Table 4 Methodology and Main Findings of the Included Studies
Author, Year | Location | Study design | Data Source | Type of Mental Health Care Examined | Target Population | Overall Sample size | Health Insurance Mechanism type | Health Insurance Mechanism name | Sample Size | Mental Health Care Utilization Outcome of Interest | Measure of Impact | Secondary Outcomes of Interest | Measure of Impact | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Araya, R., et al., 2006 [44] | Santiago, Chile | Cross-sectional study | Santiago Mental Disorders Survey; Psychiatric symptoms were assessed with the Revised Clinical Interview Schedule (CIS-R); 1996–1998 | Outpatient Care | Adults aged 16–64 years living in private households in Santiago | 3824 (51% female) | Group of interest | SHI | National Health Fund (FONASA) | 1439 | Frequency of Mental Health Consultation within the previous six months | 15.1% |  |  |
Comparison group (1) | Private Health Insurance | ISAPRES (Instituciones de Salud Previsional), Armed Forces and Teachers Union | 1905 | 29.2% | ||||||||||
Comparison group (2) | Uninsured | No health insurance | 480 | 18% | ||||||||||
Asawavichienjinda, T., et al., 2003 [42] | Pak Thong Chai district, Nakhon Ratchasima province, Thailand | Cross-sectional study | All data for adult (> 14 years) cases of epilepsy (two or more clinical afebrile seizures unrelated to acute metabolic derangements or to withdrawal from drugs or alcohol, or seizures occurring within a 24 h period) registered in the Registry of Epileptics who had visited a sub-district health care office or community hospital in 1997 in the district of Pak Thong Chai were extracted; interviews also conducted with patients and their caregivers. | Inpatient and Outpatient Care | Adult epileptics aged over 14 years living in Nakhon Ratchasima Province of Thailand | 72 (60% female) | Group of interest | CBHI | Health Card Scheme | 57 | Compliance with antiepileptic drug (AED) regiments over the past year; on time, without fail, without manipulating dosage 100% of the time | 88% |  |  |
Comparison group (1) | Uninsured | No health insurance | 15 | 68% | ||||||||||
Chung, W., et al., 2013 [40] | National, South Korea | Retrospective, cross-sectional study | Claims and service use data extracted from the repositories for all National Health Insurance and Aid claims | Inpatient Care | South Koreans who received inpatient care for schizophrenia between 2005 and 2006 | 58,287 (45% female) | Group of interest | NHI | Korean national health insurance | 24,301 | Proportion of Long Stay inpatients (> 6 months) | 17% | Likelihood of Long Stay inpatients (> 6 months) in psychiatric hospitals | Base |
Comparison group (1) | Government subsidies for those who do not have economic capability, and cannot work | Medical Care Aid 1 | 30,241 | 61.06%; AID Type 1 beneficiaries were four times more likely than NHI beneficiaries to be long stay (OR 4.299, 95% CI: 4.024–4.593) | AID Type 1 beneficiaries showed an OR of 5.704 (95% CI: 4.877–6.671) | |||||||||
Comparison group (2) | Government subsidies for those who do not have economic capability, and can work | Medical Care Aid 2 | 3745 | 48% | AID Type 2 beneficiaries an OR of 3.308 (95% CI: 2.713–4.034). | |||||||||
Ding, X., et al., 2018 [28] | Zhejiang, China | Cross-sectional study | Screening questionnaire was based on WHO screening questionnaires previously used in China and on the International Community-based Epilepsy Research Group (ICBERG) screening instrument followed by epilepsy specialists performing door-to-door investigations with a more specialized questionnaire in participants with suspected epilepsy from the first stage. | Inpatient and Outpatient care | Population of Zhejiang province | 118 (58% female) | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI); Urban Residence Basic Medical Insurance (UR-BMI), or New Rural Cooperative Medical scheme (NRCM) | 98 | Treatment gap for active epilepsy; proportion not receiving any antiepileptic treatment (traditional medicine or antiepileptic drugs) for active epilepsy among those with active epilepsy | 52% | Â | Â |
