Background Multimorbidity, the presence of two or more mental or physical chronic non-communicable diseases, is a major challenge for the health system in China, which faces unprecedented ageing of its population. Here we examined the distribution of physical multimorbidity in relation to socioeconomic status; the association between physical multimorbidity, health-care service use, and catastrophic health expenditures; and whether these associations varied by socioeconomic group and social health insurance schemes. MethodsIn this population-based, panel data analysis, we used data from three waves of the nationally representative China Health and Retirement Longitudinal Study (CHARLS) for 2011, 2013, and 2015. We included participants aged 50 years and older in 2015, who had complete follow-up for the three waves. We used 11 physical non-communicable diseases to measure physical multimorbidity and annual per-capita household consumption spending as a proxy for socioeconomic status. Findings Of 17 708 participants in CHARLS, 11 817 were eligible for inclusion in our analysis. The median age of participants was 62 years (IQR 56-69) in 2015, and 5766 (48•8%) participants were male. 7320 (61•9%) eligible participants had physical multimorbidity in China in 2015. The prevalence of physical multimorbidity was increased with older age (odds ratio 2•93, 95% CI 2•71-3•15), among women (2•70, 2•04-3•57), within a higher socioeconomic group (for quartile 4 [highest group] 1•50, 1•24-1•82), and higher educational level (5•17, 3•02-8•83); however, physical multimorbidity was more common in poorer regions than in the more affluent regions. An additional chronic non-communicable disease was associated with an increase in the number of outpatient visits (incidence rate ratio 1•29, 95% CI 1•27-1•31), and number of days spent in hospital as an inpatient (1•38, 1•35-1•41). We saw similar effects in health service use of an additional chronic non-communicable disease in different socioeconomic groups and among those covered by different social health insurance programmes. Overall, physical multimorbidity was associated with a significantly increased likelihood of catastrophic health expenditure (for the overall population: odds ratio 1•29, 95% CI 1•26-1•32, adjusted for sociodemographic variables). The effect of physical multimorbidity on catastrophic health expenditures persisted even among the higher socioeconomic groups and across all health insurance programmes.Interpretation Concerted efforts are needed to reduce health inequalities that are due to physical multimorbidity, and its adverse economic effect in population groups in China. Social health insurance reforms must place emphasis on reducing out-of-pocket spending for patients with multimorbidity to provide greater financial risk protection.
BackgroundUser charges are widely used health financing mechanisms in many health systems in low-income and middle-income countries (LMICs) due to insufficient public health spending on health. This study systematically reviews the evidence on the relationship between user charges and health outcomes in LMICs, and explores underlying mechanisms of this relationship.MethodsPublished studies were identified via electronic medical, public health, health services and economics databases from 1990 to September 2017. We included studies that evaluated the impact of user charges on health in LMICs using randomised control trial (RCT) or quasi-experimental (QE) study designs. Study quality was assessed using Cochrane Risk of Bias and Risk of Bias in Non-Randomized Studies—of Intervention for RCT and QE studies, respectively.ResultsWe identified 17 studies from 12 countries (five upper-middle income countries, five lower-middle income countries and two low-income countries) that met our selection criteria. The findings suggested a modest relationship between reduction in user charges and improvements in health outcomes, but this depended on health outcomes measured, the populations studied, study quality and policy settings. The relationship between reduced user charges and improved health outcomes was more evident in studies focusing on children and lower-income populations. Studies examining infectious disease–related outcomes, chronic disease management and nutritional outcomes were too few to draw meaningful conclusions. Improved access to healthcare as a result of reduction in out-of-pocket expenditure was identified as the possible causal pathway for improved health.ConclusionsReduced user charges were associated with improved health outcomes, particularly for lower-income groups and children in LMICs. Accelerating progress towards universal health coverage through prepayment mechanisms such as taxation and insurance can lead to improved health outcomes and reduced health inequalities in LMICs.Trial registration numberCRD 42017054737.
Background: Despite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. There is limited research on the rural-urban differences in health system performance in China. Method: We conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain. Findings: Compared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR = 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR = 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR = 2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR = 1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII = 7.45 vs 1.64). Conclusion: Our findings suggest that urban areas have achieved better prevention and management of noncommunicable disease than rural areas, but access to healthcare was equivalent. A better understanding of the causes of the observed variations is needed to develop appropriate policy interventions which address these disparities.
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