Yanfang Su

Assessing equity of healthcare utilization in rural China: results from nationally representative surveys from 1993 to 2008

BackgroundThe phenomenon of inequitable healthcare utilization in rural China interests policymakers and researchers; however, the inequity has not been actually measured to present the magnitude and trend using nationally representative data.MethodsBased on the National Health Service Survey (NHSS) in 1993, 1998, 2003, and 2008, the Probit model with the probability of outpatient visit and the probability of inpatient visit as the dependent variables is applied to estimate need-predicted healthcare utilization. Furthermore, need-standardized healthcare utilization is assessed through indirect standardization method. Concentration index is measured to reflect income-related inequity of healthcare utilization.ResultsThe concentration index of need-standardized outpatient utilization is 0.0486[95% confidence interval (0.0399, 0.0574)], 0.0310[95% confidence interval (0.0229, 0.0390)], 0.0167[95% confidence interval (0.0069, 0.0264)] and −0.0108[95% confidence interval (−0.0213, -0.0004)] in 1993, 1998, 2003 and 2008, respectively. For inpatient service, the concentration index is 0.0529[95% confidence interval (0.0349, 0.0709)], 0.1543[95% confidence interval (0.1356, 0.1730)], 0.2325[95% confidence interval (0.2132, 0.2518)] and 0.1313[95% confidence interval (0.1174, 0.1451)] in 1993, 1998, 2003 and 2008, respectively.ConclusionsUtilization of both outpatient and inpatient services was pro-rich in rural China with the exception of outpatient service in 2008. With the same needs for healthcare, rich rural residents utilized more healthcare service than poor rural residents. Compared to utilization of outpatient service, utilization of inpatient service was more inequitable. Inequity of utilization of outpatient service reduced gradually from 1993 to 2008; meanwhile, inequity of inpatient service utilization increased dramatically from 1993 to 2003 and decreased significantly from 2003 to 2008. Recent attempts in China to increase coverage of insurance and primary healthcare could be a contributing factor to counteract the inequity of outpatient utilization, but better benefit packages and delivery strategies still need to be tested and scaled up to reduce future inequity in inpatient utilization in rural China.

New estimates of elasticity of demand for healthcare in rural China

BACKGROUND Only limited empirical studies reported own-price elasticity of demand for health care in rural China. Neither research on income elasticity of demand for health care nor cross-price elasticity of demand for inpatient versus outpatient services in rural China has been reported. However, elasticity of demand is informative to evaluate current policy and to guide further policy making. OBJECTIVES Our study contributes to the literature by estimating three elasticities (i.e., own-price elasticity, cross-price elasticity, and income elasticity of demand for health care based on nationwide-representative data. We aim to answer three empirical questions with regard to health expenditure in rural China: (1) Which service is more sensitive to price change, outpatient or inpatient service? (2) Is outpatient service a substitute or complement to inpatient service? and (3) Does demand for inpatient services grow faster than demand for outpatient services with income growth? METHODS Based on data from a National Health Services Survey, a Probit regression model with probability of outpatient visit and probability of inpatient visit as dependent variables and a zero-truncated negative binomial regression model with outpatient visits as dependent variable were constructed to isolate the effects of price and income on demand for health care. Both pooled and separated regressions for 2003 and 2008 were conducted with tests of robustness. RESULTS Own-price elasticities of demand for first outpatient visit, outpatient visits among users and first inpatient visit are -0.519 [95% confidence interval (-0.703, -0.336)], -0.547 [95% confidence interval (-0.747, -0.347)] and -0.372 [95% confidence interval (-0.517, -0.226)], respectively. Cross-price elasticities of demand for first outpatient visit, outpatient visits among users and first inpatient visit are 0.073 [95% confidence interval (-0.176, 0.322)], 0.308 [95% confidence interval (0.087, 0.528)], and 0.059 [95% confidence interval (-0.085, 0.204)], respectively. Income elasticities of demand for first outpatient visit, outpatient visits among users and first inpatient visit are 0.098 [95% confidence interval (0.018, 0.178)], 0.136 [95% confidence interval (0.028, 0.245)] and 0.521 [95% confidence interval (0.438, 0.605)], respectively. The aforementioned results are in 2008, which hold similar pattern as results in 2003 as well as results from pooled data of two periods. CONCLUSION First, no significant difference is detected between sensitivity of outpatient services and sensitivity of inpatient services, responding to own-price change. Second, inpatient services are substitutes to outpatient services. Third, the growth of inpatient services is faster than the growth in outpatient services in response to income growth. The major findings from this paper suggest refining insurance policy in rural China. First, from a cost-effectiveness perspective, changing outpatient price is at least as effective as changing inpatient price to adjust demand of health care. Second, the current national guideline of healthcare reform to increase the reimbursement rate for inpatient services will crowd out outpatient services; however, we have no evidence about the change in demand for inpatient service if insurance covers outpatient services. Third, a referral system and gate-keeping system should be established to guide rural patients to utilize outpatient service.

