Evaluating the effectiveness of the National Health Insurance Fund in providing financial protection to households with hypertension and diabetes patients in Kenya

BACKGROUND

Non-communicable diseases (NCDs) can impose a substantial financial burden to households in the absence of an effective financial risk protection mechanism. The national health insurance fund (NHIF) has included NCD services in its national scheme. We evaluated the effectiveness of NHIF in providing financial risk protection to households with persons living with hypertension and/or diabetes in Kenya.

METHODS

We carried out a prospective cohort study, following 888 households with at least one individual living with hypertension and/or diabetes for 12 months. The exposure arm comprised households that are enrolled in the NHIF national scheme, while the control arm comprised households that were not enrolled in the NHIF. Study participants were drawn from two counties in Kenya. We used the incidence of catastrophic health expenditure (CHE) as the outcome of interest. We used coarsened exact matching and a conditional logistic regression model to analyse the odds of CHE among households enrolled in the NHIF compared with unenrolled households. Socioeconomic inequality in CHE was examined using concentration curves and indices.

RESULTS

We found strong evidence that NHIF-enrolled households spent a lower share (12.4%) of their household budget on healthcare compared with unenrolled households (23.2%) (p = 0.004). While households that were enrolled in NHIF were less likely to incur CHE, we did not find strong evidence that they are better protected from CHE compared with households without NHIF (OR = 0.67; p = 0.47). The concentration index (CI) for CHE showed a pro-poor distribution (CI: -0.190, p < 0.001). Almost half (46.9%) of households reported active NHIF enrolment at baseline but this reduced to 10.9% after one year, indicating an NHIF attrition rate of 76.7%. The depth of NHIF cover (i.e., the share of out-of-pocket healthcare costs paid by NHIF) among households with active NHIF was 29.6%.

CONCLUSION

We did not find strong evidence that the NHIF national scheme is effective in providing financial risk protection to households with individuals living with hypertension and/diabetes in Kenya. This could partly be explained by the low depth of cover of the NHIF national scheme, and the high attrition rate. To enhance NHIF effectiveness, there is a need to revise the NHIF benefit package to include essential hypertension and/diabetes services, review existing provider payment mechanisms to explicitly reimburse these services, and extend the existing insurance subsidy programme to include individuals in the informal labour market.

Disparities of obesity and non-communicable disease burden between the Tibetan Plateau and developed megacities in China

Background

Non-communicable diseases (NCDs) including risk factors, e.g., obesity, are the major causes of preventable deaths in China, yet NCD disparities in China remain under-studied.

Objective

This study aimed to compare the determinants and burden of NCDs within four selected provinces in mainland China: the least developed Qinghai-Tibet Plateau group (PG, Tibetan Autonomous Region [TAR] and Qinghai Province) and most developed megacity group (MCG, Shanghai, and Beijing).

Methods

Studies, reports, and other official sources with comparable data for NCD burden and related determinants for the four provinces were searched. Geographic, demographic, socioeconomic, and dietary characteristics and selected health indicators (e.g., life expectancy) were extracted from the China Statistical Yearbook and China Health Statistics Yearbook. Data on NCD burdens were extracted from the National Chronic Disease and Risk Factor Surveillance Study and other nationally representative studies.

Results

The overall NCD mortality rates and prevalence of metabolic risk factors including obesity, hypertension, and diabetes in mainland China have increased in the past 20 years, and this trend is expected to continue. The PG had the highest level of standardized mortality rates (SMRs) on NCDs (711.6-896.1/100,000, 6th/6-level); the MCG had the lowest (290.6-389.6/100,000, 1st/6-level) in mainland China. The gaps in SMRs were particularly high with regard to chronic respiratory diseases (PG 6th^/6-level, MCG 1st/6-level) and cardiovascular diseases (6th/6 and 4th/6 in TAR and Qinghai; 1st/6-level and 2nd/6-level in Shanghai and Beijing). In contrast, the prevalence rates of obesity, hypertension, and diabetes were generally higher or comparable in MCG compared to PG. Diabetes prevalence was particularly high in MCG (5th/5-level, 13.36-14.35%) and low in PG (1st/5-level, 6.20-10.39%). However, awareness, treatment, and control of hypertension were poor in PG. Additionally, PG had much lower and severely inadequate intakes of vegetables, fruits, and dairy products, with additional indicators of lower socioeconomic status (education, income, etc.,) compared with MCG.

Conclusion

Evidence showed large disparities in NCD burden in China's provinces. Socioeconomic disparity and dietary determinants are probably the reasons. Integrated policies and actions are needed.

Ethical issues with geographical variations in the provision of health care services

Geographical variations are documented for a wide range of health care services. As many such variations cannot be explained by demographical or epidemiological differences, they are problematic with respect to distributive justice, quality of care, and health policy. Despite much attention, geographical variations prevail. One reason for this can be that the ethical issues of geographical variations are rarely addressed explicitly. Accordingly, the objective of this article is to analyse the ethical aspects of geographical variations in the provision of health services. Applying a principlist approach the article identifies and addresses four specific ethical issues: injustice, harm, lack of beneficence, and paternalism. Then it investigates the normative leap from the description of geographical variations to the prescription of right care. Lastly, the article argues that professional approaches such as developing guidelines, checklists, appropriateness criteria, and standards of care are important measures when addressing geographical variations, but that such efforts should be accompanied and supported by ethical analysis. Hence, geographical variations are not only a healthcare provision, management, or a policy making problem, but an ethical one. Addressing the ethical issues with geographical variations is key for handling this crucial problem in the provision of health services.

What can we learn from China's health insurance reform to improve the horizontal equity of healthcare financing?

BACKGROUND

Universal health coverage is a challenge to horizontal equity in healthcare financing. Since 1998, China has extended its healthcare insurance schemes, and individuals with equal incomes but different attributes such as social status, profession, geographic access to health care, and health conditions, are covered by the same health insurance scheme. This study aims to examine horizontal inequity in the Chinese healthcare financing system in 2002 and 2007 using data from two national household health surveys.

METHODS

Multi-stage stratified random sampling was used to select 3,946 households with 13,619 individuals in 2002, and 3,958 households with 12,973 individuals in 2007. A decomposition method was used to measure the horizontal inequity and reranking in healthcare finance.

RESULTS

Over the period 2002-2007, the absolute value of horizontal inequity in total healthcare payments decreased from 997.83 percentage points to 199.87 percentage points in urban areas, and increased from 22.28 percentage points to 48.80 percentage points in rural areas. The horizontal inequity in social health insurance remained almost the same in urban areas, at around 27 percentage points, but decreased from 110.90 percentage points to 7.80 percentage points in rural areas. Horizontal inequity in out-of-pocket payments decreased from 178.43 percentage points to 80.96 percentage points in urban areas, and increased from 26.06 percentage points to 41.40 percentage points in rural areas.

CONCLUSION

The horizontal inequity of healthcare finance in China over the period 2002-2007 was reduced by general taxation and social insurance, but strongly affected by out-of-pocket payments. Increasing the benefits from social health insurance would help to reduce horizontal inequity.

