The influence of the rural health security schemes on health utilization and household impoverishment in rural China: data from a household survey of western and central China

Limited role of biological aging in unhealthy aging: A cross-sectional analysis of global life expectancy and disability data

BACKGROUND

Biological aging is known to impact quality of life, but its precise role is debated.

OBJECTIVE

This study explores how biological aging, measured by life expectancy at birth (e0), affects unhealthy aging as indicated by years lost due to disability (YLD).

METHODS

Data from international organizations, including e0, YLD, and confounding factors like income, obesity, and urbanization, were analyzed. Correlations were visualized with scatter plots, and associations were assessed using Pearson's and nonparametric methods. Partial, multilevel modelling and multiple regression analyses were conducted to determine e0's impact on YLD.

RESULTS

e0 strongly correlated with YLD, explaining about 50 % of its variance. After adjusting for confounders, e0's contribution fell to 12.18 %. Multiple regression identified e0 and urbanization as significant predictors.

CONCLUSIONS

Biological aging influences YLD, but its effect diminishes when accounting for other factors, highlighting the need for a comprehensive approach to healthy aging.

Inequity in the healthcare utilization among latent classes of elderly people with chronic diseases and decomposition analysis in China

BACKGROUND

Studies have shown chronic disease-based healthcare utilization inequity is common. Hence, exploring this issue can help in establishing targeted measures and protecting the rights and interests of vulnerable groups. Against this background, the purpose of this study is to explore the latent classification of elderly patients with chronic disease and compare healthcare utilization inequity among latent classes.

METHODS

This study used the data of 7243 elderly patient with chronic diseases collected from the China Health and Retirement Longitudinal Study in 2018. Latent class analysis was used to classify the patients with chronic diseases, and analysis of variance and [Formula: see text] tests were utilized to test the differences in characteristics among latent classes. Healthcare utilization inequity was measured based on the concentration index (CI), and the CI was decomposed to compare the horizontal index of healthcare utilization among the latent classes.

RESULTS

The patients with chronic diseases were divided into five latent classes, namely, the musculoskeletal system, hypertension, respiratory system, digestive system and cardiovascular system groups. Statistically significant differences in social demographic characteristics were observed among the five latent classes (P < 0.05). A pro-rich healthcare utilization inequity for all respondents was observed (outpatient CI = 0.080, inpatient CI = 0.135), and a similar phenomenon in latent classes was found except for the musculoskeletal system group in outpatient visits (CI = -0.037). The digestive system group had the worst equity (outpatient CI = 0.197, inpatient CI = 0.157) and the respiratory system group had the best (outpatient CI = 0.001, inpatient CI = 0.086). After balancing the influence of health need factors, healthcare utilization inequity was almost alleviated. Furthermore, for all respondents, the contribution of health need factors (65.227% for outpatient and 81.593% for inpatient) was larger than that of socioeconomic factors (-21.774% for outpatient and 23.707 for inpatient), and self-rated health status was the greatest contributor (57.167% for outpatient and 79.399% for inpatient). The characteristics were shown in latent classes.

CONCLUSIONS

Healthcare utilization inequity still exists in elderly patients with chronic diseases, and the specific performances of inequity vary among latent classes. Moreover, self-rated health status plays an important role in healthcare utilization inequity. Providing financial support to low-income patients with certain chronic diseases, focusing on their physical and mental feelings and guiding them to evaluate their health status correctly could be essential for alleviating healthcare utilization inequity among elderly patients with chronic diseases.

How Do Intergenerational Economic Support, Emotional Support and Multimorbidity Affect the Catastrophic Health Expenditures of Middle-Aged and Elderly Families?–Evidence From CHARLS2018

Objectives

The elderly face multiple vulnerabilities such as health, economy and society, and are prone to catastrophic health expenditures. This study aims to analyze the impact of children's intergenerational economic support, emotional support, and illness on the catastrophic health expenditures of middle-aged and elderly families.

Methods

Using China Health and Retirement Longitudinal Study (CHARLS 2018) data to calculate the catastrophic health expenditure of Chinese households as the dependent variable. Taking children's intergenerational economic support, emotional support and multimorbidity as core independent variables, gender, age, marital status, medical insurance and other variables as control variables, and perform logistic regression analysis. According to the heterogeneity analysis of age and gender, the impact of intergenerational economic support, emotional support and multimorbidity on the catastrophic health expenditure of middle-aged and elderly families is explored.

Results

When catastrophic health expenditures occur in middle-aged and elderly families, the children's intergenerational economic support will increase significantly, especially in families with members aged 60–74. Children's emotional support can effectively reduce the risk of catastrophic health expenditures for middle-aged and elderly families. Compared with children's intergenerational economic support and emotional support, the impact of multimorbidity on the catastrophic health expenditures of middle-aged and elderly families is the most significant. Suffering from multimorbidity can increase the risk of catastrophic health expenditures for middle-aged and elderly families, especially families with male members suffering from multiple diseases.

Conclusions

It is recommended that we should do a good job in popularizing the knowledge of chronic diseases to minimize the occurrence of multimorbidity. The government should establish group medical insurance related to chronic disease diagnosis. According to the severity of the disease or the special circumstances of the patient, the level of medical insurance reimbursement is divided in detail, especially for chronic disease clinics and drug reimbursement. Children should be encouraged to strengthen the emotional connection and effective care of the elderly, focusing on the elderly 60–74 years old, in order to reduce their care pressure and maintain the physical and mental health of the elderly.

