The impact of economic crisis on health-care consumption in Korea.

This study uses urban household income-expenditure survey data, national health insurance claims data, and public health centre surveys to examine the impact of economic crisis on the consumption of health services in Korea. The analysis shows that the health-care consumption of Korean households has been adversely affected by the recent economic crisis, as measured by amount of expenditure on health. Distributional implications for health sector use are also found. Whereas the use of medical services by upper income groups is only slightly affected by the economic crisis, lower income groups are spending relatively less on medical services. Of all households, unemployed households are hit hardest by the crisis. Analysis shows that for all households, the rate of expenditure decrease is relatively higher for drug expenditure than for expenditure on medical services. That is, facing declining income, people cut their spending in the area where the need is non-essential or less inevitable.     

基本医疗保险对家庭消费结构影响的研究*

目的分析基本医疗保障制度对家庭消费结构的影响,为相关政策的制定提供意见和建议。方法数据来源于2014年中国家庭动态跟踪调查(CFPS),样本量为12 305个家庭。采用似不相关回归模型对数据进行分析。结果城乡家庭覆盖基本医疗保险对家庭的食品支出、衣着支出、日常消费支出、居住支出和医疗保健支出具有显著的影响。结论城乡家庭覆盖基本医疗保险影响家庭的消费结构,并且该影响程度在城镇家庭和农村家庭有所不同。     

山东省农村居民高血压治疗费用及影响因素分析

目的:描述山东省农村自报高血压患者调查前一年治疗高血压病的费用,分析其影响因素,并为降低农村高血压患者治疗费用提供建议。方法:通过入户调查和现场体检收集资料。运用描述性统计方法描述高血压患者调查前一年治疗费用,并运用对数正态变换、t检验、方差分析和多元线性回归等统计方法,分析影响治疗费用的因素。结果:农村高血压患者调查前一年人均治疗费用为787.7元,是否患有并发症、是否按医嘱服药、调查前一年是否曾住院、患者对病情的知晓程度和患者病程的长短是影响高血压治疗费用的主要因素。结论:农村高血压患者疾病经济负担沉重,并发症和住院治疗是导致费用增加的主要原因,选择治疗方案时应考虑经济因素。健康知识和治疗依从性对治疗费用的影响有待进一步研究。     

Adverse selection in a voluntary Rural Mutual Health Care health insurance scheme in China

This study examines adverse selection in a subsidized voluntary health insurance scheme, the Rural Mutual Health Care (RMHC) scheme, in a poor rural area of China. The study was made possible by a unique longitudinal data set: the total sample includes 3492 rural residents from 1020 households. Logistic regression was employed for the data analysis. The results show that although this subsidized scheme achieved a considerable high enrollment rate of 71% of rural residents, adverse selection still exists. In general, individuals with worse health status are more likely to enroll in RMHC than individuals with better health status. Although the household is set as the enrollment unit for the RMHC for the purpose of reducing adverse selection, nearly 1/3 of enrolled households are actually only partially enrolled. Furthermore, we found that adverse selection mainly occurs in partially enrolled households. The non-enrolled individuals in partially enrolled households have the best health status, while the enrolled individuals in partially enrolled households have the worst health status. Pre-RMHC, medical expenditure for enrolled individuals in partially enrolled households was 206.6 yuan per capita per year, which is 1.7 times as much as the pre-RMHC medical expenditure for non-enrolled individuals in partially enrolled households. The study also reveals that the pre-enrolled medical expenditure per capita per year of enrolled individuals was 9.6% higher than the pre-enrolled medical expenditure of all residents, including both enrolled and non-enrolled individuals. In conclusion, although the subsidized RMHC scheme reached a very high enrollment rate and the household is set as the enrollment unit for the purpose of reducing adverse selection, adverse selection still exists, especially within partially enrolled households. Voluntary RMHC will not be financially sustainable if the adverse selection is not fully taken into account.     

我国灾难性卫生支出标准的界定：基于医疗支出对家庭基本生活消费的影响

目的：基于医疗支出对家庭基本生活消费的影响,对适合我国国情的灾难性卫生支出标准进行界定。方法：利用中国家庭追踪调查（CFPS）2012年、2014年、2016年和2018年四期的非平衡面板数据,运用双向固定效应模型和倾向得分匹配方法进行分析。结果：医疗支出强度与家庭基本生活消费并不是简单的线性关系,而是存在拐点的“倒U型”关系;异质性分析表明,医疗支出强度与家庭基本生活消费之间的“倒U形”关系主要表现在农村居民家庭和中等收入家庭,城市居民家庭和低收入家庭、高收入家庭不明显;适合我国实际情况的灾难性卫生支出标准与WHO提出的标准有所差异。建议：针对重点救助对象的医疗救助政策应该继续实施,且覆盖范围需不断扩大;以灾难性卫生支出为指标识别医疗支出型贫困,并根据我国国情制定其标准。     

