Inequity in level of healthcare utilization before and after universal health coverage reforms in China: evidence from household surveys in Sichuan Province

Healthcare utilization and its association with socioeconomic status in China: Evidence from the 2011-2018 China Health and Retirement Longitudinal Study

INTRODUCTION

Healthcare utilization often favors the higher-socioeconomic status (SES) and having chronic diseases may exacerbate this inequality. This study aims to examine the trends in health service use over time, the effect of SES on healthcare utilization, and the role of chronic diseases in this association.

METHODS

Data used in this study were from the China Health and Retirement Longitudinal Study (CHARLS) in 2011, 2013, 2015, and 2018, which is the first nationally representative survey of the middle-aged and older. The sample included people aged 45 years and older who responded to all the waves. A total of 10,922 adults were included in this study. Healthcare utilization was categorized into outpatient and inpatient service use and SES was measured by per-capita household expenditure. A multilevel zero-inflated negative binomial regression model was performed to analyze outpatient and inpatient service use, separately.

RESULTS

The rates of outpatient service use in 2011, 2013, 2015, and 2018 were 19.11%, 21.45%, 20.12%, and 16.32%, respectively, while the rates of inpatient service use were 8.40%, 13.04%, 14.17%, and 18.79%, respectively. Compared to individuals in the lowest quintile of per-capita household expenditure, those in higher quintiles had higher odds of outpatient service use (Q2: odds ratio = 1.233, p < 0.0001; Q3: 1.416, p < 0.0001; Q4: 1.408, p < 0.0001; or Q5: 1.439, p < 0.0001) and higher rates of inpatient service use (Q2: incidence rate ratio = 1.273, p < 0.0001; Q3: 1.773, p < 0.0001; Q4: 2.071, p < 0.0001; or Q5: 1.992, p < 0.0001). Additionally, having morbidity generally increased healthcare utilization, but did not play a significant role in moderating the relationship between SES and healthcare utilization.

CONCLUSIONS

Healthcare utilization rates were overall low in China, but relatively high for people in higher quintiles of per-capita household expenditure or those with morbidity, compared to their counterparts. Policy actions are required to provide more health education to the public, to further optimize health insurance schemes targeting outpatient services, especially for the low-SES, and to establish new health delivery models for NCD management in the primary health care setting.

Decomposition of Healthcare Utilization Inequality in Iran: The Prominent Role of Health Literacy and Neighborhood Characteristics

Unequal utilization in healthcare can potentially affect the right to health. Access to healthcare services and achieving positive health outcomes and health equity are essential principles in promoting human rights. This study aims to assess and analyze socioeconomic-related inequalities in outpatient health services utilization (OHSU) among various socio-demographic subgroups to inform policies that foster health equity. Data were collected through a cross-sectional survey of 1200 households in Tehran, Iran. Inequality in OHSU among the socio-demographic subgroups was calculated by concentration, Wagstaff, and Erigers indices. Decomposition was used to identify the factors contributing to inequality in OHSU. Marginal effect and elasticity were used to calculate the relative absolute shares of socio-demographic variables in the inequality. The rate of OHSU was 63.61% (CI: 60-66.80) which concentrated among households with better socioeconomic status. Based on the results, living in an affluent neighborhood (Relative share (RS): 85.48) and having a disabled member in the household (RS: 6.58) were the most important factors in the concentration of OHSU in favor of the privileged groups. In contrast, very low levels of health knowledge (RS: -83.79) and having basic insurance coverage (RS: -3.92) concentrated OHSU in favor of the lower socioeconomic households. The study was conducted based on survey data, and this may lead to some limitations. Given that this study was a cross-sectional study, we were unable to establish causal relationships between explanatory variables and outpatient health service utilization and its relevant predictors. Households with disabled member(s), as well as a member(s) with chronic diseases, may experience severe inequalities in access to healthcare services. Policies that facilitate access to health services for these households can play a significant role in improving health equity.

Horizontal inequity trends of health care utilization in rural China after the medicine and healthcare system reform: based on longitudinal data from 2010 to 2018

BACKGROUND

To assess the effectiveness of China's medicine and health care reform in promoting equity in health care utilization among rural residents, it is necessary to analyze temporal trends in equity in health care utilization among rural residents in China. This study is the first to assess horizontal inequity trends in health care utilization among rural Chinese residents from 2010 to 2018 and provides evidence for improving government health policies.