Comparison group (1) | Uninsured | No health insurance | 20 | 90% | Â | Â | ||||||||
El-Sayed, A.M., et al., 2015 [45] | 22 low-income, 17 lower-middle, and 9 upper-middle countries (World Bank 2003) | Cross-sectional study | World Health Survey (WHS) 2002–2004 | Inpatient and Outpatient Care | Populations of LMICs with diagnosed depression and schizophrenia | 10,419 (Depression, n = 8762; Schizophrenia, n = 1657) | Group of interest | SHI or NHI | Countries where most or all health services, including primary care, are provided by the government (even if private or NGO sector services may exist in parallel and some out-of-pocket expenses may exist). | 3797 Depression, n = 3437; Schizophrenia, n = 360 | Receipt of treatment for depression or schizophrenia based on self-report | • Depression: 82.2% of those diagnosed with depression received treatment • Schizophrenia: 86.7% of those diagnosed with Schizophrenia received treatment | Attributable benefit defined as the degree to which insurance coverage mitigated treatment gaps relative to 100% for rural populations and for the poorest 50% of the sample | Among men, the attributable benefit of insurance among the poorest 50% was 53.1% for depression Among men, the attributable benefit of insurance among rural residents was 53.4% for depression,Among women, the attributable benefit of insurance among the poorest 50% was 24.7% for depression and 94.8% for schizophrenia. |
Comparison group (1) | Private health insurance | Countries with no or minimal services provided by the government, or where only limited health services were provided by the government (e.g., for maternal and child health, HIV/ AIDS care, vaccinations, or for special groups such as children, elderly, impoverished). | 6622 Depression, n = 5325; Schizophrenia, n = 1297 | • Depression: 37.1% of those diagnosed with depression received treatment • Schizophrenia: 53.3% of those diagnosed with Schizophrenia received treatment • In adjusted models among men, the uninsured had lower likelihood of treatment for depression (0.59, 95% CI 0.37–0.92). Among women, the uninsured were significantly less likely to receive treatment for schizophrenia (0.57, 95% CI 0.47–0.69); The poorest 50% were significantly less likely to receive treatment for depression (0.81, 95% CI 0.72–0.92) | ||||||||||
Feng, Y., et al., 2012 [29] | Changsa, China | Retrospective Cross-sectional study | Claims and service use data extracted from the repositories of the social insurance agencies, in addition to qualitative interviews and a field survey of policy documents and implementation methods | Inpatient Care | Population of Changsha, China, diagnosed with schizophrenia who made use of inpatient care in 2010 | 527 | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI) | 70 | Average Length of Inpatient Stay | 50.6 days | Utilization of antipsychotics; prescription of FGA and SGA | Those with UE-BMI coverage were rarely prescribed FGA alone (3%) and most inpatients received SGA alone (58%). Inpatients covered by UR-BMI faced the opposite situation with most inpatients receiving FGA alone (42.5%) and the proportion receiving SGA alone (32.8%) was far less than UE-BMI inpatients. |
Comparison group (1) | SHI | Urban Residence Basic Medical Insurance (UR-BMI) | 457 | 187.1 days | ||||||||||
He, P., et al., 2017 [30] | National, China | Cohort study | Second National Sample Survey on Disability follow-up investigations from 2007 to 2013; Children aged 0–6 years: Those who were suspected of having IDs were then tested in the developmental quotient (DQ) by the Gesell Developmental Inventory for a definite diagnosis with IDs (DQ < 76). Children aged 7–17 years were screened by interviewers using disability screening questionnaires at their homes. If the screening found that the subjects had an ID tendency, they would be referred to developmental paediatricians and psychiatrists to make the final diagnosis of IDs based on both intelligence quotient (IQ < 70) and adaptive behaviour. | Rehabilitative care (occupational, physical, and speech or communication therapy) | Children (0–10) and