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

Health Poverty Alleviation Project in Rural China: Impact on Poverty Vulnerability, Health Status, Healthcare Utilization, Health Expenditures

BACKGROUND

China has lead to the inception of the Health Poverty Alleviation Project (HPAP) in 2015. While the previous studies suggest that, despite its apparent reduction in patients' financial strain, the long-term poverty reduction effects are yet to be fully elucidated. This study explores HPAP's enduring impact on poverty reduction and the potential moral hazards.

METHODS

Data were obtained from four waves of the China Health and Retirement Longitudinal Study (CHARLS) spanning 2011-2018. We employed difference-in-differences (DID) models to gauge HPAP's influence on participants' poverty vulnerability, health outcomes, and healthcare utilization. The dynamic DID model is employed to test the robustness of HPAP policy effects. The mediation effect models were used to understand HPAP policy outcomes through physical examinations and inpatient care.

RESULTS

Our dataset encompassed 40,384 participants, of which 5946 (14.72%) had been exposed to HPAP and 34,438 (85.28%) had not access. Our findings reveal that HPAP decreases poverty vulnerability by 3.3% (p < 0.01) and attenuates health deterioration by 1.84% (p < 0.01). Furthermore, HPAP enhances inpatient care utilization by 9.34% (p < 0.01) and self-treatment behaviors by 4.1% (p < 0.01) while significantly slashing outpatient and inpatient expenses (p < 0.05). The implementation of HPAP has significantly reduced healthcare costs by 72.8% (p < 0.05) out-of-pocket (OOP) payments of outpatient care during the past month for the last time, and 89.39% (p < 0.05) out-of-pocket (OOP) payments of inpatient care during past the year for the last time. Mechanistic analyses have shown that the indirect effect of the HPAP policy decreases poverty vulnerability by -0.132% (p < 0.05) physical examinations and -0.309% (p < 0.05) inpatient care.

CONCLUSION

The HPAP initiative markedly attenuates poverty vulnerability and forestalls health decline among the rural populace. Moreover, HPAP bolsters healthcare service use, such as physical examinations and inpatient care, primarily attributed to the release of pent-up demand rather than moral hazards.

The impact of medical financial assistance on healthcare expenses and the medical financial burden: Evidence from rural China

Background

The medical financial burden has become a key limitation to accessing healthcare in rural areas of China as healthcare expenses continue to rise. To ensure that low-income people have access to basic healthcare services, China has implemented medical financial assistance (MFA) policy, which provides social health insurance and medical cash assistance for low-income people.

Methods

Using data from the 2014 China Family Panel Studies (CFPS), the propensity score matching (PSM) method was applied to estimate the impact of MFA on healthcare expenses and the medical financial burden.

Results

Empirical results showed that the total annual healthcare expenditure of MFA beneficiaries is significantly higher than that of non-beneficiaries after matching. Although low-income individuals are now covered by MFA, neither the out-of-pocket expenditure to per capita household non-food expenditure ratio nor the likelihood of catastrophic healthcare expenditure (CHE) decrease significantly.

Conclusion

Medical financial assistance (MFA) has reduced the inequality in healthcare utilization to a certain extent by improving access to healthcare for low-income people. However, people with low income still face a heavy medical financial burden even when they are covered by MFA. Policymakers should pay attention to raising the standards of MFA in rural areas and providing higher subsidies for the reasonable healthcare expenditures of low-income people.

Measurement and Decomposition of the Health Poverty of Rural Residents in China

Narrowing the health gap and promoting health equality is the key to effectively blocking the intergenerational transmission of rural poverty. Previous studies have mainly focused on the relationship between health and poverty, but assessments of health poverty are lacking, especially with regard to the health poverty of rural residents. Based on China's large sample household survey data, this study uses the Alkire-Foster (AF) method to measure and decompose the health poverty of rural residents. The results show that the health poverty of Chinese rural residents greatly improved from 2016 to 2018. However, significant regional differences exist with regard to the level of health poverty. The marginal contribution of economic poverty alleviation is diminishing; the equalization of health services and security has shifted to a policy focus. Community environmental management has also become an important aspect of health poverty governance, and individual health literacy and behavior have played an important role in endogenous poverty alleviation. Ultimately, this paper offers some insightful policy implications. This study extends the multidimensional poverty measurement system and reveals the relationship between health poverty and regional economic and social development. The findings also enhance the understanding of the health poverty of rural residents in developing countries.

