Fig 5 - available from: International Journal for Equity in Health
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Background:
Aging and the chronic non-communicable diseases (NCDs) challenge the Chinese government in the process of providing hospitalization services fairly and reasonably. The Chinese government has developed the basic medical insurance system to solve the problem of "expensive medical cost and difficult medical services" for vulnerable groups...
Contexts in source publication
Context 1
... of inpatient use. Other detailed data on the decomposition of inequality in probability of inpatient services utilization is shown in Additional file 1: Tables S1, S2 and S3. Table 4 displays the contribution for each variable to inequality of the frequency of inpatient services utilization. The contribution of three variable-groups is shown in Fig. ...
Context 2
... the insured individuals were set as the rural population with poor economic capacity. This setup played a decisive role to reduced pro-rich inequality in inpatient services utilization. Table 5 Oaxaca-type decomposition of change for inequality in probability and frequency of inpatient service utilization, China The comparison between Fig. 4 and Fig. 5 shows that the contribution of three variable-groups to the inequity of probability of inpatient service utilization is similar to the number of inpatient service utilization. Enabling variables made the strong pro-rich inequality of the probability and frequency of inpatient service utilization. Need variables slightly decreased the ...
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Citations
... Despite this, disparities in healthcare utilization remain a serious concern in China [17,22], largely due to population ageing and epidemiological transition [5,13,[23][24][25][26]. Rapid population ageing leads to a growing prevalence of non-communicable diseases (NCDs) [27][28][29][30]. ...
... It is thus expected that the prevalence of multiple NCDs may exaggerate the effect of SES on health service use [1]. Additionally, published studies in China were mostly based on cross-sectional study designs [1-5, 7, 9, 13-15, 19, 20, 23, 29, 45, 47-49, 51], while little evidence was from longitudinal studies [8,24,26,52]. Due to broader socioeconomic changes, population ageing, disease burden changes, and health service development [23], investigating the longitudinal changes in healthcare utilization is warranted. ...
... NCDs often impair people's quality of life and their functional ability [70]; thus, patients with NCDs often increase health service use to meet their health needs [32,53,70]. Given rapid population ageing and increasing burden of NCDs [5,13,23,24], disparities in health service use tend to pose a more significant threat to China's health system [19]. Hence, new health service delivery models to effectively manage NCDs are needed [70]. ...
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.
... 64 Two other Chinese studies suggested another mechanism involving occupation, namely doctor-driven supplierinduced demand in the UEBMI scheme because doctors knew that UEBMI members were employed and had regular income making cost-sharing more affordable. 60,63 In Thailand, the universal coverage scheme (UCS) covered the population not covered by formal sector schemes for civil servants and private sector employees, so a large proportion were farmers who had lower education and income levels. Consequently, it was hypothesised that their lower level of health literacy led to sub-optimal uptake of free-of-charge preventive services. ...
... The evidence suggested that such benefit package variation led to disparities in service received, favouring UEBMI members and disadvantaging especially the low-income population in NRCMS. 60,61,63,65 A similar picture was seen in Indonesia. The study indicated that, overall, covering basic services and medicines in the benefit package was positively associated with outpatient utilisation. ...
Background: Various features in health insurance schemes may lead to variation in health care. Unwarranted variations raise concerns about suboptimal quality of care, differing treatments for similar needs, or unnecessary financial burdens on patients and health systems. This realist review aims to explore insurance features that may contribute to health care variation in Asian countries; and to understand influencing mechanisms and contexts. Methods: We undertook a realist review. First, we developed an initial theory. Second, we conducted a systematic review of peer-reviewed literature in Scopus, MEDLINE, EMBASE, and Web of Science to produce a middle range theory for Asian countries. The Mixed Methods Appraisal Tool (MMAT) was used to appraise the methodological quality of included studies. Finally, we tested the theory in Thailand by interviewing nine experts, and further refined the theory. Results: Our systematic search identified 14 empirical studies. We produced a middle range theory in a context-mechanism-outcome configuration (CMOc) which presented seven insurance features: benefit package, cost-sharing policies, beneficiaries, contracted providers, provider payment methods, budget size, and administration and management, that influenced variation through 20 interlinked demand- and supply-side mechanisms. The refined theory for Thailand added eight mechanisms and discarded six mechanisms irrelevant to the local context. Conclusion: Our middle range and refined theories provide information about health insurance features associated with health care variation. We encourage policymakers and researchers to test the CMOc in their specific contexts. Appropriately validated, it can help design interventions in health insurance schemes to prevent or mitigate the detrimental effects of unwarranted health care variation.