adolescents (11–17 years) living with intellectual disabilities across the 31 provinces of China | 744 (41% female) | Group of interest | SHI | Urban Residence Basic Medical Insurance (UR-BMI), or New Rural Cooperative Medical scheme (NRCM) | 222 | Likelihood of Rehabilitation service utilization defined as likelihood of individuals receiving at least one rehabilitation service (occupational, physical, and speech or communication therapy) in the past 12 months | • With the exception of the first year of follow-up (2007); the remaining years showed a significantly lower likelihood of service use among the uninsured participants (2008–2013). • OR ranged from 0.50 in 2008 to 0.55 in 2013 (OR range 0.50–0.63) |  |  |
Comparison group (1) | Uninsured | No health insurance | 522 | Â | ||||||||||
Hirunrassamee, S., et al., 2009 [43] | Bangkok and two Provinces in the northeastern region, Thailand | Retrospective chart review | Hospital electronic diagnosis and drug dispensing databases were used as data sources. The records were available on an individual patient level. Data from the entire patient populations of the three hospital from three fiscal years—October 1, 2002, to September 30, 2005—were retrieved for this study. | Inpatient Care | Population of Thailand diagnosed as having epilepsy who visited or were admitted to any of the three hospitals under study between October 1, 2002, and September 30, 2005; and were treated with anti-epileptic drugs for no less than 90 consecutive days (to qualify as suffering epilepsy as a chronic condition rather than an occasional one) | 439 | Group of interest | NHI | Universal Health Coverage scheme (previously 30 Baht Scheme) | 89 | Utilization of new drugs (anti-epileptics which render better control of seizures with fewer side effects: lamotrigine 100 mg) | 13% | Average drug cost (Baht) per seizure free case | 7318.29 Baht among UHC beneficiaries; SSS 14,416.76 Baht; CSMBS 6623.55 Baht (the most cost-effective system for this disease condition) |
Comparison group (1) | Social Health Insurance | Social Security Scheme (SSS) | 62 | 19% | ||||||||||
Comparison group (2) | Social Health Insurance | Civil Service Medical Benefits Scheme (CSMBS) | 288 | 31% | ||||||||||
Hwang, J.E., et al., 2018 [41] | National, South Korea | Cross-sectional study | Health Insurance Review and Assessment service (HIRA)-Aged Patient Sample database containing claim data on 1 million elderly patients, accounting for 20% of the elderly population in Korea. Data for Patients who were prescribed antidepressents in primary care settings between January and December 2013 were extracted. | Outpatient care | The elderly (> = 65) population in South Korea who were prescribed antidepressents in 2013 | 132,316 (67% female) | Group of interest | NHI | Korean national health insurance | 119,106 | Utilization of tricyclic antidepressants (TCAs) among elderly Koreans in primary care settings measured as the proportion of antidepressants prescribed that were TCAs | 49.70% |  |  |
Comparison group (1) | Government subsidies for those who do not have economic capability, and can/cannot work | Medical Care Aid | 13,464 | 51.60% | Â | Â | ||||||||
Comparison group (2) | Government subsidies for Veterns | Veterans Health | 178 | 54.5%; Patients with Veterans health coverage were 1.62 times more likely to be prescribed TCAs compared with those who had NHI | Â | Â | ||||||||
Jian, W., et al., 2009 [31] | Beijing, China | Difference in difference | Data was extracted from the Hospital Information System (HIS). | Inpatient Care | Population of urban China hospitalized between 2002 and 2004 for Schizophrenia, Bipolar Affective Disorder, Vascular Dementia, Mental and behavioural disorders due to alcohol, Manic episodes or Depressive episode. | 1137 | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI); Urban Residence Basic Medical Insurance (UR-BMI) | 396 | Length of Inpatient Admission | 120.66 days |  |  |
Comparison group (1) | GHI | Government Health Insurance Scheme (GIS) | 212 | 98.89 days |  |  | ||||||||
Comparison group (2) | Uninsured | No health insurance | 529 | 60 days |  |  | ||||||||