Outreach screening to address demographic and economic barriers to diabetic retinopathy care in rural China

IMPORTANCE

Poor access to existing care for diabetic retinopathy (DR) limits effectiveness of proven treatments.

OBJECTIVES

We examined whether outreach screening in rural China improves equity of access.

DESIGN, SETTING AND PARTICIPANTS

We compared prevalence of female sex, age > = 65 years, primary education or below, and requiring referral care for DR between three cohorts with diabetes examined for DR in neighboring areas of Guangdong, China: passive case detection at secondary-level hospitals (n = 193); persons screened during primary-level DR outreach (n = 182); and individuals with newly- or previously-diagnosed diabetes in a population survey (n = 579). The latter reflected the "ideal" reach of a screening program.

RESULTS

Compared to the population cohort, passive case detection reached fewer women (50·8% vs. 62·3%, p = 0·006), older adults (37·8% vs. 51·3%, p < 0·001), and less-educated persons (39·9% vs. 89·6%, p < 0·001). Outreach screening, compared to passive case detection, improved representation of the elderly (49·5% vs. 37·8%, p = 0·03) and less-educated (70·3% vs. 39·9%, p<0·001). The proportion of women (59.8% vs 62.3%, P>0.300) and persons aged > = 65 years (49.5% vs 51.3%, p = 0.723) in the outreach screening and population cohorts did not differ significantly. Prevalence of requiring referral care for DR was significantly higher in the outreach screening cohort (28·0%) than the population (14·0%) and passive case detection cohorts (7·3%, p<0·001 for both).

CONCLUSIONS AND RELEVANCE

Primary-level outreach screening improves access for the poorly-educated and elderly, and removes gender inequity in access to DR care in this setting, while also identifying more severely-affected patients than case finding in hospital.

Analysing the impact of private health insurance on inequities in health care utilization: a longitudinal study from China

Since the early 2000s, Chinese government has sought to encourage the growth of private health insurance (PHI) while simultaneously expanding the breadth of coverage in its social health insurance (SHI) system. This paper examines how the prevalence of PHI has changed during this period and the extent to which PHI contributed to the growth of horizontal and geographical inequities with a focus on healthcare utilization. National data from China Health and Nutrition Survey between 2000 and 2015 were analysed using a multilevel modelling approach. The analysis investigated the impact of SHI membership as related to PHI uptake, PHI enrolees' utilization of health services and out-of-pocket (OOP) expenses. This study found being covered by an SHI scheme reduced the uptake of PHI between 2004 and 2015. Having PHI caused an increase in utilizing outpatient care but did not affect OOP expenses. Coverage prevalence of PHI in a residential community was positively associated with the average level of healthcare utilization. Coverage prevalence of PHI and its effects on healthcare utilization varied geographically. The findings suggest that expanding the role of PHI was not effective without clear support from government policy. Furthermore, the expansion of PHI may cause an increase in horizontal and geographical inequities in healthcare utilization.

Perceived effect of financial risk protection by the Urban-Rural Resident Basic Medical Insurance Scheme: a mixed-methods study of rural residents in China

OBJECTIVES

It is to explore the perceived financial risk protection effect of the Urban-Rural Resident Basic Medical Insurance Scheme (URRBMI) and its influencing factors to provide evidence to further improve the URRBMI.

DESIGN

It is a cross-sectional survey.

PARTICIPANTS

This mixed-methods study is conducted in five provinces in rural China. Through stratified cluster random sampling, 1681 rural residents participate in a cross-sectional questionnaire survey (1657 valid questionnaires are retrieved). Thirty rural residents participate in in-depth interviews.

PRIMARY AND SECONDARY OUTCOME MEASURES

A multivariate logistic regression analysis is adopted to identify factors influencing respondents' perceptions. Semistructured interviews are used to identify the reasons why some respondents believed the URRBMI to be ineffective.

RESULTS

Overall, 77.5% of respondents believe that the URRBMI is effective. Respondents, who are older, have a higher household income, prefer primary health facilities and provide a higher rating for critical illness compensation and maximum compensatory payouts. They are more likely to give the URRBMI a higher effectiveness rating than their counterparts. Qualitatively, participants who believe the URRBMI to be ineffective list the following reasons: low outpatient service coverage, insufficient or undersupplied drugs and services in the insurance list, problems in the arrangement of deductibles and maximum compensatory payouts, provider-induced behaviour and increased healthcare service price.

CONCLUSIONS

This exploration focuses on the reasons why rural residents think the scheme is invalid, which are vital for policy reform. Policies should focus on benefits design and coverage, the assumption of a supervisory role, avoiding financial risk stemming from critical illness and cross-sectoral actions to strengthen the primary healthcare system and comprehensive social security wealth.

Inequity in inpatient services utilization: a longitudinal comparative analysis of middle-aged and elderly patients with the chronic non-communicable diseases in China

Background

Aging and the chronic non-communicable diseases (NCDs) challenge the Chinese government in the process of providing hospitalization services fairly and reasonably. The Chinese government has developed the basic medical insurance system to solve the problem of “expensive medical cost and difficult medical services” for vulnerable groups and alleviate the unfair phenomenon. However, few studies have confirmed its effect through longitudinal comparison. This study aimed to explore the trend in the inequity of inpatient use among middle-aged and elderly individuals with NCDs in China.

Methods

This longitudinal comparative study was based on CHARLS data in 2011, 2013 and 2015. Concentration index (CI) was used to measure the variation trend of inequity of inpatient services utilization, while the decomposition method of the CI was applied to measure the factors contributing to inequity in inpatient services utilization. The effect of each factor on the change of inequity in inpatient services utilization was divided into the change of the elasticity and the change of inequality using the Oaxaca-type decomposition method.

