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.

Health Academy Program and physical activity levels in Brazilian state capitals / Programa Academia da Saúde e níveis de atividade física nas capitais brasileiras

The objective of this study was to analyze the impact of a community-based physical activity program, the Health Academy Program (Academia da Saúde or PAS), on leisure-time physical activity (LTPA) among the population living at the Brazilian state capitals. We pooled individual data from the National Surveillance for Protective and Risk Factors for Chronic Diseases (VIGITEL) between 2006 and 2016 and estimated odds ratios according to levels of exposure by using a multilevel logistic regression. Total sample was composed of 572,437 individuals. In the initial model, chances of reaching sufficient LTPA was 1.20 (95%CI: 1.16-1.25) times higher among individuals exposed since 2011. In the analyses adjusted for year, sex, age and education, this probability was only 1.04 (95%CI: 1.00-1.08) times higher among exposed individuals. Odds of reaching recommended LTPA was 1.09 (95%CI: 1.04-1.15) times higher among women exposed since 2011 as compared to women in the control group with no exposure. No other statistically significant results were found. We conclude that the PAS cannot substantially affect whole populations. Yet it is possible to visualize a positive influence of the program on specific subgroups, pointing to its potential to reduce gender inequity in LTPA practice. We recommend more tailored interventions before indistinctively scaling up the program, as well as we suggest better monitoring for large scale evaluations

O objetivo deste estudo foi analisar o efeito de um programa de atividade física de base comunitária, o Programa Academia da Saúde (PAS), no nível de atividade física durante o lazer (AFDL) da população residente nas capitais brasileiras. Reunimos dados individuais do sistema de Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico ( VIGITEL) entre 2006 e 2016 e estimamos os odds ratios de acordo com níveis de exposição ao programa usando uma regressão logística multinível. A amostra total foi composta por 572.437 indivíduos. No modelo inicial, as chances de se atingir níveis suficientes de AFDL foram 1,20 (95%IC: 1,16-1,25) vezes maior entre os indivíduos expostos desde 2011. Nas análises ajustadas por ano, sexo, idade e escolaridade, essa probabilidade foi apenas 1,04 (95%IC: 1,00-1,08) vezes maior entre indivíduos expostos. As chances de se atingir níveis de AFDL suficiente foram 1,09 (95%IC: 1,04-1,15) vezes maior entre as mulheres expostas desde 2011 em comparação ao grupo controle de mulheres não expostas. Nenhum outro resultado estatisticamente significativo foi encontrado. Concluímos que o PAS não pode afetar substancialmente populações inteiras. No entanto, é possível visualizar influência positiva em subgrupos específicos, apontando para o seu potencial em reduzir a desigualdade de gênero em relação a prática de AFDL. Recomendamos intervenções mais personalizadas antes de escalonar indistintamente o programa, bem como sugerimos um melhor monitoramento para avaliações em larga escala