中国卫生软援助：实践、问题与对策——以对外卫生人力资源合作为例

中国卫生软援助是中国对外援助的重要组成部分。以卫生人力资源援助为主的卫生软援助集中反映了中国对外援助的基本理念和创新机制,是南南合作的典范。本文回顾了包括派遣医疗队、医疗卫生官员培训和提供中国政府奖学金等形式的中国卫生人力资源援助的成功实践。同时指出中国卫生软援助缺乏战略规划,参与援助的主体单一,对卫生软援助的实践和研究总结不足等。建议加强战略规划,主体多元化,提升总结中国软援助的能力,从而不断提高软援助的有效性。     

Understanding the effectiveness of government health expenditure in improving health equity: Preliminary evidence from global health expenditure and child mortality rate

Governments around the world are committed to enhance health equity, but the effectiveness of government health expenditure in improving health equity is still full of controversy. To respond to it, this study investigates the influence of government health expenditure (including domestic government health expenditure and foreign‐sourced health expenditure distributed by government) on child mortality rate across the world, in doing so evaluates its role in improving the social equity of health outcome. Using data of health expenditure and child mortality rate across the world (2000‐2015), empirical results show that both domestic government and foreign‐sourced health expenditure can greatly reduce the child mortality rate of families in rural areas with the lower level of maternal education and in the medium or low‐income stratum. Further, even though domestic government health expenditure is found more effective to reduce the child mortality rate of males, foreign‐sourced health expenditure can help cover such gender bias due to making a greater reduction in child mortality rate of females.     

The Effectiveness of Health Screening

Using a matched insurant–general practitioner panel data set, we estimate the effect of a general health‐screening program on individuals' health status and health‐care cost. To account for selection into treatment, we use regional variation in the intensity of exposure to supply‐determined screening recommendations as an instrumental variable. We find that screening participation increases inpatient and outpatient health‐care costs up to 2 years after treatment substantially. In the medium run, we find cost savings in the outpatient sector, whereas in the long run, no statistically significant effects of screening on either health‐care cost component can be discerned. In sum, screening participation increases health‐care cost. Given that we do not find any statistically significant effect of screening participation on insurants' health status (at any point in time), we do not recommend a general health‐screening program. However, given that we find some evidence for cost‐saving potential for the sub‐sample of younger insurants, we suggest more targeted screening programs. Copyright © 2014 John Wiley & Sons, Ltd.     

控制卫生费用 还是投资于健康--兼论健康产业模式

探讨我国卫生和卫生系统与经济的关系。由于政府、社会和病人无法承受越来越高的卫生费用,以至于控制卫生费用已成为我国卫生政策的核心。而作者从另一角度阐述健康投资对于宏观经济发展的价值与贡献。通过分析我国近年来的人群健康状况、卫生资源和卫生费用等的变化发展趋势,发现在有限的卫生费用下总体健康状况持续改善。提出了投资于健康有利于降低疾病负担,提高劳动生产力,从而促进经济的发展。     

Limiting health‐care access to undocumented immigrants: A wise option?

The number of undocumented migrants in high‐income countries has increased in recent decades, imposing considerable political, fiscal, and social pressures on governments. This has fostered discussions on whether and to what extent undocumented migrants should get access to public programs and public benefits. Looking at the 2012 Spanish health reform, this is the first paper to document the impacts of a restriction on access to the health‐care system for undocumented migrants on health‐care utilization, health‐care system perceptions, and self‐reported health in a high‐income country. We show that such restrictions may significantly reduce planned care for undocumented migrants and result in sharp fall in positive opinions about the health‐care services still left available to them. We also exploit the heterogeneity in implementing the policy across regions and report stronger effects in regions that enforced the national ban more fully. Furthermore, in the first 3 years since the implementation of the reform, we find suggestive evidence of a worsening in self‐assessed health. This study is relevant for policymakers in the developed world, especially in countries that have recently implemented initiatives aimed at reducing the health‐care coverage for targeted groups, such as the United Kingdom and the United States.     

Is health care infected by Baumol's cost disease? Test of a new model

Rising health care costs are a policy concern across the Organisation for Economic Co‐operation and Development, and relatively little consensus exists concerning their causes. One explanation that has received revived attention is Baumol's cost disease (BCD). However, developing a theoretically appropriate test of BCD has been a challenge. In this paper, we construct a 2‐sector model firmly based on Baumol's axioms. We then derive several testable propositions. In particular, the model predicts that (a) the share of total labor employed in the health care sector and (b) the relative price index of the health and non‐health care sectors should both be positively related to economy‐wide productivity. The model also predicts that (c) the share of labor in the health sector will be negatively related and (d) the ratio of prices in the health and non‐health sectors unrelated, to the demand for non‐health services. Using annual data from 28 Organisation for Economic Co‐operation and Development countries over the years 1995–2016 and from 14 U.S. industry groups over the years 1947–2015, we find little evidence to support the predictions of BCD once we address spurious correlation due to coincident trending and other econometric issues.     