... Between 1998 and 2008, health care utilization in Brazil became increasingly equitable, shifting from a largely favorable utilization of health care services by the rich to a slightly excessive utilization by the rich [10]. Similarly, outpatient utilization and inpatient utilization in China vary among individuals with different incomes [11][12][13]. According to the China National Health Services Survey, the concentration index for outpatient and inpatient health service utilization in China in 2008 was 0.015 and 0.197, respectively, with higher-income groups using more outpatient and inpatient services [14]. ...
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.
... Several reports have assessed the association between income and health care utilization among middle-aged and elderly populations [20,21]. One study of Chinese patients ≥45 years of age identified significant differences in inpatient service utilization based on per capita household expenditures [22]. Low income and poor health status were negatively associated with the equitable and rational utilization of health care among the middle-aged and elderly patients. ...
Background: Elderly population is particularly vulnerable to socioeconomic disparities. This study assessed inequalities in health care utilization among the elderly in China and identified contributing factors. Methods: This study used data from the 2018 China Health and Retirement Longitudinal Study survey. A non-linear probit regression model based on the Andersen Health Care Utilization Model was used to identify determinants of health care utilization among the elderly. The concentration index (CI) and the decomposition of the CI were calculated to evaluate inequalities in health care utilization among the elderly and identify related contributors. Results: The CI for actual and standardized outpatient visits was 0.0889 and 0.0945, respectively, and the corresponding values for inpatient service utilization were 0.1134 and 0.1176, respectively. Factors that contributed to greater inequalities in the utilization of outpatient and inpatient service included income (73.68% for outpatient service; 85.20% for inpatient service), Urban Employee Basic Medical Insurance (UEBMI) (40.75% for outpatient service; 32.03% for inpatient service) and non-agricultural Hukou status (12.63% for outpatient service; 18.73% for inpatient service). New Rural Cooperative Medical Scheme (NRCMS) (−34.30% for outpatient service; −33.18% for inpatient service) and poor health status (−7.36% for outpatient service; −8.30% for inpatient service) reduced inequalities in outpatient and inpatient utilization. Conclusions: This study found that a key contributor to these inequalities was income, followed by UEBMI coverage. Meanwhile, health care coverage through NRCMS was associated with fewer disparities in health care utilization.
... In European countries, female gender, older age, lower education level [42], lower social status [43], and unmarried or living alone [44] are important factors associated with physical and mental health. This situation is also more noticeable in developing countries, especially China [40,[45][46][47][48]. It is also the case that social relationships with mutual interaction and economic support are beneficial for physical and psychological health [49][50][51][52]. ...
Background:
Poverty vulnerability has been defined as the likelihood of a family falling into poverty in the upcoming months. Inequality is a major cause of poverty vulnerability in developing countries. There is evidence that establishing effective government subsidies and public service mechanisms significantly reduces health poverty vulnerability. One of the ways to study poverty vulnerability is by using empirical data such as income elasticity of demand to perform the analysis. Income elasticity refers to the extent to which changes in consumers' income affect changes in demand for commodities or public goods. In this work, we assess health poverty vulnerability in rural and urban China. We provide two levels of evidence on the marginal effects of the design and implementation of government subsidies and public mechanisms in reducing health poverty vulnerability, before and after incorporating the income elasticity of demand for health.
Methods:
Multidimensional physical and mental health poverty indexes, according to the Oxford Poverty & Human Development Initiative and the Andersen model, were implemented to measure health poverty vulnerability by using the 2018 China Family Panel Survey database (CFPS) as the data source for empirical analysis. The income elasticity of demand for health care was used as the key mediating variable of impact. Our assessment was conducted by a two-level multidimensional logistic regression using STATA16 software.
