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Background: Air pollution affects residents' health to varying extents according to differences in socioeconomic status. However, there has been a lack of research on whether air pollution contributes to unfair health costs. Methods: In this research, data from the China Labour Force Dynamics Survey are matched with data on PM2.5 average concentration and precipitation, and the influence of air pollution on the health expenditures of residents is analysed with econometric methods involving a two-part model, instrument variables and moderating effects. Results: The findings reveal that air pollution significantly impacts Chinese residents' health costs and leads to low-income people face health inequality. Specifcally, the empirical evidence shows that air pollution has no significant influence on the probability of residents' health costs (β = 0.021, p = 0.770) but that it increases the amount of residents' total outpatient costs (β = 0.379, p < 0.006), reimbursed outpatient cost (β = 0.453, p < 0.044) and out-of-pocket outpatient cost (β = 0.362, p < 0.048). The heterogeneity analysis of income indicates that low-income people face inequality due to health cost inflation caused by air pollution, their total and out-of-pocket outpatient cost significantly increase with PM2.5 (β = 0.417, p = 0.013; β = 0.491, p = 0.020). Further analysis reveals that social basic medical insurance does not have a remarkable positive moderating effect on the influence of air pollution on individual health inflation (β = 0.021, p = 0.292), but supplementary medical insurance for employees could reduce the effect of air pollution on low-income residents' reimbursed and out-of-pocket outpatient cost (β=-1.331, p = 0.096; β=-2.211, p = 0.014). Conclusion: The study concludes that air pollution increases the amount of Chinese residents' outpatient cost and has no significant effect on the incidence of outpatient cost. However, air pollution has more significant impact on the low-income residents than the high-income residents, which indicates that air pollution leads to the inequity of medical cost. Additionally, the supplementary medical insurance reduces the inequity of medical cost caused by air pollution for the low-income employees. [ABSTRACT FROM AUTHOR]

Background: Poverty vulnerability has been defined as the likelihood of a family falling into poverty in the upcoming months. Inequality is a major cause of poverty vulnerability in developing countries. There is evidence that establishing effective government subsidies and public service mechanisms significantly reduces health poverty vulnerability. One of the ways to study poverty vulnerability is by using empirical data such as income elasticity of demand to perform the analysis. Income elasticity refers to the extent to which changes in consumers' income affect changes in demand for commodities or public goods. In this work, we assess health poverty vulnerability in rural and urban China. We provide two levels of evidence on the marginal effects of the design and implementation of government subsidies and public mechanisms in reducing health poverty vulnerability, before and after incorporating the income elasticity of demand for health. Methods: Multidimensional physical and mental health poverty indexes, according to the Oxford Poverty & Human Development Initiative and the Andersen model, were implemented to measure health poverty vulnerability by using the 2018 China Family Panel Survey database (CFPS) as the data source for empirical analysis. The income elasticity of demand for health care was used as the key mediating variable of impact. Our assessment was conducted by a two-level multidimensional logistic regression using STATA16 software. Results: The first level regression indicates that the marginal utility of public mechanism (PM) in reducing urban and rural vulnerability as expected poverty on physical and mental health (VEP-PH&MH) was insignificant. On the other hand, government subsidies (GS) policies had a positive suppression effect on VEP-PH&MH to a relatively low degree. The second level regression found that given the diversity of health needs across individual households, i.e., the income elasticity of demand (HE) for health care products, PM and GS policies have a significant effect in reducing VEP-PH&MH in rural and urban areas. Our analysis has verified the significant positive impact of enacting accurate GS and PM policies on effectively reducing VEP-PH&MH in rural as well as urban areas. Conclusions: This study shows that implementing government subsidies and public mechanisms has a positive marginal effect on reducing VEP-PH&MH. Meanwhile, there are individual variations in health demands, urban-rural disparities, and regional disparities in the effects of GS and PM on inhibiting VEP-PH&MH. Therefore, special consideration needs to be given to the differences in the degree of health needs of individual residents among urban and rural areas and regions with varying economic development. Furthermore, considerations of this approach in the current worldwide scenario are analyzed. [ABSTRACT FROM AUTHOR]

Background: The determinants of access to immunizers are still poorly understood, leading to questions about which criteria were considered in this distribution. Given the above, the present study aimed to analyze the determinants of access to the SARS-CoV-2 vaccine by different countries. Methods: The study covered 189 countries using data from different public databases, and collected until February 19, 2021. We used eight explanatory variables: gross domestic product (GDP), extreme poverty, human development index (HDI), life expectancy, median age, coronavirus disease 2019 (COVID-19) cases, COVID-19 tests, and COVID-19 deaths. The endogenous variables were total vaccine doses, vaccine doses per thousand, and days of vaccination. The structural equation modeling (SEM) technique was applied to establish the causal relationship between the country's COVID-19 impact, socioeconomic variables, and vaccine access. To support SEM, we used confirmatory factor analysis, t-test, and Pearson's correlation. Results: We collected the sample on February 19, and to date, 80 countries (42.1%) had already received a batch of immunizers against COVID-19. The countries with first access to the vaccine (e.g., number of days elapsed since they took the first dose) were the United Kingdom (68), China (68), Russia (66), and Israel (62). The countries receiving the highest doses were the United States, China, India, and Israel. The countries with extreme poverty had lower access to vaccines and the richer countries gained priority access. Countries most affected by COVID (deaths and cases) also received immunizers earlier and in greater volumes. Unfortunately, similar to other vaccines, indicators, such as income, poverty, and human development, influence vaccines' access. Thus affecting the population of vulnerable and less protected countries. Therefore, global initiatives for the equitable distribution of COVID need to be discussed and encouraged. Conclusions: Determinants of vaccine distribution consider the impact of the disease in the country and are also affected by favorable socioeconomic indicators. The COVID-19 vaccines need to be accessible to all affected countries, regardless of their social hands. [ABSTRACT FROM AUTHOR]