Results

The affluent middle-aged and elderly patients with NCDs used more inpatient services than poor groups. The per capita household consumption expenditure (PCE) and Urban Employee Basic Medical Insurance (UEBMI) contributed to the decline in pro-rich inequality of inpatient use, while the New Rural Cooperative Medical Scheme (NRCMS) contributed to the decline in pro-poor inequality of inpatient use.

Conclusions

There was a certain degree of pro-rich unfairness in the probability and frequency of inpatient services utilization for middle-aged and elderly individuals with NCDs in China. The decrease of pro-wealth contribution of PCE and UEBMI offset the decrease of pro-poor contribution of NRCMS, and improved the equity of inpatient services utilization, favoring poor people.

The effects of poverty reduction policy on health services utilization among the rural poor: a quasi-experimental study in central and western rural China

Background

China poverty reduction policy (PRP) addresses two important elements: the targeted poverty reduction (TPA) project since 2015 in line with social assistance policy as national policy; and reducing inequality in health services utilization by making provision of medical financial assistance (MFA). Therefore, this study aims to assess the effects of the PRP in health services utilization (both inpatient and outpatient services) among the central and western rural poor of China.

Methods

The study conducted household survey and applied propensity score matching (PSM) method to assess the effects of the PRP on health services utilization among the rural poor of Central and Western China. A sensitivity test was also performed on the PSM results to test their robustness.

Results

Key findings showed 17.6% of respondents were the beneficial of PRP. The average treatment effects on the treated (ATT) of the PRP on the inpatient visits within one year was found significantly positive (P = 0.026).

Conclusion

There has been relationship between PRP with medical financial assistance and reduction of inequality in health services utilization by the poorer, in particular to accessing the inpatient services from the county or township hospitals of China. Policy makers should pay attention for making provision of improving responsiveness of supply, when subsidizing on the demand side.

Determinants of Household Catastrophic Health Expenditure: A Systematic Review

The World Health Organization estimates that annually 150 million people experience severe (catastrophic) financial difficulties as a result of healthcare payments. Therefore, a systematic review was carried out to identify the determinants of household catastrophic health expenditure (CHE) in low-to high-income countries around the world. Both electronic and manual searches were conducted. The main outcome of interest was the determinants of CHE due to healthcare payments. Thirty eight studies met the inclusion criteria for review. The analysis revealed that household economic status, incidence of hospitalisation, presence of an elderly or disabled household member in the family, and presence of a family member with a chronic illness were the common significant factors associated with household CHE. The crucial finding of the current study is that socioeconomic inequality plays an important role in the incidence of CHE all over the world, where low-income households are at high risk of financial hardship from healthcare payments. This suggests that healthcare financing policies should be revised in order to narrow the gap in socioeconomic inequality and social safety nets should be implemented and strengthened for people who have a high need for health care.

The cost-effectiveness analysis of the New Rural Cooperative Medical Scheme in China

OBJECTIVE

The New Rural Cooperative Medical Scheme (NCMS) is a universal healthcare coverage plan now covering over 98% of rural residents in China, first implemented in 2003. Rising costs in the face of modest gains in health and financial protections have raised questions about the cost-effectiveness of the NCMS.

METHODS

Using the most recent estimates of the NCMS's health and economic consequences from a comprehensive review of the literature, we conducted a cost-effectiveness analysis using a Markov model for a hypothetical cohort between ages 20 and 100. We then did one-way sensitivity analyses and a probabilistic sensitivity analysis using Monte Carlo simulations to explore whether the incremental cost-effectiveness ratio (ICER) falls below 37,059 international dollars [Int$], the willingness-to-pay (WTP) threshold of three times per capita GDP of China in 2013.

FINDINGS

The ICER of the NCMS over the lifetime of an average 20-year-old rural resident in China was about Int$71,480 per quality-adjusted life year (QALY) gained (95% confidence interval: cost-saving, Int$845,659/QALY). There was less than a 33% chance that the system was cost-saving or met the WTP threshold. However, the NCMS did fall under the threshold when changes in the program costs, the risk of mortality and hypertension, and the likelihood of labor force participation were tested in one-way sensitivity analyses.

CONCLUSION

The NCMS appears to be economically inefficient in its current form. Further cost-effectiveness analyses are warranted in designing insurance benefit packages to ensure that the NCMS fund goes toward health care that has a good value in improving survival and quality of life.

Rural-urban disparities in the utilization of mental health inpatient services in China: the role of health insurance

Reducing rural-urban disparities in health and health care has been a key policy goal for the Chinese government. With mental health becoming an increasingly significant public health issue in China, empirical evidence of disparities in the use of mental health services can guide steps to reduce them. We conducted this study to inform China's on-going health-care reform through examining how health insurance might reduce rural-urban disparities in the utilization of mental health inpatient services in China. This retrospective study used 10 years (2005-2014) of hospital electronic health records from the Shandong Center for Mental Health and the DaiZhuang Psychiatric Hospital, two major psychiatric hospitals in Shandong Province. Health insurance was measured using types of health insurance and the actual reimbursement ratio (RR). Utilization of mental health inpatient services was measured by hospitalization cost, length of stay (LOS), and frequency of hospitalization. We examined rural-urban disparities in the use of mental health services, as well as the role of health insurance in reducing such disparities. Hospitalization costs, LOS, and frequency of hospitalization were all found to be lower among rural than among urban inpatients. Having health insurance and benefiting from a relatively high RR were found to be significantly associated with a greater utilization of inpatient services, among both urban and rural residents. In addition, an increase in the RR was found to be significantly associated with an increase in the use of mental health services among rural patients. Consistent with the existing literature, our study suggests that increasing insurance schemes' reimbursement levels could lead to substantial increases in the use of mental health inpatient services among rural patients, and a reduction in rural-urban disparities in service utilization. In order to promote mental health care and reduce rural-urban disparities in its utilization in China, improving rural health insurance coverage (e.g., reducing the coinsurance rate) would be a powerful policy instrument.