METHODS

Longitudinal data obtained from China Family Panel Studies from 2010 to 2018 were used to determine trends in outpatient and inpatient utilization. Concentration index, concentration curve, and horizontal inequity index were calculated to measure inequalities. Decomposition analysis was applied to measure the contribution of need and non-need factors to the unfairness.

RESULTS

From 2010 to 2018, outpatient utilization among rural residents increased by 35.10%, while inpatient utilization increased by 80.68%. Concentration indices for health care utilization were negative in all years. In 2012, there was an increase in the concentration index for outpatient utilization (CI = -0.0219). The concentration index for inpatient utilization decreased from -0.0478 in 2010 to -0.0888 in 2018. Except for outpatient utilization in 2012 (HI = 0.0214), horizontal inequity indices for outpatient utilization were negative in all years. The horizontal inequity index for inpatient utilization was highest in 2010 (HI = -0.0068) and lowest in 2018 (HI = -0.0303). The contribution of need factors to the inequity exceeded 50% in all years.

CONCLUSIONS

Between 2010 and 2018, low-income groups in rural China used more health services. This seemingly pro-poor income-related inequality was due in large part to the greater health care need among low-income groups. Government policies aimed at increasing access to health services, particularly primary health care had helped to make health care utilization in rural China more equitable. It is necessary to design better health policies for disadvantaged groups to reduce future inequities in the use of health services by rural populations.

Equity and efficiency of medical and health service system in China

BACKGROUND

Equity and efficiency are basic value dimensions to evaluate the effectiveness of China's medical and health service system (MHS) reform and development. Coordinated development of equity and efficiency is necessary to realize high-quality development of medical and health services. This study aims to evaluate the equity, efficiency, and combined efforts in coordinating the MHS during 1991-2020 reform.

METHODS

Data on China's MHS were obtained from the China Statistical Yearbook 1992-2021. Ratios of urban to rural residents' medical expenditure and number of medical professionals per 10,000 people were employed to evaluate MHS's equity. The data envelopment analysis-Malmquist model was employed to evaluate MHS's efficiency. We constructed a combined-efforts-in-coordination model to examine the coordination degree between equity and efficiency.

RESULTS

Equity of medical expenditure burden significantly improved from during 1991-2007. Urban residents' 1991 medical expenditure burden was 87.8% of that of rural residents, which increased to 100.1% in 2007. Urban areas' mean medical expenditure burden was 105.94% of that in rural areas during 1991-2007. The gap in equity of medical expenditure burden between urban and rural areas slowly widened after 2007, with urban areas' mean burden being 68.52% of that in rural areas during 2007-2020. Medical and health resources allocation shows an alarming inequity during this period, with mean number of medical professionals per 10,000 people in urban areas being 238.30% of that in rural areas. Efficiency experienced several fluctuations before 2008. Since 2008, efficiency was high (0.915) and remained stable, except in 2020. The combined-efforts-in-coordination score for medical expenditure burden was less than 0.2 for 80% of the years, while that for in medical and health resources was more than 0.5 for 99.67% of the years.

CONCLUSIONS

MHS inequity remains between urban and rural China, primarily because of disproportionate allocation of medical and health resources. The government should enhance rural medical professionals' salary and welfare and provide medical subsidies for rural residents to adjust resource allocation levels in urban and rural areas, control differences in medical expenditure burden between urban and rural residents to a reasonable range, and continuously improve urban and rural residents' equity level.

Study on the Impact of Government Health Expenditure Equity on Residents' Health Level in the Chengdu-Chongqing Economic Circle of China

BACKGROUND

When the global COVID-19 epidemic continues to spread, residents pay more attention to their health. This paper studies the relationship between the equity of government health expenditure and the health level of residents.

METHODS

The Theil index and a principal component analysis were used to measure the equity of government health expenditure and the health level of residents in the Chengdu-Chongqing economic circle. Then, an empirical study on the relationship between the equity of government health expenditure and the health level of residents in this region was conducted with the System GMM model.

RESULTS

1. The Theil index rose from 0.0115 in 2015 to 0.0231 in 2017 and gradually decreased to 0.0106 in 2020. 2. The overall health level of residents showed an upward trend, rising from 1.95 in 2015 to 2.33 in 2017, then remained high and fluctuated slightly. 3. There was a positive correlation between the Theil index and the health level of residents at a significance level of 1% (β = 0.903, p < 0.01).

CONCLUSIONS

1. The Theil index was close to 0, indicating that the equity of government health expenditure in the Chengdu-Chongqing economic circle was generally good. 2. The health level of residents in the Chengdu-Chongqing economic circle had improved compared to before. 3. The fairer the government's health expenditure, the higher the residents' health level.

