Hospitalisation among the elderly in urban China

OBJECTIVES: The aim of this study was to examine the trend of hospitalisation amongst the elderly in urban China and analyse the main socio-economic factors which are affecting the use of inpatient care. METHODS: Data from the Chinese national household health interview surveys conducted in 1993, 1998 and 2003 were analysed. The following variables were selected: gender, health insurance coverage and household income. RESULTS: Elderly people with insurance are more likely to use inpatient services than those who were not insured. Elderly people in the low income group are less likely than ones in the high income group to use inpatient services. Non-hospitalisation is more common amongst elderly women than elderly men and amongst the non-insured. The likelihood of elderly people in the low income groups not using inpatient services has increased dramatically from 12% in 1993 to 134% in 2003. Financial difficulty appeared to be the most common reason for not accessing inpatient care, particularly for elderly people without health insurance. CONCLUSIONS: Elderly people with low income, without health insurance, and women appear to be more vulnerable in their access to inpatient care. Appropriate policies could be developed to protect these groups of people from high health care expenses.     

Equity in utilization of cancer inpatient services by income classes

Equity in health care services has been prioritized on the Korean government's policy agenda since the government-driven national health insurance achieved universal coverage in 1989 along with the final inclusion of the self-employed as beneficiaries. The purpose of this study is to identify disparities in the utilization of health care services, especially cancer inpatient services among different income groups in Jeju Island of South Korea. We analyzed the national health insurance data about qualification of beneficiaries and utilization of health care services consumed by Jeju Island's residents for 1 year of period (from January to December 2000) and acquired their utilization features of cancer inpatient services. The independent variable was 10 different income levels according to the national health insurance fee imposed on each household in 2000. The dependent variable was the volume of cancer inpatient services utilized, that was measured by admission days and costs for treatment. The utilization of cancer inpatient services in the 10 different income groups was analyzed in three geographical categories of medical institutions: (1) within Jeju Island; (2) outside Jeju Island; (3) South Korea in total. We calculated the concentration-indices of cancer inpatient services utilization in admission days and cost as a pair amongst these three geographical categories each. Both of the concentration-indices were negative for the category of 'within Jeju Island', positive for that of 'outside Jeju Island', and positive for that of 'South Korea in total'. These results suggest the relatively poor experience considerable inequality in the utilization of cancer inpatient services in Jeju Island, because lower income groups have higher incidence rates in most cancers and inevitably have more needs in health services.     

Who is giving up the free lunch? The insured patients’ decision to access health insurance benefits and its determinants: Evidence from a low-income country

ObjectivesThis paper examines the determinants of the insured's decision to use their health insurance card when seeking outpatient and inpatient health care in Vietnam.MethodsUses Vietnam's latest Household Living Standard Survey data and random-intercept logistic regression to assess the influence of the observed individual, household and commune/ward factors on the insured's decision to access health insurance benefits while controlling for the unobserved commune/ward-specific factors.ResultsCompared to the compulsory enrollees, the voluntary enrollees and the beneficiaries of the Health Care Fund for the Poor are less likely to use their card when seeking inpatient care. An individual's likelihood of accessing insurance benefits varies inversely with income and the level of education, suggesting that the outpatient care provided to the insured is of inferior quality.ConclusionsAlthough health insurance has the potential of increasing access and reducing the financial burden of health care utilization, Vietnam's experience clearly suggests that these benefits may not be fully realized as long as the quality of care remains low and the high opportunity costs of accessing insurance benefits deter the insured from accessing benefits.     

Privatisation & marketisation of post-birth care: the hidden costs for new mothers

Introduction

Health care financing reforms in both China and Vietnam have resulted in greater financial difficulties in accessing health care, especially for the rural poor. Both countries have been developing rural health insurance for decades. This study aims to evaluate and compare equity in access to health care in rural health insurance system in the two countries.

Methods

Household survey and qualitative study were conducted in 6 counties in China and 4 districts in Vietnam. Health insurance policy and its impact on utilization of outpatient and inpatient service were analyzed and compared to measure equity in access to health care.