Impact of the New Cooperative Medical Scheme on the Rural Residents' Hospitalization Medical Expenses: A Five-Year Survey Study for the Jiangxi Province in China

This survey study was conducted to understand the effect of the New Cooperative Medical Scheme (NCMS) on farmers’ medical expenses through comparing the information from five investigations and to obtain a scientific basis for a more applicable NCMS. The survey was carried out through interviewing farmers in their homes. The multi-phase stratified cluster random sampling was adopted to select 3 counties from all 92 counties of the Jiangxi province, 9 townships from the 3 selected counties, 27 villages from the selected 9 townships, and 60 families from each village between 2006 and 2014, and a longitudinal comparative analysis was conducted. The numbers of households/overall sample for the five years were 1924/8082, 1879/8015, 1885/7506, 1890/7857, and 1896/7811, respectively. We collected family members’ social demographic characteristics, health resources, and peoples’ health and medical expenses and reimbursement of each family member. The adjusted hospitalization expenses per capita of township hospitals and county hospitals were totally on a rising trend. However, the costs of tertiary hospitals were on a decreasing tendency. In addition, the expenses for county hospitalization per admission were on an upward trend in general. Furthermore, the total hospitalization expenses and reimbursement per capita (the insurance paid out for the hospitalization expenses) were also all on an upward trend. The proportion of reimbursement also had a tendency of increasing from 24.41% in 2006 to 41.34% in 2014. The costs paid from farmers’ pockets were fluctuated, but in general all lower than the costs in 2006. Furthermore, the percentage of hospitalization expenses from farmers’ annual incomes gradually decreased each year from 56.38% in 2006 to 26.58% in 2014. NCMS program has had an obvious impact on the hospitalization expenses in the Jiangxi rural area. It reduced the hospitalization expenses of the tertiary hospitals significantly. In addition, the program has also encouraged farmers to get more health care. However, there are still some shortages associated with present construction of the NCMS. Hence, there is a need for local government to continue to take effective countermeasures to control the rising trend of hospitalization expense.

Is the medical financial assistance program an effective supplement to social health insurance for low-income households in China? A cross-sectional study

BACKGROUND

China uses both social health insurance (SHI) programs and a medical financial assistance (MFA) program to protect the poor from illness-induced financial risks. The MFA provides a dual benefit package targeting low-income families: subsidizing these families' participation in SHI programs, and providing cash aid to protect them from catastrophic health expenditure (CHE). This study aims to investigate: (1) the association between MFA subvention for SHI enrollment and SHI enrollment; (2) the association between MFA cash aid and CHE; and (3) the association between SHI enrollment and CHE in low-income households in China.

METHODS

Using nationally representative data from a comprehensive survey of low-income households in 2014, we construct an estimate of CHE based on out-of-pocket health spending data. Controlling for other covariates, we estimate the three associations using a three-level logistic model.

RESULTS

The MFA program subsidizes 50.1% of low-income households to aid their enrollment in SHI programs and provides cash aid to 24.1% of these households. Multilevel logistic analysis reveals that MFA subvention has no significant association with low-income households' SHI enrollment, that MFA cash aid has no significant association with CHE, and that full SHI enrollment is inversely associated with CHE status.

CONCLUSIONS

The MFA program is currently not an effective supplement to SHI programs in China in terms of promoting SHI enrollment and providing financial risk protection. The Chinese government needs to invest more funds to expand further low-income household enrollment in SHI programs and to widen the benefit package of MFA cash aid.

Health service utilisation of rural-to-urban migrants in Guangzhou, China: does employment status matter?

OBJECTIVE

To describe the self-reported health status and service utilisation of employed, retired and unemployed migrants in Guangzhou, a megacity in southern China.

METHODS

A cross-sectional study adapted from the National Health Service Survey was conducted between September and December in 2014. Based on the distribution of occupation of migrants, multistage sampling was used to recruit individuals. Logistic regression was applied to explore the factors influencing their service utilisation.

RESULTS

Of 2906 respondents, 76.6% were employed, 9.2% retired and 14.2% unemployed. Only 8.1% reported having an illness in the previous 2 weeks, and 6.5% reported having been hospitalised in the previous year. Employed migrants had the lowest recent physician consultation rate (3.4%) and the lowest annual hospitalisation rate (4.5%) (P < 0.05); unemployed migrants had the highest rates (6.8% and 14.5% respectively, P < 0.05). Retired migrants were more likely to return to their hometown for health care (8.6%) than employed (1.5%) and unemployed migrants (3.4%) (P < 0.05). After adjusting for age and gender, employment status remained significant in explaining the recent two-week treatment-seeking behaviour of migrants (P < 0.05).

CONCLUSION

Disparity of service utilisation continues to be a problem for migrants due to the poor health awareness, lack of time and inconvenience of medical insurance reimbursement. Employed migrants make the least use of health services.

Does the new cooperative medical scheme reduce inequality in catastrophic health expenditure in rural China?