Utilization of health services among the elderly in Iran during the COVID-19 outbreak: A cross-sectional study

Background and Aims

Elderly people are potentially vulnerable with a higher need for health services, and utilization of Essential Public Health Services (EPHS) among this group is of high importance. This study aimed to examine the utilization of health services among the elderly in Iran during the coronavirus disease 2019 outbreak.

Methods

This was a cross-sectional study conducted in 21 public health centers in Sirjan, Southern Iran, from May to December 2020. A total of 420 elderly patients were selected through a systematic random sampling method. Data were collected using a questionnaire and were analyzed using SPSS v22.0. The binary logistic regression was used to examine the effect of demographic, socioeconomic and morbidity status on inpatient and outpatient healthcare utilization.

Results

Our results showed that 56% of the elderly had a history of hospitalization during the last year. Although 60% of the elderly reported they had a perceived need for outpatient services, only 49% of them reported that they utilized outpatient services. 51% and 35.5% of the elderly reported that their inpatient and outpatient costs were covered by health insurance, respectively. Others reported their health spending was financed through out-of-pocket payments. Male gender aged 80 and above, urban residents, higher socioeconomic and supplemental insurance coverage were associated with an increase in health services utilization. The elderly with Cancer, mental disorders, kidney disease, and cardiovascular diseases (CVDs) were more likely to be hospitalized.

Conclusion

There were demographic and socioeconomic inequalities in health services utilization among the elderly. Therefore, appropriate interventions and strategies are needed to reduce these inequalities in health services utilization among the elderly. In addition, given that the hospitalization rate was significantly higher among the elderly with chronic diseases than those without, it is crucial and necessary to take interventions to reduce the burden of chronic diseases in the future.

Inequity in Health Services Utilization in Economically Underdeveloped Regions of Northeast China

Background

The Chinese health system has long been committed to eliminating inequalities in health services utilization. However, few studies have analyzed or measured these inequalities in economically underdeveloped regions in China.

Methods

A total of 6,627 respondents from 3,000 households in Heilongjiang Province were extracted from the Sixth National Health Services Survey. We measured horizontal inequity in both 2-week outpatient rate and annual inpatient rate, and then identified the factors contributing to inequality.

Results

The horizontal inequity indices of the 2-week outpatient and annual impatient rates in Heilongjiang Province were 0.0586 and 0.1276, respectively. Household income, health status, place of residence, basic medical insurance, and commercial health insurance were found to be the main factors affecting inequality in health services utilization. The contributions of household income to these two indices were 184.03 and 253.47%, respectively. Health status factors, including suffering from chronic disease, limitations in daily activities, and poor self-rated health, played positive roles in reducing inequality in these two indices. The contributions of place of residence to these two indices were 27.21 and −28.45%, respectively. Urban Employee Basic Medical Insurance made a pro-rich contribution to these two indices: 56.25 and 81.48%, respectively. Urban and Rural Resident Basic Medical Insurance, Urban Resident Basic Medical Insurance, New Rural Cooperative Medical Scheme, and other basic medical insurance made a pro-poor contribution to these two indices: −73.51 and −54.87%, respectively. Commercial health insurance made a pro-rich contribution to these two indices: 20.79 and 7.40%, respectively. Meanwhile, critical illness insurance made a slightly pro-poor contribution to these two indices: −4.60 and −0.90%, respectively.

Conclusions

The findings showed that the “equal treatment in equal need” principle was not met in the health services utilization context in Heilongjiang Province. To address this issue, the government could make policy changes to protect low-income populations from underused health services, and work to improve basic medical insurance, critical illness insurance, and social security systems.

The cycle of commodification: migrant labour, welfare, and the market in global China and Vietnam

China and Vietnam have experienced waves of labour and welfare reform since both countries shifted to market socialism, pursuing a development model that depends on the labour of millions of rural–urban migrants in global factories. Their similar development trajectories are productive for theorizing the relationship between labour and welfare. This article conceptualises the two countries’ distinctive regime of migrant labour welfare as integral to a cycle of commodification that encompasses the overlapping processes of commodification, de-commodification and re-commodification of labour. After decades of collectivized labour under state socialism, the cycle begins with the commodification of labour through market reforms that led to mass rural–urban migration and the rise of the global factory alongside the dismantling of the former socialist welfare system. It was then followed by de-commodification attempts aimed at providing forms of social protection that offset the labour precarity caused by decades of labour market liberalisation. Despite the emergence of new universal welfare programs, the market has increasingly intruded into social protection, especially through financialized products targeted at the labouring masses who must compensate for the failings of public welfare programs. As such, these welfare regimes are undergoing a process of re-commodification in which the protection of labour is re-embedded into the market as a commodity to be consumed by the migrant workers with their meagre wages. The “cycle of commodification” offers an analytical framework to understand welfare regimes as a social and political field that keeps evolving in response to the changing global valuation of labour.

