Community-based health insurance in poor rural China: the distribution of net benefits

The collapse of China's Cooperative Medical System (CMS) in 1978 resulted in the lack of an organized financing scheme for health care, adversely affecting rural farmers' access to health care, especially among the poor. The Chinese government recently announced a policy to re-establish some forms of community-based insurance (CBI). Many existing schemes involve low premiums but high co-payments. We hypothesized that such benefit design leads to unequal distribution of the "net benefits" (NB)--benefits net of payment--because even though low premiums are more affordable to poor farmers, high co-payments may have a significant deterrent effect on the poor in the use of services in CBI. To test this hypothesis empirically, we estimated the probability of farmers joining a re-established CBI using logistic regression, and the utilization of health care services for those who joined the scheme using the two-part model. Based on the estimations, we predicted the distribution of NB among those who joined the CBI and for the entire population in the community. Our data came from a household survey of 4160 members of 1173 households conducted in six villages in Fengshan Township, Guizhou Province, China. Three principal findings emerged from this study. First, income is an important factor influencing farmers' decision to join a CBI despite the premium representing a very small fraction of household income. Secondly, both income and health status influence enrollees' utilization of health services: richer/sicker participants obtain greater NB from the CBI than poorer/healthier members, meaning that the poorer/healthier participants subsidize the rich/sick. Thirdly, wealthy farmers benefit the most from the CBI with low premium and high co-payment features at every level of health status. In conclusion, policy recommendations related to the improvement of the benefit distribution of CBI schemes are made based on the results from this study.     

上海市浦东新区卫生事业发展主要问题与改革思路

上海市浦东新区自改革开放以来,经济超常规发展,医疗卫生事业保持与经济同步发展。然而,发展的同时也面临着一些重要的问题:一级医院利用效率不高、社区卫生服务的发展方向、贫困人口就医、医疗费用的控制等问题。对这些问题的认识与把握,是保证新区卫生事业健康有序发展的关键之一     

Lessons from understanding the role of community hospital director in Thailand: clinician versus manager

In 2001, Thailand adopted the Universal Health Coverage (UHC) policy. This policy focuses on primary health care (PHC), with the aim of reforming the Thai health system to provide health services to all, regardless of a person's ability to pay. The community hospital director (CHD) is the middle manager of the provincial health system and the leader of the district health system of Thailand. In recent reforms the emphasis for improving efficiency lies with changes in the provision of primary health services at the community level and this entails understanding the role of the CHD. A qualitative study, utilizing individual interviews and a focus group discussion, was undertaken in order to understand the factors affecting the implementation of rural health care in Thailand. Findings identified several barriers that limit the role of the CHD and a major result of the study was recognition of the dual role of the CHD as both clinician and manager. This study concluded that the goal of the UHC policy in providing equity of access to PHC to all citizens may not be achieved unless the role of CHDs is supported with training in health management and PHC and is supported by the government.     

Incoherent policies on universal coverage of health insurance and promotion of international trade in health services in Thailand

The Thai government has implemented universal coverage of health insurance since October 2001. Universal access to antiretroviral (ARV) drugs has also been included since October 2003. These two policies have greatly increased the demand for health services and human resources for health, particularly among public health care providers. After the 1997 economic crisis, private health care providers, with the support of the government, embarked on new marketing strategies targeted at attracting foreign patients. Consequently, increasing numbers of foreign patients are visiting Thailand to seek medical care. In addition, the economic recovery since 2001 has greatly increased the demand for private health services among the Thai population. The increasing demand and much higher financial incentives from urban private providers have attracted health personnel, particularly medical doctors, from rural public health care facilities. Responding to this increasing demand and internal brain drain, in mid-2004 the Thai government approved the increased production of medical doctors by 10,678 in the following 15 years. Many additional financial incentives have also been applied. However, the immediate shortage of human resources needs to be addressed competently and urgently. Equity in health care access under this situation of competing demands from dual track policies is a challenge to policy makers and analysts. This paper summarizes the situation and trends as well as the responses by the Thai government. Both supply and demand side responses are described, and some solutions to restore equity in health care access are proposed.     

