Abstract
BackgroundChina’s economic reform in 1978 has sparked unprecedented economic growth, which leads to a market-oriented health system that heavily depends on health insurance. Since the 1990s, China has established basic medical insurance schemes and ultimately achieved universal health coverage by 2020. However, the gains in service coverage may come at a major cost to individuals and households. More worryingly, the financial burden of health expenditure has become more pronounced, due to rapid population ageing and epidemiological transition. Population ageing has shifted the disease burden from infectious diseases to non-communicable diseases (NCDs). Being diagnosed with one NCD significantly increases the risk of multiple NCDs (i.e., multimorbidity), thereby posing a major challenge to individuals, households, and health system in China. Given the rising prevalence of multimorbidity, health disparities between socioeconomic groups are widening and there are also sharp increases in health and economic burdens of NCDs. Examining catastrophic health expenditure is considered a critical component to understand the economic burden of health spending.
This research thus aims to: (1) identify the trend in the prevalence of multimorbidity over time among the middle-aged and elderly in China and if it varies across socioeconomic status (SES), (2) examine the longitudinal change in healthcare utilization rates over time and whether it differs across SES, and (3) investigate the trend in the incidence of catastrophic health expenditure over time and whether it is greater on households with lower SES. In face of unprecedented population ageing, redressing socioeconomic disparities in health to achieve health equity is of particular importance in China. All the findings from this research may help us understand the extent to which both horizontal equity and vertical equity are being addressed or should be handled in the future, thereby shedding light on health system design and future health reforms in China. All the findings also demonstrate the current progress towards health-associated Sustainable Development Goals (SDGs) and the “Healthy China 2030” Plan, thereby advancing the achievement of all the SDGs by 2030.
Methods
Data used in this research were from four waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013, 2015 and 2018, which is the first nationally representative longitudinal survey of the middle-aged and older. A total of 10,922 individuals in 6,953 households were finally included.
Multimorbidity was defined as having two or more NCDs and treated as a binary variable. Healthcare utilization was categorized into outpatient and inpatient service use and treated as a count variable. Catastrophic health expenditure was measured by health out-of-pocket surpassing a predefined threshold of a household’s non-subsistence/non-food expenditure and treated as a binary variable. Threshold levels were based on a fixed threshold (40%) for all SES groups and a set of variable thresholds for different SES groups. SES was measured by per-capita household expenditure, which was then divided into quintiles.
To adjust for the nested effects of individual-, household-, and community-level determinants, multilevel mixed-effects logistic regression models and multilevel zero-inflated negative binomial regression models were used to analyze the determinants of multimorbidity and catastrophic health expenditure, and healthcare utilization, respectively.
Results
In terms of horizontal equity, this research found that the prevalence of multimorbidity increased from 41.89% in 2011 to 72.40% in 2018. It also suggested that outpatient utilization rates rose from 19.11% in 2011 to 21.45% in 2013 and then decreased to 16.32% in 2018, whereas inpatient utilization rates grew from 8.40% to 18.79% between 2011 and 2018. Additionally, this research found that, at a fixed threshold, the incidence of catastrophic health expenditure was 10.90%, 9.46%, 13.23%, or 24.75% in 2011, 2013, 2015, and 2018, respectively, which were often lower than those measured at variable thresholds. While in terms of vertical equity, this research revealed that being in higher quintiles of per-capita household expenditure was generally associated with higher odds of multimorbidity, higher probability of outpatient utilization, and higher rates of inpatient utilization, but was related to lower odds of catastrophic health expenditure, regardless of the thresholds set.
Discussion
The crisis of accessibility and affordability of health care remains a serious concern in China. To provide more equitable and affordable health care, concerted efforts are needed to provide more health education to the public, establish a prevention-oriented and community-based integrated health service delivery system targeting NCD management, further optimize and unify health insurance schemes targeting outpatient services, redesign cost-sharing arrangements and provider payment methods, and expand private health insurance coverage. More attention should be given to the low-SES, those with NCDs, and the elderly. As China remains at an early stage of health transition, the prevalence of multimorbidity will be dramatically increasing, thereby leaving more massive health and economic burdens on individuals, households, and health system. Therefore, multimorbidity management should be a clinical and public health priority in China, where developing new service delivery and financing models for multimorbidity is warranted.
| Date of Award | 2024 |
|---|---|
| Original language | English |
| Supervisor | Itismita MOHANTY (Supervisor) & Theo NIYONSENGA (Supervisor) |