Rural‐urban disparity in risk exposure to involuntary social health insurance transition in China: An investigation of chronic disease patients' mental health problems

Chronic disease patients have long suffered from mental health problems because of the long‐lasting and costly treatments. Although the multilevel social health insurance system in China attempts to provide them with full‐fledged health insurance coverage, the increasing prevalence of gig economy unexpectedly disrupts this situation. As the social health insurance system in China is closely associated with employment status, unemployed rural‐to‐urban migrant workers/regular urban workers have to accept the transition from urban employee basic medical insurance (UEBMI) to new cooperative medical scheme (NCMS)/urban resident basic medical insurance (URBMI). This study investigates the influence of this involuntary health insurance transition on the mental health of chronic disease patients. Empirical results show that the experience of transition from UEBMI to NCMS would significantly deteriorate the mental health of chronic disease patients, while the transition from UEBMI to URBMI would not. Accordingly, chronically ill rural‐to‐urban migrant workers are vulnerable to the involuntary health insurance transition that further deteriorates their mental health, and the multilevel social health insurance system in China cannot cope well with the emerging phenomenon of frequent employment change in labor market.     

The cost of coverage: rural health insurance in China

China has undergone great economic and social change since 1978 with far reaching implications for the health care system and ultimately for the health status of the population. The Chinese Medical Reform of the 1980s made cost recovery a primary objective. The urban population is mostly protected by generous government health insurance. A high share government budget is allocated to urban health care. Rural cooperative health insurance reached a peak in the mid-1970s when 90% of the rural population were covered. In the 1980s rural cooperative health insurance collapsed and present coverage is less than 8%. The decline has been accompanied by reports of growing equity problems in the financing of and access to health care. This article is the first in a four-year study of the impact on equity of the changes in Chinese health care financing. The article examines the relationship between rural cooperative health insurance as the explanatory variable and health care expenditure, curative vs. preventive expenditure and tertiary curative care expenditure as dependent variables using a natural experimental design with a 'twin' county as a control. The findings support the hypothesis that cooperative health insurance will induce higher growth of health care expenditure. The findings also support the hypothesis that cooperative health insurance will lead to a shift from preventive medicine to curative medicine and to a higher level of tertiary curative care expenditure. The empirical evidence from the Chinese counties is contradicting World Bank health financing policies.     

Health in China and India: a cross-country comparison in a context of rapid globalisation

China and India are similarly huge nations currently experiencing rapid economic growth, urbanisation and widening inequalities between rich and poor. They are dissimilar in terms of their political regimes, policies for population growth and ethnic composition and heterogeneity. This review compares health and health care in China and India within the framework of the epidemiological transition model and against the backdrop of globalisation. We identify similarities and differences in health situation. In general, for both countries, infectious diseases of the past sit alongside emerging infectious diseases and chronic illnesses associated with ageing societies, although the burden of infectious diseases is much higher in India. Whilst globalisation contributes to widening inequalities in health and health care in both countries--particularly with respect to increasing disparities between urban and rural areas and between rich and poor--there is evidence that local circumstances are important, especially with respect to the structure and financing of health care and the implementation of health policy. For example, India has huge problems providing even rudimentary health care to its large population of urban slum dwellers whilst China is struggling to re-establish universal rural health insurance. In terms of funding access to health care, the Chinese state has traditionally supported most costs, whereas private insurance has always played a major role in India, although recent changes in China have seen the burgeoning of private health care payments. China has, arguably, had more success than India in improving population health, although recent reforms have severely impacted upon the ability of the Chinese health care system to operate effectively. Both countries are experiencing a decline in the amount of government funding for health care and this is a major issue that must be addressed.     

Household health expenditures in Nepal: implications for health care financing reform.

