Improving equity in access to care: The impact of health insurance and family planning messages on access to maternal and reproductive health in Zambia

Introduction
Equitable access to maternal and reproductive health (MRH) services remains a major challenge in low- and lower-middle-income countries (LLMICs), including Zambia. Despite health system reforms such as the National Health Insurance Scheme (NHIS) and family planning (FP) communication strategies, disparities persist, particularly among socioeconomically disadvantaged populations. This thesis investigates the impact of health insurance and FP message delivery on MRH service utilisation and equity in Zambia to generate evidence to inform policy and improve access to essential health services like contraception, antenatal care (ANC), delivery care, and postnatal care (PNC).

Methods
To address the aim of this thesis, several methods were used. Study I was a systematic review of peer reviewed literature published between 2010 and 2023, assessing the impact of not-for-profit health insurance on MRH service utilisation and financial protection in LLMICs. Study II analysed Zambia Demographic and Health Survey (DHS) data from 2007, 2013/14, and 2018 (N=19,973 sexually active women aged 15 – 49) to assess inequality and inequity in modern contraceptive use and unmet need using Erreygers Concentration Index (EI) and decomposition analysis. Study III used causal inference methods (logistic regression, augmented inverse probability weighting [AIPW]) to estimate the impact of FP message delivery modes, mass media, counselling, and both, on contraceptive use (N=19,958). Study IV involved qualitative interviews with 21 stakeholders involved in NHIS implementation, analysed using inductive content analysis in NVivo 14.

Results
This review found that health insurance in LLMICs significantly increased MRH service utilisation, particularly facility-based delivery (up to 20.3 percentage points), ≥4 ANC visits (2–11 percentage points), and skilled birth attendance. However, it had limited impact on early ANC, PNC, and contraceptive use. Financial protection improved in some contexts, with notable reductions in out-of-pocket expenditure (e.g., Indonesia: 1,136,966 Indonesian Rupiah for non-contributory insurance). In Zambia, modern contraceptive use increased from 37.3% in 2007 to 49.8% in 2018, while unmet need rose to 19.8%. Inequality in contraceptive use was pro-rich (EI declining from 0.2046 to 0.1124), and unmet need was pro-poor (EI from –0.0484 to –0.0427). Education and contraceptive counselling reduced inequality, while living with a partner increased it. FP messages delivered via counselling and mass media significantly increased contraceptive use. AIPW estimates showed average treatment effects (ATE) of 3.4% for mass media, 14.6% for counselling, and 17.1% for both. However, exposure to FP messages declined over time, especially mass media (from 43.95% in 2007 to 22.88% in 2018). Logistic regression confirmed the highest odds of contraceptive use among those exposed to both counselling and mass media (AOR=1.73), followed by counselling alone (AOR=1.47), and mass media (AOR=1.18). Stakeholder interviews revealed implementation challenges for NHIS, including political interference, exclusion of poor and informal sector populations, urban bias in provider accreditation, and financial sustainability concerns. Participants emphasized the need for reforms to improve equity and efficiency.

Conclusion
Health insurance and FP communication strategies positively influence MRH service utilisation and equity, but their impact is uneven across socioeconomic groups. Insurance schemes should be redesigned to include vulnerable populations, and FP messaging should prioritize high-quality counselling and integrated delivery approaches. Persistent inequalities in contraceptive use and unmet need highlight the need for targeted, context-sensitive interventions. Strengthening governance, expanding coverage, and monitoring equity outcomes are essential for Zambia and similar LLMICs to achieve universal health coverage and improve maternal health outcomes.