Community health workers' mobility in China: Evidence from 2008 to 2017

Background

Community health workers (CHWs) are essential to improve the responsiveness of the national health system and the capacity of community health services. Since the implementation of the new program for health system reform in 2009, China has adopted an unprecedented policy to attract and retain CHWs to increase the quantity and quality of CHWs equitably. The policy's effects need to be further determined. The purpose of this study was to illustrate the temporal and spatial dynamics of CHWs' mobility in China from 2008 to 2017.

Methods

This study used a multistage stratified sampling method to collect 14,094 CHW mobility records from 24 counties and 12 districts in six provinces in China for analysis. The data cover the period from 2008 to 2017. Descriptive statistics and chi-square test were adopted to analyse the distribution of mobile CHWs across different years and different subgroups from 2008 to 2017.

Results

This study found that China's CHWs were in a state of net inflow from 2008 to 2017. The number of net inflows continued to increase from 2008 to 2011 and had a slight downward trend afterwards. CHW turnover occurred more in rural areas and amongst males, physicians, management and support staff, intermediate and senior professional titles, ≥30 years old group and contractual temporary employees. By contrast, the attraction and retention of CHWs are remarkable amongst nurses, pharmacists, imaging and laboratory technicians, junior title, junior college degree and above and <30 years old group.

Conclusions

China has made great achievements with the policy targeting the attraction and retention of CHWs since the implementation of the new program for health system reform in 2009. However, CHWs in China are faced with the dilemma of an extremely high total mobility, the attraction of CHWs in rural areas is still insufficient, the professional structure of CHWs is unreasonable, and the attrition of high-quality health workers exists. China must pay attention to the fair allocation of urban and rural areas, dynamically adjust the recruitment structure of health technicians, improve the mechanism for attracting and retaining technicians with higher titles and guarantee the benefits of temporary employees.

The Impact of Multidimensional Health Levels on Rural Poverty: Evidence from Rural China

Poor health and poverty interact and restrict each other. While this relationship is acknowledged, little is known about the extent of its impact. By integrating multisource data, this study used spatial econometric models to quantitatively reveal the relationship between health and rural poverty and explore its intrinsic mechanisms. The results indicated that health-care system input, individual health status, and individual health-seeking behavior have a significantly positive effect on the eradication of rural poverty. The health-care system input is characterized by spatial spillover, significantly contributing to rural poverty alleviation in the region and neighboring regions, as well. However, the effect of health-care system services’ capability was negative. Thus, it is necessary to increase investment in the health-care system and pay attention to both the health status and healthy behaviors of rural residents. Moreover, further effort should be given to the supply-side reform of health services as a breakthrough point.

Poverty Vulnerability and Health Risk Action Path of Families of Rural Elderly With Chronic Diseases: Empirical Analysis of 1,852 Families in Central and Western China

Health poverty has become the most important cause of poverty and return to poverty. Understanding the health risk factors and action paths of poverty in families of rural elderly with chronic diseases is important to alleviate return to poverty because of illness. This study selected families with at least one elderly member (over 60 years old) with chronic diseases (sample size was 1,852 families) in two provinces and four counties in central and western China. The three-stage feasible generalized least square method was adopted, and the appropriate poverty line standard was selected to measure the poverty vulnerability index. A poverty vulnerability index ≥50% was considered to indicate vulnerability. The poverty vulnerability index and actual income status were combined to classify the samples. A structural equation model was established to explore the path of each health risk factor on the entire sample and various types of poverty vulnerabilities. The mean poverty vulnerability of 1,852 families was 0.5974 ± 0.25213, and among which, 1,170 households had a poverty vulnerability value ≥0.5, accounting for 63.17% of the entire sample. The incidence of poverty was higher among people with low vulnerability to poverty. Health shock was the direct cause of poverty for people with potential and avoidance poverty. The mediating roles of family and community significantly differed in various types of poverty vulnerability. The social and economic environment in rural areas should be enhanced in a diversified manner, and the income-generating ability of rural households should be improved based on actual local conditions. Moreover, the prevention and control of poverty vulnerabilities should be diversified and targeted. Policies implemented should be based on people and localities, the causes of poverty and returning to poverty, and the types of poverty vulnerabilities. The use efficiency of medical insurance should be further improved, and the responsibility of medical insurance targeted poverty alleviation must be clarified.