政府当前对公共卫生事业投入现状分析

目的:分析当前政府对公共卫生事业投入现状。方法:依据政府公共财政基本功能,与世界相关国家的政府投入现状比较,分析我国卫生事业费占财政支出比重状况及原因。结果:我国政府卫生投入状况不适应公共卫生发展需要。结论:政府财力相对匮乏,疾病谱改变使原有的经费更加紧张,应尽快解决这一状况。     

Access to health care resources in the UK: the case of care for arthritis

The paper uses new and detailed data from a population sample of individuals with arthritis to examine the impact of objective measures of need for treatment and individual measures of socio-economic position on the distribution of public and private health care. The quality of the data and the range of explanatory factors are more detailed than previously used to study of the allocation of NHS care. The results indicate that broadly the NHS appears to meet its equity goal of equal care for equal medical need, though there is evidence that education increases the amount of resources received. The results also show the importance of the interaction between the public and private sectors in the UK.     

Medical education in Thailand

In order to make training more relevant to community needs, medical educators throughout Thailand have been attempting to address issues concerning the training of their undergraduates. Support for a reorientation of medical education and acceptance of the frame-work put forward by the World Health Organization are evident in national health plans and in national medical education conferences. This paper outlines some of the basic problems faced by health policy makers in Thailand and presents a brief chronology of recent events in the history of medical education in Thailand.     

Migrant Workers in Agriculture: A View from Thailand

There has been a dramatic increase in the global movement of workers during the last few decades. As Thailand has developed rapidly over the past 20 years, it has attracted laborers (both authorized and unauthorized) from the neighboring countries of Myanmar, People’s Democratic Republic of Lao (Lao PDR), and Cambodia. Given that agriculture has been Thailand’s most important industry, its continued growth has been dependent on migrant workers. Both crop agriculture and animal-production agriculture have employed migrant labor. Migrants have been hired to plant, weed, fertilize, spray pesticides, and harvest crops such as rice, corn, sugar cane, and cassava. They have worked at rubber and coffee plantations, as well as in the production of ornamental crops. Also, migrants have labored on pig, beef, and duck farms. There have been numerous documented health problems among migrant workers, including acute diarrhea, malaria, and fever of unknown causes. Occupational illness and injury have been a significant concern, and there has been limited health and safety training. This article reviewed the demographic changes in Thailand, studied the agricultural crops and animal production that are dependent on migrant labor, discussed the health status and safety challenges pertaining to migrant workers in agriculture, and described several recommendations. Among the recommendations, the conclusions of this study have suggested that addressing the cost for health care and solutions to health care access for migrant labor are needed.     

Public health in Thailand: emerging focus on non-communicable diseases

Over the past three decades, the public health landscape in Thailand has shifted remarkably. Currently chronic non-communicable diseases represent the largest cause of mortality in the Thai population. In light of the current situation, this paper synthesizes what is known about the chronic non-communicable disease situation in Thailand and analyzes current policy responses. Relevant contextual factors such as socio-economic transitions, health systems development, and health workforce capacities are also considered. Primary data for this study were collected by a review of policy documents, government statements, and statistics reported by the Thailand Ministry of Public Health. Secondary data were obtained by a thorough review of the existing literature. The paper finds that while current policy responses to chronic non-communicable diseases in the health sector have focused on improving prevention and control of risk factors, a stronger emphasis on chronic disease treatment and management may be needed in the future. The paper concludes with an exploration of the potential for developing and implementing realistic public health responses to the growing burden of chronic non-communicable diseases in a Southeast Asian country context by utilizing existing capacities in research, policy, and health workforce development.     

西部地区农村居民医疗消费的致贫研究

我国的贫困人口很多,医疗保健消费是导致贫困的重要原因之一,西部农村地区疾病损伤占致贫原因的27.3%.医疗消费（特别是大额医疗支出）给农村居民带来很大的经济负担,对农村地区低收入人群来说更是如此,一方面需要支付大额医疗费,另一方面疾病使劳动能力降低或丧失,这就导致因病致贫和因病返贫.经济困难是影响农村居民卫生服务利用率的主要因素之一,且在医疗服务消费过程中存在不公平性.     

Women's Work: Volunteer AIDS Care Giving in Northern Thailand

SUMMARY

Because persons with AIDS in Thailand usually are cared for by their families, and because government AIDS policy relies upon this assistance for the care of the country's sick, the research reported here addressed the questions: Who are the home and community care givers for PWA? What kind of care do they give? And, What is the impact of care giving on the care giver(s)? Informants were drawn in 1998–99 from a long-term birth cohort study of a non-clinical urban population in the country's province of highest AIDS mortality, Chiang Mai. The study was part of a larger, exploratory ethnographic study of the interplay among health, reproduction and development among persons born in 1964 and their mothers that I began in 1973. Findings include that among care-givers, parents, overwhelmingly mothers, and wives considered it their place, duty and moral benefit to care for adult children or husbands sick with AIDS.     