Decomposing socioeconomic inequality in blood pressure and blood glucose testing: evidence from four districts in Kerala, India

Background

Non-Communicable Diseases (NCDs) constitute a significant danger to the nation’s public health system, both in terms of morbidity and mortality, as well as the financial burden they inflict. Kerala is undergoing an epidemiologic transition, which has significantly impacted the state’s morbidity and mortality figures. For decades, the state has been putting in place myriad programs to reduce the burden of NCDs across population groups. Socioeconomic inequalities in NCD testing have been documented in India, although they are understudied in Kerala. The study aimed to estimate and characterize districtwise socioeconomic inequality in Blood Pressure (BP) and Blood Glucose (BG) testing.

Methods

A cross-sectional household survey was conducted between July–October 2019 in Kasaragod, Alappuzha, Kollam and Thiruvananthapuram districts of Kerala, India. A total of 6383 participants aged 30 years and above were interviewed using multistage random sampling. Descriptive statistics were derived district-wise. We computed ratios, differences, equiplots, and Erreygers concentration indices for each district to measure socioeconomic inequality in BP and BG testing. Erreygers decomposition techniques were used to estimate the relative contribution of covariates to socioeconomic inequality.

Results

There was a significant concentration of BP and BG testing favouring wealthier quintiles in Alappuzha, Kollam, and Thiruvananthapuram districts. The inequality in BP and BG testing was highest in Thiruvananthapuram (0.087 and 0.110), followed by Kollam (0.077 and 0.090), Alappuzha (0.083 and 0.073) and Kasaragod (0.026 and 0.056). Decomposition analysis revealed that wealth quintile and education contributed substantially to socioeconomic inequality in BP and BG testing in all four districts. It was also found that family history of NCDs significantly contributed to observed socioeconomic inequality in BP testing (29, 11, 16, and 27% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram, respectively). Similarly, in BG testing, family history of NCDs substantially contributed to observed socioeconomic inequality, explaining 16–17% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram respectively of the total inequality.

Conclusion

While the magnitude of socioeconomic inequality in NCD risk factor testing did not appear to be very high in four Kerala districts, although levels were statistically significant in three of them. Greater exploration is needed on how education and caste contribute to these inequalities and their relationship to NCD risk factors such as family history. From such analyses, we may be able to identify entry points to mitigate inequalities in testing access, as well as burden.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01737-x.

Socioeconomic Inequity in the Screening and Treatment of Hypertension in Kenya: Evidence From a National Survey

Background

Non-communicable diseases (NCDs) account for 50% of hospitalisations and 55% of inpatient deaths in Kenya. Hypertension is one of the major NCDs in Kenya. Equitable access and utilisation of screening and treatment interventions are critical for reducing the burden of hypertension. This study assessed horizontal equity (equal treatment for equal need) in the screening and treatment for hypertension. It also decomposed socioeconomic inequalities in care use in Kenya.

Methods

Cross-sectional data from the 2015 NCDs risk factors STEPwise survey, covering 4,500 adults aged 18-69 years were analysed. Socioeconomic inequality was assessed using concentration curves and concentration indices (CI), and inequity by the horizontal inequity (HI) index. A positive (negative) CI or HI value suggests a pro-rich (pro-poor) inequality or inequity. Socioeconomic inequality in screening and treatment for hypertension was decomposed into contributions of need [age, sex, and body mass index (BMI)] and non-need (wealth status, education, exposure to media, employment, and area of residence) factors using a standard decomposition method.

Results

The need for hypertension screening was higher among poorer than wealthier socioeconomic groups (CI = -0.077; p < 0.05). However, wealthier groups needed hypertension treatment more than poorer groups (CI = 0.293; p <0.001). Inequity in the use of hypertension screening (HI = 0.185; p < 0.001) and treatment (HI = 0.095; p < 0.001) were significantly pro-rich. Need factors such as sex and BMI were the largest contributors to inequalities in the use of screening services. By contrast, non-need factors like the area of residence, wealth, and employment status mainly contributed to inequalities in the utilisation of treatment services.

Conclusion

Among other things, the use of hypertension screening and treatment services in Kenya should be according to need to realise the Sustainable Development Goals for NCDs. Specifically, efforts to attain equity in healthcare use for hypertension services should be multi-sectoral and focused on crucial inequity drivers such as regional disparities in care use, poverty and educational attainment. Also, concerted awareness campaigns are needed to increase the uptake of screening services for hypertension.

Inequity and benefit incidence analysis in healthcare use among Syrian refugees in Egypt

BACKGROUND

The Syrian conflict has created the worst humanitarian refugee crisis of our time, with the largest number of people displaced. Many have sought refuge in Egypt, where they are provided with the same access to healthcare services as Egyptian citizens. Nevertheless, in addition to the existing shortcomings of the Egyptian health system, many obstacles specifically limit refugees' access to healthcare. This study looks to assess equity across levels of care after observing services utilization among the Syrian refugees, and look at the humanitarian dilemma when facing resource allocation and the protection of the most vulnerable.

METHODS

A cross-sectional survey was used and collected information related to access and utilization of outpatient and inpatient health services by Syrian refugees living in Egypt. We used concentration index (CI), horizontal inequity (HI) and benefit incidence analysis (BIA) to measure the inequity in the use of healthcare services and distribution of funding. We decomposed inequalities in utilization, using a linear approximation of a probit model to measure the contribution of need, non-need and consumption influential factors.

RESULTS

We found pro-rich inequality and horizontal inequity in the probability of refugees' outpatient and inpatient health services utilization. Overall, poorer population groups have greater healthcare needs, while richer groups use the services more extensively. Decomposition analysis showed that the main contributor to inequality is socioeconomic status, with other elements such as large families, the presence of chronic disease and duration of asylum in Egypt further contributing to inequality. Benefit incidence analysis showed that the net benefit distribution of subsidies of UNHCR for outpatient and inpatient care is also pro-rich, after accounting for out-of-pocket expenditures.

CONCLUSION

Our results show that without equitable subsidies, poor refugees cannot afford healthcare services. To tackle health inequities, UNHCR and organisations will need to adapt programmes to address the social determinants of health, through interventions within many sectors. Our findings contribute to assessments of different levels of accessibility to healthcare services and uncover related sources of inequities that require further attention and advocacy by policymakers.

Measuring health-related social deprivation in small areas: development of an index and examination of its association with cancer mortality

BACKGROUND

The small-area deprivation indices are varied across countries due to different social context and data availability. Due to lack of chronic disease-related social deprivation index (SDI) in Hong Kong, China, this study aimed to develop a new SDI and examine its association with cancer mortality.

METHODS

A total of 14 socio-economic variables of 154 large Tertiary Planning Unit groups (LTPUGs) in Hong Kong were obtained from 2016 population by-census. LTPUG-specific all-cause and chronic condition-related mortality and chronic condition inpatient episodes were calculated as health outcomes. Association of socio-economic variables with health outcomes was estimated for variable selection. Candidates for SDI were constructed with selected socio-economic variables and tested for criterion validity using health outcomes. Ecological association between the selected SDI and cancer mortality were examined using zero-inflated negative binomial regression.