Results

In China, Health insurance membership had no significant impact on outpatient service utilization, while was associated with higher utilization of inpatient services, especially for the higher income group. Health insurance members in Vietnam had higher utilization rates of both outpatient and inpatient services than the non-members, with higher use among the lower than higher income groups. Qualitative results show that bureaucratic obstacles, low reimbursement rates, and poor service quality were the main barriers for members to use health insurance.

Conclusions

China has achieved high population coverage rate over a short time period, starting with a limited benefit package. However, poor people have less benefit from NCMS in terms of health service utilization. Compared to China, Vietnam health insurance system is doing better in equity in health service utilization within the health insurance members. However with low population coverage, a large proportion of population cannot enjoy the health insurance benefit. Mutual learning would help China and Vietnam address these challenges, and improve their policy design to promote equitable and sustainable health insurance.     

Ability to pay and impoverishment among women who give birth at a University Hospital in Kathmandu,Nepal

Abstract

Pregnant women giving birth in Nepal need to use out-of-pocket payment for delivery care services due to a lack of insurance policies. The objective of this study was to examine the ability of pregnant Nepalese women to pay for delivery care services and the effects of the current household health expenditure on impoverishment due to hospital-based delivery services, especially normal delivery (ND) and caesarean section (CS). A cross-sectional study was conducted from May to August 2009 at Tribhuvan University Teaching Hospital. Ability to pay was defined as the current health spending being less than 5% of annual household income. Poverty occurred when a household's per capita income fell to less than US$1 per day. Impoverishment was considered as poverty headcount and normalised poverty gap. On average, the percentage of annual household income spent on current delivery care was 5.9% in the ND group and 9.7% in the CS group. The CS group had a stronger impoverishment effect resulting in a high per cent change of payment-induced poverty headcount by 78.1% and poverty gap by 97.3% compared to 7.7 and 24.1% in the ND group, respectively. There is a strong need to develop a well-prepared financial system to prevent the issue of poverty and impoverishment.     

Changing access to health services in urban China: implications for equity

The ongoing reform of public institutions and state-owned enterprises in urban China has had a profound impact on the financing, organization and provision of health services. Access to health care by the urban population has become more inequitable. One of the most pressing concerns is that those who have lost jobs have increasing difficulties accessing health care. Using the data from the national household health surveys conducted in 1993 and 1998, this paper presents empirical results of changing utilization of health care among different income groups. Over 16 000 households and 54 000 individuals in the urban areas were randomly selected to collect information on perceived need of and demand for health care and expenditures on the services. The findings show that the income gap between the highest and lowest income groups increased in real terms from 1993 to 1998. There was a significant decline in the population covered by the government insurance scheme (GIS) and the labour insurance scheme (LIS), while the proportion of the population who had to pay for services out-of-pocket increased from 28% in 1993 to 44% in 1998. There was no statistically significant change in self-reported illness in the 2 weeks prior to survey among the study population over the period. While it was found that more people who reported illness from each income group received medical treatment of some kind, there was a decline in seeking care from a health provider. Among those in the lowest income group who reported illness but did not obtain treatment of any kind, nearly 70% (as compared with 38% in 1993) claimed financial difficulty as the major reason in 1998. The use of in-patient services dropped significantly from 4.5% in 1993 to 3.0% in 1998. The decreased use of in-patient services was more serious in the lowest and lower income groups than in higher and highest income groups. The percentage of patients referred for hospital admission but not being hospitalized had a negative relationship with income level. We can conclude from the data analysis that access of the urban population, particularly the poor, to formal health services has worsened and become more inequitable since the early 1990s. Among possible reasons for this trend are the rapid rise of per capita expenditure on health services and the decline in insurance coverage.     