The association between Urban and Rural Resident Basic Medical Insurance and depressive symptoms among Chinese middle-aged and older adults: Evidence from the China Health and Retirement Longitudinal Study

It is unclear that whether Urban and Rural Resident Basic Medical Insurance (URRBMI) is associated with depressive symptoms among middle-aged and older adults. To fulfill this research gap, this study aimed to investigate the association between URRBMI and depressive symptoms among the middle-aged and older adults in China. This data of this study was sourced from the 2018 wave of China Health and Retirement Longitudinal Study (CHARLS). Ordinary least squares (OLS) regression models were used to explore the association between URRBMI and depressive symptoms. Instrumental variable (IV) method was employed to address potential endogeneity problem which is caused by reverse causation and omitted variable bias. Propensity score matching (PSM) and doubly robust estimation were employed to conduct robustness checks. We provide robust evidence indicating that participation of URRBMI was significantly correlated with a reduced depression score. Moreover, we find that improving the utilization of inpatient and outpatient care may be important channels through which URRBMI relieved depressive symptoms.

Duration of Poverty and Subsequent Cognitive Function and Decline Among Older Adults in China, 2005-2018

OBJECTIVE

To investigate the relationship between late-life duration of poverty exposure and cognitive function and decline among older adults in China.

METHODS

Data were from 3,209 participants ≥64 years of age in the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Duration of poverty, defined according to urban and rural regional standards from the China Statistical Yearbook, was assessed according to annual household income from 2005 to 2011 (never in poverty; one-third of the period in poverty; two-thirds or more of the period in poverty). Cognitive function was measured by the Chinese Mini-Mental State Examination (CMMSE) from 2011 to 2018. We used attrition-weighted, multivariable mixed-effects Tobit regression to examine the association of duration of poverty with cognitive function and rate of decline.

RESULTS

A total of 1,162 individuals (36.21%) were never in poverty over the period from 2005 to 2011; 1,172 (36.52%) were in poverty one-third of the period; and 875 (27.27%) were in poverty two-thirds or more of the period. A longer poverty duration was associated with lower subsequent CMMSE scores with a dose-response relationship (one-third vs never in poverty: β = -0.98; 95% confidence interval -1.61 to -0.35; two-thirds or more vs never in poverty: β = -1.55; 95% confidence interval -2.29 to -0.81). However, a longer duration of poverty was associated with a slower rate of CMMSE score decline over time from 2011 to 2018.

CONCLUSION

These findings provide valuable evidence for the role of cumulative late-life poverty in relation to cognitive health among older adults in a rapidly urbanizing and aging middle-income country. Our findings may support a compensation hypothesis for cognitive reserve in this setting.

The migrating mediators and the interaction associated with the use of essential public health services: a cross-sectional study in Chinese older migrants

Background

Despite the incremental implementation of the essential public health services (EPHS) during the last decade, the goal of EPHS’s equalization is impossible to cannot be achieved without appropriate policies targeting older migrants. Therefore, this study aims to examine whether the supply side meets the needs of older migrants and to explore the relationships among health status, the use of health services, and diverse factors.

Methods

The data were derived from a national cross-sectional dataset (N = 11,161) of the 2015 Chinese Migrant Dynamic Monitoring Survey. Mediating effects analysis and moderating effects analysis were conducted to explore the interactions between physical status and the use of EPHS in older migrants such as physical examination, health record, and follow-up services.

Results

The use of physical examination, health record, and follow-up services were correlated with each other. Household income, migrating for employment, and migrating for offspring were negatively associated with the use of EPHS. A positive association was observed between the use of EPHS and willingness for long-stay. The mediating effects of household income, migrating for employment, migrating for offspring, and willingness for long-stay were observed on the relationship between physical status and the use of EPHS. The moderating effects of household income and migrating for employment were discovered.

Conclusion

Public health policies that may be worthy of consideration include further enhancing the delivery capacity of primary health institutions, integrating professional clinical resources into the primary health system, and launching the target policies to improve the accessibility of EPHS in older migrants.