RESULTS

A chronic disease-related SDI constructed by six area-level socio-economic variables was selected based on its criterion validity with health outcomes in Hong Kong. It was found that social deprivation was associated with higher cancer mortality during 2011-2016 (most deprived areas: incidence relative risk [IRR] = 1.40, 95% confidence interval [CI]: 1.27-1.55; second most deprived areas: IRR = 1.34, 95%CI: 1.21-1.48; least deprived areas as reference), and the cancer mortality gap became larger in more recent years. Excess cancer death related to social deprivation was found to have increased through 2011-2016.

CONCLUSIONS

Our newly developed SDI is a valid and routinely available measurement of social deprivation in small areas and is useful in resource allocation and policy-making for public health purpose in communities. There is a potential large improvement in cancer mortality by offering relevant policies and interventions to reduce health-related deprivation. Further studies can be done to design strategies to reduce the expanding health inequalities between more and less deprived areas.

The association between an increased reimbursement cap for chronic disease coverage and healthcare utilization in China: an interrupted time series study

Hypertension and diabetes are highly prevalent in China and pose significant health and economic burdens, but large gaps in care remain for people with such conditions. In this article, drawing on administrative insurance claim data from China's Urban Employee Basic Medical Insurance (UEBMI), we use an interrupted time series design to examine whether an increase in the monthly reimbursement cap for outpatient visits using chronic disease coverage affects healthcare utilization. The cap was increased by 50 yuan per chronic disease on 1 January 2016, in one of the largest cities in China. Compared with the year before the increase, patients with only hypertension increased their spending using chronic disease coverage by 17.8 yuan (P < 0.001) or 11.6%, and those with only diabetes increased their spending using chronic disease coverage by 19.5 yuan (P < 0.001) or 10.6%, with the differences almost entirely driven by spending on drugs. In addition, these two groups of patients reduced their spending using standard outpatient coverage by 13.9 yuan (P < 0.001) or 5.7% and 14.9 yuan (P = 0.03) or 5.2%, respectively, and thus had no changes in total outpatient spending. Patients with both hypertension and diabetes, meanwhile, increased their spending using chronic disease coverage by 54.8 yuan (P < 0.001) or 18.1% and decreased their spending using standard outpatient coverage by 16.1 yuan (P = 0.002) or 6.1%, with no changes in their probability of hospitalization. Among patients with both hypertension and diabetes who had fewer-than-average outpatient visits in 2015, the hospitalization rate decreased after the 2016 reimbursement cap increase (adjusted odds ratio = 0.702, P = 0.01). These findings suggest that increasing financial protection for patients with hypertension and diabetes may be an important strategy for reducing adverse health events, such as hospitalization, in China.

Mobility-related inequality in healthcare utilization between floating and native populations and its influencing factors: evidence from China

Our goal was to examine inequality in healthcare utilization and the factors that contribute to inequality between China's floating and native populations. Based on the China Labor-force Dynamics Surveys from 2014 to 2018, which used three rounds of data, we utilized a panel probit model that included fixed effects for time and province to estimate the probability of healthcare utilization for floating and native populations. In addition, we calculated the degree of inequality in healthcare utilization by using the method of mobility-related inequality and a decomposition approach was used to explain the contribution of each factor to the inequality. The floating population utilized healthcare at a lower rate, with a 10.5% probability of visiting a hospital and a 20.9% probability of receiving hospitalized treatment. The concentration index of mobility-related inequality in healthcare utilization shows a negative coefficient of −0.137 for hospital visits and −0.356 for hospitalized treatment. Contribution decomposition shows that self-assessed health, job category and household registration account for the largest contribution to the inequality in hospital visits, contributing −0.038, 0.021 and −0.017, respectively. Age, household registration and insurance account for the largest contribution to the inequality in hospitalized treatment, contributing −0.053, 0.024 and −0.023, respectively. The floating population was less likely to use health services and faced an inequality in treatment compared with the native population.

Socioeconomic inequity in inpatient service utilization based on need among internal migrants: evidence from 2014 national cross-sectional survey in China

BACKGROUND

Providing equal treatment for those who have the same need for healthcare, regardless of their socioeconomic and cultural background, has become a shared goal among policymakers who strive to improve healthcare. This study aims to identify the socioeconomic status (SES) inequities in inpatient service utilization based on need among migrants by using a nationally representative study in China.

METHODS

The data used in this study was derived from the 2014 National Internal Migrant Population Dynamic Monitoring Survey collected by the National Health Commission of China. The sampling frame for this study was taken using the stratified multistage random sampling method. All provincial urban belt and key cities were stratified, and 119 strata were finally determined. We used logistic regression method and Blinder-Oaxaca decomposition and calculated the concentration index to measure inequities of SES in inpatient service utilization based on need. Sample weights provided in the survey were applied in all the analysis and all standard errors in this study were clustered at the strata level.

RESULTS

Of the total internal migrants, 18.75% unmet the inpatient service need. Results showed that inpatient service utilization concentrated among high-SES migrants (Concentration Index: 0.036, p < 0.001) and the decomposition results suggested that about 44.16% of the total SES gap in inpatient service utilization could be attributed to the gradient effect. After adjusting for other confounding variables, those had high school degree and university degree were more likely to meet the inpatient services need, and the OR values were 1.48 (95% CI 1.07, 2.03, p = 0.017) and 2.04 (95% CI 1.45, 2.88, p = 0.001), respectively. The OR values for Quartile 3 and Quartile 4 income groups was 1.28 (95% CI 1.01, 1.62, p = 0.044) and 1.37 (95% CI 1.02, 1.83, p = 0.035), respectively.

CONCLUSION

This study observed an inequity in inpatient service utilization where the utilization concentrates among high SES migrants. It is important for policy makers to be aware of them and more intervention should be conducted.

Which Matters for Medical Utilization Equity under Universal Coverage: Insurance System, Region or SES

BACKGROUND

China has achieved universal coverage, with a higher rate of 95% medical insurance. However, huge inequalities are concealed under universal coverage. This article aims to explore the medical insurance utilization disparities over different insurance schemes, regions, and socioeconomic statuses (SES).

METHODS

This study was based on an open-access dataset in 2010, 2012, 2014, and 2016. A longitudinal analysis and separate logistic models were performed.

RESULTS

Urban Employee Basic Medical Insurance (UEBMI) members had an outstanding advantage in specialist visiting over those on the Urban Resident Basic Medical Insurance Scheme (URBMI) (OR = 0.607, p < 0.001) and New Cooperative Medical System (NCMS) (OR = 0.262, p < 0.001). However, in terms of a doctor visiting if a person is sick, the odds of patients in the NCMS receiving a visit were 55.1% ((OR = 1.551; p < 0.05) higher than those on the UEBMI. Compared with west China, the odds of those in the north-east and east were 2.1% (p > 0.05) and 97.2% (OR = 1.972; p < 0.001) higher for seeking medical treatment if sick, and 10.8% (OR = 0.892; p < 0.01) and 42.7% lower (OR = 0.573; p < 0.001) for a specialist visiting. In terms of SES, for each unit of increase in the Standard International Occupational Prestige Scale (SIOPS), the odds of seeking medical treatment decreased by 4.3% (OR = 0.958; p < 0.05), and the odds of a specialist visiting increased by 17.1% (OR = 1.171; p < 0.001) for each unit of the annual income logarithm.

