal health coverage in five African and Asian countries: examining the association between insurance status and health-care use

Abstract

Despite major efforts to achieve universal health coverage (UHC), progress has lagged in many African and Asian countries. A key strategy pursued by many countries is the use of health insurance to increase access and affordability. However, evidence on insurance coverage and on the association between insurance and UHC is mixed. We analysed nationally representative cross-sectional data collected between 2022 and 2023 in Ethiopia, Kenya, South Africa, India, and Laos. We described public and private insurance coverage by sociodemographic factors and used logistic regression to examine the associations between insurance status and seven health-care use outcomes. Health insurance coverage ranged from 25% in India to 100% in Laos. The share of private insurance ranged from 1% in Ethiopia to 13% in South Africa. Relative to the population with private insurance, the uninsured population had reduced odds of health-care use (adjusted odds ratio 0·68, 95% CI 0·50-0·94), cardiovascular examinations (0·63, 0·47-0·85), eye and dental examinations (0·54, 0·42-0·70), and ability to get or afford care (0·64, 0·48-0·86); private insurance was not associated with unmet need, mental health care, and cancer screening. Relative to private insurance, public insurance was associated with reduced odds of health-care use (0·60, 0·43-0·82), mental health care (0·50, 0·31-0·80), cardiovascular examinations (0·62, 0·46-0·84), and eye and dental examinations (0·50, 0·38-0·65). Results were highly heterogeneous across countries. Public health insurance appears to be only weakly associated with access to health services in the countries studied. Further research is needed to improve understanding of these associations and to identify the most effective financing strategies to achieve UHC.

Figure 1

Types of insurance by country and health-care use status (A) Type of insurance by country. Insurance status is categorised as public, private (including private insurance and other voluntary or employer-offered schemes), and uninsured. Laos is assumed to have 100% public health insurance, whereas South Africa does not have public insurance. (B) Type of insurance by health-care use status. Insurance status was categorised as public, private (including private insurance and other voluntary or employer-offered schemes), and uninsured. Visits were categorised as users and non-users. Unmet health-care need, mental health care, cancer screening, cardiovascular examination, and eye and dental examination were categorised as a yes if participants received the service and a no if participants did not receive the service. The ability to receive and afford care was categorised as confident or not confident.

Figure 2

Adjusted associations between health insurance type and health-care use The health-care use outcomes considered were visits in the past 12 months, unmet need, mental health care, cancer screening, cardiovascular examination, eye and dental examination, and ability to receive and afford care. aOR=adjusted odds ratio. OR=crude odds ratio.