The impact of tobacco expenditure on household consumption patterns in rural China

Smoking is not only unhealthy, it is also expensive. Spending on tobacco could drive out other critical expenditures, including basic needs. This crowd out effect would be greatest in low-income countries, affecting not only the smoker but the rest of the family as well. The aim of this study is to examine the impact of tobacco spending on household expenditure patterns in rural China. China is a low-income country with a high prevalence of smoking, especially among men. The data, a sample of 4538 households, are from a household survey conducted in six townships in two provinces in rural China. Fractional Logit (Flogit) model is used as the estimation method. We estimate the relationship between tobacco spending and spending on 17 other categories, controlling for socio-economic and demographic characteristics of the household. The results indicate that spending on tobacco affects human capital investment (e.g. education and health), future farming productivity (e.g. farming equipment and seeds), and financial security (e.g. saving and insurance). Smokers also tend to spend more on alcohol, thus exacerbating the impact of addictive substances on spending on basic needs. Smoking expenses can harm other family members by reducing expenditures on basic needs such as foods, utilities, and durable goods consumption. Thus smoking can have important intra-family distributional impacts.     

Economic consequences of maternal illness in rural Bangladesh

We use panel data on household consumption combined with information taken from the medical records of women who gave birth in health facilities to explore the economic consequences of maternal ill health, in the context of a rural population in Bangladesh. The findings suggest that there is a large reduction in household resources associated with maternal illness, driven almost entirely by spending on health care. In spite of this loss of resources, we find that households are able to fully insure consumption against maternal ill health, although confidence intervals are unable to rule out a small effect. Households in our study area are shown to have good access to informal credit (whether it be from local money lenders or family relatives), and this appears critical in helping to smooth consumption in response to these health shocks, at least in the short term.     

新农合农村家庭灾难性卫生支出的影响研究——以湖北省孝昌县为例

目的:研究湖北省孝昌县农村居民灾难性卫生支出的发生情况及其影响因素。方法:采用多阶段分层随机抽样,抽取湖北省孝昌县3镇9村,共约1 168户家庭、4 468人,比较分析新农合补偿前后灾难性卫生支出的发生情况及其影响因素。结果:新农合补偿后,样本地区的灾难性卫生支出发生率、平均差距和相对差距均有所下降;灾难性卫生支出的影响因素有:家庭收入水平、家庭中有工作的成员的数量、家庭成员住院次数、家庭是否有慢性病患者。结论:孝昌县农村地区家庭随着收入水平的增加其灾难性卫生支出的发生率和严重程度均降低,减少该县农村地区灾难性卫生支出应该健全完善新农合对于慢性病门诊费用的补偿机制、降低低收入人群的医疗费用自付比例。     

Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance

Objective

To assess the degree to which the Chinese people are protected from catastrophic household expenditure and impoverishment from medical expenses and to explore the health system and structural factors influencing the first of these outcomes.

Methods

Data were derived from the Fourth National Health Service Survey. An analysis of catastrophic health expenditure and impoverishment from medical expenses was undertaken with a sample of 55 556 households of different characteristics and located in rural and urban settings in different parts of the country. Logistic regression was used to identify the determinants of catastrophic health expenditure.

Findings

The rate of catastrophic health expenditure was 13.0%; that of impoverishment was 7.5%. Rates of catastrophic health expenditure were higher among households having members who were hospitalized, elderly, or chronically ill, as well as in households in rural or poorer regions. A combination of adverse factors increased the risk of catastrophic health expenditure. Families enrolled in the urban employee or resident insurance schemes had lower rates of catastrophic health expenditure than those enrolled in the new rural corporative scheme. The need for and use of health care, demographics, type of benefit package and type of provider payment method were the determinants of catastrophic health expenditure.

Conclusion

Although China has greatly expanded health insurance coverage, financial protection remains insufficient. Policy-makers should focus on designing improved insurance plans by expanding the benefit package, redesigning cost sharing arrangements and provider payment methods and developing more effective expenditure control strategies.     