上海市老年人长期照护需求研究——以长宁区为例

目的 :了解上海市长宁区老年人长期照护需求。方法 :运用日常生活能力(ADL)量表和长期照护需求调研问卷对长宁区所管辖的3个居委会的所有60岁及以上的老年人进行问卷调查,共得到有效问卷1 665份。结果 :在长期照护服务需求的研究中,27.57%老年人需要生活帮助服务,15.56%的老年人需要心理护理服务,25.47%的老年人需要慢性病护理服务,23.00%的老年人需要康复护理,18.50%的老年人需要长期卧床护理服务,19.40%的老年人选择其他医疗专业护理服务。在需要长期照护服务的老年人中,有20%~55%的老年人因经济无力承担而得不到相关的服务。随着年龄和自理能力的下降,老年人对长期护理需求的6个方面的需求都有所增加(OR1),患有慢性病的老年人对长期护理需求更大;独居老人相对于与子女同住的老人对心理护理、慢性病护理、康复护理的需求更大(OR1),学历较低的老人对长期照护服务需求相对较高。结论 :政府应加大对高龄、独居、低收入的老年人的保障,建立完善的长期护理保障制度。     

基本医疗保险对我国老年人住院服务利用的影响

目的 评估基本医疗保险对我国老年人住院服务利用的影响。方法 利用2018年中国家庭追踪调查(China Family Panel Studies,CFPS)数据,运用倾向得分匹配（Propensity Score Matching,PSM）方法探讨基本医疗保险对老年人住院服务利用的影响。结果 参保增加了全样本老年人7.5%～8.7%的住院服务利用。与男性老年人相比,参保的女性老年人利用更多的住院服务,其住院服务利用增加的范围为10.0%～10.8%。与中、高收入老年人相比,参保的低收入老年人利用更多的住院服务,其住院服务利用提升的范围为8.7%～10.7%。结论 基本医疗保险的实施促进了参保老年人的住院服务利用。特别是对女性和低收入老年人,如果其拥有基本医疗保险,倾向于利用更多的住院服务。     

Utilization of Preventive Medical Services in the United States: A Comparison Between Rural and Urban Populations

Differences between rural and urban residents in their utilization of three clinical preventive services--Papanicolaou screening tests (Pap smears) for women aged 18 to 65, mammograms for women aged 50 to 69 and flu shots for people aged 65 or older--were examined using a nationally representative sample from the 1994 U.S. National Health Interview Survey. Eighty-two percent of urban women and 79 percent of rural women (P = 0.11) had Pap smears. Sixty-eight percent of urban women and 61 percent of rural women (P = 0.01) had mammograms. Flu shots were received by 55 percent of urban and 58 percent of rural elderly residents (P = 0.11). Of women aged 50 to 69 who had a high school education or whose annual household income was between $15,000 and $34,999, significantly fewer rural than urban women had mammograms (P < 0.01). However, the proportion of rural women receiving mammograms was not significantly different from that of urban women after adjusting for their education, household income and health insurance status. Education level, house-hold income and health insurance coverage were positively associated with utilizing mammograms. These results suggest that differences in the utilization of preventive services between rural and urban women vary by services. Improving socioeconomic status and health insurance coverage of rural women may reduce the disparity in mammogram use between rural and urban women. Mechanisms of how a woman's socioeconomic status affects her utilization of mammograms needs further study.     

Child health and access to health care in France: Evidence on the role of family income

BackgroundOur paper investigates the relationship between family income and child health in France. We first examine whether there is a significant correlation between family income and child general health, and the evolution of this relationship across childhood years. We then study the role of specific health problems, access to health care, and supplemental health insurance coverage, in the income gradient in general health. We also quantify the role of income in child anthropometric measurements. Whenever possible, we compare our results for France with those obtained for other developed countries.MethodsUsing data on up to approximately 24,000 French children from the Health, Health Care and Insurance Surveys, we apply econometric techniques to quantify the correlation between household income, child general health, specific health problems, anthropometric characteristics, access to health care, and supplemental insurance coverage.ResultsThere is a positive and significant correlation between family income and child general health in France. The income gradient in child general health is possibly smaller in France than in other developed countries. The gradient in general health is explained by the greater prevalence of specific health problems for low-income children. In addition, income is strongly correlated with anthropometric characteristics. Access to health care, and supplemental health insurance coverage are probably not major determinants of the gradient in general health.ConclusionThe relationship between income and health in adulthood has antecedents in childhood. Improving access to health care services for children from low-income families may not be enough to decrease social health inequalities in childhood.     

