Comprehensive Health Insurance and access to maternal healthcare services among Peruvian women: a cross-sectional study using the 2021 national demographic survey.

BACKGROUND: The government-subsidized health insurance scheme Seguro Integral de Salud ("SIS") was introduced in Peru initially to provide coverage to uninsured and poor pregnant women and children under five years old and was later extended to cover all uninsured members of the population following the Peruvian Plan Esencial de Aseguramiento Universal - "PEAS" (Essential UHC Package). Our study aimed to analyze the extent to which the introduction of SIS has increased equity in access and quality by comparing the utilization of maternal healthcare services among women with different insurance coverages. METHODS: Relying on the 2021 round of the nationally-representative survey "ENDES" (Encuesta Nacional Demográfica y de Salud Familiar), we analyzed data for 19,181 women aged 15-49 with a history of pregnancy in the five years preceding the survey date. We used a series of logistic regressions to explore the association between health insurance coverage (defined as No Insurance, SIS, or Standard Insurance) and a series of outcome variables measuring access to and quality of all services along the available maternal healthcare continuum. RESULTS: Only 46.5% of women across all insurance schemes reported having accessed effective ANC prevention. Findings from the adjusted logistic regression confirmed that insured women were more likely to have accessed ANC services compared with uninsured women. Our findings indicate that women in the "SIS" group were more likely to have accessed six ANC visits (aOR = 1.40; 95% CI 1.14-1.73) as well as effective ANC prevention (aOR = 1.32; 95% CI 1.17-1.48), ANC education (aOR = 1.59; 95% CI 1.41-1.80) and ANC screening (aOR = 1.46; 95% CI 1.27-1.69) during pregnancy, compared with women in the "Standard Insurance" group [aOR = 1.35 (95% CI 1.13-1.62), 1.22 (95% CI 1.04-1.42), 1.34 (95% CI 1.18-1.51) and 1.31(95% CI 1.15-1.49)] respectively. In addition, women in the "Standard Insurance" group were more likely to have received skilled attendance at birth (aOR = 2.17, 95% CI 1.33-3.55) compared with the women in the "SIS" insurance group (aOR = 2.12; 95% CI 1.41-3.17). CONCLUSIONS: Our findings indicate the persistence of inequities in access to maternal healthcare services that manifest themselves not only in the reduced utilization among the uninsured, but also in the lower quality of service coverage that uninsured women received compared with women insured under "Standard Insurance" or "SIS". Further policy reforms are needed both to expand insurance coverage and to ensure that all women receive the same access to care irrespective of their specific insurance coverage.

Identifying the determinants of health insurance coverage among Peruvian women of reproductive age: an assessment based on the national Peruvian demographic survey of 2017.

BACKGROUND: Like many other Latin America- and Caribbean countries, Peru has introduced a tax-financed health insurance scheme called "Sistema Integral de Salud (SIS)" to foster progress towards Universal Health Coverage. The scheme explicitly targets the poorest sections of the population. Our study explores levels of health insurance coverage and their determinants among Peruvian women following the introduction of SIS. We wish to determine the extent to which the introduction of SIS has effectively closed gaps in insurance coverage and for whom. METHODS: Relying on the 2017 round of ENDES (Encuesta Nacional Demográfica y de Salud Familiar) survey, we analyzed data for 33,168 women aged 15-49. We used multinomial logistic regression to explore the association between health insurance coverage (defined as No Insurance, SIS, Standard Insurance) and women's socio-demographic and economic characteristics. RESULTS: Out of the 33,168 women, 25.3% did not have any insurance coverage, 45.5% were covered by SIS and 29.2% were covered by a Standard Insurance scheme. Women in the SIS group were found to have lower educational levels, live in rural areas and more likely to be poorer. Women in the Standard insurance group were found to be more educated, more likely to be "Spanish", and to be wealthier. Most uninsured women appeared to belong to a middle class, not poor enough to be eligible for SIS, but also not eligible for standard insurance. CONCLUSIONS: Our study confirms that SIS has been effective in increasing coverage among vulnerable women, with coverage rates comparable with those observed among men. Nevertheless, on its own, it has proven to be insufficient to ensure universal coverage among women. Further reforms are needed to ensure that coverage is extended to all population groups.