His Majesty's Government of Nepal has embarked on an ambitious social welfare programme of increasing the accessibility of primary education and health care services in rural communities. The implications on the financing of health care services are substantial, as the number of health posts has increased twelve-fold from 1992 to 1996, from 200 to 2597. To strengthen health care financing, government policy-makers are considering a number of financing strategies that are likely to have a substantial impact on household health care expenditures. However, more needs to be known about the role of households in the current structure of the health economy before the government designs and implements policies that affect household welfare. This paper uses the Nepal Living Standards Survey, a rich, nationally-representative sample of households from 1996, to investigate level and distribution of household out-of-pocket health expenditures. Utilization and expenditures for different types of providers are presented by urban/rural status and by socioeconomic status. In addition, the sources of health sector funds are analyzed by contrasting household out-of-pocket expenditures with expenditures by the government and donors. The results indicate that households spend about 5.5% of total household expenditures on health care and that households account for 74% of the total level of funds used to finance the health economy. In addition, rural households are found to spend more on health care than urban households, after controlling for income status. Distributing health care expenditures by type of care utilized indicates that the wealthy, as well as the poor, rely heavily on services provided by the public sector. The results of this analysis are used to discuss the feasibility of implementing alternative health care financing policies.     

中国大规模推广农村初级卫生保健的实践经验

本文梳理了中国农村卫生服务体系在不同发展时期的情况和形成过程,分析了在计划经济体制下和经济体制转型时期中国农村初级卫生保健体系的特点、成效和存在的问题,总结了中国初级卫生保健体系的宝贵经验。     

An introduction to China's health care system

The Chinese health care system was originally a highly centralized one. It had great success in improving the people's health. The county-township-village three-tier health care system has contributed much to rural primary health care, and has set an example of primary health care to the developing nations. In the 1980s, this system experienced transformations along with the changes of the country's administrative system and economic policy. The transformations are characterized by the disintegration of the rural cooperative medical service, by the decentralization of township hospitals from county to township governments, by official permission for private practice, by the implementation of the personal responsibility system in health institutions, by the health security reform, and by the development of health insurance in rural areas. The long-existing health administrative problems which were aggravated in the last decade are the rural-urban differences in resource allocation and the large proportion of people without health security. With the increase of medical service prices in recent years due to the inflation of the whole economy, it is believed that the cost of health care will create an economic burden to the low-income, fee-for-service paying individuals and will further affect the health of the population. In the process of the national economic reform, it is an important and difficult task for the health administrators to adjust the health care system promptly and properly. Only by continuously carrying forward good traditions, correcting mistakes and consistently persisting in health reform, can China further raise its health care to a new, prosperous stage.     

Women's health status and gender inequality in China

This paper examines the health status of women in China by reviewing levels and trends of female mortality at several phases of a woman's life cycle focusing on infancy, girlhood, childbearing and old age. The mortality rates of Chinese women and men are compared for the period 1950–1990 as are comparisons with women in selected countries. The cause-specific death rate, expressed as a percentage of all deaths, and the burden of disease, measured in terms of the disability-adjusted life years (DALYs), are used to reflect the changing patterns of female diseases and causes of deaths. Significant improvement in the health status of Chinese women since 1950 is widely acknowledged as a major achievement for a developing country with the largest population in the world, but the differentials in women's health by region and urban/rural areas are considerable. The Physical Quality of Life Index (PQLI) indicates that the overall level of physical well-being of Chinese women has increased in recent decades, but disparity in health between men and women still exists. The Gender-Related Development Index (GDI) further reveals that China has achieved significant progress in women's health during the past four decades, but far less has been achieved with respect to gender equality overall. The final sections of the paper focus on the discussion of some health problems faced by the female population during the process of economic reform since the 1980 s. In order to promote gender equality between women and men, concerns on women's health care needs are highlighted.     

Modernization and health care in contemporary China

This paper provides an analysis of the changes that have occurred in the Chinese health care system in the reform era, post-1978. The economic reforms have brought significant benefits to many Chinese people, but the benefits have not been distributed evenly throughout Chinese society. The paper evaluates some of the evidence indicating deterioration in both the quality and quantity of health care services in the reform era. There is some alarming evidence that rural women, especially those living in the country's poorest regions, have been experiencing lower levels of accessibility to health care, and increasing levels of both morbidity and mortality. It is also evident that during the reform era the gap between service levels in rural areas and the cities has widened, and that chronic poverty still exists in large parts of the countryside. It is important to stress that these inequalities were not created by the economic reforms--in fact they were first observed during the supposedly egalitarian era associated with Mao Zedong. The economic reforms and the widespread implementation of market socialism in Chinese society, have, in general, been associated with improved health status and greater access to health care. It is also apparent, however, that pre-existing inequalities have not been eradicated by the reforms, and, particularly along the lines of gender and geography, the evidence points to a widening of inequality.     

