Catastrophic health expenditure in households with chronic disease patients: A pre-post comparison of the New Health Care Reform in Shaanxi Province, China

The effectiveness of a government-sponsored health protection scheme in reducing financial risks for the below-poverty-line population in Bangladesh

The Government of Bangladesh is piloting a non-contributory health protection scheme called Shasthyo Surokhsha Karmasuchi (SSK) to increase access to quality essential healthcare services for the below-poverty-line (BPL) population. This paper assesses the effect of the SSK scheme on out-of-pocket expenditure (OOPE) for healthcare, catastrophic health expenditure (CHE) and economic impoverishment of the enrolled population. A comparative cross-sectional study was conducted in Tangail District, where the SSK was implemented. From August 2019 to March 2020, a total of 2315 BPL households (HHs) (1170 intervention and 1145 comparison) that had at least one individual with inpatient care experience in the last 12 months were surveyed. A household is said to have incurred CHE if their OOPE for healthcare exceeds the total (or non-food) HH's expenditure threshold. Multiple regression analysis was performed using OOPE, incidence of CHE and impoverishment as dependent variables and SSK membership status, actual BPL status and benefits use status as the main explanatory variables. Overall, the OOPE was significantly lower (P < 0.01) in the intervention areas (Bangladeshi Taka (BDT) 23 366) compared with the comparison areas (BDT 24 757). Regression analysis revealed that the OOPE, CHE incidence at threshold of 10% of total expenditure and 40% of non-food expenditure and impoverishment were 33% (P < 0.01), 46% (P < 0.01), 42% (P < 0.01) and 30% (P < 0.01) lower, respectively, in the intervention areas than in the comparison areas. Additionally, HHs that utilized SSK benefits experienced even lower OOPE by 92% (P < 0.01), CHE incidence at 10% and 40% threshold levels by 72% (P < 0.01) and 59% (P < 0.01), respectively, and impoverishment by 27% at 10% level of significance. These findings demonstrated the significant positive effect of the SSK in reducing financial burdens associated with healthcare utilization among the enrolled HHs. This illustrates the importance of the nationwide scaling up of the scheme in Bangladesh to reduce the undue financial risk of healthcare utilization for those in poverty.

Effect of community-based health insurance on catastrophic health expenditure among chronic disease patients in Asella referral hospital, Southeast Ethiopia: a comparative cross-sectional study

BACKGROUND

Chronic disease-related catastrophic health spending is frequent in Ethiopia affecting several households, particularly the poorest ones. A community-based health insurance (CBHI) scheme has been in place in Ethiopia since 2011. The scheme aims to provide financial protection against health expenditure but there is little evidence of how well it protects chronic patients financially.

OBJECTIVE

The objective of the study was to evaluate the effect of community-based health insurance in reducing the incidence of catastrophic health expenditure among patients attending chronic disease follow-up departments in Asella referral hospital, Southeast Ethiopia.

METHOD

A health facility-based comparative cross-sectional study was conducted in Asella referral hospital from March 2022 to May 2022. Systematic random sampling was used to select 325 chronic patients. Data were collected using an open data kit (ODK) collect app and then imported to STATA version 16 for analysis. Propensity score matching was used to evaluate the effect of community-based health insurance on catastrophic health expenditure.

RESULT

The study enrolled a total of 325 chronic patients (157 insurance members and 168 nonmembers). More than 30% of the study participants incurred health spending that could be catastrophic based on the 15% nonfood threshold. Catastrophic health expenditure was found in 31% of insured and 47% of uninsured participants. Overshoot and mean positive overshoot were 10% and 33% for insured members, respectively and the corresponding figures were 18% and 39% for nonmembers. Community-based health insurance contributes to a 19% ((ATT = -0.19, t = -2.97)) reduction in the incidence of catastrophic health expenditure among chronic patients. This result is found to be consistent for alternative measurements of the outcome variable and the use of alternative matching algorithms.

CONCLUSION

Chronic patients, particularly those in uninsured households, had a high incidence and intensity of catastrophic health expenditure. Hence, it is relevant to expand community-based health insurance to provide financial protection for people suffering from chronic conditions.