Background: Improving health equity is a fundamental goal for establishing social health insurance. This article evaluated the benefits of the Integration of Social Medical Insurance (ISMI) policy for health services utilization in rural China. Methods: Using the China Health and Retirement Longitudinal study (2011‒2018), we estimated the changes in rates and equity in health services utilization by a generalized linear mixed model, concentration curves, concentration indices, and a horizontal inequity index before and after the introduction of the ISMI policy. Results: For the changes in rates, the generalized linear mixed model showed that the rate of inpatient health services utilization (IHSU) nearly doubled after the introduction of the ISMI policy (8.78 % vs. 16.58 %), while the rate of outpatient health services utilization (OHSU) decreased (20.25 % vs. 16.35 %) after the implementation of the policy. For the changes in inequity, the concentration index of OHSU decreased significantly from − 0.0636 (95 % CL: −0.0846, − 0.0430) before the policy to − 0.0457 (95 % CL: −0.0684, − 0.0229) after it. In addition, the horizontal inequity index decreased from − 0.0284 before the implementation of the policy to − 0.0171 after it, indicating that the inequity of OHSU was further reduced. The concentration index of IHSU increased significantly from − 0.0532 (95 % CL: −0.0868, − 0.0196) before the policy was implemented to − 0.1105 (95 % CL: −0.1333, − 0.0876) afterwards; the horizontal inequity index of IHSU increased from − 0.0066 before policy implementation to − 0.0595 afterwards, indicating that more low-income participants utilized inpatient services after the policy came into effect. Conclusions: The ISMI policy had a positive effect on improving the rate of IHSU but not on the rate of OHSU. This is in line with this policy's original intention of focusing on inpatient service rather than outpatients to achieve its principal goal of preventing catastrophic health expenditure. The ISMI policy had a positive effect on reducing the inequity in OHSU but a negative effect on the decrease in inequity in IHSU. Further research is needed to verify this change. This research on the effects of integration policy implementation may be useful to policy makers and has important policy implications for other developing countries facing similar challenges on the road to universal health coverage. [ABSTRACT FROM AUTHOR]

Background: Older adults are more prone to various diseases. Health insurance becomes effective mechanism to relieve financial burden when the insured is sick. In China, most older adults live in the countryside, and New Rural Cooperative Medical Scheme is a kind of health insurance system in rural areas. The relationship between New Rural Cooperative Medical Scheme and financial burden due to health expenditure of older adults in China was investigated. This paper aims at the impact of New Rural Cooperative Medical Scheme on the poverty among rural older adults. Methods: This study employs Probit model and Tobit model to assess the impact of New Rural Cooperative Medical Scheme on alleviating poverty among rural older adults based on a survey in nine representative counties in western China. Results: The findings show that diseases have significantly negative impact on rural elderly poverty. New Rural Cooperative Medical Scheme has impact on alleviating of the health-payment poverty due to catastrophic health expenditure, but the impact is limited. The impact of health insurance on poverty alleviation is greater for men, older adults aged between 60 to 69 and households in in economically poorer area than their counterparts. Conclusions: This study show the relationship between New Rural Cooperative Medical Scheme and catastrophic health expenditure of older adults in China. The results draw policy attention to introduce different reimbursement expense ratios for different groups to alleviate them from poverty based on more comprehensive insurance packages. [ABSTRACT FROM AUTHOR]

Background: Improving the accessibility of public services for migrants is an important endeavor to promote equity in economic and social development. As a response to the large-scale movement of migrants and the fragmentation of China's health insurance system, the Chinese Government has launched a policy of trans-provincial immediate reimbursement for healthcare expenses. The present study hopes to examine the effect of immediate reimbursement policy on the utilization of healthcare services for migrants in China., Methods: This study used two waves of data from the China Migrants Dynamic Survey (CMDS) collected in 2013 and 2017, with the sample comprising 13,540 individuals. We constructed a difference-in-differences (DID) model to investigate the impact of the policy on the utilization of healthcare services for migrants. Meanwhile, we also analyzed the heterogeneity of the policy effect by grouping the samples by industry, gender, income, and education level., Results: The results found that the trans-provincial immediate reimbursement significantly promoted the probability of migrants' utilization of quality healthcare services (average treatment effect on the treated = 0.072, p < 0.05). Heterogeneity analyses revealed that the policy effect was more pronounced among higher-income and better-educated migrants. In addition, the policy effect was more significant for female migrants, and the benefits were more marked for migrants in high-risk industries., Conclusions: The trans-provincial immediate reimbursement policy has improved the inequity of healthcare services utilization among migrants as a whole; however, within the migrants, inequity still exists. More attention should also be paid to low-income or low-education groups in future policy design., (© 2024. The Author(s).)