BACKGROUND

In 2003, the New Cooperative Medical Scheme (NCMS) was introduced in China to re-establish health insurance for the country's vast rural population. In addition, the coverage of NCMS has been expanding after the new health care reform launched in 2009. This study aims to examine whether the NCMS and its recent expansion have reached the goal of reducing the risk and inequality of catastrophic health spending for rural residents in China.

METHODS

We conducted a face-to-face household survey in three counties of the Shandong province in 2009 and 2012. Using this unique panel data, we examined the changes in the incidence and intensity of catastrophic health expenditures (CHEs) before and after NCMS reimbursement. We used concentration index (CI) and decomposition method to study the changes in inequality in CHEs.

RESULTS

We found that NCMS reimbursement played a role of reducing both the incidence and intensity of CHEs, and that this impact was stronger after the new health care reform was launched. After reimbursement, the concentration indices for CHEs were 0.073 and 0.021 in 2009 and 2012, indicating that the rich had a greater tendency to incur CHEs and there existed less inequality in the incidence of CHEs after reimbursement in 2012 compared with 2009. The decomposition analysis results suggested that changes in CHE inequality between 2009 and 2012 were attributed to changes in economic status and household size rather than reimbursement levels.

CONCLUSIONS

Our results indicated that inequality was shrinking from 2009 to 2012, which could be a result of fewer rich people having CHEs in 2012 compared with 2009. The impact of NCMS in alleviating the financial burden of rural residents was still limited, especially among the poor. Health care reform policies in China that aim to reduce CHEs must continue to place an emphasis on improving reimbursement, cost containment, and reducing income inequalities.

Defining migration and its health impact in China

The scale and rapid expansion of urbanization resulting from socio-economic transformation in China at the beginning of the 21st century has accelerated rural-urban migration. Public health concerns from this increasing internal population mobility are now receiving attention from researchers. The health problems from internal migration pose particular demands on healthcare systems and relate to its demographic characteristics, with many younger and older people being left behind in the rural countryside. A review of literature, census, policy reports, government documents and media was undertaken to look at the classification system and health characteristics of China's internal migrants. It suggests that public health bears the consequences of political and economic decisions made elsewhere in society.

Financial protection effects of modification of China's New Cooperative Medical Scheme on rural households with chronic diseases

Background

Several years have passed since the rural New Cooperative Medical Scheme (NCMS) in China was established and policies kept continuous improvement. Its policies on chronic diseases vary by county but have certain shared characteristics. Following this modification of medical insurance policy, this study reassesses the provision of insurance against expenditure on chronic diseases in rural areas, and analyzes its effect on impoverishment.

Methods

We conducted an empirical study using multi-stage stratified random sampling. We surveyed 1,661 rural households in three provinces and analyzed the responses from 1,525 households that participated in NCMS, using descriptive and logistic regression analysis.

Results

The NCMS has reduced the prevalence of poverty and catastrophic health expenditure (CHE), as measured by out-of-pocket (OOP) payments exceeding 40% of total household expenditure, by decreasing medical expenditure. It provides obvious protection to households which include someone with chronic diseases. However, these households continue to face a higher financial risk than those without anyone suffering from chronic diseases. Variables about health service utilization and OOP payment differed significantly between households with or without people suffering from chronic disease. And CHE risk is commonly associated with household income, the number of family members with chronic diseases, OOP payment of outpatient and inpatient service in all three provinces.

Conclusion

To reduce CHE risk for these households, it is critical to decrease OOP payments for health services by enhancing the effective reimbursement level of NCMS and strictly regulating the providers’ behaviors. We recommend that a combinatory changes should be made to the rural health insurance scheme in China to improve its effect. These include improving the NCMS benefit package by broadening the catalogue of drugs and treatments covered, decreasing or abolishing deductible and increasing the reimbursement ratio of outpatient services for people with chronic diseases, together with expansion of insurance fund, and modifying health providers’ behaviors by payment reform.

Identifying determinants of socioeconomic inequality in health service utilization among patients with chronic non-communicable diseases in China

Background

People with chronic non-communicable diseases (NCD) are particularly vulnerable to socioeconomic inequality due to their long-term expensive health needs. This study aimed to assess socioeconomic-related inequality in health service utilization among NCD patients in China and to analyze factors associated with this disparity.

Methods

Data were taken from the 2008 Chinese National Health Survey, in which a multiple stage stratified random sampling method was employed to survey 56,456 households. We analyzed the distribution of actual use, need-expected use, and need-standardized usage of outpatient services (over a two-week period) and inpatient services (over one-year) across different income groups in 27,233 adult respondents who reported as having a NCD. We used a concentration index to measure inequality in the distribution of health services, which was expressed as HI (Horizontal Inequity Index) for need-standardized use of services. A non-linear probit regression model was employed to detect inequality across socio-economic groups.

Results

Pro-rich inequity in health services among NCD patients was more substantial than the average population. A higher degree of pro-rich inequity (HI = 0.253) was found in inpatient services compared to outpatient services (HI = 0.089). Despite a greater need for health services amongst those of lower socio-economic status, their actual use is much less than their more affluent counterparts. Health service underuse by the poor and overuse by the affluent are evident. Household income disparity was the greatest inequality factor in NCD service use for both outpatients (71.3%) and inpatients (108%), more so than health insurance policies. Some medical insurance schemes, such as the MIUE, actually made a pro-rich contribution to health service inequality (16.1% for outpatient and 12.1% for inpatient).