Results:
The first level regression indicates that the marginal utility of public mechanism (PM) in reducing urban and rural vulnerability as expected poverty on physical and mental health (VEP-PH&MH) was insignificant. On the other hand, government subsidies (GS) policies had a positive suppression effect on VEP-PH&MH to a relatively low degree. The second level regression found that given the diversity of health needs across individual households, i.e., the income elasticity of demand (HE) for health care products, PM and GS policies have a significant effect in reducing VEP-PH&MH in rural and urban areas. Our analysis has verified the significant positive impact of enacting accurate GS and PM policies on effectively reducing VEP-PH&MH in rural as well as urban areas.
Conclusions:
This study shows that implementing government subsidies and public mechanisms has a positive marginal effect on reducing VEP-PH&MH. Meanwhile, there are individual variations in health demands, urban-rural disparities, and regional disparities in the effects of GS and PM on inhibiting VEP-PH&MH. Therefore, special consideration needs to be given to the differences in the degree of health needs of individual residents among urban and rural areas and regions with varying economic development. Furthermore, considerations of this approach in the current worldwide scenario are analyzed.
... Several reports have assessed the association between income level and health care utilization among middle-aged and elderly populations [20,21]. One study of Chinese patients ≥ 45 years of age identi ed signi cant differences in inpatient service utilization based on per capita household expenditures [22]. ...
Background: China has the world’s largest elderly population, a cohort that is particularly vulnerable to socioeconomic disparities. This study assessed inequalities in health care utilization among the elderly in China and identified contributing factors.
Methods: This study used data from the 2018 China Health and Retirement Longitudinal Study survey. A non-linear probit regression model based on the Andersen Health Care Utilization Model was used to identify determinants of health care utilization among the elderly. The concentration index (CI) was calculated to evaluate inequalities in health care utilization, with a positive value indicating that health care utilization was concentrated among wealthy individuals. The decomposition of the CI was used to identify related contributors to inequalities in health care utilization among the elderly.
Results:A total of 9,780 individuals ≥60 years of age were included in the study. The CI for actual and standardized outpatient visits was 0.0889 and 0.0945, respectively, and the corresponding values for inpatient service utilization were 0.1134 and 0.1176, respectively. Predisposing factors had a negligible effect on disparities in health care utilization while enabling factors were the most important positive contributors to these disparities. The need factors marginally alleviated the gaps in health care utilization among the elderly. Factors that contributed to greater inequality in the utilization of outpatient service included income level (73.72%), Urban Employee Basic Medical Insurance (UEBMI) (40.93%), non-agricultural Hukou status (12.61%), limited engagement in social activities (11.86%), and higher education level (9.13%). New Rural Cooperative Medical Scheme (NRCMS) reduced inequalities in outpatient utilization (-34.32%), followed by poor health status (-7.36%). Factors that contributed to greater utilization of inpatient service by wealthier patients included income level (85.15%), UEBMI (31.77%), non-agricultural Hukou status (18.66%), employment (13.30%), and chronic disease (6.28%). NRCMS (-33.19%) and poor health status (-8.30%) reduced inequalities in inpatient service utilization.
Conclusions: Socioeconomic disparities in health care utilization among the elderly are a major concern in China. This study found that a key contributor to these inequalities was income level, followed by UEBMI coverage. Meanwhile, health care coverage through NRCMS was associated with fewer disparities in health care utilization disparities.
... Studies on NCD disparities in China are limited in number and scope. Studies focused on the health service utilization of NCDs revealed increased access to NCD care for the wealthier population (14)(15)(16). A recent study compared national urban/rural health expenditure on NCDs (17). ...
Background
Non-communicable diseases (NCDs) including risk factors, e.g., obesity, are the major causes of preventable deaths in China, yet NCD disparities in China remain under-studied.
Objective
This study aimed to compare the determinants and burden of NCDs within four selected provinces in mainland China: the least developed Qinghai-Tibet Plateau group (PG, Tibetan Autonomous Region [TAR] and Qinghai Province) and most developed megacity group (MCG, Shanghai, and Beijing).