Effectiveness of tax credits for health insurance premium: Evidence from the health insurance tax credit

With the push to repeal the Affordable Care Act, there is renewed interest in using tax credits to increase health insurance coverage. Another tax credit‐driven policy, the Health Insurance Tax Credit (HITC), was implemented during 1991–1993. To date, only one paper has analyzed the effectiveness of the HITC on coverage rates. In this paper, I reexamine the effectiveness of the HITC by using the Survey of Income Program Participation and provide the first estimates of its effects on utilization and self‐reported health status. Despite using the different data set, I find a similar result regarding coverage as the previous paper—the effect of the HITC was about 5.8 percentage points. I also find that self‐reported health was significantly improved because of the HITC. I conclude by discussing the implications of these findings on the larger debate regarding current health care reform.     

Health aid and governance in developing countries

Despite anecdotal evidence that the quality of governance in recipient countries affects the allocation of international health aid, there is no quantitative evidence on the magnitude of this effect, or on which dimensions of governance influence donor decisions. We measure health‐aid flows over 1995–2006 for 109 aid recipients, matching aid data with measures of different dimensions of governance and a range of country‐specific economic and health characteristics. Everything else being equal, countries with more political rights receive significantly more aid, but so do countries with higher corruption levels. The dependence of aid on political rights, even when we control for other governance indicators, suggests that health aid is sometimes used as an incentive to reward political reforms. Copyright © 2010 John Wiley & Sons, Ltd.     

Player or referee? Aid effectiveness and the governance of health policy development: Lessons from Viet Nam

Viet Nam is one of the brightest stars in the constellation of developing countries. Its remarkable achievements in reducing poverty and improving health and education outcomes are well known, and as a result it has enjoyed generous aid programmes. Viet Nam also has a reputation for taking a strong lead in disciplining its donors and pushing for more efficient and effective forms of aid delivery, both at home and internationally.

This article discusses how efforts to improve the effectiveness of aid intersect with policy-making processes in the health sector. It presents a quantitative review of health aid flows in Viet Nam and a qualitative analysis of the aid environment using event analysis, participant observation and key informant interviews.

The analysis reveals a complex and dynamic web of incentives influencing the implementation of the aid effectiveness agenda in the health sector. There are contradictory forces within the Ministry of Health, within government as a whole, within the donor community and between donors and government. Analytical frameworks drawn from the study of policy networks and governance can help explain these tensions. They suggest that governance of health aid in Viet Nam is characterised by multiple, overlapping ‘policy networks’ which cut across the traditional donor–government divide. The principles of aid effectiveness make sense for some of these communities, but for others they are irrational and may lead to a loss of influence and resources. However, sustained engagement combined with the building of strategic coalitions can overcome individual and institutional incentives.

This article suggests that aid reform efforts should be understood not as a technocratic agenda but as a political process with all the associated tensions, perverse incentives and challenges. Partners thus need to recognise – and find new ways of making sense of – the complexity of forces affecting aid delivery.     

Association of vaccine hesitancy and immunization coverage rates in the European Union

While previous studies have validated vaccine hesitancy scales with uptake behavior at the individual level, the conditions under which aggregated survey data are useful are less clear. We show that vaccine public opinion data aggregated at the subnational level can serve as a valid indicator of aggregate vaccine behaviour. We use a public opinion survey (Eurobarometer EB 91.2) with data on vaccine hesitancy for the EU in 2019. We link this information to (subnational) regional immunization coverage rates for childhood vaccines – DTP3, MCV1, and MCV2 -- obtained from the WHO for 2019. We conduct multilevel regression analyses with data for 177 regions in 20 countries. Given the variation in vaccine hesitancy and immunization rates between countries and within countries, we affirm the valuable role that surveys can play as a public health surveillance tool when it comes to vaccine behavior. We find statistically significantly lower regional vaccine immunization rates in regions where vaccine hesitancy is more pronounced. Our results suggest that different uptake rates across subnational regions are due, at least in part, to differences in attitudes towards vaccines and vaccination. The results are robust to several alternative specifications.     