The prevalence of cardiometabolic multimorbidity and its associations with health outcomes among women in China

Objective

In China, a limited number of studies focus on women and examine the effect of cardiometabolic multimorbidity (defined as the presence of two or more cardiometabolic diseases) on health outcomes. This research aims to investigate the epidemiology of cardiometabolic multimorbidity and the association of cardiometabolic multimorbidity with long-term mortality.

Methods

This study used data from the China Health and Retirement Longitudinal Study between 2011 and 2018, which includes 4,832 women aged 45 years and older in China. Poisson-distributed Generalized Linear Models (GLM) were applied to examine the association of cardiometabolic multimorbidity with all-cause mortality.

Results

Overall, the prevalence of cardiometabolic multimorbidity was 33.1% among the total sample of 4,832 Chinese women, and increased with age, ranging from 28.5% (22.1%) for those aged 45-54 years to 65.3% (38.2%) for those aged ≥75 years in urban (rural) areas. Compared with the group of none and single disease, cardiometabolic multimorbidity was positively associated with all-cause death (RR = 1.509, 95% CI = 1.130, 2.017), after adjusting socio-demographic and lifestyle behavioral covariates. Stratified analyses revealed that the association between cardiometabolic multimorbidity and all-cause death was only statistically significant (RR = 1.473, 95% CI = 1.040, 2.087) in rural residents, but not significant in urban residents.

Conclusion

Cardiometabolic multimorbidity is common among women in China and has been associated with excess mortality. Targeted strategies and people-centered integrated primary care models must be considered to more effectively manage the cardiometabolic multimorbidity shift from focusing on single-disease.

Comparison of the Distribution of Household Financial Contributions to the Health System before and during COVID-19 Outbreak: Evidence from Nationwide Survey in Iran

Background

Health and economy has substantially been influenced by the coronavirus disease 2019 (COVID-19) pandemic. Because of these impacts, household financial contribution to health system is likely to be changed. This study aimed to compare the distribution of household financial contributions before and during the COVID-19 epidemic.

Methods

This is a cross-sectional study. The data were obtained from Iran's Households Income and Expenditure Survey as a national representative survey and included 38,328 households in 2019 (before COVID-19) and 37,577 households in 2020 (during COVID-19 pandemic). The household expenditures deflated according to the Consumer Price Index. The indices of households' out-of-pocket Payments (OPP), catastrophic health expenditures (CHE), and impoverishment were calculated based on a standard methodology. Data analysis was done using an Excel-based software.

Results

The households' total expenditures declined for both urban and rural areas during the COVID-19 outbreak. Meanwhile, health expenditure experienced a negative growth rate for urban and rural households at -25.75% and -15.47%, respectively. The average per capita of OOP annually was 1,220,416 ($41.086 PPP) Rials for urban households and 1,017,760 Rials ($34.263 PPP) for rural households in 2020 (the era of COVID-19), which had dropped -30% and -16%, respectively, relative to 2019 (before COVID-19). The proportional share of health service types from the total health expenditure did not change importantly after the onset of COVID-19. The incidence of CHE and impoverishment due to health payments reduced after the onset of COVID-19.

Conclusion

The households' health expenditures changed considerably during the COVID-19 pandemic and these changes were the same for the urban and rural areas. Despite COVID-19 multi-faceted shocks, the findings of this study showed a slight decline in the incidence of CHE and impoverishment caused by health expenditures. It might be due to forgone health services during the COVID-19 pandemic. Data from these household surveys have some limits to depicting the real effects of this crisis.

The economics of healthcare access: a scoping review on the economic impact of healthcare access for vulnerable urban populations in low- and middle-income countries

BACKGROUND

The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs.

METHODS

This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs.

RESULTS

We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality.

CONCLUSIONS

Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

A 25-Year Trend of Catastrophic Health Expenditure and Its Inequality in China: Evidence from Longitudinal Data

Purpose

The Chinese government has carried out two major cycles of reform to improve the health system and reduce the disease burden on residents. This study aims to comprehensively track the trends in the occurrence of catastrophic health expenditure (CHE) and its inequality in the past 25 years, which may help better understand the influence of health system reforms on CHE and its inequality.

Methods

The study employed the subset of data from China Health and Nutrition Survey conducted from 1991 to 2015. Health payments and net household income were used to calculate CHE. Concentration index and decomposition analysis were used to measure the magnitude of income-related inequality in CHE and decompose it into determinants, respectively.