Reforming medicare: The limited framework of political discourse on equity and economy

Medicare, the major program that organizes the delivery and financing of health care for the elderly in the United States, is being rapidly and significantly changed in order to bring Federal expenditures for health care under control. Questions of 'equity', 'justice' and 'access to health care' (that have long been associated with liberal ideology) have lost discursive currency within the realm of acceptable political debate that now focuses on 'economy' and the restoration of 'competitive market forces' to the health care industry (a point of view associated with conservative ideology). Pluralistic analyses of American health care policy most often focus on the differences between liberals and conservatives and could only explain the current bipartisan effort to reorganize Medicare as a defeat for liberals and as a vindication for the conservative perspective during a period of economic crisis. This essay develops the alternative point of view that American political debate on health care, among and between liberals and conservatives, has always taken place within a space bracketed by well defined limits established by widespread support for the market model of health care. The strength and dominance of this model that organizes and supports the private production of health care for profit is far more important in explaining the continuity in American health care policy over time and the recent policy adjustments than any examination of ideological differences between political conservatives and liberals. After analyzing the limited framework of debate structured by the market model of health care, this paper critically examines the recent changes in Medicare and challenges the market model on empirical grounds. Finally, the author returns to a discussion of the implications of these changes for equity and justice.     

天津市卫生筹资的垂直公平和水平公平研究

目的:从垂直公平和水平公平角度分析评价天津市卫生筹资系统的公平性。方法:利用国家卫生服务调查和卫生总费用数据,运用AJL收入再分配方法分析天津市卫生筹资公平性。结果:天津市卫生筹资系统呈现亲穷人,改善了卫生筹资前收入分配的不公平,但不同卫生筹资渠道收入再分配作用不同。结论:强化直接税收的再分配职能;统筹社会医疗保险,改善筹资公平性;谨慎解释个人现金卫生支出筹资的"伪公平性"。     

Access to Health Care by Migrant Farm Workers on Fruit Plantations in Eastern Thailand

Objectives: This study was undertaken to elucidate factors that influenced access to health care for migrant farm workers from Cambodia employed on fruit plantations in eastern Thailand. Methods: Data were collected from 861 participants via interview questions and focus group discussions. Results: The results revealed that 58.2% of immigrant workers were male, averaged 30.4 years of age, and 56.3% had no formal education. In the past year, 28% reported back pain and 25% had joint pain. Most of the workers (89.8%) received health care services at a nearby government health promotion hospital (THPH). From the analysis of factors contributing to the access to health services among immigrant farm workers, the data indicate that the Cambodian workers had few concerns with their ability to access health care services, reporting high and medium levels of satisfaction (with odds ratios [ORs] of 6.19 and 3.94, respectively) versus being unsatisfied. The differences between those who reported significant minor illnesses and serious illness were important, as workers with significant complaints were 3.17 and 4.85 times more likely, respectively, to have sought medical treatment than those not reporting illness. Conclusion: The main recommendation resulting from this study is that factors leading to higher degrees of satisfaction with health care services by migrant farm workers for preventative care could be improved.     

Social franchising of TB care through private GPs in Myanmar: an assessment of treatment results, access, equity and financial protection

This article assesses whether social franchising of tuberculosis (TB) services in Myanmar has succeeded in providing quality treatment while ensuring equity in access and financial protection for poor patients. Newly diagnosed TB patients receiving treatment from private general practitioners (GPs) belonging to the franchise were identified. They were interviewed about social conditions, health seeking and health care costs at the time of starting treatment and again after 6 months follow-up. Routine data were used to ascertain clinical outcomes as well as to monitor trends in case notification. The franchisees contributed 2097 (21%) of the total 9951 total new sputum smear-positive pulmonary cases notified to the national TB programme in the study townships. The treatment success rate for new smear-positive cases was 84%, close to the World Health Organization target of 85% and similar to the treatment success of 81% in the national TB programme in Myanmar. People from the lower socio-economic groups represented 68% of the TB patients who access care in the franchise. Financial burden related to direct and indirect health care costs for tuberculosis was high, especially among the poor. Patients belonging to lower socio-economic groups incurred on average costs equivalent to 68% of annual per capita household income, with a median of 28%. However, 83% of all costs were incurred before starting treatment in the franchise, while 'shopping' for care. During treatment in the franchise, the cost of care was relatively low, corresponding to a median proportion of annual per capita income of 3% for people from lower socio-economic groups. This study shows that highly subsidized TB care delivered through a social franchise scheme in the private sector in Myanmar helped reach the poor with quality services, while partly protecting them from high health care expenditure. Extended outreach to others parts of the private sector may reduce diagnostic delay and patient costs further.     

