Health insurance coverage and quality of care for reproductive and maternal health in LMICs: a multicountry propensity score matching study
11 affiliations
- 1Nossal Institute for Global Health, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
- 2Department of Health Policy and Management, Gadjah Mada University Faculty of Medicine Public Health and Nursing, Yogyakarta, Indonesia
- 3School of Public Health and Community Medicine, University of Gothenburg, Goteborg, Sweden
- 4Department of Economic Sciences, Indian Institute of Technology Kanpur, Kanpur, Uttar Pradesh, India
- 5Imperial College London, London, UK
- 6Nossal Institute for Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- 7Digital Health and Stroke Program, The George Institute for Global Health, Sydney, New South Wales, Australia
- 8School of Public Health, Harvard University, Boston, Massachusetts, USA
- 9Gadjah Mada University Faculty of Medicine Public Health and Nursing, Yogyakarta, Indonesia
- 10Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
- 11Department of Public Health, College of Public Health, National Taiwan University, Taipei, Taiwan
Abstract
Introduction: Poor maternal and child health remains a major challenge, particularly in low- and middle-income countries (LMICs). This study assessed differences in the reproductive, maternal and child health (RMCH) continuum of care between insured and uninsured populations across nine LMICs.
Methods: We analysed the latest two Demographic and Health Survey waves collected in Cambodia, Dominican Republic, Ghana, Guatemala, India, Indonesia, Jordan, Kyrgyz Republic and Peru, constituting around 23% of the global population. Propensity score matching assessed associations between health insurance and effective coverage across the care cascade for family planning, antenatal care (ANC), maternal delivery and postnatal care (PNC). Average treatment effect on the treated with 95% CIs was reported.
Results: Insurance effects varied substantially across countries. Family planning service contact was significantly higher among insured population in five of seven countries with available data, with the largest effect in Ghana (16.9 percentage points (pp), 95% CI 11.2 to 22.5). ANC quality-adjusted coverage was significantly higher among insured women in six countries, with the largest effect in India (17.2 pp, 95% CI 15.8 to 18.6). Maternal delivery service contact was significantly associated with insurance coverage in five countries, with the largest effect in Ghana (10.5 pp, 95% CI 6.1 to 14.9). PNC service contact showed significant associations in four countries, with the largest effect in Cambodia (10.3 pp, 95% CI 4.3 to 16.4). Pooled analyses showed positive associations across all outcomes, largest for ANC quality-adjusted coverage (9.9 pp, 95% CI 8.6 to 11.2) and family planning service contact (7.7 pp, 95% CI 6.0 to 9.4). Importantly, insurance coverage was concentrated among more educated women in seven countries and wealthier populations in five, highlighting persistent equity concerns.
Conclusions: Health insurance coverage was associated with higher RMCH coverage and quality, but persistent socioeconomic inequalities raise equity concerns. Expanding insurance coverage without ensuring inclusivity risks exacerbating disparities and undermining progress towards universal health coverage.
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BibTeX
@article{marthias2026health,
title = {{Health insurance coverage and quality of care for reproductive and maternal health in LMICs: a multicountry propensity score matching study}},
author = {Tiara Marthias and Kanya Anindya and Barbara McPake and Sukumar Vellakkal and Thomas Hone and Dennis La and Yang Zhao and Rifat Atun and Huan Wang and Reza Pandu and John Tayu Lee},
journal = {BMJ Global Health},
year = {2026},
month = nov,
doi = {10.1136/bmjgh-2025-022566},
url = {https://doi.org/10.1136/bmjgh-2025-022566},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Health insurance coverage and quality of care for reproductive and maternal health in LMICs: a multicountry propensity score matching study
AU - Tiara Marthias
AU - Kanya Anindya
AU - Barbara McPake
AU - Sukumar Vellakkal
AU - Thomas Hone
AU - Dennis La
AU - Yang Zhao
AU - Rifat Atun
AU - Huan Wang
AU - Reza Pandu
AU - John Tayu Lee
PY - 2026
DA - 2026/11/01
JO - BMJ Global Health
DO - 10.1136/bmjgh-2025-022566
UR - https://doi.org/10.1136/bmjgh-2025-022566
AB - Introduction: Poor maternal and child health remains a major challenge, particularly in low- and middle-income countries (LMICs). This study assessed differences in the reproductive, maternal and child health (RMCH) continuum of care between insured and uninsured populations across nine LMICs. Methods: We analysed the latest two Demographic and Health Survey waves collected in Cambodia, Dominican Republic, Ghana, Guatemala, India, Indonesia, Jordan, Kyrgyz Republic and Peru, constituting around 23% of the global population. Propensity score matching assessed associations between health insurance and effective coverage across the care cascade for family planning, antenatal care (ANC), maternal delivery and postnatal care (PNC). Average treatment effect on the treated with 95% CIs was reported. Results: Insurance effects varied substantially across countries. Family planning service contact was significantly higher among insured population in five of seven countries with available data, with the largest effect in Ghana (16.9 percentage points (pp), 95% CI 11.2 to 22.5). ANC quality-adjusted coverage was significantly higher among insured women in six countries, with the largest effect in India (17.2 pp, 95% CI 15.8 to 18.6). Maternal delivery service contact was significantly associated with insurance coverage in five countries, with the largest effect in Ghana (10.5 pp, 95% CI 6.1 to 14.9). PNC service contact showed significant associations in four countries, with the largest effect in Cambodia (10.3 pp, 95% CI 4.3 to 16.4). Pooled analyses showed positive associations across all outcomes, largest for ANC quality-adjusted coverage (9.9 pp, 95% CI 8.6 to 11.2) and family planning service contact (7.7 pp, 95% CI 6.0 to 9.4). Importantly, insurance coverage was concentrated among more educated women in seven countries and wealthier populations in five, highlighting persistent equity concerns. Conclusions: Health insurance coverage was associated with higher RMCH coverage and quality, but persistent socioeconomic inequalities raise equity concerns. Expanding insurance coverage without ensuring inclusivity risks exacerbating disparities and undermining progress towards universal health coverage.
SN - 2059-7908
ER -