Results

The incidence of CHE in China increased from 3.10% in 1993 to 8.90% in 2004 and still maintained at a high level in the following years. The incidence gap of CHE between the richest and poorest became increasingly wider over year. Moreover, the values of adjusted concentration indexes were all negative in each year, decreasing from −0.202 in 1991 to −0.613 in 2015. Income was consistently the largest contributor to the inequality in CHE. The basic medical insurance did not decrease the incidence of CHE and showed the second largest contribution on its inequality before 2004. However, this contribution began to decline after 2006.

Conclusion

After the New Health Care Reform, despite many measures taken by the Chinese government, there was still a high incidence of CHE and an increasing inequality from 1991 to 2015. The basic medical insurance in China was not enough to protect households from CHE. The use of big data tools and techniques to effectively screen the poor households, and strengthening the social medical aid system would be helpful to decrease the inequality in CHE.

Socio-Economic and Rural-Urban Differences in Healthcare and Catastrophic Health Expenditure Among Cancer Patients in China: Analysis of the China Health and Retirement Longitudinal Study

Objective: In China, cancer accounts for one-fifth of all deaths, and exerts a heavy toll on patients, families, healthcare systems, and society as a whole. This study aims to examine the temporal trends in socio-economic and rural-urban differences in treatment, healthcare service utilization and catastrophic health expenditure (CHE) among adult cancer patients in China. We also investigate the relationship between different types of treatment and healthcare service utilization, as well as the incidence of CHE.

Materials and Methods: We analyzed data from the 2011 and 2015 China Health and Retirement Longitudinal Study, a nationally representative survey including 17,224 participants (234 individuals with cancer) in 2011 and 19,569 participants (368 individuals with cancer) in 2015. The study includes six different types of cancer treatments: Chinese traditional medication (TCM); western modern medication (excluding TCM and chemotherapy medications); a combination of TCM & western medication; surgery; chemotherapy; and radiation therapy. Multivariable regression models were performed to investigate the association between cancer treatments and healthcare service utilization and CHE.

Results: The age-adjusted prevalence of cancer increased from 1.37% to 1.84% between 2011 and 2015. More urban patients (54%) received cancer treatment than rural patients (46%) in 2015. Patients with high socio-economic status (SES) received a higher proportion of surgical and chemotherapy treatments compared to patients with low SES in 2015. Incidence of CHE declined by 22% in urban areas but increased by 31% in rural areas. We found a positive relationship between cancer treatment and outpatient visits (OR = 2.098, 95% CI = 1.453, 3.029), hospital admission (OR = 1.961, 95% CI = 1.346, 2.857) and CHE (OR = 1.796, 95% CI = 1.231, 2.620). Chemotherapy and surgery were each associated with a 2-fold increased risk of CHE.

Conclusions: Significant improvements in health insurance benefit packages are necessary to ensure universal, affordable and patient-centered health coverage for cancer patients in China.

Temporal trends and variation in out-of-pocket expenditures and patient cost sharing: evidence from a Chinese national survey 2011-2015

OBJECTIVES

This study aims to examine: (1) temporal trends in the percentage of cost-sharing and amount of out-of-pocket expenditure (OOPE) from 2011 to 2015; (2) factors associated with cost-sharing and OOPE; and (3) the relationships between province-level economic development and cost-sharing and OOPE in China.

SETTING

A total of 10,316 adults aged ≥45 years from China followed-up from 2011 to 2015 were included in the analysis. We measured two main outcome variables: (1) patient cost sharing, measured by the percentage of OOPE as total healthcare expenditure, and (2) absolute amount of OOPE.

RESULTS

Based on self-reported data, we did not find substantial differences in the percentage of cost sharing, but a significant increase in the absolute amount of OOPE among the middle-aged and older Chinese between 2011 and 2015. The percentage of cost-sharing was considerably higher for outpatient than inpatient care, and the majority paid more than 80% of the total cost for prescription drugs. Provinces with higher GDP per capita tend to have lower cost-sharing and a higher OOPE than their counterparts, but the relationship for OOPE became insignificant after adjusting for individual factors.

CONCLUSION

Reducing out-of-pocket expenditure and patient cost sharing is required to improve financial protection from illness, especially for those with those with chronic conditions and reside in less developed regions in China. Ongoing monitoring of financial protection using data from various sources is warranted.