Inequality in Private Health Care Expenditures: A 36-Year Trend Study of Iranian Households

ObjectivesThroughout history, societies have been impacted by inequality. Many studies have been conducted on the topic more broadly, but only a few have investigated inequalities in out-of-pocket health payments (OHP). This study measures OHP inequality trends among the Iranian households.MethodsThis study used data from the Iranian Statistics Center on Iranian household income and expenditures. The analysis included a total of 995 300 households during the 36 years from 1984 to 2019. The Gini coefficient, Atkinson index, and Theil index were calculated for Iranian OHP.ResultsAverage Iranian household OHP increased from 33 US dollar (USD) in 1984 to 47 USD in 2019. During this 36-year span, the average±standard deviation Gini coefficient for OHP was 0.73±0.04, and the Atkinson and Theil indexes were 0.68±0.05 and 1.14±0.29, respectively. The Gini coefficients for the subcategories of OHP of outpatient diagnostic services, medical assistant accessories, hospital inpatient services, and addiction cessation were 0.70, 0.61, 0.84, and 0.64, respectively.ConclusionsIn this study, we scrutinized trends of inequality in the OHP of Iranian households. Inequality in OHP decreased slightly over the past four decades. An analysis of trends among different subgroups revealed that affluent households, such as households with insurance coverage and households in higher income deciles, experienced higher inequality. Therefore, lower inequality in health care expenditures may be related to restricted access to health care services in Iran.     

Inpatient care of the elderly in Brazil and India: Assessing social inequalities

The rapidly growing older adult populations in Brazil and India present major challenges for health systems in these countries, especially with regard to the equitable provision of inpatient care. The objective of this study was to contrast inequalities in both the receipt of inpatient care and the length of time that care was received among adults aged over 60 in two large countries with different modes of health service delivery. Using the Brazilian National Household Survey from 2003 and the Indian National Sample Survey Organisation survey from 2004 inequalities by wealth (measured by income in Brazil and consumption in India) were assessed using concentration curves and indices. Inequalities were also examined through the use of zero-truncated negative binomial models, studying differences in receipt of care and length of stay by region, health insurance, education and reported health status. Results indicated that there was no evidence of inequality in Brazil for both receipt and length of stay by income per capita. However, in India there was a pro-rich bias in the receipt of care, although once care was received there was no difference by consumption per capita for the length of stay. In both countries the higher educated and those with health insurance were more likely to receive care, while the higher educated had longer stays in hospital in Brazil. The health system reforms that have been undertaken in Brazil could be credited as a driver for reducing healthcare inequalities amongst the elderly, while the significant differences by wealth in India shows that reform is still needed to ensure the poor have access to inpatient care. Health reforms that move towards a more public funding model of service delivery in India may reduce inequality in elderly inpatient care in the country.     

The poor pay more: Health-related inequality in Thailand

This paper examines the equality of utilization for equal need and equity of out-of-pocket expenditure for health services in a large urban area in Thailand. Data from a household health interview survey were used to explore patterns of perceived morbidity, utilization of various treatment sources, and out-of-pocket payment. Financial access to health care, as reflected in medical benefit/insurance cover, appeared to influence reported illness and hospitalization rates. Gross lack of access to health care amongst lower socio-economic groups was not the main problem in this densely populated urban area because people could choose and use alternative health services according to their ability and willingness to pay. The corollary, however, was an inequitable pattern of out-of-pocket health expenditure by income quintile and per capita. The underprivileged were more likely to pay out of their own pocket for their health problems, and to pay out of proportion to their household income when compared with more privileged groups. Furthermore, the underprivileged were least likely to be covered by government health benefit schemes, in contrast in particular to civil servants, who paid less out of pocket and did not contribute to their medical benefit fund. The private health sector (private clinics and private hospitals) was the major provider of health care to urban dwellers for both outpatient and inpatient services. Policy options for the short and long term to improve the equity of payment systems for health care are discussed.     