Challenges to equity in health and health care: a Zimbabwean case study

The current economic crisis in Africa has posed a serious challenge to policies of comprehensive and equitable health care. This paper examines the extent to which the Zimbabwe government has achieved the policy of "Equity in Health" it adopted at independence in 1980, that is provision of health care according to need. The paper identifies groups with the highest level of health needs in terms of both health status and economic factors which increase the risk of ill health. It describes a series of changes within the health sector in support of resource redistribution towards health needs, including a shift in the budget allocation towards preventive care, expansion of rural infrastructures, increased coverage of primary health care, introduction of free health services for those earning below Z$150 a month in 1980, increased manpower deployment in the public sector and the reorientation of medical training towards the health needs of the majority. The implementation of equity policies in health have however been challenged by several trends and features of the health care system, these becoming more pronounced in the economic stagnation period after 1983. These include the reduction in allocations to local authorities, increasing the pressure for fees, the static nominal level of the free health care limit despite inflation, the continued concentration of financial, higher cost manpower and other resources within urban, central and private sector health care and the lack of effective functioning of the referral system, with high cost central quaternary facilities being used as primary or secondary level care by nearby urban residents. While primary health care expansion has clearly been one of the success stories of Zimbabwe's health care post 1980, the paper notes plateauing coverage, with evidence of lack of coverage in more high risk, socio-economically marginal communities. Measures to address these continuing inequalities are discussed. Their implementation is seen to be dependent on increasing the capacity and organisation of the poor to more strongly influence policy and resource distribution in the health sector.     

The impact of the 1997-98 East Asian economic crisis on health and health care in Indonesia

This article identifies the effects of the 1997-98 East Asian economic crisis on health care use and health status in Indonesia. The article places the findings in the context of a framework showing the complex cause and effect relationships underlying the effects of economic downturns on health and health care. The results are based on primary analysis of Indonesian household survey data and review of a wide range of sources from the Indonesian government and international organizations. Comparisons are drawn with the effects of the crisis in Thailand. The devaluation of the Indonesian currency, the Rupiah, led to inflation and reduced real public expenditures on health. Households' expenditures on health also decreased, both in absolute terms and as a percentage of overall spending. Self-reported morbidity increased sharply from 1997 to 1998 in both rural and urban areas of Indonesia. The crisis led to a substantial reduction in health service utilization during the same time period, as the proportion of household survey respondents reporting an illness or injury that sought care from a modern health care provider declined by 25%. In contrast to Indonesia, health care utilization in Thailand actually increased during the crisis, corresponding to expansion in health insurance coverage. The results suggest that social protection programmes play a critical role in protecting populations against the adverse effects of economic downturns on health and health care.     

Health and health care in Vietnam

The South East Asian state of Vietnam is currently undergoing a transition from a centralised socialism to a so-called socialist market economy strongly promoting the private sector. For the last 17 years economy experienced an impressive growth. If the assumption is true that economic growth is positively correlated with the health status of the population, the strengthened economy of Vietnam must go along with an improved health situation and health care system of this country. The following paper evaluates this assumption. It is demonstrated that there is indeed a strongly positive correlation between health and development in many aspects. However, it becomes obvious that economic growth is definitely accompanied by increasing regional and social disparity challenging the health care policy of Vietnam and her international partners.     

中国农村卫生发展现状与策略思考

该文回顾和总结了建国50多年来我国农村卫生工作取得的成就和经验,客观分析了经济转型时期农村卫生工作面临的矛盾、困难和机遇,最后对农村卫生改革提出若干思考:调整政府卫生投入政策,确保公共卫生和预防保健工作的落实,改革农村卫生服务体系的产权结构和管理体制,巩固农村卫生服务网,发展初级卫生保健,建立适宜的农村健康保健制度.     