Framing and signalling effects of taxes on sugary drinks: A discrete choice experiment among households in Great Britain

Taxes on sugar‐sweetened beverages (SSBs) are in place in many countries to combat obesity with emerging evidence that these are effective in reducing purchases of SSBs. In this study, we tested whether signalling and framing the price increase from an SSB tax explicitly as a health‐related, earmarked measure reduces the demand for SSBs more than an equivalent price increase. We measured the demand for non‐alcoholic beverages with a discrete choice experiment (DCE) administered online to a randomly selected group of n = 603 households with children in Great Britain (GB) who regularly purchase SSBs. We find a suggestive evidence that a price increase leads to a larger reduction in the probability of choosing SSBs when it is signalled as a tax and framed as a health‐related and earmarked policy. Respondents who did not support a tax on SSBs, who were also more likely to choose SSBs in the first place, were on average more responsive to a price increase framed as an earmarked tax than those who supported the tax. The predictive validity of the DCE, to capture preferences for beverages, was confirmed using actual purchase data. The findings imply that a well‐signalled and earmarked tax on SSBs could improve its effectiveness at reducing the demand.     

High deductible health plans: does cost sharing stimulate increased consumer sophistication?

Objective

To determine whether increased cost sharing in health insurance plans induces higher levels of consumer sophistication in a non‐elderly population.

Study design

This analysis is based on the collection of survey and demographic data collected from enrollees in the RAND health insurance experiment (HIE). During the RAND HIE, enrollees were randomly assigned to different levels of cost sharing (0, 25, 50 and 95%).

Methods

The study population compromises about 2000 people enrolled in the RAND HIE, between the years 1974 and 1982. Effects on health‐care decision making were measured using the results of a standardized questionnaire, administered at the beginning and end of the experiment. Points of enquiry included whether or not enrollees' (i) recognized the need for second opinions (ii) questioned the effectiveness of certain therapies and (iii) researched the background/skill of their medical providers. Consumer sophistication was also measured for regular health‐care consumers, as indicated by the presence of a chronic disease.

Principal findings

We found no statically significant changes (P < 0.05) in the health‐care decision‐making strategies between individuals randomized to high cost sharing plans and low cost sharing plans. Furthermore, we did not find a stronger effect for patients with a chronic disease.

Conclusions

The evidence from the RAND HIE does not support the hypothesis that a higher level of cost sharing incentivizes the development of consumer sophistication. As a result, cost sharing alone will not promote individuals to become more selective in their health‐care decision‐making.     

Towards comprehensive malaria planning: the effect of government capacity, health policy, and land use variables on malaria incidence in India

We present what we believe is the first empirical research that accounts for subnational government capacity in estimating malaria incidence. After controlling for relevant extrinsic factors, we find evidence of a negative effect of state government capacity on reported malaria cases in Indian states over the period 1993-2002. Government capacity is more successful in predicting malaria incidence than potentially more direct indicators such as state public health expenditures and economic development levels. We find that high government capacity can moderate the deleterious health effects of malaria in rice producing regions. Our research also suggests that government capacity may have exacerbated the effectiveness of the World Bank Malaria Control Project in India over the period studied. We conclude by proposing the integration of government capacity measures into existing planning efforts, including vulnerability mapping tools and disease surveillance efforts.     

Mental health parity legislation,cost‐sharing and substance‐abuse treatment admissions

Treatment is highly cost‐effective in reducing an individual's substance abuse (SA) and associated harms. However, data from Treatment Episodes (TEDS) indicate that per capita treatment admissions substantially lagged behind increases in heavy drug use from 1992 to 2007. Only 10% of individuals with clinical SA disorders receive treatment, and almost half who forgo treatment point to accessibility and cost constraints as barriers to care. This study investigates the impact of state mental health and SA parity legislation on treatment admission flows and cost‐sharing. Fixed effects specifications indicate that mandating comprehensive parity for mental health and SA disorders raises the probability that a treatment admission is privately insured, lowering costs for the individual. Despite some crowd‐out of charity care for private insurance, mandates reduce the uninsured probability by a net 2.4 percentage points. States mandating comprehensive parity also see an increase in treatment admissions. Thus, increasing cost‐sharing and reducing financial barriers may aid the at‐risk population in obtaining adequate SA treatment. Supply constraints mute effect sizes, suggesting that demand‐focused interventions need to be complemented with policies supporting treatment providers. These results have implications for the effectiveness of the 2008 Federal Mental Health Parity and Addiction Equity Act in increasing SA treatment admissions and promoting cost‐sharing. Copyright © 2009 John Wiley & Sons, Ltd.     