Equity and determinants in universal health coverage indicators in Iraq, 2000-2030: a national and subnational study

Background

Equity is one of three dimensions of universal health coverage (UHC). However, Iraq has had capital-focused health services and successive conflicts and political turmoil have hampered health services around the country. Iraq has embarked on a new reconstruction process since 2018 and it could be time to aim for equitable healthcare access to realise UHC. We aimed to examine inequality and determinants associated with Iraq’s progress towards UHC targets.

Methods

We assessed the progress toward UHC in the context of equity using six nationally representative population-based household surveys in Iraq in 2000–2018. We included 14 health service indicators and two financial risk protection indicators in our UHC progress assessment. Bayesian hierarchical regression model was used to estimate the trend, projection, and determinant analyses. Slope and relative index of inequality were used to assess wealth-based inequality.

Results

In the national-level health service indicators, inequality indices decreased substantially from 2000 to 2030. However, the wide inequalities are projected to remain in DTP3, measles, full immunisations, and antenatal care in 2030. The pro-rich inequality gap in catastrophic health expenditure increased significantly in all governorates except Sulaimaniya from 2007 to 2012. The higher increases in pro-rich inequality were found in Missan, Karbala, Erbil, and Diala. Mothers’ higher education and more antenatal care visits were possible factors for increased coverage of health service indicators. The higher number of children and elderly population in the households were potential risk factors for an increased risk of catastrophic and impoverishing health payment in Iraq.

Conclusions

To reduce inequality in Iraq, urgent health-system reform is needed, with consideration for vulnerable households having female-heads, less educated mothers, and more children and/or elderly people. Considering varying inequity between and within governorates in Iraq, reconstruction of primary healthcare across the country and cross-sectoral targeted interventions for women should be prioritised.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01532-0.

Patient Choice of Health Care Providers in China: Primary Care Facilities versus Hospitals

As China's health system is faced with challenges of overcrowded hospitals, there is a great need to better understand the recent patterns and determinants of people's choice between primary care facilities and hospitals for outpatient care. Based on recent individual-level data from the China Health and Retirement Longitudinal Survey (CHARLS) and official province-level data from China health statistical yearbooks, we examine the patterns of outpatient visits to primary care facilities versus hospitals among middle-aged and older individuals and explore both supply- and demand-side correlates that explain these patterns. We find that 53% of outpatient visits were paid to primary care facilities as opposed to hospitals in 2015, compared to 60% in 2011. Both supply and demand factors were associated with this decline. On the supply side, we find that the density of primary care facilities did not account for this decline, but higher densities of hospitals and licensed doctors were associated with lower use of primary care facilities. On the demand side, we find that individuals with higher socioeconomic status and greater health care needs were less likely to use primary health care facilities. Our findings suggest that a high concentration of health care professionals in hospitals diverts patients away from primary care facilities. Staffing the primary care facilities with a well-trained health care workforce is the key to a well-functioning primary care system. The findings also suggest a need to address demand-side inequality issues.

Factors influencing the use of health services by trauma patients according to insurance type and injury severity score in South Korea: Based on Andersen's behavioral model

This study aims to understand the difference in trauma patients' use of health services in Korea according to insurance type and the Injury Severity Score. Andersen's behavioral model of health service use is employed to identify the factors influencing their use. Claims data from January 1 to December 31, 2016 were extracted from both the Health Insurance Review and Assessment Service and the automobile insurance screening center for all the medical treatments identified with the Korean Triage and Acuity Scale and Injury Severity Score. Using the Health Insurance Review and Assessment Service's remote statistical analysis system, hierarchical regression and negative binomial analyses were conducted to determine the effect of predisposing, enabling, and need factors on health service use. The results demonstrate that the use of Korean health services is relatively equitable since medical expenses for trauma patients are greatly influenced by need factors. However, the length of time trauma patients stay in the hospital appears to differ according to insurance type. This study suggests that healthcare policies need to increase coverage benefits and improve medical billing for patients with severe trauma, as well as develop a more robust screening system for patients with mild to moderate impairments.