中国西部三省慢性病家庭用药负担调查

目的:调查中国西部三省慢性病患者家庭用药负担及医改政策实施后的改善状况。方法:采用问卷调查方法,在广西、陕西、四川3省分别抽取省会城市和1个中等城市,每城市抽取三级、二级医院和社区卫生服务中心2家,对每家机构就诊的慢性病患者进行问卷调查。结果:共发放问卷900份,回收有效问卷838份,有效回收率为93.11%。97.85%的患者参加了各种医疗保险。家庭平均健康总支出1 364.84元/月,占月总支出的37.43%;慢性病支出700.34元/月,占健康总支出的51.31%。平均购药总费用为628.74元/月,用药负担为16.73%。主要所患慢性病为高血压、糖尿病,家庭疾病负担最重的为缺血性心脏病、慢性肾病。不同省份、省会城市和非省会城市、不同级别医疗机构用药负担有较大差异。患者对医改效果有体会,但对医改政策不熟悉。结论与建议:所调查患者基本纳入医保,但慢病患者家庭用药负担仍然较重。因此,相关部门还需进一步采取措施,提高慢性疾病门诊报销比例,减轻患者用药费用负担。     

Is Previous Disaster Experience a Good Predictor for Disaster Preparedness in Extreme Poverty Households in Remote Muslim Minority Based Community in China?

Disaster preparedness is an important preventive strategy for protecting health and mitigating adverse health effects of unforeseen disasters. A multi-site based ethnic minority project (2009–2015) is set up to examine health and disaster preparedness related issues in remote, rural, disaster prone communities in China. The primary objective of this reported study is to examine if previous disaster experience significantly increases household disaster preparedness levels in remote villages in China. A cross-sectional, household survey was conducted in January 2011 in Gansu Province, in a predominately Hui minority-based village. Factors related to disaster preparedness were explored using quantitative methods. Two focus groups were also conducted to provide additional contextual explanations to the quantitative findings of this study. The village household response rate was 62.4 % (n = 133). Although previous disaster exposure was significantly associated with perception of living in a high disaster risk area (OR = 6.16), only 10.7 % households possessed a disaster emergency kit. Of note, for households with members who had non-communicable diseases, 9.6 % had prepared extra medications to sustain clinical management of their chronic conditions. This is the first study that examined disaster preparedness in an ethnic minority population in remote communities in rural China. Our results indicate the need of disaster mitigation education to promote preparedness in remote, resource-poor communities.     

Catastrophic medical expenditure risk

We propose a measure of household exposure to particularly onerous medical expenses. The measure can be decomposed into the probability that medical expenditure exceeds a threshold, the loss due to predictably low consumption of other goods if it does and the further loss arising from the volatility of medical expenses above the threshold. Depending on the choice of threshold, the measure is consistent with a model of reference-dependent utility with loss aversion. Unlike the risk premium, the measure is only sensitive to particularly high expenses, and can identify households that expect to incur such expenses and would benefit from subsidised, but not actuarially fair, insurance. An empirical illustration using data from seven Asian countries demonstrates the importance of taking account of informal insurance and reveals clear differences in catastrophic medical expenditure risk across and within countries. In general, risk is higher among poorer, rural and chronically ill populations.     

The economic impact of chronic diseases: How do households respond to shocks? Evidence from Russia

The epidemiological burden of chronic diseases is increasing worldwide and there is very little empirical evidence regarding the economic impact of chronic diseases on individuals and households. The primary objective of this paper is to explore the evidence on how chronic diseases affect household healthcare expenditure, non-health consumption, labour (earned) income, and to demonstrate how transfers may provide some insurance against shocks from chronic diseases. We have explicated a two-part Heckit model on household level data obtained from the Living Standard Measurement Surveys (LSMS) from Russia to control for nontrivial proportion of zeros in the dependent variables, skewed distribution of expenditure data and endogeneity. The results indicate that chronic diseases are significantly associated with higher levels of household healthcare expenditure in Russia and productivity losses reflected by reduced labour supply and reduced household labour income. Non-healthcare expenditure also increased. Results suggest that households are able to insure non-health consumption against chronic diseases, possibly from transfers, which also increased. In addition, socioeconomic status indicators significantly explained the impact of chronic diseases on households. Insurance and higher average education in households were associated with higher healthcare expenditure. Household transfers were significant in Russia despite an appreciable level of insurance cover. We conclude that households depend on informal coping mechanisms in the face of chronic diseases, irrespective of insurance cover. These results have implications for policies regarding the financing of treatment and control of chronic diseases in the country studied.     

On health insurance and household decisions: A treatment effect analysis

In developing countries, where health insurance is not a commonly purchased financial instrument, recent debates have revolved around extending health insurance coverage to a wider range of the population, primarily via compulsory insurance schemes. However, these debates rarely consider the competing demands placed on the family budget, which will influence the acceptability of the program by the populace. In this paper, we draw on data from the 2000 income and expenditure survey to examine treatment effects associated with household insurance status, providing a detailed examination of expenditure substitution patterns within South Africa. In agreement with economic theory, the expansion of health insurance coverage via compulsory schemes creates additional burdens for households, which households accommodate via expenditure substitution. The observed variation in the household's ability to accommodate increased expenditure can and should be used in future to assess policy options and in the design of an optimal social health insurance program.     