A hierarchical modeling approach to estimate regional acute health effects of particulate matter sources

Exposure to particulate matter (PM) air pollution has been associated with a range of adverse health outcomes, including cardiovascular disease hospitalizations and other clinical parameters. Determining which sources of PM, such as traffic or industry, are most associated with adverse health outcomes could help guide future recommendations aimed at reducing harmful pollution exposure for susceptible individuals. Information obtained from multisite studies, which is generally more precise than information from a single location, is critical to understanding how PM impacts health and to informing local strategies for reducing individual‐level PM exposure. However, few methods exist to perform multisite studies of PM sources, which are not generally directly observed, and adverse health outcomes. We developed SHared Across a REgion (SHARE), a hierarchical modeling approach that facilitates reproducible, multisite epidemiologic studies of PM sources. SHARE is a two‐stage approach that first summarizes information about PM sources across multiple sites. Then, this information is used to determine how community‐level (i.e., county‐level or city‐level) health effects of PM sources should be pooled to estimate regional‐level health effects. SHARE is a type of population value decomposition that aims to separate out regional‐level features from site‐level data. Unlike previous approaches for multisite epidemiologic studies of PM sources, the SHARE approach allows the specific PM sources identified to vary by site. Using data from 2000 to 2010 for 63 northeastern US counties, we estimated regional‐level health effects associated with short‐term exposure to major types of PM sources. We found that PM from secondary sulfate, traffic, and metals sources was most associated with cardiovascular disease hospitalizations. Copyright © 2017 John Wiley & Sons, Ltd.     

DID REFORM OF THE NON‐GROUP HEALTH INSURANCE MARKET AFFECT THE DECISION TO BE SELF‐EMPLOYED? EVIDENCE FROM STATE REFORMS IN THE 1990s

This paper estimates whether state‐level implementation of community rating and guaranteed issue regulations in the non‐group health insurance market during the 1990s affected the decision of taxpayers to be self‐employed. Using a panel of tax returns that span 1987–2000, we find no statistically significant effect of the reforms on the propensity to be self‐employed overall, although we find evidence of an increase in self‐employment among older taxpayers and weaker evidence of decreases among younger cohorts. Copyright © 2013 John Wiley & Sons, Ltd.     

The contribution of self‐help/mutual aid groups to mental well‐being

This article explores the contribution of self‐help/mutual aid groups to mental well‐being. Self‐help/mutual aid groups are self‐organising groups where people come together to address a shared a health or social issue through mutual support. They are associated with a range of health and social benefits, but remain poorly understood. This article draws on data from stage one of ESTEEM, a project which runs from 2010 to 2013. Stage one ran from 2010 to 2011 and involved participatory, qualitative research carried out in two UK sites. Twenty‐one groups were purposively selected to include a range of focal issues, longevity, structures and ethnic backgrounds. Researchers carried out 21 interviews with group coordinators and twenty group discussions with members to explore the groups' purpose, nature and development. Preliminary analysis of the data suggested that mental well‐being was a common theme across the groups. Subsequently the data were re‐analysed to explore the groups' contribution to mental well‐being using a checklist of protective factors for mental well‐being as a coding framework. The findings showed that groups made a strong contribution to members' mental well‐being by enhancing a sense of control, increasing resilience and facilitating participation. Group members were uplifted by exchanging emotional and practical support; they gained self‐esteem, knowledge and confidence, thereby increasing their control over their situation. For some groups, socio‐economic factors limited their scope and threatened their future. The article provides an evidence‐base which illustrates how self‐help/mutual aid groups can enhance mental well‐being. If supported within a strategy for social justice, these groups enable people with varied concerns to develop a tailored response to their specific needs. The authors suggest that policy‐makers engage with local people, investing in support proportionate to the needs of different populations, enabling them to develop their own self‐help/mutual aid groups to enhance their sense of mental well‐being.     

The Impacts of China's Urban Employee Basic Medical Insurance on Healthcare Expenditures and Health Outcomes

At the end of 1998, China launched a government‐run mandatory insurance program, the urban employee basic medical insurance (UEBMI), to replace the previous medical insurance system. Using the UEBMI reform in China as a natural experiment, this study identifies variations in patient cost sharing that were imposed by the UEBMI reform and examines their effects on the demand for healthcare services. Using data from the 1991–2006 waves of the China Health and Nutrition Survey, we find that increased cost sharing is associated with decreased outpatient medical care utilization and expenditures but not with decreased inpatient care utilization and expenditures. Patients from low‐income and middle‐income households or with less severe medical conditions are more sensitive to prices. We observe little impact on patient's health, as measured by self‐reported health status. Copyright © 2015 John Wiley & Sons, Ltd.