Background: China carried out a comprehensive drug price reform (CDPR) in 2017 to control the growing expense of drug effectively and reduce the financial burden of inpatients. However, early studies in pilot regions found the heterogeneity in the effectiveness of CDPR from different regions and other negative effects. This study aimed to evaluate the effects of the reform on medical expenses, medical service utilisation and government financial reimbursement for inpatients in economically weaker regions. Methods: Shihezi was selected as the sample city, and 238,620 inpatients, who were covered by basic medical insurance (BMI) and had complete information from September 2016 to August 2018 in public hospitals, were extracted by cluster sampling. An interrupted series design was used to compare the changing trends in medical expenses, medical service utilisation and reimbursement of BMI for inpatients before and after the reform. Results: Compared with the baseline trends before the CDPR, those after the CDPR were observed with decreased per capita hospitalisation expenses (HE) by ¥301.9 per month (p < 0.001), decreased drug expense (DE) ratio at a rate of 0.32% per month (p < 0.05) and increased ratio of diagnosis and treatment expenses (DTE) at a rate of 0.25% per month (p < 0.01). The number of inpatients in secondary and tertiary hospitals declined by 458 (p < 0.001) and 257 (p < 0.05) per month, respectively. The BMI reimbursement in tertiary hospitals decreased by ¥254.7 per month (p < 0.001). Conclusion: The CDPR controlled the increase in medical expenses effectively and adjusted its structure reasonably. However, it also reduced the medical service utilisation of inpatients in secondary and tertiary hospitals and financial reimbursement for inpatients in tertiary hospitals. [ABSTRACT FROM AUTHOR]

Background: China has made intensive efforts to eliminate extreme poverty by 2020. This paper aims to evaluate the changes in health service needs, utilization, and medical expenses for poor people during the poverty alleviation period., Methods: The study used data from national health services surveys in 2013 and 2018. The poor people were identified and certified by the local government. Health service needs, utilization, medical expenses, and reimbursement rates were analyzed and compared between 2013 and 2018, between the poor and the non-poor groups., Results: People living in poverty were usually elderly, illiterate, and unemployed. The poor people had a significantly higher two-week morbidity rate and a higher prevalence of chorionic non-communicable diseases than the non-poor group. For both the poor and non-poor, health service needs increased between 2013 and 2018. Accordingly, the poor people had more use of outpatient and inpatient services. The annual inpatient admission rates were 20.8% and 13.1% for the poor and non-poor, respectively, in 2018. The average medical expenses per inpatient admission were much lower for the poor than for the non-poor. Out-of-pocket (OOP) payment share decreased from 41.9% to 2013 to 31.9% in 2018 for the poor, while for the non-poor, the OOP rate was much higher (45.4%) and had no significant changes between the two surveys. The reduction in the OOP share occurred mostly in rural areas., Conclusions: Poverty alleviation in China may have positive effect in improving poor people's access to health services, and reducing their financial burden due to illness and health service utilization., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Healthcare financing should be equitable. Fairness in financial contribution and protection against financial risk is based on the notion that every household should pay a fair share. Health policy makers have long been concerned with protecting people from the possibility that ill health will lead to catastrophic financial payments and subsequent impoverishment. A number of studies on health care financing equity have been conducted in some provinces of China, but in Guangxi, we found such observation is not enough. What is the situation in Guagnxi? A research on rural areas of Guangxi can add knowledge in this field and help improve the equity and efficiency of health financing, particularly in low-income citizens in rural countries, is a major concern in China's medical sector reform. Methods: Socio-economic characteristics and healthcare payment data were obtained from two rounds of household surveys conducted in 2009 (4634 respondents) and 2013 (3951 respondents). The contributions of funding sources were determined and a progressivity analysis of government healthcare subsidies was performed. Household consumption expenditure and total healthcare payments were calculated and incidence and intensity of catastrophic health payments were measured. Summary indices (concentration index, Kakwani index and Gini coefficient) were obtained for the sources of healthcare financing: indirect taxes, out of pocket payments, and social insurance contributions. Results: The overall health-care financing system was regressive. In 2013, the Kakwani index was 0.0013, the vertical effect of all the three funding sources was 0.0001, and some values exceeded 100%, indicating that vertical inequity had a large influence on causing total health financing inequity. The headcount of catastrophic health payment declined sharply between 2009 and 2013, using total expenditure (from 7.3% to 1.2%) or non-food expenditure (from 26.1% to 7.5%) as the indicator of household capacity to pay. Conclusion: Our study demonstrates an inequitable distribution of government healthcare subsidies in China from 2009 to 2013, and the inequity was reduced, especially in rural areas. Future healthcare reforms in China should not only focus on expanding the coverage, but also on improving the equity of distribution of healthcare benefits. [ABSTRACT FROM AUTHOR]