The effect of health care expenditure on patient outcomes: Evidence from English neonatal care

The relationship between health care expenditure and health outcomes has been the subject of recent academic inquiry in order to inform cost‐effectiveness thresholds for health technology assessment agencies. Previous studies in public health systems have relied upon data aggregated at the national or regional level; however, there remains debate about whether the supply side effect of changes to expenditure are identifiable using data at this level of aggregation. We use detailed patient data derived from electronic neonatal records across England along with routinely available cost data to estimate the effect of changes to patient expenditure on clinical health outcomes in a well‐defined patient population. A panel of 32 neonatal intensive care units for the period 2009–2013 was constructed. Accounting for the potential endogeneity of expenditure a £100 increase in the cost per intensive care cot day (sample average cost: £1,127) is estimated to reduce the risk of mortality of 0.38 percentage points (sample average mortality: 11.0%) in neonatal intensive care. This translates into a cost per life saved in neonatal intensive care of approximately £420,000.     

Innovation and participation for healthy public policy: the first National Health Assembly in Thailand

Aim This paper aims to describe and disseminate the process and initial outcomes of the first National Health Assembly (NHA) in Thailand, as an innovative example of health policy making. Setting The first NHA, held in December 2008 in Bangkok, brought together over 1500 people from government agencies, academia, civil society, health professionals and the private sector to discuss key health issues and produce resolutions to guide policy making. It adapted the approach used at the World Health Assembly of the World Health Organization. Method Findings are derived from a literature review, document analysis, and the views and experiences of the authors, two of whom contributed to the organization of the NHA and two of whom were invited external observers. Results Fourteen agenda items were discussed and resolutions passed. Potential early impacts on policy making have included an increase in the 2010 public budget for Thailand’s universal health coverage scheme as total public expenditure has decreased; cabinet endorsement of proposed Strategies for Universal Access to Medicines for Thai People; and establishment of National Commissions on Health Impact Assessment and Trade and Health. Discussion The NHA was successful in bringing together various actors and sectors involved in the social production of health, including groups often marginalized in policy making. It provides an innovative model of how governments may be able to increase public participation and intersectoral collaboration that could be adapted in other contexts. Significant challenges remain in ensuring full participation of interested groups and in implementing, and monitoring the impact of, the resolutions passed.     

The impact of aging on different types of health care: The example of the Polish health insurance system

The aging phenomenon, which is being observed all over the world, can strongly affect health policy and a planning in the health care sector. However, the impact of demographic changes on different parts of it can be varied. The main objective of this study was to check the possible impact of aging on health expenditure (HE) regarding different types of health care and to evaluate whether this impact is significant for all analyzed areas. To show a relationship between age and HE a special indicator (old‐age sensitivity) was defined, showing a difference between the standardized value of HE per capita in the age group 65+ and in the group 20 to 64 (defined as the reference group). Then a simple prognosis of expenditure was prepared. Both analyses were done separately for 11 types of health care services and 2 types of goods reimbursement. The results show that while sensitivity varies between the different types of care, however, it is strong in most of them. Because of the prognosis, the expenditure will be increasing for the 9 types of care and decreasing for 4 of them. While in the case of the low values of sensitivity the HE is actually decreasing, the high value of sensitivity does not result in a growing tendency. Our main conclusion is that it is very important for health policy and planning to take into account the diversity of the types of health care and the different influences of changes in the size and structure of population on them.     

The determinants of health care expenditure: testing pooling restrictions in small samples

Health care expenditure has increased substantially in all Western industrialized countries in the last decades. The necessity to contain the increase in health care expenditure has motivated the analysis of its determinants to explain differences across countries and health systems. However, recent studies have questioned the use of cross section data arguing that health systems are too different to allow for such comparisons. In this paper we investigate whether this criticism is really justified. We analyze the variations of health care expenditure in OECD countries relative to income, population aging and technological change. Our analysis is based on pooled cross section data and time series. Firstly, formulating error correction models for individual countries we demonstrate that in almost all cases the investigated variables are cointegrated. Secondly, we use a bootstrap framework for inference and examine whether the influence of explanatory variables is unique across countries. Applying recursive estimation procedures we find evidence for cross country homogeneity during the period 1961-1979. In the last two decades health care dynamics become more and more country specific thus indicating divergence of health systems and the growing importance of country-specific effects in the explanation of differences in health care expenditure.