CONCLUSIONS

NCMS members and residents in west China were in a disadvantage status in terms of access to specialists, though had a higher probability of medical care if sick. SES variables were positively correlated with a specialist visiting consistently. We suggest a further focus on healthcare quality in the west and rural areas.

Inequality in the health services utilization in rural and urban china: A horizontal inequality analysis

BACKGROUND

Inequality in health and health care remains a rather challenging issue in China, existing both in rural and urban area, and between rural and urban. This study used nationally representative data to assess inequality in both rural and urban China separately and to identify socioeconomic factors that may contribute to this inequality.

METHODS

This study used 2008 National Health Services Survey data. Demographic characteristics, income, health status, medical service utilization, and medical expenses were collected. Horizontal inequality analysis was performed using nonlinear regression method.

RESULTS

Positive inequity in outpatient services and inpatient service was evident in both rural and urban area of China. Greater inequity of outpatient service use in urban than that in rural areas was evident (horizontal inequity index [HI] = 0.085 vs 0.029). In contrast, rural areas had greater inequity of inpatient service use compared to urban areas (HI = 0.21 vs 0.16). The decomposition analysis found that the household income made the greatest pro-rich contribution in both rural and urban China. However, chronic diseases and aging were also important contributors to the inequality in rural area.

CONCLUSION

The inequality in health service in both rural and urban China was mainly attributed to the household income. In addition, chronic disease and aging were associated with inequality in rural population. Those findings provide evidences for policymaker to develop a sustainable social welfare system in China.

Examining income-related inequality in health literacy and health-information seeking among urban population in China

Background

Health literacy and health-information seeking behaviour (HISB) play vital roles in health outcome improvements. This study examines the extent of income-related inequality in health literacy and health-information seeking as well as the contributions of the main socioeconomic determinants in China.

Methods

We analysed representative data of participants aged over 18 years as well as older adults from the Guangzhou Community Health Survey. A concentration index (CI) was used to quantify the degree of income-related inequity in health literacy and health-information seeking. Probit regression models were employed to decompose the CI into the contributions to each factor.

Results

Results showed a significant pro-rich distribution of adequate health literacy (CI: 0.0602, P < 0.001; horizontal index [HI]: 0.0562, P < 0.001) and HISB from healthcare professionals (CI: 0.105, P < 0.001; HI: 0.0965, P < 0.001). The pro-rich distribution of health literacy was mainly attributable to education background (contribution: 54.76%), whereas income inequalities contributed most to the pro-rich distribution of health-information seeking among an urban population (contribution: 62.53%).

Conclusion

Public interventions in China to reduce inequality in health literacy and HISBs among the urban population, coupled with easily accessible information sources on health, warrant further attention from policymakers.

Factors influencing integrated wellbeing in older Chinese outpatients with chronic diseases

To evaluate wellbeing and its determinants among older Chinese outpatients with non-communicable diseases (NCDs), outpatients (aged ≥60 years) with NCDs between September 2012 and September 2014 were enrolled in the study by convenience sampling. Each subject completed an integrated wellbeing questionnaire for subjective, psychological and social dimensions of wellbeing. Statistical analyses were performed using t-test, ANOVA, Spearman rank correlation and multivariate regression analysis to identify correlates of wellbeing status. The average integrated wellbeing score was 52.57 out of 98, with maximum of 72. Educational background and monthly income were positively associated with wellbeing (Spearman r=0.226 and 0.394 respectively; all P<0.001). The number of co-morbid conditions and the disease duration showed a negative correlation with wellbeing (Spearman r=-0.373 and -0.538 respectively; all P<0.001). Lack of access to health insurance, being single and presence of complications were associated with lower wellbeing (all P≤0.001). As the first study using an integrated wellbeing model, the results suggested wellbeing promotion among older outpatients with chronic diseases, especially those with lower income, lower education level, those who lack health insurance, single individuals, those with co-morbid conditions, longer disease duration and those with complications.

Inter-provincial inequality of public health services in China: the perspective of local officials' behavior

Background

After economic reform, China experienced rising public health services inequality between the eastern developed and mid-west undeveloped provinces. The fiscal transfer payment system which aims to shape the disparities was considered inefficient. However, there are only a few studies that address the political reason when analyzing the inter-provincial public health services inequality. And the previous studies did not consider a possible non-linear relationship between the fiscal transfer payments and the inter-provincial public health services equalization.

Methods

This paper argues that the local officials’ fanatical pursuit of local economic growth which driven by the Political Promotion Tournament and the polarized fiscal self-sufficiency (fiscal capacities) of local governments are responsible for the inter-provincial inequality of public health services and the inefficiency of fiscal transfer payments. By constructing panel threshold regression models with fiscal self-sufficiency of local governments as threshold variable, this study tries to empirically investigate the optimal level of the local governments’ self-sufficiency at which the fiscal transfer payments can effectively promote equalization.

Results

Threshold effects exist between fiscal transfer payments and inter-provincial public health services equalization. The effects on inter-provincial public health services equalization show trends that first increase and then decrease as the fiscal self-sufficiency of local governments increases. And there exist a range of fiscal self-sufficiency between 29.236 and 43.765% or between 28.575 and 45.746% for local governments where the fiscal transfer payments can effectively achieve equalization. Currently, the vast majority of provinces in China remain in the ineffective regime where the fiscal transfer payments are inefficient in shaping inequality.

Conclusions

This paper explains the reason of inequality in public health services and the inefficiency of fiscal transfer payment system from Chinese local officials’ behavior aspect, and try to find out an effective solution by focusing on the local government’s fiscal capacity. The effective way to narrow the inequality is to establish a flexible tax-sharing system to adjust local governments’ fiscal capacities and give local governments with low fiscal self-sufficiency more fiscal resources. The new policy measures recently launched by Chinese central government coincide with our recommendations.

Inequality in access to health care, health insurance and the role of supply factors

While disparities in access to health services by different economic groups have been well documented, much less is known about the factors that are contributing to these disparities. In this paper, we take the case of Indonesia, which has the six-worst wealth inequality in the world. The data is derived from the national socio-economic survey from 2011 to 2016, giving a total sample of over 5.5 million individuals. We find that only access to outpatient care at public primary health facilities is pro-poor, whilst access to other types of health care is pro-rich. Decomposition analysis demonstrates that the pro-rich access is driven by households' economic conditions, geographical variations, and supply-side factors that tend to disfavour the poor. Exploiting a nation-wide health insurance expansion during the study period, we go beyond most studies to examine how inequality in access and the contributions of these determinants may have changed under the new regime. We find that access gaps have narrowed, driven by a weaker association between access and households' economic status. Urban areas see a bigger reduction. Access to health services is generally greater, supported by increased participation of private providers under the new regime. However, we have yet to see a bigger reduction in the access gap due to more equal distribution of health infrastructure. Policies that may foster economic growth and increase households' economy, as well as health taskforce reallocation to reach greater number of poor and/or rural patients may reduce the inequality in access to health services further.

Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda

Five Sustainable Development Goals (SDGs) set targets that relate to the reduction of health inequalities nationally and worldwide. These targets are poverty reduction, health and wellbeing for all, equitable education, gender equality, and reduction of inequalities within and between countries. The interaction between inequalities and health is complex: better economic and educational outcomes for households enhance health, low socioeconomic status leads to chronic ill health, and non-communicable diseases (NCDs) reduce income status of households. NCDs account for most causes of early death and disability worldwide, so it is alarming that strong scientific evidence suggests an increase in the clustering of non-communicable conditions with low socioeconomic status in low-income and middle-income countries since 2000, as previously seen in high-income settings. These conditions include tobacco use, obesity, hypertension, cancer, and diabetes. Strong evidence from 283 studies overwhelmingly supports a positive association between low-income, low socioeconomic status, or low educational status and NCDs. The associations have been differentiated by sex in only four studies. Health is a key driver in the SDGs, and reduction of health inequalities and NCDs should become key in the promotion of the overall SDG agenda. A sustained reduction of general inequalities in income status, education, and gender within and between countries would enhance worldwide equality in health. To end poverty through elimination of its causes, NCD programmes should be included in the development agenda. National programmes should mitigate social and health shocks to protect the poor from events that worsen their frail socioeconomic condition and health status. Programmes related to universal health coverage of NCDs should specifically target susceptible populations, such as elderly people, who are most at risk. Growing inequalities in access to resources for prevention and treatment need to be addressed through improved international regulations across jurisdictions that eliminate the legal and practical barriers in the implementation of non-communicable disease control.

Socioeconomic inequalities of outpatient and inpatient service utilization in China: personal and regional perspectives

BACKGROUND

China's health system has shown remarkable progress in health provision and health outcomes in recent decades, however inequality in health care utilization persists and poses a serious social problem. While government pro-poor health policies addressed affordability as the major obstacle to equality in health care access, this policy direction deserves further examination. Our study examines the issue of health care inequalities in China, analyzing both regional and individual socioeconomic factors associated with the inequality, and provides evidence to improve governmental health policies.

METHODS

The China Health and Nutrition Survey (CHNS) 1991-2011 data were used to analyze the inequality of health care utilization. The random effects logistic regression technique was used to model health care utilization as the dependent variable, and income and regional location as the independent variables, controlling for individuals' age, gender, marital status, education, health insurance, body mass index (BMI), and period variations. The dynamic trend of 1991-2011 regional disparities was estimated using an interaction term between the regional group dummy and the wave dummy.

RESULTS

The probability of using outpatient service and inpatient services during the previous 4 weeks was 8.6 and 1.1% respectively. Compared to urban residents, suburban (OR: 0.802, 95% CI: 0.720-0.893), town (OR: 0.722, 95% CI: 0.648-0.804), rich (OR: 0.728, 95% CI: 0.656-0.807) and poor village (OR: 0.778, 95% CI: 0.698-0.868) residents were less likely to use outpatient service; and rich (OR: 0.609, 95% CI: 0.472-0.785) and poor village (OR: 0.752, 95% CI: 0. 576-0.983) residents were less likely to use inpatient health care. But the differences between income groups were not significant, except the differences between top and bottom income group in outpatient service use.

CONCLUSION

Regional location was a more important factor than individual characteristics in determining access to health care. Besides demand-side subsidies, Chinese policy makers should pay enhanced attention to health care resource allocation to address inequity in health care access.

Should the poor have no medicines to cure? A study on the association between social class and social security among the rural migrant workers in urban China

Background

The rampant urbanization and medical marketization in China have resulted in increased vulnerabilities to health and socioeconomic disparities among the rural migrant workers in urban China. In the Chinese context, the socioeconomic characteristics of rural migrant workers have attracted considerable research attention in the recent past years. However, to date, no previous studies have explored the association between the socioeconomic factors and social security among the rural migrant workers in urban China. This study aims to explore the association between socioeconomic inequity and social security inequity and the subsequent associations with medical inequity and reimbursement rejection.

Methods

Data from a regionally representative sample of 2009 Survey of Migrant Workers in Pearl River Delta in China were used for analyses. Multiple logistic regressions were used to analyze the impacts of socioeconomic factors on the eight dimensions of social security (sick pay, paid leave, maternity pay, medical insurance, pension insurance, occupational injury insurance, unemployment insurance, and maternity insurance) and the impacts of social security on medical reimbursement rejection. The zero-inflated negative binomial regression model (ZINB regression) was adopted to explore the relationship between socioeconomic factors and hospital visits among the rural migrant workers with social security.

Results

The study population consisted of 848 rural migrant workers with high income who were young and middle-aged, low-educated, and covered by social security. Reimbursement rejection and abusive supervision for the rural migrant workers were observed. Logistic regression analysis showed that there were significant associations between socioeconomic factors and social security. ZINB regression showed that there were significant associations between socioeconomic factors and hospital visits among the rural migrant workers. Also, several dimensions of social security had significant associations with reimbursement rejections.

Conclusions

This study showed that social security inequity, medical inequity, and reimbursement inequity happened to the rural migrant workers simultaneously. Future policy should strengthen health justice and enterprises’ medical responsibilities to the employed rural migrant workers.

Electronic supplementary material

The online version of this article (10.1186/s12939-017-0692-x) contains supplementary material, which is available to authorized users.

Forecasting the regional distribution and sufficiency of physicians in Japan with a coupled system dynamics-geographic information system model

BACKGROUND

In Japan, the shortage of physicians has been recognized as a major medical issue. In our previous study, we reported that the absolute shortage will be resolved in the long term, but maldistribution among specialties will persist. To address regional shortage, several Japanese medical schools increased existing quota and established "regional quotas." This study aims to assist policy makers in designing effective policies; we built a model for forecasting physician numbers by region to evaluate future physician supply-demand balances.

METHODS

For our case study, we selected Hokkaido Prefecture in Japan, a region displaying disparities in healthcare services availability between urban and rural areas. We combined a system dynamics (SD) model with geographic information system (GIS) technology to analyze the dynamic change in spatial distribution of indicators. For Hokkaido overall and for each secondary medical service area (SMSA) within the prefecture, we analyzed the total number of practicing physicians. For evaluating absolute shortage and maldistribution, we calculated sufficiency levels and Gini coefficient. Our study covered the period 2010-2030 in 5-year increments.

RESULTS

According to our forecast, physician shortage in Hokkaido Prefecture will largely be resolved by 2020. Based on current policies, we forecast that four SMSAs in Hokkaido will continue to experience physician shortages past that date, but only one SMSA would still be understaffed in 2030.

CONCLUSION

The results show the possibility that diminishing imbalances between SMSAs would not necessarily mean that regional maldistribution would be eliminated, as seen from the sufficiency levels of the various SMSAs. Urgent steps should be taken to place doctors in areas where our forecasting model predicts that physician shortages could occur in the future.