Background: China uses both social health insurance (SHI) programs and a medical financial assistance (MFA) program to protect the poor from illness-induced financial risks. The MFA provides a dual benefit package targeting low-income families: subsidizing these families' participation in SHI programs, and providing cash aid to protect them from catastrophic health expenditure (CHE). This study aims to investigate: (1) the association between MFA subvention for SHI enrollment and SHI enrollment; (2) the association between MFA cash aid and CHE; and (3) the association between SHI enrollment and CHE in low-income households in China. Methods: Using nationally representative data from a comprehensive survey of low-income households in 2014, we construct an estimate of CHE based on out-of-pocket health spending data. Controlling for other covariates, we estimate the three associations using a three-level logistic model. Results: The MFA program subsidizes 50.1% of low-income households to aid their enrollment in SHI programs and provides cash aid to 24.1% of these households. Multilevel logistic analysis reveals that MFA subvention has no significant association with low-income households' SHI enrollment, that MFA cash aid has no significant association with CHE, and that full SHI enrollment is inversely associated with CHE status. Conclusions: The MFA program is currently not an effective supplement to SHI programs in China in terms of promoting SHI enrollment and providing financial risk protection. The Chinese government needs to invest more funds to expand further low-income household enrollment in SHI programs and to widen the benefit package of MFA cash aid. [ABSTRACT FROM AUTHOR]

Background: Equity is one of the major goals of China's recent health system reform. This study aimed to evaluate the equality of the distribution of health resources and health services between hospitals and primary care institutions. Methods: Data of this study were drawn from the China Health Statistical Year Books. We calculated Gini coefficients based on population size and geographic size, respectively, for the indicators: number of institutions, number of health workers and number of beds; and the concentration index (CI) for the indicators: per capita outpatient visits and annual hospitalization rates. Results: The Gini coefficients against population size ranged between 0.17 and 0.44 in the hospital sector, indicating a relatively good equality. The primary care sector showed a slightly higher level of Gini coefficients (around 0.45) in the number of health workers. However, inequality was evident in the geographic distribution of health resources. The Gini coefficients exceeded 0.7 in the geographic distribution of institutions, health workers and beds in both the hospital and the primary care sectors, indicating high levels of inequality. The CI values of hospital inpatient care and outpatient visits to primary care institutions were small (ranging from -0.02 to 0.02), indicating good wealth-related equality. The CI values of outpatient visits to hospitals ranged from 0.16 to 0.21, indicating a concentration of services towards the richer populations. By contrast, the CI values of inpatient care in primary care institutions ranged from -0.24 to -0.22, indicating a concentration of services towards the poorer populations. The eastern developed region also had a high internal inequality compared with the other less developed regions. Conclusion: Significant inequality in the geographic distribution of health resources is evident, despite a more equitable per capita distribution of resources. Richer people are more likely to use well-resourced hospitals for outpatient care. By contrast, poorer people are more likely to use poorly-resourced primary care institutions for inpatient care. There is a risk of the emergence of a two-tiered health care delivery system. [ABSTRACT FROM AUTHOR]

Background: Enhancing the pooling of basic medical insurance plays a vital role in strengthening the resilience to risk and co-payment capacity of medical insurance funds. In China, there is a concerted effort to shift from municipal to provincial pooling of medical insurance. While existing research suggests that provincial pooling of basic health insurance affects the health of participants, the findings are not yet consistent, and there is limited research on the specific pathways of impact between the two. Therefore, this study aims to explore the influence of provincial pooling of basic medical insurance on participants' health and analyze the mediating role of medical cost burden and medical service utilization., Methods: Using data from the 2012-2018 China Labor Dynamics Survey (CLDS), this study focuses on a sample of urban workers enrolled in basic medical insurance. After excluding samples with missing information, a total of 5,684 participants were included in the analysis. The effects of the provincial pooling policy of basic medical insurance on participants' medical cost burden, medical service utilization, and health were analyzed using double difference modeling. Furthermore, structural equation modeling was employed to explore the mediating paths between provincial pooling and health., Results: The findings reveal that provincial pooling of basic medical insurance significantly impacts participants' medical cost burden, medical service utilization, and health. Specifically, provincial pooling helps reduce the participants' medical cost burden (β = -0.1205; P < 0.001), improves the level of medical institutions visited (β = 1.7962; P < 0.001), and promotes health improvement (β = 1.8370; P < 0.001). The mediating effect analysis demonstrates that the direct effect of provincial pooling on health is 1.073 (P < 0.001), with a mediating effect of medical cost burden between provincial pooling and health measuring 0.129 (P < 0.001). Heterogeneity analysis indicates that provincial pooling is more effective in reducing the burden of medical costs for low-income (β = -0.2273; P < 0.001) and high-age participants (β = -0.2710; P < 0.001), and it also helps increase the burden of medical costs for low-income (β = 4.0875; P < 0.001) and high-age participants (β = 1.9010; P < 0.001) based on provider ranking. Moreover, it is found that provincial pooling is more beneficial in improving the health of high-income (β = 1.7984; P < 0.001) and middle- and high-age enrollees (β = 1.9220; P < 0.001; β = 0.5900; P < 0.001). Further analysis reveals that the provincial unified income and expenditure mode has a more positive effect than the provincial risk adjustment fund mode in reducing the medical expense burden of the insured (-0.2053 < -0.0775), improving the grade of medical institutions (1.8552 > 0.8878), and enhancing the health level (2.8406 > 0.6812)., Conclusion: The study concludes that provincial pooling of basic medical insurance has a direct positive impact on participants' health and indirectly promotes health improvement by reducing the burden of medical costs. The effects of provincial pooling on participants' medical cost burden, medical service utilization, and health vary based on income and age. Additionally, the provincial-level unified collection and payment model proves to be more advantageous in optimizing the functioning of health insurance funds through the "law of large numbers" principle., (© 2023. The Author(s).)