Hospitalization for urinary tract infections and the quality of preventive health care received by people with spina bifida

BackgroundThe preventive health care needs of people with disabilities often go unmet, resulting in medical complications that may require hospitalization. Such complications could be due, in part, to difficulty accessing care or the quality of ambulatory care services received.ObjectiveTo use hospitalizations for urinary tract infections (UTIs) as a marker of the potential quality of ambulatory care services received by people affected by spina bifida.MethodsMarketScan inpatient and outpatient medical claims data for 2000 through 2003 were used to identify hospitalizations for UTI, which is an ambulatory care sensitive condition, for people affected by spina bifida and to calculate inpatient discharge rates, average lengths of stay, and average medical care expenditures for such hospitalizations.ResultsPeople affected by spina bifida averaged 0.5 hospitalizations per year, and there were 22.8 inpatient admissions with UTI per 1000 persons with spina bifida during the period 2000–2003, in comparison to an average of 0.44 admission with UTI per 1000 persons for those without spina bifida. If the number of UTI hospitalizations among people affected by spina bifida were reduced by 50%, expenditures could be reduced by $4.4 million per 1000 patients.ConclusionsConsensus on the evaluation and management of bacteriuria could enhance clinical care and reduce the disparity in UTI discharge rates among people affected by spina bifida compared to those without spina bifida. National evidence-based guidelines are needed.     

Health Insurance and Health Care among the Mid‐Aged and Older Chinese: Evidence from the National Baseline Survey of CHARLS

We document the recent profile of health insurance and health care among mid‐aged and older Chinese using data from the China Health and Retirement Longitudinal Study conducted in 2011. Overall health insurance coverage is about 93%. Multivariate regressions show that respondents with lower income as measured by per capita expenditure have a lower chance of being insured, as do the less‐educated, older, and divorced/widowed women and rural‐registered people. Premiums and reimbursement rates of health insurance vary significantly by schemes. Inpatient reimbursement rates for urban people increase with total cost to a plateau of 60%; rural people receive much less. Demographic characteristics such as age, education, marriage status, per capita expenditure, and self‐reported health status are not significantly associated with share of out‐of‐pocket cost after controlling community effects. For health service use, we find large gaps that vary across health insurance plans, especially for inpatient service. People with access to urban health insurance plans are more likely to use health services. In general, Chinese people have easy access to median low‐level medical facilities. It is also not difficult to access general hospitals or specialized hospitals, but there exists better access to healthcare facilities in urban areas. Copyright © 2016 John Wiley & Sons, Ltd.     

Ethnicity,household composition and COVID-19 mortality: a national linked data study

ObjectiveTo estimate the proportion of ethnic inequalities explained by living in a multi-generational household.DesignCausal mediation analysis.SettingRetrospective data from the 2011 Census linked to Hospital Episode Statistics (2017-2019) and death registration data (up to 30 November 2020).ParticipantsAdults aged 65 years or over living in private households in England from 2 March 2020 until 30 November 2020 (n=10,078,568).Main outcome measuresHazard ratios were estimated for COVID-19 death for people living in a multi-generational household compared with people living with another older adult, adjusting for geographic factors, socioeconomic characteristics and pre-pandemic health.ResultsLiving in a multi-generational household was associated with an increased risk of COVID-19 death. After adjusting for confounding factors, the hazard ratios for living in a multi-generational household with dependent children were 1.17 (95% confidence interval [CI] 1.06–1.30) and 1.21 (95% CI 1.06–1.38) for elderly men and women. The hazard ratios for living in a multi-generational household without dependent children were 1.07 (95% CI 1.01–1.13) for elderly men and 1.17 (95% CI 1.07–1.25) for elderly women. Living in a multi-generational household explained about 11% of the elevated risk of COVID-19 death among elderly women from South Asian background, but very little for South Asian men or people in other ethnic minority groups.Conclusion Elderly adults living with younger people are at increased risk of COVID-19 mortality, and this is a contributing factor to the excess risk experienced by older South Asian women compared to White women. Relevant public health interventions should be directed at communities where such multi-generational households are highly prevalent.     