Financial protection effects of private health insurance: experimental evidence from Chinese households with resident basic medical insurance

BACKGROUND

After achieving universal basic medical insurance coverage, Chinese government put the development of private health insurance (PHI) on its agenda to further strengthen financial risk protection. This paper aims to assess the level of financial protection that PHI provides for its insured households on the basis of resident basic medical insurance (RBMI).

METHODS

We employed balanced panel data collected between 2015 and 2017 from the China Household Finance Survey (CHFS). Catastrophic health expenditure (CHE) and impoverishment due to health spending were applied to measure the financial protection effects. Random effects panel logistic regression model was performed to identify the factors associated with CHE and impoverishment among households covered by RBMI. In the robustness test, the method of propensity score matching (PSM) was employed to solve the problem of endogeneity.

RESULTS

From 2015 to 2017, the CHE incidence increased from 12.96 to 14.68 % for all sampled households, while the impoverishment rate decreased slightly from 5.43 to 5.32 % for all sampled households. In 2015, the CHE incidence and impoverishment rate under RBMI + PHI were 4.53 and 0.72 %, respectively, which were lower than those under RBMI alone. A similar phenomenon was observed in 2017. Regression analysis also showed that the households with RBMI + PHI were significantly less likely to experience CHE (marginal effect: -0.054, 95 %CI: -0.075 to -0.034) and impoverishment (marginal effect: -0.049, 95 %CI: -0.069 to -0.028) compared to those with RBMI alone. The results were still robust after using PSM method to eliminate the effects of self-selection on the estimation results.

CONCLUSIONS

In the context of universal basic medical insurance coverage, the CHE incidence and impoverishment rate of Chinese households with RBMI were still considerably high in 2015 and 2017. PHI played a positive role in decreasing household financial risk on the basis of RBMI.

Does health insurance contribute to improved utilization of health care services for the elderly in rural Tanzania? A cross-sectional study

Background: Health care systems in developing countries such as Tanzania depend heavily on out-of-pocket payments. This mechanism contributes to inefficiency, inequity and cost, and is a barrier to patients seeking access to care. There are efforts to expand health insurance coverage to vulnerable groups, including older adults, in Sub-Saharan African countries. Objective: To analyse the association between health insurance and health service use in rural residents aged 60 and above in Tanzania. Methods: Data were obtained from a household survey conducted in the Nzega and Igunga districts. A standardised survey instrument from the World Health Organization Study on global AGEing and adult health was used. This comprised of questions regarding demographic and socio-economic characteristics, health and insurance status, health seeking behaviours, sickness history (three months and one year prior to the survey), and the receipt of health care. A multistage sampling method was used to select wards, villages and respondents in each district. Local ward and hamlet officers guided the researchers in identifying households with older people. Crude and adjusted logistic regression methods were used to explore associations between health insurance and outpatient and inpatient health care use. Results: The study sample comprised 1,899 people aged 60 and above of whom 44% reported having health insurance. A positive statistically significant association between health insurance and the utilisation of outpatient and inpatient care was observed in all models. The odds of using outpatient (adjusted OR = 2.20; 95% CI: 1.54, 3.14) and inpatient services (adjusted OR = 3.20; 95% CI: 2.46, 4.15) were higher among the insured. Conclusion: Health insurance is a predictor of outpatient and inpatient health services in people aged 60 and above in rural Tanzania. Further research is needed to understand the perceptions of both the insured and uninsured regarding the quality of care received.

Urban-rural differences in catastrophic health expenditure among households with chronic non-communicable disease patients: evidence from China family panel studies

Background

The prevalence of chronic non-communicable diseases (NCDs) challenges the Chinese health system reform. Little is known for the differences in catastrophic health expenditure (CHE) between urban and rural households with NCD patients. This study aims to measure the differences above and quantify the contribution of each variable in explaining the urban-rural differences.

Methods

Unbalanced panel data were obtained from the China Family Panel Studies (CFPS) conducted between 2012 and 2018. The techniques of Fairlie nonlinear decomposition and Blinder-Oaxaca decomposition were employed to measure the contribution of each independent variable to the urban-rural differences.

Results

The CHE incidence and intensity of households with NCD patients were significantly higher in rural areas than in urban areas.