Background: The self-rated health of older adults (SHOA) plays an important role in enhancing their medical service utilization and quality of life. However, the determinants and magnitude variations in SHOA at the family level (SHOAFL) remain unknown. The purpose of this study was to assess the status and equitable level of SHOAFL in China, as well as to analyze the influencing factors and the precise nature and scope of their impacts., Methods: This study analyzed the data from the "Chinese residents' health service needs survey in the New Era", and included a total of 1413 families with older adults. The status and influencing factors of SHOAFL were analyzed using mean comparison and Logistic regression (LR) models. The Concentration Index method was used to explore the equity of the distribution of SHOAFL. The relationship between differences in personal characteristics among family members and differences in SHOA was determined by the method of Coupling Coordination Degree (CCD)., Results: The total score of SHOAFL was 66.36 ± 15.47, and LR results revealed that the factors with a significant impact on SHOAFL were number of people living in family, distance to the nearest medical service institution, travel time to the nearest medical service institution, annual family income, yearly family medical and health expenditures, average age, and residence (all P < 0.05). The Concentration index of SHOAFL ranged from -0.0315 to 0.0560. CCD of the differences between SHOA and medical insurance and smoking status were 0.9534 and 0.7132, respectively., Conclusion: The SHOAFL was found to be generally but more inclined towards urban families with high incomes and a short time to medical service institution. The observed disparities in SHOA among family members were mostly attributable to differences in health insurance and pre-retirement occupations. The status and equality of SHOAFL may be improved if policymakers prioritize making services more accessible to older rural residents with low incomes. Concurrently, reducing the existing discrepancy in health insurance coverage between older couples may also enhance their health., (© 2023. The Author(s).)

Background: Health expenditure for tuberculosis (TB) care often pushes households into catastrophe and poverty. New Cooperative Medical Scheme (NCMS) aims to protect households from catastrophic health expenditure (CHE) and impoverishment in rural China. This article assesses the effect of NCMS on relieving CHE and impoverishment from TB care in rural China. Methods: Three hundred fourty-seven TB cases are included in the analysis. We analyze the incidence and intensity of CHE and poverty, and assess the protective effect of NCMS by comparing the CHE and impoverishment before and after reimbursement. Results: After out-of-pocket (OOP) payment for TB care, 16.1 % of non-poor fall below poverty line. The NCMS reduces the incidence of CHE and impoverishment by 11.5 % and 7.3 %. After reimbursement, 46.7 % of the households still experience CHE and 35.4 % are below the poverty line. The NCMS relieves the mean gap, mean positive gap, poverty gap and normalized positive gap by 44.5 %, 51.0 %, US$115.8 and 31.6 % respectively. Conclusions: The NCMS has partial effect on protecting households from CHE and impoverishment from TB care. The limited protection could be enhanced by redesigning benefit coverage to improve the "height" of the NCMS and representing fee-for-service with alternative payment mechanisms. [ABSTRACT FROM AUTHOR]

Background: After achieving universal basic medical insurance coverage, Chinese government put the development of private health insurance (PHI) on its agenda to further strengthen financial risk protection. This paper aims to assess the level of financial protection that PHI provides for its insured households on the basis of resident basic medical insurance (RBMI)., Methods: We employed balanced panel data collected between 2015 and 2017 from the China Household Finance Survey (CHFS). Catastrophic health expenditure (CHE) and impoverishment due to health spending were applied to measure the financial protection effects. Random effects panel logistic regression model was performed to identify the factors associated with CHE and impoverishment among households covered by RBMI. In the robustness test, the method of propensity score matching (PSM) was employed to solve the problem of endogeneity., Results: From 2015 to 2017, the CHE incidence increased from 12.96 to 14.68 % for all sampled households, while the impoverishment rate decreased slightly from 5.43 to 5.32 % for all sampled households. In 2015, the CHE incidence and impoverishment rate under RBMI + PHI were 4.53 and 0.72 %, respectively, which were lower than those under RBMI alone. A similar phenomenon was observed in 2017. Regression analysis also showed that the households with RBMI + PHI were significantly less likely to experience CHE (marginal effect: -0.054, 95 %CI: -0.075 to -0.034) and impoverishment (marginal effect: -0.049, 95 %CI: -0.069 to -0.028) compared to those with RBMI alone. The results were still robust after using PSM method to eliminate the effects of self-selection on the estimation results., Conclusions: In the context of universal basic medical insurance coverage, the CHE incidence and impoverishment rate of Chinese households with RBMI were still considerably high in 2015 and 2017. PHI played a positive role in decreasing household financial risk on the basis of RBMI.