The impact of public voluntary health insurance on private health expenditures in Vietnam

As a financing mechanism with the potential to raise additional funds for health services, whilst improving access to services amongst the poor, non-profit health insurance has become increasingly attractive to health policy-makers. Using data from a household survey in Vietnam, out of pocket health expenditure are compared between members and eligible non-members of the government-implemented voluntary health insurance scheme. Expenditures are analysed for individuals who sought care during their most recent illness. Using an endogenous dummy variable model to control for bias resulting from self-selection into the scheme, we find that health insurance reduces average out-of-pocket expenditures by approximately 200%. Whilst income inelastic, health expenditures are found to be significantly influenced by an individuals level of income, irrespective of insurance status. Despite this, insurance reduces expenditures significantly more for the poor than for the rich.     

The market for nurse practitioner services among women 18 to 40 years of age

Telephone interviews were conducted with a stratified random sample of 331 greater New Haven, Connecticut area residents to examine factors associated with using nurse practitioner (NP) services. About 81% of women aged 18 to 40 (N = 109) said they would seek NP care if services were covered under health insurance. Women who said they would seek care were more likely to be dissatisfied with their present health care, to have less education, and to be from lower income families with two or more members. Women in this age group were more likely to use NP services and to seek NP care if care cost the same or less than MD care than all others in the original study sample. They were also more likely to demonstrate innovative purchase behavior and to have knowledge of nurse practitioners, and less likely to perceive NP care as different from MD care. Analysis of the characteristics, attitudes, and values of women aged 18 to 40 years reveals that they are the most likely target market for NP services.     

Health needs and health status of the elderly in rural Bangladesh

This study was undertaken to understand the health status of elderly people and to gather some information about their perceived health needs. This study was conducted in the north-western part of Dhaka district in the year 1999-2000. People aged over 60 years constituted about 3.5% of the total population with more than half (55.6%) belonging to the middle class and another one third to the lower class. Elderly people made up 5.7% of all out-patient consultations and 6.9% of all in-patient admissions. Hypertension, peptic ulcer, chronic obstructive pulmonary diseases, pneumonia, skin diseases and anaemia were common among these people. Only 14% of the elderly people in this rural area were insured, but these insured people constituted about half (48%) of the in-patient and 90% of the out-patient elderly patients. Thus insurance has significantly increased their health care access (p<0.05). Provision of free health care, drugs at a cheaper price, services at their doorsteps, free ambulance service and allocation of old age allowance were some of their notable demands. A cheaper, accessible and effective geriatric health care service with an emphasis on health promotion, income generating activities and rehabilitation programme should be developed to protect the health and well being of the elderly people.     

Healthcare Use and Voluntary Health Insurance After Retirement in Thailand

Background

The dramatic changes occurring in the age structure of the Thai population make providing healthcare services for the elderly a major challenge for decision makers. Because the number of the elderly will be increasing, together with the number of retired workers, under the Social Health Insurance (SHI) scheme, there will be the unmet needs for healthcare use after retirement. The SHI scheme does not cover workers after retirement unless they could use free healthcare for the elderly. In addition, the government budget is tight regarding the support of universal healthcare and long-term care services for all of the elderly. Therefore, the government could support retired workers who have the ability to pay by facilitating voluntary health insurance.

Objective

The main objectives of the present study are to analyze the characteristics of workers that need health insurance after retirement and to identify the factors explaining healthcare use to offer healthcare services to meet the workers’ needs and expectations.

Methods

Four hundred insured workers under the Social Health Insurance (SHI) Scheme in Thailand were interviewed using a structured questionnaire. The Anderson–Newman model of healthcare use is the conceptual framework used in this study to understand the factors that explain healthcare use patterns of workers. Multiple regressions are employed extensively to evaluate the variables that predict healthcare use.

Results

According to the survey, a person that purchases voluntary health insurance is likely to be female, have a higher personal income, and healthy. The characteristics related to healthcare use were poor health status, a high personal income, and peeople afflicted by chronic illness.

Conclusions

There is a gap between healthcare service use and the demand for voluntary health insurance. People that have a high income are more likely to purchase voluntary health insurance, while people in worse health and afflicted by chronic illness may have greater difficulty purchasing voluntary health insurance because they face higher premiums or are denied coverage by insurers.