Socioeconomic determinants of access to health services among older adults: a systematic review

OBJECTIVE

The objective of this study was to analyze the association between the socioeconomic characteristics and the access to or use of health services among older adults.

METHODS

This is a systematic review of the literature. The search has been carried out in the databases PubMed, LILACS and Web of Science, without restriction of dates and languages; however we have included only articles published in Portuguese, English, and Spanish. The inclusion criteria were: observational design, socioeconomic factors as variables of interest in the analysis of the access to or use of health services among older adults, representative sample of the target population, adjustment for confounding factors, and no selection bias.

RESULTS

We have found 5,096 articles after deleting duplicates and 36 of them have been selected for review after the process of reading and evaluating the inclusion criteria. Higher income and education have been associated with the use and access to medical appointments in developing countries and some developed countries. The same association has been observed in dental appointments in all countries. Most studies have shown no association between socioeconomic characteristics and the use of inpatient and emergency services. We have identified greater use of home visits in lower-income individuals, with the exception of the United States.

CONCLUSIONS

We have observed an unequal access to or use of health services in most countries, varying according to the type of service used. The expansion of the health care coverage is necessary to reduce this unequal access generated by social inequities.

Utilization of alternative systems of medicine as health care services in India: Evidence on AYUSH care from NSS 2014

AYUSH, an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homeopathy represents the alternative systems of medicine recognized by the Government of India. Understanding the patterns of utilization of AYUSH care has been important for various reasons including an increased focus on its mainstreaming and integration with biomedicine-based health care system. Based on a nationally representative health survey 2014, we present an analysis to understand utilization of AYUSH care across socioeconomic and demographic groups in India. Overall, 6.9% of all patients seeking outpatient care in the reference period of last two weeks have used AYUSH services without any significant differentials across rural and urban India. Importantly, public health facilities play a key role in provisioning of AYUSH care in rural areas with higher utilization in Chhattisgarh, Kerala and West Bengal. Use of AYUSH among middle-income households is lower when compared with poorer and richer households. We also find that low-income households display a greater tendency for AYUSH self-medication. AYUSH care utilization is higher among patients with chronic diseases and also for treating skin-related and musculo-skeletal ailments. Although the overall share of AYUSH prescription drugs in total medical expenditure is only about 6% but the average expenditure for drugs on AYUSH and allopathy did not differ hugely. The discussion compares our estimates and findings with other studies and also highlights major policy issues around mainstreaming of AYUSH care.

Inpatient Treatment for the Middle-aged and Elderly in Central China

Background

Compared to outpatient treatment and self-treatment, inpatient treatment corresponds to more severe illness and poses more serious health and financial burden to patients. The goal of this study is to provide an updated and comprehensive description of the prevalence, characteristics, and cost of inpatient treatment for the middle-aged and elderly in Central China, which is highly populated, less-developed, and agriculture-dominating.

Methods

A survey was conducted in August 2013 in the Henan province. Data on 1,464 subjects were collected.

Results

Among the surveyed subjects, 582 had at least one episode of inpatient treatment. Subjects with different inpatient treatment status differ in the distributions of age, education, occupation, area, health insurance coverage, physical condition, and presence of chronic disease. The surveyed subjects had up to six inpatient treatments within 12 months. Different episodes have different characteristics. Age and the presence of chronic disease are significantly associated with the number of inpatient treatments. The utilization of grade III hospital for inpatient treatment is associated with gender, marital status, and per capita income. The total and out-of-pocket costs are associated with education, utilization of type III hospital, and insurance utilization.

Conclusion

This study has provided a comprehensive description of inpatient treatment for Central China, an area with low developmental and economic status. The observations may assist improving health conditions and disease treatment for this less-advantaged area.

Treatment of Type 2 diabetes mellitus in Chongqing of China: unaffordable care for the poor

AIM

This study aims to investigate the medical expenditure of people with Type 2 diabetes mellitus in Chongqing, China; to explore factors that contribute to the expenditure; and to examine the financial burden placed on households, particularly poor households.

METHODS

A cross sectional survey was conducted with a sample of people diagnosed with Type 2 diabetes mellitus in 2014. Of the 664 people eligible, 76% were interviewed. Descriptive statistics and log-linear regression were used to examine respondents' age, sex and level education, location of residence, income and type of health insurance associated with out-of-pocket expenditure on accessing diabetes mellitus care.

RESULTS

In a year, average out-of-pocket expenditure on the purchase of drugs from pharmacies and having outpatient care were US $333 and US $310, respectively. The average out-of-pocket expenditure on accessing inpatient care was 3.7 times (US $1159) that of accessing outpatient care. After adjusting for age and sex, out-of-pocket expenditure on diabetes care was significantly higher for people covered by the Urban Employee Basic Medical Insurance programme and those enrolled in the identified priority diseases reimbursement programme, which provided higher reimbursement rates for outpatient and (or) inpatient care. Out-of-pocket expenditures on the purchase of drugs from pharmacies, having outpatient and inpatient care, respectively, were 9.8%, 16.2% and 62.6% of annual household income in low-income group.

CONCLUSION

Even with health insurance coverage, poor people with Type 2 diabetes mellitus suffered from significant financial hardship. This has significant implications for models of care and healthcare financing in China with the growing burden of diabetes.

The mediation effect of health literacy between subjective social status and depressive symptoms in patients with heart failure

OBJECTIVES

Depressive symptoms are prevalent and cause adverse outcomes in heart failure. Previous studies have linked depressive symptoms with socioeconomic status. However, little is known about the mechanisms underlying this relationship. This study aimed to evaluate the association between socioeconomic status and depressive symptoms, and to examine whether access to healthcare, health literacy and social support mediated this relationship in patients with heart failure.

METHODS

Cross-sectional design was used to study 321 patients with heart failure recruited from a general hospital. Demographics, clinical data, depressive symptoms, socioeconomic status (i.e., education, employment, income, and subjective social status), access to healthcare, health literacy, and social support were collected by patient interview, medical record review or questionnaires. A series of logistic regressions and linear regressions were conducted to examine mediation.

RESULTS

The mean age of patients with heart failure was 63.6±10.6years. Fifty-eight patients (18%) had depressive symptoms. Lower subjective social status (OR=1.321, p=0.012) and lower health literacy (OR=1.065, p<0.001) were separately associated with depressive symptoms. When subjective social status and health literacy were entered simultaneously, the relationship between subjective social status and depressive symptoms became non-significant (OR=1.208, p=0.113), demonstrating mediation. Additionally, lower social support was associated with depressive symptoms (OR=1.062, p=0.007).

CONCLUSIONS

In patients with heart failure, health literacy mediated the relationship between subjective social status and depressive symptoms. Lower social support was associated with depressive symptoms. Interventions should take these factors into account.

The impact of predisposing, enabling, and need factors in utilization of health services among rural residents in Guangxi, China

Background

Healthcare in China has significantly improved, meanwhile many  socio-economic risk factors and health conditions factors affect accessibility and utilization of health services in rural areas. Inequity of health service in China needs to  be estimated and reduced. Andersen behavioral model is useful to assess the association of health service utilization with predisposing, enabling, and need factors.