The urban-rural differences in CHE incidence increased from 8.07% in 2012 to 8.18% in 2018, while the urban-rural differences in CHE intensity decreased from 2.15% in 2012 to 2.05% in 2018. From 2012 to 2018, the disparity explained by household income and self-assessed health status of household head increased to some extent. During the same period, the contribution of education attainment to the urban-rural differences in CHE incidence decreased, while the contribution of education attainment to the urban-rural differences in CHE intensity increased slightly.

Conclusions

Compared with urban households with NCD patients, rural households with NCD patients had higher risk of incurring CHE and heavier economic burden of diseases. There was no substantial change in urban-rural inequality in the incidence and intensity of CHE in 2018 compared to 2012. Policy interventions should give priority to improving the household income, education attainment and health awareness of rural patients with NCDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10887-6.

Measurement and determinants of catastrophic health expenditure among elderly households in China using longitudinal data from the CHARLS

BACKGROUND

Catastrophic health expenditure (CHE) among the Chinese elderly warrants attention. However, the incidence, intensity and determinants of CHE have not been fully investigated. This study explores the incidence, intensity and determinants of CHE among elderly Chinese citizens, i.e., those aged 60 years or older.

METHODS

Data were obtained from three waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013 and 2015. The cut-off points used in this study for CHE were 10% of the total expenditures and 40% of non-food expenditure. Under the guidance of Andersen's model of health services utilization, this study used logistic regression analysis to explore the determinants of CHE.

RESULTS

The incidence of CHE defined as more than 40% of non-food expenditure rose over the study period, 2011-2015, from 20.86% (95% CI: 19.35 to 22.37%) to 31.00% (95% CI: 29.28 to 32.72%). The intensity of CHE also increased. The overshoot (O) based on non-food expenditure rose from 3.12% (95% CI: 2.71 to 3.53%) to 8.75% (95% CI: 8.14 to 9.36%), while the mean positive overshoot (MPO) rose from 14.96% (95% CI: 12.99 to 16.92%) to 28.23% (95% CI: 26.26 to 30.19%). Thus, the problem of CEH was even more serious in 2015 than in 2011. Logistic regression revealed that households were more likely to face CHE if they had a spouse as a household member, reported an inpatient event in the last year, reported an outpatient visit in the last month, were disabled, were members of a poor expenditure quartile, lived in the middle and western zones or resided in an urban area. In contrast, CEH was not significantly affected by respondents being older than 75 years or having a chronic health condition, by household size or by insurance type.

CONCLUSIONS

Key policy recommendations include the gradual improvement of medical assistance and the expansion of the use of health insurance to reduce household liability for health expenditures.

Rural and urban differences in health system performance among older Chinese adults: cross-sectional analysis of a national sample

Background

Despite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. There is limited research on the rural-urban differences in health system performance in China.

Method

We conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain.

Findings

Compared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR = 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR = 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR = 2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR = 1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII = 7.45 vs 1.64).

Conclusion

Our findings suggest that urban areas have achieved better prevention and management of non-communicable disease than rural areas, but access to healthcare was equivalent. A better understanding of the causes of the observed variations is needed to develop appropriate policy interventions which address these disparities.

The effect of medical insurance on catastrophic health expenditure: evidence from China

Background

The Chinese government has established a nationwide multiple-level medical insurance system. However, catastrophic health expenditure (CHE) causes great harm to the quality of life of households and pushes them into poverty. The objective of this paper is to assess the effect of medical insurance on CHE in China and compare the financial protection effects of different medical insurances.

Methods

Panel data were obtained from China Family Panel Studies (CFPS) conducted in the years of 2012, 2014, and 2016. CHE incidence was measured by performing a headcount, and its intensity was estimated using overshoot and mean positive overshoot (MPO). In addition, concentration index (CI) was used to measure the degree of socioeconomic inequality of CHE occurrence. Furthermore, random effects panel Probit regression model was employed to assess the effect of medical insurance on CHE. Lastly, random effects panel Logit regression model was adopted to perform a robustness check.