Tracking socio-economic inequalities in healthcare utilization in Iran: a repeated cross-sectional analysis

Background

Although some healthcare reforms such as Health Transformation Plan (HTP) were implemented in Iran to provide required healthcare services, few studies have been conducted to track the impacts of these reforms on socio-economic inequality in healthcare utilization. This study aims to track socio-economic inequalities in healthcare utilization and their changes between 2008 and 2016 in Iran.

Methods

Required data were obtained from two of Iran’s utilization of healthcare services survey conducted in 2008 and 2016. Erreygers concentration index (EI) was used to measure inequality in the utilization of outpatient and inpatient healthcare services (UOH and UIH). The decomposition of EI (DEI) was used to explain healthcare utilization inequality. Oaxaca decomposition (OD) was also employed to track the changes in EI in this period.

Result

Inequality in UOH increased from 0.105 to 0.133 in the studied years, indicating the pro-rich distribution of UOH. Inequality in UIH decreased from 0.0558 to − 0.006. DEI showed that economic status was the main factor that contributed to inequality in the UOH and UIH. OD showed that residence in rural areas and supplementary insurance were the main contributing factors in the increased inequality of UOH. Moreover, OD also showed that economic status was the main contributing factor in the reduced inequality of UIH.

Conclusion

While Iran still suffers from significant socio-economic inequalities in UOH, it seems that healthcare reforms, especially HTP, have reduced UIH inequality. Expanding healthcare reforms into the outpatient sector and also implementing effective health financing policies could be recommended as a remedy against UOH inequality.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Towards universal health coverage: achievements and challenges of 10 years of healthcare reform in China

Universal health coverage (UHC) has been identified as a priority for the global health agenda. In 2009, the Chinese government launched a new round of healthcare reform towards UHC, aiming to provide universal coverage of basic healthcare by the end of 2020. We conducted a secondary data analysis and combined it with a literature review, analysing the overview of UHC in China with regard to financial protection, coverage of health services and the reported coverage of the WHO and the World Bank UHC indicators. The results include the following: out-of-pocket expenditures as a percentage of current health expenditures in China have dropped dramatically from 60.13% in 2000 to 35.91% in 2016; the health insurance coverage of the total population jumped from 22.1% in 2003 to 95.1% in 2013; the average life expectancy increased from 72.0 to 76.4, maternal mortality dropped from 59 to 29 per 100 000 live births, the under-5 mortality rate dropped from 36.8 to 9.3 per 1000 live births, and neonatal mortality dropped from 21.4 to 4.7 per 1000 live births between 2000 and 2017; and so on. Our findings show that while China appears to be well on the path to UHC, there are identifiable gaps in service quality and a requirement for ongoing strengthening of financial protections. Some of the key challenges remain to be faced, such as the fragmented and inequitable health delivery system, and the increasing demand for high-quality and value-based service delivery. Given that China has committed to achieving UHC and ‘Healthy China 2030’, the evidence from this study can be suggestive of furthering on in the UHC journey and taking the policy steps necessary to secure change.

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.

Health care inequality under different medical insurance schemes in a socioeconomically underdeveloped region of China: a propensity score matching analysis

Background

Since economic inequality is often accompanied by health inequalities, health care inequalities are increasingly becoming a hot issue on a global scale. As a developing country, China is still facing the same problems as other countries in the world. Especially in underdeveloped regions, owing to the relatively backward economy, health care inequality may be more serious. The objective of this study was to explore health care inequality in a socioeconomically underdeveloped city, thus providing a certain theoretical basis for further development and reform of the medical insurance schemes.

Methods

We mainly extracted relevant insurance information of 628,952 insured enrollees, as well as consumption of outpatient visit and hospitalization. The propensity score matching had been used to estimate different urban medical insurance schemes effect on healthcare utilization, the choice of hospital types and healthcare cost.

Results

Insured enrollees spent most hospitalization expenses in tertiary-level hospitals, which had lowest hospitalization compensation ratios. Healthcare utilization and cost vary significantly by different insurance schemes. Urban employees had significantly higher outpatient visit rates in all hospital types than urban residents. Urban employees preferred to receive hospitalization treatment in tertiary-level hospitals, while those who receive hospitalization treatment in first-level hospitals are more likely to be enrolled in Urban Residents Basic Medical Insurance. Hospitalization expenses and hospitalization compensation ratios of urban employees were also significantly higher than urban residents in all hospital types.