Wang, Z.-M., et al., 2015 [32] | Beijing, China | Retrospective chart review | An extensive chart review was carried out, collecting data from an electronic chart management system (ECMS) for discharged patients aged 18 to 59 years. | Inpatient care | Patients receiving inpatient care at Beijing Anding Hospital (aged 18–59) with a primary psychiatric diagnosis (F-code) | 19,982 (52% female) | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI); Urban Residence Basic Medical Insurance (UR-BMI), or New Rural Cooperative Medical scheme (NRCM) | 9865 | Likelihood of Electroconvulsive therapy (ECT) use known for high risk of significant cognitive impairments | 44% |  |  |
Comparison group (1) | Uninsured | Uninsured, either not registered with any of China’s health insurance schemes or living in a place of residence that is not their place of residence as registered | 10,117 | 56% ECT use was independently associated with less health insurance OR: 0.7 |  |  | ||||||||
Xu, J., et al., 2018 [33] | Shadong province, China | Retrospective chart review | Hospitals’ Electronic Health Records (EHR). The EHR data documents all inpatient expenses incurred during hospitalization in a detailed and itemized way. | Inpatient Care | Population of Shandong province with a primary psychiatric diagnosis (F-code) | 9504(53% female) | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI); Urban Residence Basic Medical Insurance (UR-BMI), or New Rural Cooperative Medical scheme (NRCM) | 3215 | Utilization rate measured by length of stay | 70 days • UE-BMI: 137.52 days • UR-BMI: 63.70 days NCMS: 24.99 days | Utilization rate measured by frequency of hospitalizations | Frequency of hospitalization: 2 • UE-BMI: 3.96 • UR-BMI: 2.27 • NCMS: 1.91 |
Comparison group (1) | Uninsured | Uninsured, either not registered with any of China’s health insurance schemes or living in a place of residence that is not their place of residence as registered | 6289 | 45 days | Uninsured: 1 | |||||||||
Xue, Q., et al., 2014 [34] | Wuhan and Wuxi cities, China | Cross sectional study | Claim records of inpatients with at least one schizophrenia- relevant diagnosis (ICD-10 code F20) in the year 2010 were derived from the two cities’ respective Urban Employees’ Basic Medical Insurance (UE-BMI) and the Urban Residents’ Basic Medical Insurance (UR-BMI) reimbursement databases in an anonymous form. G | Inpatient Care | Urban population of China with diagnosed schizophrenia (F20) receiving inpatient care and antipsychotic medication in 2010 | 2904 (45% female) | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI) | 2728 | Coverage of second-generation antipsychotic medication excluding clozapine (SGA); | SGA: 53%; | Coverage of first-generation antipsychotics) FGA) and coverage of clozapine (CL) | FGA: 22% CL: 25% |
Comparison group (1) | SHI | Urban Residence Basic Medical Insurance (UR-BMI) | 176 | SGA: 53%; | FGA: 35% CL: 12% | |||||||||
Yu-tao, X., et al., 2007 [35] | Hong Kong and Beijing, China | Cross sectional study | Interviews with subjects in Hong Kong were randomly selected from patients diagnosed with schizophrenia attending the outpatient clinic of a university-affiliated general hospital; their Beijing counterparts, matched according to sex, age, age at onset, and length of illness, were recruited from patients with schizophrenia attending the Adult psychiatric Outpatient Clinic at Beijing Anding Hospital. Case notes were also reviewed. | Outpatient care | Clinically stable outpatients with schizophrenia in Beijing and Hong Kong between 2005 and 2006 | 505 (52% female) | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI); Urban Residence Basic Medical Insurance (UR-BMI), or Government Insurance Scheme (GIS) | 462 | Treated with/prescribed Anticholinergic medication (ACM) known for a variety of side effects including the impairment of cognitive capacity | 50% | Â | Â |
Comparison group (1) | Uninsured | Uninsured, either not registered with any of China’s health insurance schemes or living in a place of residence that is not their place of residence as registered | 43 | 33% |  |  | ||||||||