Building institutions for an effective health system: lessons from China's experience with rural health reform

This paper is concerned with the management of health system changes aimed at substantially increasing the access to safe and effective health services. It argues that an effective health sector relies on trust-based relationships between users, providers and funders of health services, and that one of the major challenges governments face is to construct institutional arrangements within which these relationships can be embedded. It presents the case of China, which is implementing an ambitious health reform, drawing on a series of visits to rural counties by the author over a 10-year period. It illustrates how the development of reform strategies has been a response both to the challenges arising from the transition to a market economy and the result of actions by different actors, which have led to the gradual creation of increasingly complex institutions. The overall direction of change has been strongly influenced by the efforts made by the political leadership to manage a transition to a modern economy which provides at least some basic benefits to all. The paper concludes that the key lessons for other countries from China's experience with health system reform are less about the detailed design of specific interventions than about its approach to the management of institution-building in a context of complexity and rapid change.     

Health care in China: a rural-urban comparison after the socioeconomic reforms.

This article provides an overview of the current Chinese health care system with particular emphasis on rural-urban differences. China''s post-1978 economic reforms, although they improved general living standards, created some unintended consequences, as evidenced by the disintegration of the rural cooperative medical system and the sharp reduction in the number of "barefoot doctors", both of which were essential elements in the improvement of health status in rural China. The increase in the elderly population and their lack of health insurance and pensions will also place enormous pressure on services for their care. These changes have disproportionately affected the rural health care system, leaving the urban system basically intact, and have contributed to the rural-urban disparity in health care. Based on recent data the article compares current rural-urban differences in health care policy, systems, resources, and outcomes, and proposes potential solutions to reduce them.     

From economic development to public health improvement: China faces equity challenges

In the past three decades China has been going through a period of rapid economic growth, which has had profound repercussions for the nation’s public health system. Prior to the current health reforms much of the population was left uninsured and facing high financial risk from inadequate healthcare, with especially deep divisions between the urban and rural populations, which continues to pose a huge challenge to health equity and social justice. This paper explores the relationship between economic development and public health and discusses a series of health disparity issues that are emerging in China. These include: (1) health risk and access to care issues among unregistered urban populations (i.e. migrants); (2) low recognition of mental health, and the stigma associated with people with mental illness or communicable disease; and (3) challenges to the traditional system of family care for the elderly, as younger generations migrate to the cities and the remaining rural population ages. Implications for government policy and action to address these issues and improve public health as well as equity are discussed.     

Equity in health -- an overview

This article presents an overview of the current status of health equity in India. India is undergoing health transition leading to improvements in the nation's overall health and fertility indicators. Access and availability of health care resources as well as financial distribution are highly inequitable. The sharp difference between the health status in rural and urban areas is linked with poverty, social status, and disproportionate growth of health infrastructure. Public health services are reported to be inconvenient, unfriendly, and ineffective due to lack of staff or drugs. It did not meet the demands of the people. The inequity affecting the health sector is categorized as social equity, economic equality, political equality, and gender-related equity.     

Health impacts of macroeconomic crises and policies: determinants of variation in childhood malnutrition trends in Cameroon