Background: In light of the health poverty alleviation policy, we explore whether the New Rural Cooperative Medical System (NRCMS) has effectively reduced the economic burden of medical expenses on rural middle-aged and elderly people and other impoverished vulnerable groups. The study aims to provide evidence that can be used to improve the medical insurance system. Methods: Data were obtained from the 2015 China Health and Retirement Longitudinal Study (CHARLS). The method of calculating the catastrophic health expenditure (CHE) and impoverishment by medical expense (IME) was adopted from the World Health Organization (WHO). The treatment effect model was used to identify the determinants of CHE for rural middle-aged and elderly people. Results: The incidence of CHE in rural China for middle-aged and elderly people is 21.8%, and the IME is 8.0%. The households that had enrolled in the NRCMS suffered higher CHE (21.9%) and IME (8.0%), than those that had not enrolled (CHE: 20.6% and IME: 7.7%). The NRCMS did not provide sufficient economic protection from CHE for households with three or more chronic diseases, inpatients, or households with members aged over 65 years. Key risk factors for the CHE included education levels, households with inpatients, households with members aged over 65 years, and households with disabilities. Conclusions: Although the NRCMS has reduced barriers to the usage of household health services by reducing people's out-of-pocket payments, it has not effectively reduced the risk of these households falling into poverty. Our research identifies the characteristics of vulnerable groups that the NRCMS does not provide enough support for, and which puts them at a greater risk of falling into poverty due to health impoverishment. [ABSTRACT FROM AUTHOR]

Background: China poverty reduction policy (PRP) addresses two important elements: the targeted poverty reduction (TPA) project since 2015 in line with social assistance policy as national policy; and reducing inequality in health services utilization by making provision of medical financial assistance (MFA). Therefore, this study aims to assess the effects of the PRP in health services utilization (both inpatient and outpatient services) among the central and western rural poor of China. Methods: The study conducted household survey and applied propensity score matching (PSM) method to assess the effects of the PRP on health services utilization among the rural poor of Central and Western China. A sensitivity test was also performed on the PSM results to test their robustness. Results: Key findings showed 17.6% of respondents were the beneficial of PRP. The average treatment effects on the treated (ATT) of the PRP on the inpatient visits within one year was found significantly positive (P = 0.026). Conclusion: There has been relationship between PRP with medical financial assistance and reduction of inequality in health services utilization by the poorer, in particular to accessing the inpatient services from the county or township hospitals of China. Policy makers should pay attention for making provision of improving responsiveness of supply, when subsidizing on the demand side. [ABSTRACT FROM AUTHOR]

Background: Understanding the health status of the poor households and the influence of unhealthy on their income can provide some vital insights into the effectiveness and appropriateness of poverty reduction solutions., Methods: Based on a nationwide cross-sectional survey of 29,712 rural poor households, this study systematically investigated the causes of poverty and health status of Chinese rural poor households, and revealed the relationship between health, income and poverty., Results: The health status of the rural poor in China is not optimistic, with 51.63% attributing their poverty to the illness of household members. NCDs are the biggest health threat to the rural poor in China. Over 60% of all the households have at least one patient and more than a quarter of the households with patients cannot afford expensive medical expenses. Although 98% of all the households participate in China's a rural health insurance system - the New Rural Cooperative Medical Scheme - 16% are still unable to bear their medical expenses after reimbursement from the scheme. Further, high altitude, ill-health and low-income are interlinked and mutually reinforcing. The per capita net income of poor households was inversely proportional to the altitude of their places of residence, family aging and unhealthy status, but was positively correlated with the number of workforces in their families., Conclusions: Poverty due to illness is one of the root causes of rural poverty in China. With the backward medical infrastructure in high altitude areas, people are more prone to fall into the vicious circle of poverty-unhealthy-low income-poverty. The establishment of effective long-term mechanism of disease prevention and intervention is an important prerequisite to enhance the endogenous development power of the poor and reduce poverty.

Background: Self-treatment is a common and widespread behaviour, of which the risks are multiplied in old age. However, the determinants of self-treatment among elders in rural China remain unclear. This study aims to explore the prevalence and associated factors of self-treatment among elders in rural China, trying to discover the vulnerable groups as well as the service gaps among the rural elders., Methods: Based on a multi-stage stratified random sampling method, a cross-sectional household survey was conducted among 30 villages in Sinan County, an impoverished county in western China. Data were collected through a household-individual combined questionnaires. The analysis was restricted to elders who reported illness within the last 2 weeks, and the final sample size was 330 (individuals). Bivariate and multiple logistic regression analysis were performed in the whole sample group and four subgroups to obtain the prevalence ratios regarding the associated factors., Results: In the present study, 35.2% of the elders with illness within the last 2 weeks reported self-treatment. The variables associated with self-treatment in the whole sample group were health status (OR 6.75, 95%CI 1.93-23.60), recent alcohol consumption (OR 0.42, 95%CI 0.21-0.83) and the utilisation of family practice services (OR 0.59, 95%CI 0.36-0.96); the same predictors were found in the subgroup of elders with chronic diseases. No significant predictors were found in the subgroup of elders without chronic diseases. Empty-nest elders with higher affinity to traditional Chinese medicine (OR 0.39, 95%CI 0.18-0.86) or drinking alcohol recently (OR 0.28, 95%CI 0.09-0.82) were less likely to self-treat, while the non-empty-nest elders who were no less than 75 years old (OR 3.10, 95%CI 1.33, 7.22) or at better health status (OR 9.20, 95%CI 1.73-48.75) were more likely to self-treat., Conclusion: Self-treatment was prevalent among the elders in rural China. Better health status, no recent alcohol consumption and no utilisation of family practice are associated with self-treatment among rural elders. Older elders in the non-empty nest group were more likely to self-treat, while the empty-nest elders with self-care habits in traditional Chinese medicine were less likely to self-treat. Deeper understanding of the self-treatment behaviour among rural elders may provide insights for identifying the potential service gaps and developing improvement strategies in the health care delivery system for the elderly in China.