Methods
Studies, reports, and other official sources with comparable data for NCD burden and related determinants for the four provinces were searched. Geographic, demographic, socioeconomic, and dietary characteristics and selected health indicators (e.g., life expectancy) were extracted from the China Statistical Yearbook and China Health Statistics Yearbook. Data on NCD burdens were extracted from the National Chronic Disease and Risk Factor Surveillance Study and other nationally representative studies.
Results
The overall NCD mortality rates and prevalence of metabolic risk factors including obesity, hypertension, and diabetes in mainland China have increased in the past 20 years, and this trend is expected to continue. The PG had the highest level of standardized mortality rates (SMRs) on NCDs (711.6–896.1/100,000, 6th/6-level); the MCG had the lowest (290.6–389.6/100,000, 1st/6-level) in mainland China. The gaps in SMRs were particularly high with regard to chronic respiratory diseases (PG 6th/6-level, MCG 1st/6-level) and cardiovascular diseases (6th/6 and 4th/6 in TAR and Qinghai; 1st/6-level and 2nd/6-level in Shanghai and Beijing). In contrast, the prevalence rates of obesity, hypertension, and diabetes were generally higher or comparable in MCG compared to PG. Diabetes prevalence was particularly high in MCG (5th/5-level, 13.36–14.35%) and low in PG (1st/5-level, 6.20–10.39%). However, awareness, treatment, and control of hypertension were poor in PG. Additionally, PG had much lower and severely inadequate intakes of vegetables, fruits, and dairy products, with additional indicators of lower socioeconomic status (education, income, etc.,) compared with MCG.
Conclusion
Evidence showed large disparities in NCD burden in China's provinces. Socioeconomic disparity and dietary determinants are probably the reasons. Integrated policies and actions are needed.
... The China Pulmonary Health (CHP) study from 2015 have demonstrated that the absolute number of people with asthma increased with age [46]. Older adults living in rural areas face long treatment courses and high treatment costs for chronic diseases [47] .NRPS is primarily designed to provide income for the elderly to reduce their nancial burden as part of a social security system [48]. Our ndings regarding the effect of NRPS on health status were generally consistent with the study by Cheng [19] and suggested that NRPS could improve the health of older adults with COPD and asthma by reducing the nancial burden on families. ...
Background
Many researchers have examined the impact of social insurance on health in elderly. However, in most cases, they have only demonstrated correlational results and have not been able to determine causal effects, possibly because confounding biases have not been fully addressed. In this study, we investigated the health effects of the New Rural Pension Scheme (NRPS) on the elderly with chronic diseases in rural areas, and to explore the causal relationship and effects of NRPS and health status.
Methods
This paper used data from the 2018 China Health and Aged Care Tracking Survey (CHARLS) and applied Bayesian networks and fuzzy regression discontinuity design to conduct causal analysis. Bayesian networks were used to explore the causal directed acyclic graphs of factors related to NRPS and health status. Based on the results of Bayesian network, a fuzzy regression discontinuity design was employed to estimate the causal effect of NRPS on health status.
Results
Among rural elderly with chronic diseases, Bayesian network mapping of causal relationships among NRPS, health status and covariates showed that age was a common cause of NRPS receipt and satisfaction with health. The results of the fuzzy regression discontinuity analysis showed that the effect of receiving NRPS on the health status was positive, but there was no statistically significant difference concerning the interval estimates. The results of the subgroup analysis with chronic obstructive pulmonary disease (COPD) and asthma indicated that the effect of NRPS receipt on the health status of elderly people with COPD was positive. There was a statistically significant effect of receiving NRPS on self-rated health description (β1=3.177,P=0.040) and health satisfaction (β1=5.307,P=0.031) in COPD population and a statistically significant effect of receiving NRPS on health satisfaction in asthma population (β1=9.850,P=0.040).
Conclusion
This paper has confirmed the contribution and positive causal effect of NRPS on health status in a subgroup of older adults with COPD and asthma, using the CHARLS database as evidence. Thus, Chinese government should increase the take-up rate of the NRPS to enhance their positive impact on health status of elderly people with chronic diseases in rural areas.
... Disease-based healthcare utilization discrepancy is considerably more common than other discrepancies, especially in chronic diseases. Numerous studies have found that healthcare utilization is usually concentrated in rich populations with chronic diseases [12,25]. In Serbia, residents with non-communicable chronic diseases are three times more likely to make a general practitioner visit and approximately two times more likely to be hospitalized than others [26]. ...