Results

From 2012 to 2016, the total CHE incidence jumped from 15.05% to 15.24%, and the CI in CHE changed from − 0.0076 to − 0.1512. Moreover, the total overshoot increased from 0.0333 to 0.0344, while the total MPO grew from 0.2213 to 0.2257. Furthermore, the global regression results show that residents covered by Supplementary Medical Insurance (SMI) were linked to a decreased probability of experiencing CHE. In addition, the regression results by gender indicate that SMI coverage for male residents had a significant effect on the prevention of CHE, while the effect was not significant for female residents. The regression results by health status show that SMI had a significant impact on reducing the likelihood of CHE occurrence for healthy residents, whilst the impact was not significant for unhealthy residents. Lastly, the robustness check results were consistent with those of previous findings.

Conclusion

The results of this study suggest that CHE incidence and intensity became relatively higher among households. In addition, CHE occurrence was concentrated among the poorer households and the equality status worsened. Moreover, financial protection effects of the four medical insurance schemes against CHE varied significantly. Furthermore, the protection effect of SMI against CHE shows significant gender and health status disparities.

Explaining Income-Related Inequalities in Dietary Knowledge: Evidence from the China Health and Nutrition Survey

Lack of adequate dietary knowledge may result in poor health conditions. This study aims to measure income-related inequality in dietary knowledge, and to explain the sources of the inequality. Data were from the China Health and Nutrition Survey (CHNS) conducted in 2015. A summary of the dietary knowledge score and dietary guideline awareness was used to measure the dietary knowledge of respondents. The concentration index was employed as a measure of socioeconomic inequality and was decomposed into its determining factors. The study found that the proportion of respondents who correctly answered questions on dietary knowledge was significantly low for some questions. Compared to rural residents, urban residents had a higher proportion of correctly answered dietary knowledge questions. In addition, there are pro-rich inequalities in dietary knowledge. This observed inequality is determined not only by individual factors but also high-level area factors. Our study recommends that future dietary education programs could take different strategies for individuals with different educational levels and focus more on disadvantaged people. It would be beneficial to consider local dietary habits in developing education materials.

Catastrophic health expenditure incidence and its equity in China: a study on the initial implementation of the medical insurance integration system

BACKGROUND

By 2013, several regions in China had introduced health insurance integration policies. However, few studies addressed the impact of medical insurance integration in China. This study investigates the catastrophic health expenditure and equity in the incidence of catastrophic health expenditure by addressing its potential determinants in both integrated and non-integrated areas in China in 2013.

METHODS

The primary data are drawn from the fifth China National Health Services Survey in 2013. The final sample comprises 19,788 households (38.4%) from integrated areas and 31,797 households (61.6%) from non-integrated areas. A probit model is employed to decompose inequality in the incidence of catastrophic health expenditure in line with the methodology used for decomposing the concentration index.

RESULTS

The incidence of catastrophic health expenditure in integrated areas is higher than in non-integrated areas (13.87% vs. 13.68%, respectively). The concentration index in integrated areas and non-integrated areas is - 0.071 and - 0.073, respectively. Average household out-of-pocket health expenditure and average capacity to pay in integrated areas are higher than those in non-integrated areas. However, households in integrated areas have lower share of out-of-pocket expenditures in the capacity to pay than households in non-integrated areas. The majority of the observed inequalities in catastrophic health expenditure can be explained by differences in the health insurance and householders' educational attainment both in integrated areas and non-integrated areas.

CONCLUSIONS

The medical insurance integration system in China is still at the exploratory stage; hence, its effects are of limited significance, even though the positive impact of this system on low-income residents is confirmed. Moreover, catastrophic health expenditure is associated with pro-poor inequality. Medical insurance, urban-rural disparities, the elderly population, and use of health services significantly affect the equity of catastrophic health expenditure incidence and are key issues in the implementation of future insurance integration policies.

Trends and socio-economic disparities in catastrophic health expenditure and health impoverishment in China: 2010 to 2016

OBJECTIVES

To investigate trends and socio-economic disparities in the catastrophic health expenditure (CHE) and health impoverishment in China after major reform of the health system and to examine the impacts of the chronic disease on CHE and impoverishment.

METHODS

We obtained data from four rounds of the China Family Panel Studies 2010-2016, with a sample size of 14 960 households. We defined CHE as the point at which annual household health payments exceeded 40% of annual capacity to pay. Impoverishment is measured by the $1.90 per day poverty line. Multivariate logistic regression models were performed to identify impacts of the family member with chronic disease on CHE and impoverishment.