Background: Illness is the leading cause (44%) of poverty in China. Since 2016, The health poverty alleviation project, an integral component of the Targeted Poverty Alleviation in China, was implemented in 2016 to strengthen financial risk protection against illness for financially backward segments of the population. However, the effects of the health poverty alleviation project on financial risk protection have not been explored in the literature, this paper aims to bridge the gap. Methods: Using panel data on 63,426 rural households in Chishui City, China, from 2014 to 2017, the difference-in-differences with propensity score matching method was employed. Results: The health poverty alleviation project reduces out-of-pocket payments by 15% on average and decreases the probability of catastrophic health expenditure (annual out-of-pocket payments exceeding 10% of annual household income) and impoverishing health spending occurrence (out-of-pocket payments are forcing a household into poverty or into deeper poverty) by 7.7 and 11.7%, respectively. Additionally, the project increases the number of annual hospitalizations per household by 0.035. Conclusion: Our study demonstrates that the health poverty alleviation project significantly improves financial risk protection by reducing out-of-pocket payments and decreasing the probability of incurring catastrophic or impoverishing levels of health expenditure. Our study has implications for the poverty reduction policies and reform of the Chinese health financing system. [ABSTRACT FROM AUTHOR]

Background: Inequalities in health care services are becoming an increasing concern in the world including in China. This study measured the income-related inequalities of residents in Hangzhou of China in access to general practice and specialist care and identified socioeconomic factors associated with such inequalities. Methods: A cross-sectional questionnaire survey was conducted on 1048 residents in ten urban communities in Hangzhou, China. The percentage and frequency of respondents visiting general practice (GP) and hospital specialist clinics over the past four weeks prior to the survey were estimated. Income-related inequalities in access to these services were measured by the concentration index. Logistic regression and Poisson regression models were established to decompose the contributions of socioeconomic factors (residency, income, education, marital status, and social health insurance) to the inequalities in the probability and frequency of accessing these services, respectively, after adjustment for the needs factors (age, sex and illness conditions). Results: The GP services were in favor of the poor, with a concentration index of − 0.0464 and − 0.1346 for the probability and frequency of GP visits, respectively. In contrast, the specialist services were in favor of the rich, with a concentration index of 0.1258 and 0.1279 for the probability and frequency of specialist visits, respectively. Income is the biggest contributor to the inequalities, except for the frequency of visits to specialists in which education played the greatest role. Conclusions: Income-related inequalities in GP and specialist care are evident in China. Policy interventions should pay increasing attention to the emergence of a two-tier system, potentially enlarging socioeconomic disparities in health care services. [ABSTRACT FROM AUTHOR]

Background: As the proportion of elderly residents living in large-scale affordable housing communities (LAHCs) increases in China, serious problems have become apparent related to the spatial allocation of elderly healthcare facilities (EHFs), e.g., insufficient provision and inaccessibility. To address these issues, this study developed a location allocation model for EHFs to ensure equitable and efficient access to healthcare services for the elderly in LAHCs. Methods: Based on discrete location theory, this paper develops a two-stage optimization model for the spatial allocation of EHFs in LAHCs. In the first stage, the candidate locations of EHFs are specified using geographic information system (GIS) techniques. In the second stage, the optimal location and size of each EHF are determined based on the greedy algorithm (GA). Finally, the proposed two-stage optimization model is tested using the Daishan LAHC in Nanjing, Eastern China. Results: The demand of the elderly for accessibility to EHFs is in line with Nanjing's planning standards. Deep insights into spatial data are revealed by GIS techniques that enable candidate locations of EHFs to be obtained. In addition, the model helps EHF planners achieve equity and efficiency simultaneously. Two optimal locations for EHFs in the Daishan LAHC are identified, which in turn verifies the validity of the model. Conclusions: As a strategy for allocating EHFs, this two-stage model improves the equity and efficiency of access to healthcare services for the elderly by optimizing the potential sites for EHFs. It can also be used to assist policymakers in providing adequate healthcare services for the low-income elderly. Furthermore, the model can be extended to the allocation of other public-service facilities in different countries or regions. [ABSTRACT FROM AUTHOR]