Conclusions

Inequality in health services amongst NCD patients in China remains largely determined by patient financial capability. The current insurance schemes are insufficient to address this inequity. A comprehensive social policy that encompasses a more progressive taxation package and redistribution of social capital as well as pro-poor welfare is needed.

Exploratory analysis of health-related quality of life among the empty-nest elderly in rural China: an empirical study in three economically developed cities in eastern China

BACKGROUND

Along with rapid economic development, the aging process in China is gradually accelerating. The living conditions of empty-nest rural elderly are worrisome. As a more vulnerable group, empty-nest elderly are facing more urgent health problems. This study explores the health-related quality of life (HRQOL) of empty-nest elderly in rural China and aims to arouse more social concern for their HRQOL.

METHODS

Research subjects were empty-nest rural elderly from three cities: Nanjing, Suzhou, and Wenzhou (ages ≥ 60, n = 967). This study used the five-dimensional European quality of health scale (EQ-5D) and the 12-item Short Form Health Survey (SF-12) to measure the HRQOL of the respondents. Spearman correlation coefficient, stereotype logistic regression, ordered probit regression and multinomial logistic regression, and Structural equation model (SEM) methods are employed to study the relationship.

RESULTS

(1) The Spearman correlation coefficient shows that the correlations of similar domains between the SF-12 and the EQ-5D scales are relatively strong. (2) Men's scores are higher than that of women's in general health (GH) and anxiety/depression (AD) models. (3) The scores of physical component summary (PCS), physical functioning (PF), mental health (MH), and usual activities (UA) decline with age. (4) Apart from PCS, vitality (VT), and role-emotional (RE) as dependent variables, the education passes all the significance tests. The higher the education is, the higher the scores of physical or psychological health are. (5) The scores of PCS and bodily pain (BP) of empty-nest elderly are divorced or higher in other marital status. (6) In SEM analysis, the effect of basic information of empty-nest elderly on SF-12 scale is more significant.

CONCLUSIONS

First, the frequency histograms of EQ-5D show that the scores of empty-nest elderly in rural China are generally low. Second, in all SF-12 items, the HRQOL is low. Third, men's scores are higher than that of women's. The elderly with higher education reported higher scores than those with lower education. Fourth, the effect of socio-demographic variables of the rural Chinese empty-nest elderly on SF-12 scores is more significant, whereas the effect on EQ-5D scores is less significant.

The economic burden of hypertension in rural south-west China

OBJECTIVE

To estimate the economic burden of hypertension in a given year in rural Yunnan Province of China, including direct, indirect and intangible costs.

METHODS

A prevalence-based cost-of-illness method was used to estimate the economic burden of hypertension. Data on participants' demographic characteristics, inpatient hospitalisation expenditures, outpatient visit expenditures, self-medication costs and indirect costs related to hypertension were collected from a cross-sectional health examination and questionnaire survey, involving 9396 consenting individuals aged ≥ 18 years and 3500 households. Blood pressure (BP) levels were determined from the average of three BP measurements. Years of life lost (YLL) because of hypertension was estimated using medical death certificates.

RESULTS

The overall prevalence of and YLL/1000 population because of hypertension was 24.8% and 1.5 years for the survey population, respectively. Mean unit direct medical costs, direct non-medical costs, morbidity costs, mortality costs, intangible costs and cost of illness were estimated to be $ 467.2, $ 20.1, $ 23.5, $ 8265.1, $ 417.4 and $ 9393.3, respectively. The total cost of hypertension was estimated to be $ 231.7 million. Direct costs represented the largest component of economic cost of hypertension. On average, males had higher overall direct, indirect and intangible costs of hypertension than females. Both indirect and intangible costs decreased with age, whereas direct costs increased with age. The incidence of household catastrophic health payment and household impoverishment because of hypertension was 8.9% and 4.1%, respectively.

CONCLUSIONS

Hypertension inflicts a considerable economic burden upon individual households and society as a whole in Yunnan Province, China.

The financial burden from non-communicable diseases in low- and middle-income countries: a literature review

Non-communicable diseases (NCDs) were previously considered to only affect high-income countries. However, they now account for a very large burden in terms of both mortality and morbidity in low- and middle-income countries (LMICs), although little is known about the impact these diseases have on households in these countries. In this paper, we present a literature review on the costs imposed by NCDs on households in LMICs. We examine both the costs of obtaining medical care and the costs associated with being unable to work, while discussing the methodological issues of particular studies. The results suggest that NCDs pose a heavy financial burden on many affected households; poor households are the most financially affected when they seek care. Medicines are usually the largest component of costs and the use of originator brand medicines leads to higher than necessary expenses. In particular, in the treatment of diabetes, insulin--when required--represents an important source of spending for patients and their families. These financial costs deter many people suffering from NCDs from seeking the care they need. The limited health insurance coverage for NCDs is reflected in the low proportions of patients claiming reimbursement and the low reimbursement rates in existing insurance schemes. The costs associated with lost income-earning opportunities are also significant for many households. Therefore, NCDs impose a substantial financial burden on many households, including the poor in low-income countries. The financial costs of obtaining care also impose insurmountable barriers to access for some people, which illustrates the urgency of improving financial risk protection in health in LMIC settings and ensuring that NCDs are taken into account in these systems. In this paper, we identify areas where further research is needed to have a better view of the costs incurred by households because of NCDs; namely, the extension of the geographical scope, the inclusion of certain diseases hitherto little studied, the introduction of a time dimension, and more comparisons with acute illnesses.