Conclusions

Health care inequality is mainly reflected in the imbalance between hospitalization expenses and hospitalization compensation ratios, as well as inequalities under different medical insurance schemes in healthcare utilization, the choice of hospital types and healthcare cost in socioeconomically underdeveloped regions of China. We should conduct a targeted medical insurance reform for the socioeconomically underdeveloped regions, rather than applying templates of ordinary regions. Further efforts are needed in the future to provide equal health care for every patient.

China's achievements and challenges in improving health insurance coverage

China has undertaken waves of healthcare reforms to keep pace with its rapid economic growth. By 2011, universal health insurance coverage was successfully achieved through the creation of a basic social medical insurance system. Growing economic power, extensive government subsidies, and strategies for program implementation are critical to that achievement. However, the breadth and depth of coverage varies considerably across insurance schemes and localities. The disjointed insurance scheme led to inequality in coverage, accessibility, and affordability of medical services, lopsided allocation of health resources, and increasing medical expenditures, and these remain crucial challenges for healthcare insurance coverage. This paper describes societal conditions, polices, achievements and challenges in improving health insurance coverage in China. Thailand's experience in universal health insurance coverage and its implications for China's new medical reform are also discussed. Solutions including sustainable increases in government investment, transformation of payment methods, reinforcement of primary health care delivery and the referral system, and standardization of benefits packages are strongly recommended to address challenges in China's long-running medical reform.

A systematic review of the health-financing mechanisms in the Association of Southeast Asian Nations countries and the People's Republic of China: Lessons for the move towards universal health coverage

We systematically review the health-financing mechanisms, revenue rising, pooling, purchasing, and benefits, in the Association of Southeast Asian Nations (ASEAN) and the People’s Republic of China, and their impact on universal health coverage (UHC) goals in terms of universal financial protection, utilization/equity and quality. Two kinds of sources are reviewed: 1) academic articles, and 2) countries’ health system reports. We synthesize the findings from ASEAN countries and China reporting on studies that are in the scope of our objective, and studies that focus on the system (macro level) rather than treatment/technology specific studies (micro level).The results of our review suggest that the main sources of revenues are direct/indirect taxes and out of pocket payments in all ASEAN countries and China except for Brunei where natural resource revenues are the main source of revenue collection. Brunei, Indonesia, Philippines, Malaysia, and Viet Nam have a single pool for revenue collection constituting a national health insurance. Cambodia, China, Lao, Singapore, and Thailand have implemented multiple pooling systems while Myanmar has no formal arrangement. Capitation, Fee-for-Service, DRGs, Fee schedules, Salary, and Global budget are the methods of purchasing in the studied countries. Each country has its own definition of the basic benefit package which includes the services that are perceived as essential for the population health. Although many studies provide evidence of an increase in financial protection after reforming the health-financing mechanisms in the studied countries, inequity in financial protection continue to exist. Overall, the utilization of health care among the poor has increased as a consequence of the implementation of government subsidized health insurance schemes which target the poor in most of the studied countries. Inappropriate policies and provider payment mechanisms impact on the quality of health care provision. We conclude that the most important factors to attain UHC are to prioritize and include vulnerable groups into the health insurance scheme. Government subsidization for this kind of groups is found to be an effective method to achieve this goal. The higher the percentage of government expenditure on health, the greater the financial protection is. At the same time, there is a need to weigh the financial stability of the health-financing system. A unified health insurance system providing the same benefit package for all, is the most efficient way to attain equitable access to health care. Capacity building for both administrative and health service providers is crucial for sustainable and good quality health care.

Does the critical illness insurance reduce patients' financial burden and benefit the poor more: a comprehensive evaluation in rural area of China

BACKGROUND

Critical illness insurance (CII) is one kind of health insurance that is gradually gaining attention worldwide. China implemented CII in 2012 to decrease patients' out-of-pocket (OOP) medical payments. The aims of this study were to determine if the project had positive impacts on relieving financial burden and improving health equity.

METHODS

A series of questionnaire surveys were undertaken in two counties before and after the intervention in rural China. OOP expenditure, catastrophic Health Expenditure (CHE) incidence, and associated average gap (AG) were assessed across different income groups and project durations, measuring short-term direct medical cost. Medical debt rate and amount were used to measure long-term financial burden; concentration index (CI) was calculated for equity. All data were evaluated by descriptive statistics and multi-variate variance analysis. The linear regression and logit regression with random effect analysis upon area was used to evaluate the effect of CII.