Background: The actual distribution of stroke and myocardial infarction (MI) associated with social economic status (SES) among the Chinese population is unclear. We aim to understand the development of disparity in stroke and myocardial infarction (MI) across different income groups in Chinese population., Methods: Data about stroke and MI disease, income, gender, and areas were obtained from China Chronic Disease and Risk Factor (CCDRF) Survey in 2007, 2010, and 2013. Respondents were categorized into different income groups according to their income rank, disease rate was calculated in each group, and difference in disparities between genders, health behaviors, and areas were further identified. Association of disease prevalence rate and income was verified by logistic regression. Trends in stroke and MI disease prevalence rate across income gradients; trends in the correlation between stroke and MI disease prevalence rate and income over time; variation in stroke and MI disease levels and its disparity across income groups by gender, region, and health behavior. Disease prevalence rate is age-adjusted by using China census 2010 population structure as a standard., Results: Three waves of survey were included, the sample size in each wave was 45,095 (year 2007), 84,117 (year 2010), and 134,962 (year 2013). Four major findings were delivered. First, the stroke and MI prevalence rate of Chinese population increased from 2007 to 2013. Second, for each survey wave, a negative correlation between stroke and MI risk with income was identified, and this correlation became weaker over time. The gap in stroke and MI prevalence rate between the richest people and the poorest people decreased from 2007 (gap = 2.5 percentage points) to 2013 (gap = 1.6 percentage points). Third, the identified health inequality varied across genders, regions, and health behaviors. For example, female population used to face a sharper decline in prevalence rate when income grew, this correlation, however, faded over time. The rural-urban difference in disease risk was found to be the largest in the bottom income group (in 2013, the prevalence rate in urban area was 5%, which was 1.8% higher than rural places), this rural-urban difference converged as income increased. Fourth, conditioning on the smoking behavior, the negative association of income and stroke and MI prevalence rate was identified, however, conditioning on the drinking behavior, the association of income and disease morbidity was inconclusive., Conclusion: During 2007 and 2013, the Chinese residents experienced a growth in stroke and MI prevalence rate, meanwhile, the increase in income was associated with a decrease in prevalence rate. However, this health disparity became weaker over time since the prevalence rate was more equally distributed across income gradients as time passed by. Although male population faced a systematically higher stroke and MI disease risk than female, the prevalence disparity in different income groups were similar in both sexes in 2013. In addition, there were also regional differences in inequality in terms of the association of disease and income.

Background: Beginning in 2010, China has endeavoured to expand health coverage and provide residents with fair access to primary health care with the intention of improving health equity. This study aims to measure changes in income-related health inequity in China between 2010 and 2014. Methods: Data were extracted from the nationally representative annual survey of the China Family Panel Studies in 2010 and 2014 with a first wave of 31,743 respondents and a second wave of 32,006 respondents over age 15. In both years, subjects were stratified into the following five categories of income: poorest 20%, lower 20%, medium 20%, higher 20% and richest 20%. The concentration curve and index was used to compare the distribution of health status in income quintiles, and a logistic model was used to examine the relationship between health and socioeconomic indicators with self-assessed health as the primary outcome of interest. Results: Income was significantly associated with self-assessed health in China. The concentration curve was above the line of equality in both years, while the self-assessed health line in 2014 was closer to the equality line. The concentration index (CIN) displayed the similar result of decreasing inequality, with the CIN in 2014 (− 0.157) closer to zero (the line of equality) than that of 2010 (− 0.167). In 2010, there was a decreasing trend of people reporting poor health from the poorest to the richest, while in 2014, there was no significant difference between the poorest and lower 20% or between the higher 20% and the medium 20%. The odds ratio of the prevalence of self-reporting poor health between the poorest and richest increased from 0.555 (95% CI: 0.484–0.636) in 2010 to 0.598 (95% CI: 0.513–0.696) in 2014. Conclusions: From 2010 to 2014, the self-assessed health gap between income groups in China decreased, and health equity improved. However, health differences remain. In order to achieve better health for all, China should further strengthen the role of primary care in reducing health inequity. [ABSTRACT FROM AUTHOR]

Background: As the proportion of elderly residents living in large-scale affordable housing communities (LAHCs) increases in China, serious problems have become apparent related to the spatial allocation of elderly healthcare facilities (EHFs), e.g., insufficient provision and inaccessibility. To address these issues, this study developed a location allocation model for EHFs to ensure equitable and efficient access to healthcare services for the elderly in LAHCs., Methods: Based on discrete location theory, this paper develops a two-stage optimization model for the spatial allocation of EHFs in LAHCs. In the first stage, the candidate locations of EHFs are specified using geographic information system (GIS) techniques. In the second stage, the optimal location and size of each EHF are determined based on the greedy algorithm (GA). Finally, the proposed two-stage optimization model is tested using the Daishan LAHC in Nanjing, Eastern China., Results: The demand of the elderly for accessibility to EHFs is in line with Nanjing's planning standards. Deep insights into spatial data are revealed by GIS techniques that enable candidate locations of EHFs to be obtained. In addition, the model helps EHF planners achieve equity and efficiency simultaneously. Two optimal locations for EHFs in the Daishan LAHC are identified, which in turn verifies the validity of the model., Conclusions: As a strategy for allocating EHFs, this two-stage model improves the equity and efficiency of access to healthcare services for the elderly by optimizing the potential sites for EHFs. It can also be used to assist policymakers in providing adequate healthcare services for the low-income elderly. Furthermore, the model can be extended to the allocation of other public-service facilities in different countries or regions.