The Financial Impact of the 'Zero-Markup Policy for Essential Drugs' on Patients in County Hospitals in Western Rural China

Objective With a quasi-experimental design, this study aims to assess whether the Zero-markup Policy for Essential Drugs (ZPED) reduces the medical expense for patients at county hospitals, the major healthcare provider in rural China. Methods Data from Ningshan county hospital and Zhenping county hospital, China, include 2014 outpatient records and 9239 inpatient records. Quantitative methods are employed to evaluate ZPED. Both hospital-data difference-in-differences and individual-data regressions are applied to analyze the data from inpatient and outpatient departments. Results In absolute terms, the total expense per visit reduced by 19.02 CNY (3.12 USD) for outpatient services and 399.6 CNY (65.60 USD) for inpatient services. In relative terms, the expense per visit was reduced by 11% for both outpatient and inpatient services. Due to the reduction of inpatient expense, the estimated reduction of outpatient visits is 2% among the general population and 3.39% among users of outpatient services. The drug expense per visit dropped by 27.20 CNY (4.47 USD) for outpatient services and 278.7 CNY (45.75 USD) for inpatient services. The proportion of drug expense out of total expense per visit dropped by 11.73 percentage points in outpatient visits and by 3.92 percentage points in inpatient visits. Conclusion Implementation of ZPED is a benefit for patients in both absolute and relative terms. The absolute monetary reduction of the per-visit inpatient expense is 20 times of that in outpatient care. According to cross-price elasticity, the substitution between inpatient and outpatient due to the change in inpatient price is small. Furthermore, given that the relative reductions are the same for outpatient and inpatient visits, according to relative thinking theory, the incentive to utilize outpatient or inpatient care attributed to ZPED is equivalent, regardless of the 20-times price difference in absolute terms.

The impact of China’s Zero-Markup Drug Policy on county hospital revenue and government subsidy levels

In 2009, the Chinese government passed the Zero-Markup Drug Policy, which strives to contain the costs of medicines and ultimately reduce the financial burden to the public, especially those in low-income settings. This study aims to evaluate the impact of the Zero-Markup Drug Policy on health care provision, revenue structures in county hospitals, and demand for fiscal compensation from the government. Our study employs a difference-in-difference model to measure the difference in several indicators between two hospitals, Ningshan County Hospital, which implemented the policy, and Zhenping County Hospital, which had not. The main indicators include health care provision, drug revenue as a part of total hospital revenue, and level of government subsidy. The data come from hospital financial statements and operation reports. The findings of the study show that for Ningshan County Hospital the zero-markup policy led to an increase in health care provision and a sustained total hospital income despite a decrease in drug revenue. The enhancement in outpatient and inpatient visits also represents progress from the lens of the government, whose mission is to ensure greater access to care for the population. The study demonstrates that with minimal or no subsidy, the government can catalyse the zero-markup policy and potentially generate positive outcomes for county hospitals.

Improving Vignette Descriptions and Question Formats to Measure Distance Vision: Evidence from Cognitive Interviews among Students in China

Vignette design has been largely neglected in anchoring vignette studies. This study aimed to contribute to the science of vignette design by developing and evaluating vignettes for measuring vision in rural China. Cognitive interviews were conducted among 36 participants in a Chinese middle school. The respondents either directly evaluated vision of the vignette character (i.e., noncomparative judgment) or compared their own vision with that of the vignette character (i.e., comparative judgment). It was found that a hypothetical person in the vignette was successfully envisioned by participants in grade 7 and beyond. However, more than half the participants were unable to accurately estimate distances expressed in meters. Some participants were critical in self-evaluation, yet tolerant of others’ performance. Participants more easily produced an answer and had greater confidence in the answer in comparative judgment than for noncomparative judgment. We conclude with recommendations for designing concise and complete vignettes and suggest the use of comparative rather than noncomparative judgment.

Social Determinants of mHealth Effectiveness: Evidence from a Large-Scale Experiment

mHealth, the use of mobile technologies for healthcare management and delivery, offers great promise to promote health and improve care. However, to date, most mHealth treatments have failed to demonstrate a significant impact on clinical outcomes, and there is surprisingly little knowledge of factors that drive its efficacy. This study examines mHealth effectiveness by investigating both mHealth design and social support. To do so, we leverage one of the world’s largest field experiments on improving the health of expectant mothers and reducing the rate of cesarean sections. We hypothesize that 1) the combination of both self-directed mHealth and provider-directed mHealth ensures the highest mHealth effectiveness; 2) the husband, as one of the most significant social supports for expectant women, can be an important moderator of mHealth effectiveness. Our analyses show that the combined mHealth design achieves significant reduction in cesarean section use. In addition, a husband’s healthy behavior is pivotal in enabling mHealth interventions to be effective we find that the cesarean section reduction rate of women whose husbands engage in healthy behavior is four times higher than it is for those whose husbands do not fully engage in healthy behavior. Further analyses reveal that the husband’s healthy behavior has a stronger influence on mHealth effectiveness when the wife has higher status in the marriage. Our findings represent the first study to examine the effectiveness of these two mHealth designs (self-directed and provider-directed) and the critical role of social support in determining mHealth effectiveness. The study has important implications for both academic research and the practice of mHealth.

Assessment of Primary Health Care System Performance in Nigeria: Using the Primary Health Care Performance Indicator Conceptual Framework

Abstract Abstract—Health gains oftentimes associated with income growth have been stubbornly slow in Nigeria in the past 25 years. One plausible reason for this stagnation is underperformance in the countrys primary health care (PHC) system. The Primary Health Care Performance Indicators conceptual framework is used to examine Nigerias PHC system and possible causes of underperformance. Analysis was conducted using a variety of sources including recent facility level information from the World Bank Service Delivery Indicators Survey. Results show that Nigeria has a relative abundance of PHC centers, reasonable geographic access to PHC, and relatively high health worker density. However, the performance of the PHC system is hindered by (1) segmented supply chains; (2) a lack of financial access to PHC; (3) a lack of infrastructure, drugs, equipment, and vaccines at the facility level; and (4) poor health worker performance. Altogether, these factors reflect two overarching system-level challenges—financing and governance—that are key root causes of the dysfunctions observed in the PHC system in Nigeria. Compared with peer African countries, Nigeria ranks low on nearly all PHC performance indicators. The government has taken important steps to address these root causes of underperformance, but policy gaps remain in achieving sustainable and equitable provision of PHC for the people of Nigeria.