Will China's Cooperative Medical System fail again? Insight from farmer satisfaction survey

This paper studied the sustainability of China's New Rural Cooperative Medical System (NCMS) by evaluating the satisfaction rate of its participants-the farmers. The study related the overall satisfaction of the farmers to their satisfaction with the four different aspects of the program. It also identified which personal and program attributes affect the farmers' satisfaction rate. Survey data of 1278 households from 66 counties in Shandong Province of China were collected in 2011 using a multi-stage stratified cluster-sampling method. To overcome the nepotistic barriers in rural China, field surveys in each township were conducted by university students from the same place. Data were analyzed using multiple regressions and structural equation modeling method. The results showed that 86% of the farmers were either satisfied or very satisfied with the NCMS and 82% indicated their intention to continue participating in the program. Aside from its financial benefits, both the publicity and reimbursement procedure of the program were found to be significant factors in influencing the satisfaction of the farmers. Majority of the participants held positive opinions toward the NCMS, contradicting the negative assessments made by many previous studies. Given the high proportion of farmers willing to continue with the program, it is likely to be sustainable in the near future. Greater publicity and education efforts should be made to make the farmers better informed about the program, and measures should be taken to improve its reimbursement procedure and the setting of the premium level.

Assessing the household financial burden associated with the chronic non-communicable diseases in a rural district of Vietnam

BACKGROUND

While there is accumulated evidence showing the rapid rise of the burden caused by non-communicable diseases (NCDs) in Vietnam, information on the extent to which households in the country suffer financial catastrophe or impoverishment caused by the diseases is still largely lacking. This paper aims to examine the self-reported prevalence of major chronic diseases among a population in rural Vietnam and to analyse the household financial burden associated with these diseases.

METHODS

A cross-sectional survey of 800 randomly selected households was carried out in Vo Nhai District, Thai Nguyen Province, in 2010. Face-to-face interviews were conducted with key informants of selected households on diagnosed chronic NCDs, health care utilization and health expenditure of all household members. The World Health Organization's definitions of catastrophic expenditure and impoverishment were used. Both descriptive and analytical statistics were applied.

RESULTS

The prevalence of chronic NCDs in households and individuals was 29.3 and 33.4%, respectively. The catastrophic health expenditure and impoverishment rates among the households who have at least one member with a chronic disease were 14.6 and 7.6%, respectively. These rates were significantly higher than the corresponding figures among the households whose members were free from the diseases (4.2 and 2.3%, respectively). The odds of experiencing catastrophic health expenditure and impoverishment among the household with NCD patients were 3.2 and 2.3 times greater than that of other households.

CONCLUSION

Findings from this study indicate that the epidemiological and household financial burdens caused by chronic diseases in Vietnam are now substantial and need immediate mitigation measures.

The effect of new cooperative medical scheme on health outcomes and alleviating catastrophic health expenditure in China: a systematic review

BACKGROUND

In 2002, the Chinese government launched a new rural health financing policy to provide health insurance (New Cooperative Medical Scheme, NCMS) for its rural population. NCMS, jointly financed by governments and individual households, aims to protect households from impoverishment due to catastrophic health expenditure. In 2011, NCMS covered more than 96% of the rural population. We have systematically searched and reviewed available evidence to estimate the effects of NCMS on health outcomes and on alleviating catastrophic health expenditure.

METHODS

PubMed, Web of Science with Conference Proceedings, ProQuest Digital Dissertations, CMCI, CNKI, and VIP were searched. We also obtained literature from colleague communications. Quasi-experimental studies regarding the effect of NCMS on health outcomes and catastrophic health expenditure were included. Two independent reviewers screened the literature, extracted the data, and assessed the study quality.

RESULTS

Fifteen studies out of the 6123 studies in the literature fulfilled criteria and were included in this review. Twelve studies identified the relationship between NCMS and health outcomes, among which six studies measured sickness or injury in the past four weeks, four measured sickness or injury in the past two weeks, and five measured self-reported health status. Four studies focused on the relationship between NCMS and alleviating catastrophic health expenditure. However, the results from these studies were in conflict: individual studies indicated that NCMS had positive, negative, or no effect on health outcomes and/or the incidence of catastrophic health payments, respectively.

CONCLUSIONS

We still have no clear evidence that NCMS improves the health outcomes and decreases the alleviating catastrophic health expenditure of the China's rural population. In addition, the heterogeneity among individual studies reminds us that provider payment method reforms, benefit package and information systems around NCMS should be improved in the future.

Revisiting current "barefoot doctors" in border areas of China: system of services, financial issue and clinical practice prior to introducing integrated management of childhood illness (IMCI)

BACKGROUND

Under-5-years child mortality remains high in rural China. Integrated management of childhood illness (IMCI) was introduced to China in 1998, but only a few rural areas have been included. This study aimed at assessing the current situation of the health system of rural health care and evaluating the clinical competency of village doctors in management of childhood illnesses prior to implementing IMCI programme in remote border rural areas.

METHODS

The study was carried out in the border areas of Puer prefecture of Yunnan province. There were 182 village doctors in the list of the health bureau in these border areas. Of these, 154 (84.6%) were recruited into the study. The local health system components were investigated using a qualitative approach and analyzed with triangulation of information from different sources. The clinical component was assessed objectively and quantitatively presented using descriptive statistics.

RESULTS

The study found that the New Rural Cooperative Medical Scheme (NRCMS) coordinated the health insurance system and the provider service through 3 tiers: village doctor, township and county hospitals. The 30 RMB per person per year premium did not cover the referral cost, and thereby decreased the number of referrals. In contrast to available treatment facilities and drug supply, the level of basic medical education of village doctors and township doctors was low. Discontent among village doctors was common, especially concerning low rates of return from the service, exceptions being procedures such as injections, which in fact may create moral hazards to the patients. Direct observation on the assessment and management of paediatric patients by village doctors revealed inadequate history taking and physical examination, inability to detect potentially serious complications, overprescription of injection and antibiotics, and underprescription of oral rehydration salts and poor quality of counseling.