家庭卫生筹资公平性研究

目的　测算上海市郊区家庭卫生筹资公平性状况 ,并估计全国情况。方法　通过家庭入户调查获得卫生支出、政府卫生投入等数据 ,应用WHO所介绍的卫生系统绩效评价中的家庭卫生筹资公平性指标及其测量方法。结果　测算出家庭卫生筹资公平性系数为 0 735 ;合作医疗覆盖率能提高家庭卫生筹资公平性。结论　上海市郊区家庭卫生筹资公平性水平与WHO对我国的估计相符 ,而全国的筹资公平性水平要更低 ;WHO所推荐的卫生筹资公平性测算方法中 ,政府对家庭卫生补贴的测算不适合我国实情。     

Cigarette smoking and poverty in China

Drawing on the 1998 China national health services survey data, this study estimated the poverty impact of two smoking-related expenses: excessive medical spending attributable to smoking and direct spending on cigarettes. The excessive medical spending attributable to smoking is estimated using a regression model of medical expenditure with smoking status (current smoker, former smoker, never smoker) as part of the explanatory variables, controlling for people's demographic and socioeconomic characteristics. The poverty impact is measured by the changes in the poverty head count, after smoking-related expenses are subtracted from income. We found that the excessive medical spending attributable to smoking may have caused the poverty rate to increase by 1.5% for the urban population and by 0.7% for the rural population. To a greater magnitude, the poverty headcount in urban and rural areas increased by 6.4% and 1.9%, respectively, due to the direct household spending on cigarettes. Combined, the excessive medical spending attributable to smoking and consumption spending on cigarettes are estimated to be responsible for impoverishing 30.5 million urban residents and 23.7 million rural residents in China. Smoking related expenses pushed a significant proportion of low-income families into poverty in China. Therefore, reducing the smoking rate appears to be not only a public health strategy, but also a poverty reduction strategy.     

Costs of illness and coping strategies in a coffee-growing rural district of Ethiopia

The paper describes a cross-sectional household survey conducted in randomly-selected villages in rural Ethiopia to assess strategies of households for coping with financial and time costs of illness. Results of the survey showed that the average monthly household health expenditure was 32.87 Birr (about 4.1 US dollars [1 US dollar = 8 Birr at the time of study]). In addition, the average time lost due to illness was 9.23 days for the sick and 7.38 days for their caretakers. Monetary price was a significant (p<0.05) deterrent from visiting health facilities among households with no land or house, the divorced or widowed, and those with annual income less than 500 Birr (62.5 US dollars). The main strategies to cope with the financial costs of illness were waiver privileges, selling household assets, and using savings. Division of labour among household members was used for compensating for the loss of working time due to sickness. The findings of the study indicate that financial and time costs of illness seem to significantly contribute to the impoverishment of rural households.     

Impacts of chronic non-communicable diseases on households’ out-of-pocket healthcare expenditures in Sri Lanka

This article examines the effects of chronic non-communicable diseases (NCDs) on households’ out-of-pocket health expenditures in Sri Lanka. We explore the disease specific impacts on out-of-pocket health care expenses from chronic NCDs such as heart diseases, hypertension, cancer, diabetics and asthma. We use nationwide cross-sectional household income and expenditure survey 2012/2013 data compiled by the department of census and statistics of Sri Lanka. Employing propensity score matching method to account for selectivity bias, we find that chronic NCD affected households appear to spend significantly higher out-of-pocket health care expenditures and encounter grater economic burden than matched control group despite having universal public health care policy in Sri Lanka. The results also suggest that out-of-pocket expenses on medicines and other pharmaceutical products as well as expenses on medical laboratory tests and other ancillary services are particularly higher for households with chronic NCD patients. The findings underline the importance of protecting households against the financial burden due to NCDs.     

Insuring against health shocks: Health insurance and household choices

This paper provides empirical evidence on the role of public health insurance in mitigating adverse outcomes associated with health shocks. Exploiting the rollout of a universal health insurance program in rural China, I find that total household income and consumption are fully insured against health shocks even without access to health insurance. Household labor supply is an important insurance mechanism against health shocks. Access to health insurance helps households to maintain investment in children's human capital during negative health shocks, which suggests that one benefit of health insurance could arise from reducing the use of costly smoothing mechanisms.