BACKGROUND: It is generally hypothesized that macro economic shocks worsen child health by lowering household economic status and limiting access to health care, but this proposition seldom has been tested empirically. We examined the effects of economic crises and adjustment programmes during the 1990s in Cameroon on childhood malnutrition in population subgroups and evaluated the household and health system mediators of these effects. METHODS: We used pooled cross-sectional data from two Demographic and Health Surveys conducted in 1991 and 1998. In multivariate analysis, we stratified data on child sex and age, maternal education, and place and region of residence. We used a linear regression model to estimate the net effects of changes in average household economic status and maternal health seeking behaviour (MHSB) on changes in the prevalence of malnutrition for each stratum, adjusting for all other variables. RESULTS: The prevalence of malnutrition in children younger than 3 years increased from 16 to 23% (P < 0.001) between 1991 and 1998. The increase in urban areas, from 13 to 15% (P = 0.391), mostly occurred in children of low-educated mothers. The increase in rural areas, from 19 to 25% (P < 0.001), mostly occurred in boys, children older than 6 months of age, those born to low-educated mothers, and those of low economic status. In urban areas, the advantage associated with higher maternal education was robust to all controls, and declines in economic status and MHSB were the mediators of increasing malnutrition. In rural areas, increase in malnutrition was higher in children with lower baseline economic status; decline in MHSB was a significant mediator of worsening nutritional status. CONCLUSIONS: The negative nutritional effects during economic crises and adjustment programmes of the 1990s in Cameroon were largest among children of low socioeconomic status. Declines in household economic status and access to health care were the mediators of increasing malnutrition.     

The Chinese health care regulatory institutions in an era of transition

The purpose of this paper is to contribute to a better understanding of Chinese health care regulation in an era of transition. It describes the major health care regulatory institutions operating currently in China and analyzes the underlying factors. The paper argues that in the transition from a planned to a market economy, the Chinese government has been employing a hybrid approach where both old and new institutions have a role in the management of emerging markets, including the health care market. This approach is consistent with the incremental reform strategy adopted by the Party-state. Although a health care regulatory framework has gradually taken shape, the framework is incomplete, with a particular lack of emphasis on professional self-regulation. In addition, its effectiveness is limited despite the existence of many regulatory institutions. In poor rural areas, the effectiveness of the regulatory framework is further undermined or distorted by the extremely difficult financial position that local governments find themselves in. The interpretations of the principle of 'rule of law' by policy makers and officials at different levels and the widespread informal network of relations between known individuals (Guanxi) play an important role in the operation of the regulatory framework. The findings of this paper reveal the complex nature of regulating health care in transitional China.     

Changes in the health care system of Vietnam in response to the emerging market economy

This paper discusses the impact on the Vietnamese health care system of the change from a centralized socialist system to a market economy. It discusses recent policies based on expectations in relation to actual outcomes, and the impacts these changes have had on health care delivery and health infrastructure in Vietnam. It has become clear that the private medical sector is draining resources from the State rather than complementing the weakened national health system. Impacts on health education, pharmaceuticals, infrastructure support, geographic distribution of physicians, and equity are all discussed in terms of recent economic changes. It is suggested that adjustments must be made to ensure adequate health care for all Vietnamese including those in rural areas and the urban poor. The State must develop mechanisms to support the national health service before further deterioration occurs.     

以照顾家人为目的城乡来源流动老年人健康及锻炼行为比较分析

目的 分析比较以照顾家人为目的城乡来源的流动老年人的健康及锻炼行为。 方法 在“2015年全国流动人口卫生计生动态监测调查数据”中获取研究对象3 175名。采用logistic回归分析城乡老年人自评健康及锻炼行为的影响因素。 结果 以照顾家人为目的的流动老年人自评健康和锻炼时长普遍较高,但城乡来源老年人存在差异。二项logistic回归发现,未患高血压/糖尿病、共同居住、本地朋友数量多是城乡老年人自评健康状况好的共性因素,而城市老年人中个人经济独立（OR=1.62, 95%CI: 1.08~2.44）、农村老年人中家庭人均收入更高（OR=1.74, 95%CI : 1.38~2.18）与自评健康状况好相关。有序logistic回归表明,朋友数量多是城乡老年人锻炼时间长的共性因素,而城市老年人经济独立（OR=1.63, 95%CI : 1.08~2.45）和独立居住（OR=1.56, 95%CI : 1.08~2.22）、农村老年人患高血压/糖尿病（OR=1.35, 95%CI : 1.10~1.65）和健康自评好（OR=1.32, 95%CI : 1.11~1.56）与锻炼时间长相关。结论 城乡来源的流动老年人自评健康和锻炼行为及影响因素既有共性也存在差异,需要关注流动老年人群的异质性,同时需要加强社会支持和家庭支持以促进流动老年人健康。