Social Support and Health Services Use in People Aged over 65 Years Migrating within China: A Cross-Sectional Study

Background: Due to the household registration system, Chinese elderly migrants have insufficient access to health services and social support. Thus, this study examined the use of health services, the access to social support, and the interaction among the elderly migrating within China. Methods: Data were obtained from the China Migrant Dynamic Monitoring Survey in 2015, adopting probability proportionate to size as the sampling strategy. Structural equation modeling and mediating effect tests were employed to explore the associations. Results: Approximately 45.9% of elderly migrants did not seek health services when needed. The use of outpatient and inpatient services was more common than free essential public health services. The use of health services was negatively associated with migrating duration and migrating for offspring, while it was positively associated with outer social support. The mediating effects of outer social support were discovered on the relationships between the use of health services and independent variables such as migrating duration and migrating for offspring, respectively. Conclusion: Elderly migrants with a longer migrating duration or migrated for offspring seem to obtain less outer social support, resulting in a decreased use of health services. Outer social support was suggested as a key effort to improve the equalization of health services in Chinese elderly migrants.

Outpatient and Inpatient Service Use by Chinese Adults Living in Rural Low-Income Households

This study applied the Andersen Model of Health Care Utilization to explore the variables associated with health service use among Chinese adults living in rural low-income households. A survey of 2,429 adults living in 787 low-income households in Jiangsu, China was conducted in 2017. Respondents were asked the presence of outpatient service in the past one month and the amount of hospitalization in the past one year. Mixed effect logistic and negative binomial models were used to examine the relationship of individual-level and household-level characteristics with health service use. Health condition was the predominant determinant of both outpatient and inpatient service use (Odds Ratio [OR] >1, p < .001). Individuals living in a poor household were less likely to use outpatient service (OR = 0.05, 95% confidence interval CI: 0.00, 0.71), and the longer in poverty status the less likely to use outpatient service (OR = 0.92, CI: 0.86, 0.99). Age was associated with a lower likelihood to use outpatient service (OR = 0.93, CI: 0.93, 1.00), and this relationship was stronger for larger households (OR = 1.01, CI: 1.00, 1.01). For inpatient service use, most household-level measures were insignificant. Rural Chinese health service use was influenced primarily by needs variables. Outpatient service use was constrained by household enabling variables. Older adults were at a disadvantage of using outpatient service when the family prioritized younger members in allocating resources. These results suggest the need for policy advocacy to expand insurance reimbursement and improve benefits for poor older adults.

Prevalence and associated factors of self-treatment behaviour among different elder subgroups in rural China: a cross-sectional study

Background

Self-treatment is a common and widespread behaviour, of which the risks are multiplied in old age. However, the determinants of self-treatment among elders in rural China remain unclear. This study aims to explore the prevalence and associated factors of self-treatment among elders in rural China, trying to discover the vulnerable groups as well as the service gaps among the rural elders.

Methods

Based on a multi-stage stratified random sampling method, a cross-sectional household survey was conducted among 30 villages in Sinan County, an impoverished county in western China. Data were collected through a household–individual combined questionnaires. The analysis was restricted to elders who reported illness within the last 2 weeks, and the final sample size was 330 (individuals). Bivariate and multiple logistic regression analysis were performed in the whole sample group and four subgroups to obtain the prevalence ratios regarding the associated factors.

Results

In the present study, 35.2% of the elders with illness within the last 2 weeks reported self-treatment. The variables associated with self-treatment in the whole sample group were health status (OR 6.75, 95%CI 1.93–23.60), recent alcohol consumption (OR 0.42, 95%CI 0.21–0.83) and the utilisation of family practice services (OR 0.59, 95%CI 0.36–0.96); the same predictors were found in the subgroup of elders with chronic diseases. No significant predictors were found in the subgroup of elders without chronic diseases. Empty-nest elders with higher affinity to traditional Chinese medicine (OR 0.39, 95%CI 0.18–0.86) or drinking alcohol recently (OR 0.28, 95%CI 0.09–0.82) were less likely to self-treat, while the non-empty-nest elders who were no less than 75 years old (OR 3.10, 95%CI 1.33, 7.22) or at better health status (OR 9.20, 95%CI 1.73–48.75) were more likely to self-treat.

Conclusion

Self-treatment was prevalent among the elders in rural China. Better health status, no recent alcohol consumption and no utilisation of family practice are associated with self-treatment among rural elders. Older elders in the non-empty nest group were more likely to self-treat, while the empty-nest elders with self-care habits in traditional Chinese medicine were less likely to self-treat. Deeper understanding of the self-treatment behaviour among rural elders may provide insights for identifying the potential service gaps and developing improvement strategies in the health care delivery system for the elderly in China.