RESULTS

Between 2010 and 2016, the incidence of CHE in China decreased from 19.37% to 15.11% and from 7.39% to 5.14% for health impoverishment; however, the decrease in level of impoverishment was less in rural areas (from 6.16% down to 3.03%) than in urban areas (from 8.46% down to 7.81%). The gap between impoverishment rates across the income quartiles is growing. Multivariable analysis showed that households with two or more members suffering chronic diseases were significantly more likely to incur CHE (aOR: 2.46, 95% CI: 1.93-3.13) and impoverishment (aOR: 2.66, 95% CI: 1.87-3.78) than households with no members suffering chronic diseases, after adjusting for sociodemographic covariates.

CONCLUSIONS

Important advances have been made in achieving greater financial protection for Chinese citizens. Nevertheless, greater attention to the poor households with chronic disease members is needed. Policymakers in China should focus on optimising integrated rural-urban health insurance by expanding the current benefit packages and strengthening poverty alleviation efforts.

What has driven the spatial spillover of China's out-of-pocket payments?

Background

Even though China launched a series of measures to alleviate several financial burdens (including health insurance scheme, increased government investment, and so on), the economic burden of health expenditure has still not been alleviated. Out-of-pocket payments (OPPs) show not only a time correlation but also some degree of spatial correlation. The aims of the current study were thus to identify the spatial cluster of OPPs, to investigate the main factors affecting variation, and to explore the spatial spillover sources of China’s OPP.

Methods

Global and local spatial autocorrelation tests were validated to identify the spatial cluster of OPPs using the panel data of 31 provinces in China from 2005 to 2016. The Spatial Durbin Model, established in this paper, measured the spatial spillover effect of OPPs and analyzed the possible spillover sources (demand, supply, and socio-economic factors.

Results

OPPs were found to have a significant and positive spatial correlation. The results of the Spatial Durbin Model showed the direct and indirect effects of demand, supply, and socio- economic factors on China’s OPPs. Among the demand factors, the direct and indirect correlation (elasticity) coefficients were positive. Among the supply factors, the direct and indirect effects of the share of primary health beds on residents’ OPPs were negative. The ratio of health technicians in hospitals to those in primary health institutions on per capital OPPs had a significant indirect effect. Among the socio-economic factors, the direct effects of GDP, government health expenditure, and urbanization on OPPs were found to be positive. There were no significant indirect effects of socio-economic factors on OPPs.

Conclusion

This paper finds that China’s OPPs are not randomly distributed but, overall, present a positive spatial cluster, even though a series of measures have been launched to promote health equity. Socio-economic factors and those associated with demand were found to be the main influences of variation in OPPs, while demand was seen to be the driver of the positive spatial spillover of OPPs, whereby effective supply could inhibit these positive spillover effects.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4451-0) contains supplementary material, which is available to authorized users.

Decomposing inequality in catastrophic health expenditure for self-reported hypertension household in Urban Shaanxi, China from 2008 to 2013: two waves' cross-sectional study

OBJECTIVE

Despite the latest wave of China's healthcare reform initiated in 2009 has achieved unprecedented progress in rural areas, little is known for specific vulnerable groups' catastrophic health expenditure (CHE) in urban China. This study aims to estimate the trend of incidence, intensity and inequality of CHE in hypertension households (households with one or more than one hypertension patient) in urban Shaanxi, China from 2008 to 2013.

METHODS

Based on the fourth and the fifth National Health Service Surveys of Shaanxi, we identified 460 and 1289 households with hypertension in 2008 and 2013, respectively for our analysis. We classified hypertension households into two groups: simplex households (with hypertension only) and mixed households (with hypertension plus other non-communicable diseases). CHE would be identified if out-of-pocket healthcare expenditure was equal to or higher than 40% of a household's capacity to pay. Concentration index and its decomposition based on Probit regressions were employed to measure the income-related inequality of CHE.

RESULTS

We find that CHE occurred in 11.2% of the simplex households and 22.1% of the mixed households in 2008, and the 21.5% of the simplex households and the 46.9% of mixed households incurred CHE in 2013. Furthermore, there were strong pro-poor inequalities in CHE in the simplex households (-0.279 and -0.283) and mixed households (-0.362 and -0.262) both in 2008 and 2013. The majority of observed inequalities in CHE could be associated with household economic status, household head's health status and having elderly members.