... Thus, low-income patients have lower rates of healthcare utilization than affluent patients, and are more likely to not use the healthcare that they need or opt for cheaper healthcare services [47][48][49][50]. For example, studies have shown that the medical expenditure of inpatient visits is considerably higher than that of outpatient visits, and thus, low-income patients are more likely to use outpatient than inpatient visits [25,51,52]. This conclusion is also reflected in our study, which shows that socio-economic factors prompt low-income patients to use more outpatient visits and high-income patients to use more inpatient visits generally. ...
... Theoretically, medical insurance can reduce healthcare utilization inequity because of financial support. However, a review of the literature revealed that medical insurance has intensified the inequity between the UEBMI and the URRBMI [25,58]. The possible reasons are the UEBMI has a higher reimbursement rate, and bigger benefits packages than the URRBMI. ...
Abstract Background Studies have shown chronic disease-based healthcare utilization inequity is common. Hence, exploring this issue can help in establishing targeted measures and protecting the rights and interests of vulnerable groups. Against this background, the purpose of this study is to explore the latent classification of elderly patients with chronic disease and compare healthcare utilization inequity among latent classes. Methods This study used the data of 7243 elderly patient with chronic diseases collected from the China Health and Retirement Longitudinal Study in 2018. Latent class analysis was used to classify the patients with chronic diseases, and analysis of variance and $${x}^{2}$$ x 2 tests were utilized to test the differences in characteristics among latent classes. Healthcare utilization inequity was measured based on the concentration index (CI), and the CI was decomposed to compare the horizontal index of healthcare utilization among the latent classes. Results The patients with chronic diseases were divided into five latent classes, namely, the musculoskeletal system, hypertension, respiratory system, digestive system and cardiovascular system groups. Statistically significant differences in social demographic characteristics were observed among the five latent classes (P
... Factors including the availability and characteristics of health resources, health status, demographic characteristics, health needs, enabling factors, and family support influenced the selection and frequency of health services [34][35][36][37][38][39]. We, therefore, included current residence, GDP per capita (PGDP at prefecture-city-level), and economic region [40] (provincelevel), self-reported health status, activities of daily life (ADLs) limitations, instrumental activities of daily life (IADLs) limitations, depression, age, sex, marital status, education, work status, drinking, smoking, number of chronic diseases, frequency of social activity, medical insurance status, per capita household consumption expenditure (PCE), number of caregivers, and living arrangements as covariates. ...
With rapid economic growth and aging, hospital inpatient and emergency services utilization has grown rapidly, and has emphasized an urgent requirement to adjust and optimize the structure of health service utilization. Studies have shown that primary care is an effective way to reduce inpatient and emergency room (ER) service utilization. This study aims to examine whether middle-aged and elderly individuals who selected primary care outpatient services in the last month had less ER and hospital inpatient service utilization than those who selected hospitals outpatient services via the self-referral system. Data were obtained from four waves of the nationally representative China Health and Retirement Longitudinal Study (CHARLS). We pooled respondents who had outpatient visits and were aged 45 years and above. We used logistic regressions to explore the association between types of outpatient and ER visits or hospitalization, and then used zero-truncated negative binomial regression to examine the impact of outpatient visit types on the number of hospitalizations and the length of hospitalization days. A trend test was used to explore the trend of outpatient visit types and the ER or hospital inpatient services utilization with the increase in outpatient visits. Among the 7544 respondents in CHARLS, those with primary care outpatient visits were less likely to have ER visits (adjusted OR = 0.141, 95% CI: 0.101-0.194), hospitalization (adjusted OR = 0.623, 95% CI: 0.546-0.711), and had fewer hospitalization days (adjusted IRR = 0.886, 95% CI: 0.81-0.969). The trend test showed that an increase in the number of total outpatient visits was associated with a lower hospitalizations (p = 0.006), but a higher odds of ER visits (p = 0.023). Our findings suggest that policy makers need to adopt systematic policies that focus on restructuring and balancing the structure of resources and service utilization in the three-tier healthcare system.