Methods

A survey was conducted among 4634 residents of 897 households in 2012. Logistic regression analysis was performed to explore the association of predisposing (age, gender, marital status, ethnicity and family size), enabling (education level, travel time to the nearest health facility, medical expense per capita, and health insurance coverage), and need factors (chronic disease) with the utilization of health services (i.e. physician visit and hospitalization).

Results

We observed a significant association between need factor (chronic diseases) and health service unitization, after adjusting for all predisposing and enabling factors (physician visits: odds ratio (OR) = 5.87, 95 % confidence interval (CI) = 4.71–7.32; hospitalization: OR = 4.04, 95 % CI = 2.90–5.61, respectively). In addition, age, gender, marital status, family size and education level were significant predictors of health service utilization. The travel time to the nearest health facility was associated with the utilization of physician visits, and expenditure on healthcare was a hindering factor of hospitalization.

Conclusions

The predisposing and enabling factors had a minor impact on health service utilization, while the need factor was a dominant predictor of health service utilization among rural residents in China.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1825-4) contains supplementary material, which is available to authorized users.

Inequality and inequity in healthcare utilization in urban Nepal: a cross-sectional observational study

Inequality in access to quality healthcare is a major health policy challenge in many low- and middle-income countries. This study aimed to identify the major sources of inequity in healthcare utilization using a population-based household survey from urban Nepal. A cross-sectional survey was conducted covering 9177 individuals residing in 1997 households in five municipalities of Kathmandu valley between 2011 and 2012. The concentration index was calculated and a decomposition method was used to measure inequality in healthcare utilization, along with a horizontal inequity index (HI) to estimate socioeconomic inequalities in healthcare utilization. Results showed a significant pro-rich distribution of general healthcare utilization in all service providers (Concentration Index: 0.062, P < 0.001; HI: 0.029, P < 0.05) and private service providers (Concentration Index: 0.070, P < 0.001; HI: 0.030, P < 0.05). The pro-rich distribution of probability in general healthcare utilization was attributable to inequalities in the level of household economic status (percentage contribution: 67.8%) and in the self-reported prevalence of non-communicable diseases such as hypertension (36.7%) and diabetes (14.4%). Despite the provision of free services by public healthcare providers, our analysis found no evidence of the poor making more use of public health services (Concentration Index: 0.041, P = 0.094). Interventions to reduce the household economic burden of major illnesses, coupled with improvement in the management of public health facilities, warrant further attention by policy-makers.

Who benefits most from influenza vaccination policy: a study among the elderly in Beijing, China

Background

Influenza continues to have a major impact on vulnerable populations worldwide, particularly among the elderly (≥60 years of age). Vaccination for targeted groups is recommended by the WHO as the most effective way to control influenza infections. Since 2009, the Beijing municipal government has provided influenza vaccination to the elderly at no out-of-pocket cost to reduce influenza threats and improve related health equality. The study aims to evaluate the equality of the policy, and to analyze factors that bring influences to equality.

Methods

Based on data from a household survey, concentration index (CI) was calculated to measure the socioeconomic inequality in influenza vaccination. A Logit regression model was used to decompose CI, in which the contribution of each determinant was calculated and the percentages of these contribution were obtained.

Results

Free influenza vaccination at point of use shows significant pro-poor distribution among the elderly in Beijing (CI = −0.115). After the decomposition of CI, the elderly with lower income, higher education, and living in rural areas were more likely to get the influenza vaccination, in which place of residence (contribution percentage = 57 %) held the most contribution of variance.

Conclusions

Beijing’s free influenza vaccination strategy at point of use could provide the poor elderly with equal opportunities to receive preventive health service, showing a significant pro-poor distribution. The poor elderly, who live in rural areas with high education, benefit most from the policy. Further policy interventions should target the population living in urban areas in order to improve the utilization of public health services and health equality.

Disparity in reimbursement for tuberculosis care among different health insurance schemes: evidence from three counties in central China

Background

Health inequity is an important issue all around the world. The Chinese basic medical security system comprises three major insurance schemes, namely the Urban Employee Basic Medical Insurance (UEBMI), the Urban Resident Basic Medical Insurance (URBMI), and the New Cooperative Medical Scheme (NCMS). Little research has been conducted to look into the disparity in payments among the health insurance schemes in China. In this study, we aimed to evaluate the disparity in reimbursements for tuberculosis (TB) care among the abovementioned health insurance schemes.

Methods

This study uses a World Health Organization (WHO) framework to analyze the disparities and equity relating to the three dimensions of health insurance: population coverage, the range of services covered, and the extent to which costs are covered. Each of the health insurance scheme’s policies were categorized and analyzed. An analysis of the claims database of all hospitalizations reimbursed from 2010 to 2012 in three counties of Yichang city (YC), which included 1506 discharges, was conducted to identify the differences in reimbursement rates and out-of-pocket (OOP) expenses among the health insurance schemes.

Results

Tuberculosis patients had various inpatient expenses depending on which scheme they were covered by (TB patients covered by the NCMS have less inpatient expenses than those who were covered by the URBMI, who have less inpatient expenses than those covered by the UEBMI). We found a significant horizontal inequity of healthcare utilization among the lower socioeconomic groups. In terms of financial inequity, TB patients who earned less paid more. The NCMS provides modest financial protection, based on income. Overall, TB patients from lower socioeconomic groups were the most vulnerable.

Conclusion

There are large disparities in reimbursement for TB care among the three health insurance schemes and this, in turn, hampers TB control. Reducing the gap in health outcomes between the three health insurance schemes in China should be a focus of TB care and control. Achieving equity through integrated policies that avoid discrimination is likely to be effective.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0102-4) contains supplementary material, which is available to authorized users.

Study on Equity and Efficiency of Health Resources and Services Based on Key Indicators in China

BACKGROUND

This study aims to evaluate the dialectical relationship between equity and efficiency of health resource allocation and health service utilization in China.

METHODS

We analyzed the inequity of health resource allocation and health service utilization based on concentration index (CI) and Gini coefficient. Data envelopment analysis (DEA) was used to evaluate the inefficiency of resource allocation and service utilization. Factor Analysis (FA) was used to determine input/output indicators.

RESULTS

The CI of Health Institutions, Beds in Health Institutions, Health Professionals and Outpatient Visits were -0.116, -0.012, 0.038, and 0.111, respectively. Gini coefficient for the 31 provinces varied between 0.05 and 0.43; out of these 23 (742%) were observed to be technically efficient constituting the "best practice frontier". The other 8 (25.8%) provinces were technically inefficient.

CONCLUSIONS

Health professionals and outpatient services are focused on higher income levels, while the Health Institutions and Beds in Health Institutions were concentrated on lower income levels. In China, a few provinces attained a basic balance in both equity and efficiency in terms of current health resource and service utilization, thus serving as a reference standard for other provinces.