CONCLUSION

There is a need to improve health finance and clinical competency of the village doctors in the study area.

Major inducing factors of hypertensive complications and the interventions required to reduce their prevalence: an epidemiological study of hypertension in a rural population in China

Background

The complications of hypertension cause severe health problems in rural areas in China. We (i) screened the major factors inducing hypertensive complications and provided intervention measures; and (ii) verified the efficacy of the New Rural Cooperative Medical Scheme (NRCMS; a medical insurance scheme for rural residents) for hypertension management.

Methods

A survey was conducted in the villages of Yunnan (an underdeveloped province in southwest China). The NRCMS was initiated there in 2005. Data were collected through questionnaires, physical examination, electrocardiography, as well as blood and urine tests. To detect factors inducing hypertension complications, a generalized estimating equations model was developed. Multivariable logistic regression was used to analyze influencing factors for hypertension control.

Results

Poor management of hypertension was observed in women. Being female, old, poorly educated, a smoker, ignorant of the dangerousness of hypertension, and having uncontrolled hypertension made patients more prone to hypertension complications. Combination therapy with ≥2 drugs helped control hypertension, but most rural patients disliked multidrug therapy because they considered it to be expensive and inconvenient. The NRCMS contributed little to reduce the prevalence of complications and improve control of hypertension.

Conclusions

The present study suggested that the NRCMS needs to be reformed to concentrate on early intervention in hypertension and to concentrate on women. To increase hypertension control in rural areas in China, compound products containing effective and inexpensive drugs (and not multidrug therapy) are needed.

Can the New Cooperative Medical Scheme promote rural elders' access to health-care services?

The aim of the present study was to examine the impact of the New Cooperative Medical Scheme (NCMS) on rural elders' access to health-care services. Articles were identified from PubMed, Elsevier, Wiley, EBSCO, EMBASE, SCI Expanded, ProQuest, Google, and CNKI which is the most informative database in Chinese, with the search terms "rural", "China", "old", "older", or "elder", "elderly", or "aged", "aging", "medical insurance", or "community-based medical insurance", or "cooperative medical scheme". Related websites and yearbooks were searched as well. The NCMS has improved the health-care utilization of rural elders, and they have the highest satisfaction with it among all age groups. However, affordability difficulty remained the common barrier for the rural elderly to access quality health care, in spite of the special considerations given to the rural elderly, such as premium remission and free check-ups. Faced with ever-growing health challenges, some impoverished rural elders with poor physical health and functional limitations may lack sufficient access to basic health-care services. Followed by the provider payment reform initiated by the NCMS, a stricter regulation for doctors' prescriptions, clinical practice and disease management is needed to promote rural elders' access to health-care services. Health management for rural elders can be expected for the NCMS to promote rural elders' health-care access once a better coordination between the NCMS and health-care system can be achieved.

Assessing the suitability of fractional polynomial methods in health services research: a perspective on the categorization epidemic

OBJECTIVE

To show how fractional polynomial methods can usefully replace the practice of arbitrarily categorizing data in epidemiology and health services research.

METHODS

A health service setting is used to illustrate a structured and transparent way of representing non-linear data without arbitrary grouping.

RESULTS

When age is a regressor its effects on an outcome will be interpreted differently depending upon the placing of cutpoints or the use of a polynomial transformation.

CONCLUSIONS

Although it is common practice, categorization comes at a cost. Information is lost, and accuracy and statistical power reduced, leading to spurious statistical interpretation of the data. The fractional polynomial method is widely supported by statistical software programs, and deserves greater attention and use.

Ecological analysis of health care utilisation for China's rural population: association with a rural county's socioeconomic characteristics

Background

The problem of accessibility and affordability of health care is reported to be a major social concern in modern China. It is pronounced in rural households which represent 60% of China's population. There are a few large scale studies which have been conducted into socioeconomic inequalities in health care utilisation for rural populations. Those studies that exist are mainly bivariate analyses. The aim of this study is to examine the relationship between socioeconomic characteristics and health service utilisation among rural counties, using aggregated data from a nationally representative dataset, within a multivariate regression analysis framework.

Methods

Secondary data analysis was conducted on China's National Health Services Survey (NHSS) 2003. Aggregated data on health care utilisation, socioeconomic position, demographic characteristics and health status were used. The samples included 67 rural counties. Multivariate linear regression analyses were performed.

Results

The results of the ecological multivariate analyses showed a positive relationship between private insurance coverage and the use of outpatient care (p-value < 0.05, standardised coefficient = 0.22). Annual income was positively correlated with annual medical expenditure (p-value < 0.01, standardised coefficient = 0.56). A rural county's area socioeconomic stratum, a composite measure frequently used in bivariate studies including the NHSS analysis report, could not explain any association with the use of health care.

Conclusions

This study highlights that richer rural households with a greater ability to pay are more able to use health services in China. The findings suggest that the scope of medical insurance might be restrictive, or the protection provided might be limited, and the health care costs might still be too high. Additional efforts are required to ensure that poorer Chinese rural households are able to utilise health care according to their needs, regardless of their income levels or private insurance coverage. This would require targeted strategies to assist low income families and a broad spectrum of interventions to address the social determinants of health.