Yu-Tao, X., et al., 2007 [35] | Hong Kong and Beijing, China | Cross sectional study | Clinically stable outpatients with schizophrenia were randomly selected and interviewed in Hong Kong (HK) and Beijing (BJ). Assessment instruments included the Structured Clinical Interview for DSM-IV, Brief Psychiatric Rating Scale, Simpson and Angus Scale of Extrapyramidal Symptoms, Barnes Akathisia Rating Scale and the Hong Kong and Mainland China World Health Organization Quality of Life Schedule-Brief version. | Outpatient care | Clinically stable outpatients with schizophrenia in Beijing and Hong Kong between 2005 and 2006 | 398 (49% female) | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI); Urban Residence Basic Medical Insurance (UR-BMI), or Government Insurance Scheme (GIS) | 359 | Treated with/prescribed clozapine | 13% | Â | Â |
Comparison group (1) | Uninsured | Uninsured, either not registered with any of China’s health insurance schemes or living in a place of residence that is not their place of residence as registered | 39 | 36% |  |  | ||||||||
Zhang, X.-Q., et al., 2015 [37] | Beijing, China | Retrospective chart review | Extensive chart review was carried out, collecting data from an electronic chart management system (ECMS) for discharged patients aged 60 years and above | Inpatient Care | Geriatric (aged 60 years and older) inpatients with an F-code diagnosis treated between 2007 and 2013 in Beijing | 2339 (59% female) | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI); Urban Residence Basic Medical Insurance (UR-BMI), or Government Insurance Scheme (GIS) | 1846 | Proportion receiving Electroconvulsive therapy (ECT) | 24.2%; Those with health insurance were significantly less likely to receive ECT, OR 0.6 (0.4–0.8) |  |  |
Comparison group (1) | Uninsured | Uninsured, either not registered with any of China’s health insurance schemes or living in a place of residence that is not their place of residence as registered | 493 | 46% |  |  | ||||||||
Zhou, Y., et al., 2017 [39] | Guangzhou, China | Cohort study | Survey upon discharge from Guangzhou Huiai Hospital (Positive and Negative Syndrome Scale (PANSS), for clinical symptoms, Insight and Treatment Attitudes Questionnaire (ITAQ) for insight and treatment attitudes, drug attitude inventory (DAI) and family experience interview schedule (FEIS)) and follow up call one year later to determine medication use post-discharge | Inpatient Care | Patients aged 16–60 years who have diagnosed schizophrenia living in Guangzhou, China; and their caregivers | 236 (46% female) | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI); Urban Residence Basic Medical Insurance (UR-BMI), or Government Insurance Scheme (GIS) | 105 | Proportion discontinuing psychotropic medication one-year post-discharge | 14% |  |  |
Comparison group (1) | Uninsured | Uninsured, either not registered with any of China’s health insurance schemes or living in a place of residence that is not their place of residence as registered (i.e also those registered with NRCM) | 131 | 35% |  |  | ||||||||
Zhou, Y., et al., 2014 [38] | Guangdong province, China | Retrospective chart review | Hospitals’ Electronic Health Records (EHR) from Guangdong Psychiatric Hospital | Inpatient Care | Patients with any F-code diagnoses living in Guangdong, China who were discharged between 2010 and 2013 | 8478 (42% female) | Group of interest | SHI | Urban Employee Basic Medical Insurance (UE-BMI); Urban Residence Basic Medical Insurance (UR-BMI) | 2055 | Number of inpatient admissions | 3.3 | Likelihood of first, second or third hospitalization | GIS and BMI groups were 1.6 and 2 times more likely to be in a second hospitalization than others; 2.1 and 3 times more likely to be in a first hospitalisation, and; 5.3 and 4.8 times more likely to be in more than 3 hospitalizations |
Comparison group (1) | Government Insurance System (GIS) | Government Insurance Scheme (GIS) | 276 | 4.1 | ||||||||||
Comparison group (2) | New Rural Cooperative Medical Scheme (NCMS) | New Rural Cooperative Medical Scheme (NCMS) andothers | 4897 | 1.7 | ||||||||||