RESULTS

Six hundred and thirteen and 834 patients were surveyed at baseline and final evaluation. After the program, the OOP payments of hospitalizations sharply decreased from RMB 39,363.2 to RMB 28,426.1 (p < 0.001), with the largest decrease for lowest income patients (from RMB 44,507.6 to RMB 29,214.2). With longer duration of CII, more OOP medical payments decreased. The amount of medical debt was decreased by RMB 7,209.4 among all the patients, and the decrease was highest in the highest income group (RMB 8,119.9). The CI of AG changed a lot (from -0.858 to -0.670).

CONCLUSION

The CII has effectively reduced the financial burden of patients with high medical cost, whether in the short-term or a longer length of time. It also improved health equity in health service utilization and expenditure. However, rich householders still receive more benefits from the policy, government health insurance financing is increased, and the policy needs to further benefit the poor.

Health insurance status and risk factors of mortality in patients with septic acute kidney injury in Ningbo, China

OBJECTIVE

To investigate the relationship between health insurance status and outcomes of septic acute kidney injury (AKI) related hospitalizations in an intensive care unit (ICU) in Ningbo, China.

METHODS

For this retrospective study, information was extracted from patients notes and billing records for patients >18 years of age with a diagnosis of AKI admitted to the ICU department, Ningbo First Hospital from April 2013 to March 2018.

RESULTS

Of the 368 patients with sepsis admitted to ICU, 167 (45%) developed AKI; 95 patients were insured and 72 were uninsured. Compared with insured patients, uninsured patients were younger, had higher Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores, but had less catheter interventions and received less renal replacement therapy (RRT). Results from a multivariate analysis showed that independent predictors of ICU mortality were age, APACHE II scores, MODS scores, use of RRT and lack of insurance.

CONCLUSIONS

Uninsured patients with septic AKI were younger, stayed a shorter time in ICU, had higher illness severity scores and a higher ICU mortality than insured patients. Importantly a major risk factor for ICU mortality in this group was lack of insurance.

Association between social health insurance and choice of hospitals among internal migrants in China: a national cross-sectional study

OBJECTIVES

There is a tendency to pursue higher-level hospitalisation services in China, especially for internal migrants. This study aims to investigate the choices of hospitalisation services among internal migrants, and evaluate the association between social health insurance and hospitalisation choices.

METHODS

Data were from a 2014 nationally representative cross-sectional sample of internal migrants aged 15-59 years in China. Descriptive analyses were used to perform the distribution of healthcare facility levels for hospitalisation services, and multinomial logistic regression was applied to examine the association between social health insurance and hospitalisation choices.

RESULTS

Of the 6121 inpatient care users, only 11.50% chose the primary healthcare facilities for hospitalisation services, 44.91% chose the secondary hospitals and 43.59% preferred the tertiary hospitals. The choices presented large regional variations across the country. Compared with the uninsured, social health insurance had no statistically significant effect on patient choices of healthcare facility levels among internal migrants in China, whereas socioeconomic status was positively associated with the choices.

CONCLUSIONS

Social health insurance had little influence on the hospital choice among the internal migrants. Thus, social health insurance should be consolidated and portable to enhance the proper incentive of health insurance on healthcare seeking behaviours.

The impacts of implementation of National Essential Medicines Policies on primary healthcare institutions: a cross-sectional study in China

Background

In 2009, China implemented the National Essential Medicines Policies (NEMPs) as part of a new round of medical system reforms. This study aims to evaluate the impacts of the NEMPs on primary healthcare institutions and discuss the roles of the policies in the new healthcare reforms of China.

Methods

The study selected a total of six representative provinces of China, generating a sample of 261 primary healthcare institutions from August to December in 2010. A questionnaire survey developed by the study team was distributed to all of the primary healthcare institutions. Nine indicators from three dimensions as the outcome variables were used and calculated to evaluate the impacts of implementation of policies. All of the outcome variables were tested using independent-samples T test between the treatment group (with the NEMPs implemented) and the control group (without the NEMPs implemented).

Results

The ratio of drug sales and institution revenues at primary healthcare institutions was 42.99% in the treatment group, which was significantly lower than the control group (53.90%, p < 0.01), while the ratio of financial subsidies of the treatment group was shown to be higher (30.78% VS 20.82%, p < 0.01). The rate of healthcare workers income growth was greater in the treatment group (15.35% VS 5.79%, p = 0.006). The treatment group exhibited higher outpatient and emergency visits per month in urban areas (2720 VS 1763 visits per month) and rural areas (3830 VS 3633), and higher prescriptions per month in urban areas (2048 VS 1025, p = 0.005) and rural areas (3806 VS 3251). The treatment group used more essential medicines and received greater income from essential medicines while the drug price markup rate was lower.