CONCLUSION

We find a sharp increase of CHE occurrence and the sustained strong pro-poor inequalities for simplex and mixed households in urban Shaanxi Province of China from 2008 to 2013. Our study suggests that more concerns are needed for the vulnerable groups such as hypertension households in urban areas of China.

New Health Care Reform and Impoverishment among Chronic Households in China: A Random-Intercept Approach

High out-of-pocket (OOP) payments for chronic disease care often contribute directly to household poverty. Although previous studies have explored the determinants of impoverishment in China, few published studies have compared levels of impoverishment before and after the New Health Care Reform (NHCR) in households with members with chronic diseases (hereafter referred to as chronic households). Our study explored this using data from the fourth and fifth National Health Service Surveys conducted in Shaanxi Province. In total, 1938 households in 2008 and 7700 households in 2013 were included in the analysis. Rates of impoverishment were measured using a method proposed by the World Health Organization. Multilevel logistic modeling was used to explore the influence of the NHCR on household impoverishment. Our study found that the influence of NHCR on impoverishment varied by residential location. After the reform, in rural areas, there was a significant decline in impoverishment, although the impoverishment rate remained high. There was little change in urban areas. In addition, impoverishment in the poorest households did not decline after the NHCR. Our findings are important for policy makers in particular for evaluating reform effectiveness, informing directions for health policy improvement, and highlighting achievements in the efforts to alleviate the economic burden of households that have members with chronic diseases.

Urban and Rural Disparities in Hospital Utilization among Indonesian Adults

BACKGROUND

Equal access to healthcare facilities, patient's satisfaction, and respect for the desire of the patient were recognized as the basic principles of each of the health care system. Each person must be given the opportunity to access health services in accordance with the requirements of their health. We aimed to prove the existence of disparities hospital utilization based on the category of urban-rural areas.

METHODS

The research used the 2013 Indonesian Basic Health Survey (RKD) as analysis material, that was designed a cross-sectional survey. With the multi-stage cluster random sampling method, 722,329 respondents were obtained. Data were analyzed using Multinomial Logistic Regression tests.

RESULTS

The results showed adults living in urban were likely to use hospital outpatient facilities 1.246 times higher than adults living in rural areas (OR 1.246; 95% CI 1.026 - 1.030). The likelihood of utilizing at the same time outpatient and inpatient facilities at 1.134 times higher in adults living in urban than those in rural areas (OR 1.134; 95% CI 1.025 - 1.255). While for the category of hospital inpatient utilization, there was no significant difference.

CONCLUSION

There was a disparity in hospital utilization between urban-rural areas. Urban show better utilization than rural areas in outpatient and at the same time the use of inpatient care.

Facing the urban-rural gap in patients with chronic kidney disease: Evidence from inpatients with urban or rural medical insurance in central China

BACKGROUND

In view of the irreversible pathology of progressive exacerbation, the societal burden of chronic kidney disease (CKD) is increasing along with the rise in total health expenditure. Meanwhile, disparities remain among urban and rural citizens with different types of health insurance. This study aimed to assess the socioeconomic disparities between hospitalized CKD patients in urban and rural areas.

METHOD

A total of 501 CKD inpatients with urban or rural medical insurance (UMI or RMI, respectively) were selected from the top six tertiary hospitals in Wuhan. Demographic and socioeconomic data were collected as influencing factors. Data evaluation was performed using univariate and multivariate analyses.

RESULT

Socioeconomic characteristics showed differences among hospitalized CKD patients with different health insurances. Patients with RMI were younger, and reported lower education levels, poor domestic economic conditions, shorter duration, and less frequent hospital stays than those with UMI (P<0.05). The predictors revealed varying associations between UMI and RMI. Among the hospitalized CKD patients with UMI, male and low-education individuals presented high hospitalization expenses (βgender = -0.406, βeducation level = 0.357, P<0.05). By contrast, no significant difference in this aspect was found among RMI inpatients.

CONCLUSIONS

Care delivery and reimbursement models should be re-designed and implemented to improve equity among different CKD patients. The national health education should also be enhanced to prevent CKD and provide early treatment.