SOCIAL ENGAGEMENT AND USE OF HYPERTENSIVE MEDICATION AMONG ADULTS IN CHINA

This study’s objectives were, first, to examine the association between social engagement and the odds of taking hypertensive medications and treatment among adults in China; and second, to explore the lifestyle and psychological mechanisms underlying this association. Data were from the WHO Study on Global AGEing and Adult Health (WHO-SAGE), a national survey of 11,046 participants aged 18 to 69 conducted in China in 2010. The key outcome was a dichotomous indicator of whether the respondent was taking hypertensive medication or other treatment. A series of logistic regression models were fitted to examine the research questions. Higher levels of social engagement were found to be associated with a lower odds of taking hypertensive medication or treatment, and the association was stronger for women than for men. Lifestyle factors (i.e. smoking and BMI) and perceived overall life satisfaction were significant covariates. Life satisfaction helped explain some of the social engagement benefit for both men and women and BMI only appeared to be a mediator for men. Being married was not significantly associated with lower odds of taking hypertensive medication or treatment in either men or women. Social engagement seems to be protective against hypertension for adult men and women in China, although causation could not be determined in this cross-sectional study. Psychosocial mechanisms are probably at work, but these vary by gender.

Health care utilization in older people with cardiovascular disease in China

BACKGROUND

Population is ageing rapidly and prevalence of cardiovascular diseases is increasing in China. This study aims to examine the patterns of outpatient and inpatient health care utilization across different demographic and socioeconomic groups in older people with cardiovascular disease in China.

METHODS

Data were from World Health Organization (WHO) Study on Global Aging and Adult Health (SAGE) Wave 1. Chinese older people aged over 50 years with cardiovascular disease were included in the analysis. Outpatient and inpatient care utilization rates were presented and compared by demographic and socioeconomic characteristics. Multivariable logistic regression was used to examine the association between socioeconomic factors and health care utilization.

RESULTS

In total, 4162 older people with cardiovascular disease in SAGE China Wave 1 were included in the analysis. 86.4% of them had health insurance. 54.9% of the patients received outpatient care and 17.7% received inpatient care over the past 12 months. Outpatient care utilization rate was significantly associated with age. Patients in older groups used more outpatient care than those in younger groups (p = 0.010). Inpatient care utilization rate peaked at 70-79 years group (23.2%), and then reduced to 17.5% in 80 years plus group. Rich patients used more outpatient service than the poorer (p < 0.001). No association was found between household wealth status and inpatient service utilization.

CONCLUSION

Within the context of high health insurance coverage in China, the pattern of outpatient care utilization differs from that of inpatient care utilization among older patients aged over 50 years old with cardiovascular disease. Patients tend to use more outpatient care as they became older. As for inpatient care, the oldest patients aged over 80 years use less inpatient care than the 70-79 group. Household economic status plays an important role in outpatient care utilization, but it shows no association with inpatient care utilization in Chinese older patients.

Hypertension Awareness and Associated Factors among Older Chinese Adults

Hypertension is one of the most preventable chronic conditions. Improving hypertension awareness is a critical first step to reducing morbidity and mortality from hypertension in the elderly, yet the factors associated with hypertension awareness in China are poorly understood. The objective of this paper is to examine the extent to which older Chinese adults are aware of their hypertension, and factors associated with this awareness. We included 2404 adults aged 60 years or older clinically identified as hypertensive from panel data surveyed in 1997, 2000, 2004, and 2006 as part of the China Health and Nutrition Survey. Comparing this data with respondents' self-reported diagnosis of hypertension enabled us to characterize hypertension awareness. Covariates included socio-demographic, health status, functional disability, and behavioral factors. Generalized estimating equations were used to identify factors for hypertension awareness. We found 22.9% in 1997 and 42.7% in 2006 of study participants were aware of their hypertensive status. Lower awareness was found among those who lived in rural areas [odds ratio (OR) = 0.64, 95% Confidence Interval (CI), 0.47-0.88]. Higher awareness was noted for persons who were aware of their hypertensive status in a previous survey wave (OR = 7.43, 95% CI, 5.45-10.13), had high income (OR = 1.55, 95% CI, 1.05-2.28), had stage two hypertension (OR = 2.28, 95% CI, 1.69-3.06), had acute condition (OR = 2.54, 95% CI, 1.89-3.42), and had greater activities of daily living limitations (OR = 1.24, 95% CI, 1.08-1.43). Studying dynamics of hypertension awareness can help inform both clinical and public health approaches to improve healthcare.

Biobanking across the phenome - at the center of chronic disease research

Background

Recognized public health relevant risk factors such as obesity, physical inactivity, smoking or air pollution are common to many non-communicable diseases (NCDs). NCDs cluster and co-morbidities increase in parallel to age. Pleiotropic genes and genetic variants have been identified by genome-wide association studies (GWAS) linking NCD entities hitherto thought to be distant in etiology. These different lines of evidence suggest that NCD disease mechanisms are in part shared.

Discussion

Identification of common exogenous and endogenous risk patterns may promote efficient prevention, an urgent need in the light of the global NCD epidemic. The prerequisite to investigate causal risk patterns including biologic, genetic and environmental factors across different NCDs are well characterized cohorts with associated biobanks. Prospectively collected data and biospecimen from subjects of various age, sociodemographic, and cultural groups, both healthy and affected by one or more NCD, are essential for exploring biologic mechanisms and susceptibilities interlinking different environmental and lifestyle exposures, co-morbidities, as well as cellular senescence and aging. A paradigm shift in the research activities can currently be observed, moving from focused investigations on the effect of a single risk factor on an isolated health outcome to a more comprehensive assessment of risk patterns and a broader phenome approach. Though important methodological and analytical challenges need to be resolved, the ongoing international efforts to establish large-scale population-based biobank cohorts are a critical basis for moving NCD disease etiology forward.

Summary

Future epidemiologic and public health research should aim at sustaining a comprehensive systems view on health and disease. The political and public discussions about the utilitarian aspect of investing in and contributing to cohort and biobank research are essential and are indirectly linked to the achievement of public health programs effectively addressing the global NCD epidemic.

Access to healthcare and medical expenditure for the middle-aged and elderly: observations from China

Background

In the evaluation of a healthcare system, it is of interest to identify factors associated with the usage of different healthcare facilities and with different levels of medical expenditure.

Methods

A survey was conducted in January and February of 2012 in China. It focused on the middle-aged and elderly with age of 45 and above. A total of 2,093 people from 1,152 households were surveyed.

Results

For inpatient treatment, the probability of using grade III hospitals, which had the highest level of care, was positively associated with age, being married, living in urban areas, and having higher income. For outpatient treatment, the probability of using grade III hospitals was positively associated with age, being married, working in enterprises, living in urban areas, living in central and western regions, and having higher income, and negatively associated with being farmers. The total and out-of-pocket (OOP) medical expenses were analyzed separately. It was found that the expense level was associated with age, education, occupation, living in urban areas, type of hospital used, insurance being used, and per capita income.

Conclusion

The access to healthcare and level of medical expenditure were found as associated with demographic characteristics. In addition, differences between areas and regions were observed. Such results may be useful for identifying vulnerable population and for tuning future healthcare development policies.