Conclusions

The NEMPs appear to affect the transformation of the operation mechanisms of primary healthcare institutions, the improvement of the mechanisms for government investment, and the healthcare pricing system. Meanwhile, the gaps between urban and rural areas need to be addressed. In conclusion, the NEMPs of China are instrumental to the aim of providing basic healthcare services to every citizen.

An economy-ralated equity analysis of health service utilization by women in economically underdeveloped regions of western China

BACKGROUND

The Chinese government has long been committed to eliminating the inequality in the utilization of health services; however, it still lacks an analysis or measurement of the economy-related inequality in the utilization of women's health services.

METHODS

The economy-related utilization of health services in women aged 15 years and above was assessed by the horizontal inequity index of a two-week outpatient rate and annual inpatient rate from the 5th National Health Service Survey of Shaanxi Province. The concentration index of each factor was decomposed into the contribution of each factor to the economic-related inequality of health service utilization based on the Probit regression model.

RESULTS

The horizontal inequity indexes of the two-week outpatient rate was 0.0493, and the horizontal inequity indexes of the annual impatient rate was 0.0869. The contributions of economic status to the two indexes were 190.71% and 115.80%, respectively. Economic status, age, basic medical insurance, educational status, marital status, urban/rural area, and self-rated health were the main impact factors that affected the inequality in women's health services utilization in Shaanxi.

CONCLUSIONS

Health service utilization was different between women with different social demographic characteristics, and unequal health service utilization is evident among women in Shaanxi.

Horizontal Inequity in Health Care Utilization among the Middle-Aged and Elderly in China

Background: Equitable utilization of health care is a primary goal of the Chinese health system. This study aimed to examine horizontal inequity in health care utilization and identify the factors resulting in inequity among the middle-aged and elderly in China. Methods: The data were obtained from the China Health and Retirement Longitudinal Study (CHARLS). We employed the concentration index (CI) and horizontal inequity (HI) to measure inequity in health care utilization. Non-linear regression models were used to decompose the CI into the contribution of each factor. Results: The CIs for the probability of and total number of outpatient visits were 0.0642 and 0.0780, respectively, and those for inpatient visits were 0.1418 and 0.1471, respectively. The HIs were also significantly positive. Living standard was the most important contributor. The contribution of health insurance varied between plans. Conclusions: This study supported the presence of pro-rich inequity in health care utilization for both probability and frequency among the middle-aged and elderly in China. Narrowing the living standard gap and improving the health insurance benefit package for the elderly should help to resolve these inequities.

Perceived challenges to achieving universal health coverage: a cross-sectional survey of social health insurance managers/administrators in China

OBJECTIVE

China has achieved over 96% health insurance coverage. However, universal health coverage (UHC) entails population coverage and the range of services covered and the extent to which health service costs are covered. This study aimed to determine the performance of the health insurance system in China in terms of its role in UHC and to identify challenges in the progress of UHC as perceived by health insurance managers/administrators.

METHODS

A cross-sectional questionnaire survey was conducted in Beijing, Ningbo, Harbin and Chongqing over the period of 2014 and 2015. A stratified cluster random sampling strategy was adopted to select study participants. A total of 1277 (64.8%) respondents who reported familiarity with the current health insurance system and the requirements of UHC provided valid data for analyses. They gave a rating on the role of the current health insurance system in achieving UHC. A multivariate logistic regression model was developed to determine the associations between the rating and the features of insurance arrangements.

RESULTS

There was consensus among the respondents on the performance of the current health insurance system in terms of its role in UHC, regardless who they were and what responsibility they held in their organisation (ie, policy development, managing fund transactions, and so on). Overall, about 45% of the respondents believed that there is a long way to go to achieve UHC. The low rating was found to be associated with limited financial protection (OR=1.656, 95% CI 1.279 to 2.146), healthcare inequity (OR=1.607, 95% CI 1.268 to 2.037), poor portability (OR=1.347, 95% CI 1.065 to 1.703) and ineffective supervision and administration of funds (OR=1.339, 95% CI 1.061 to 1.692) as perceived by the respondents.

CONCLUSION

Health insurance managers/administrators in China are pessimistic about the achievements of the current health insurance system. They are concerned about the overall lack of benefit that insurance programmes bring to members, including low levels of entitlements, large healthcare inequity, limited financial protection and poor portability. A singular amendment of the structural design of the existing funds may not be enough to offer a satisfactory solution to these identified barriers. There is a need to increase funding capacities, to develop unified and consistent policies and to increase the level of fund pooling.