Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance

Bull World Health Organ 2012;90:664–671 | doi:10.2471/BLT.12.102178 Research 664 Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance Ye Li,a Qunhong Wu,a Ling Xu,b David Legge,c Yanhua Hao,a Lijun Gao,a Ning Ninga & Gang Wand Introduction According to the World health report 2000, one of the fun- damental functions of a health system is to put in place a health financing system that protects the population against the financial risks associated with ill health. Such risks can be quantified in terms of catastrophic health expenditure and impoverishment from medical expenses. Catastrophic health expenditure is defined as out-of-pocket spending for health care that exceeds a certain proportion of a household’s income with the consequence that households suffer the burden of disease.1 A household is said to have been impoverished by medical expenses when health-care expenditure has caused it to drop below the poverty line.2 In China, health insurance coverage has increased dra- matically over the last decade, from 15% in 2000 to 96% in 2011.3,4 The Medical Insurance for Urban Employees (MIUE) scheme, designed exclusively for urban employees, is a man- datory programme based on cost sharing between employers and employees, with risk pooling managed at the municipal level.5 The Medical Insurance for Urban Residents scheme (MIUR) is for urban residents who are not covered by the MIUE and is co-financed by enrolees and local government.6 The New Cooperative Medical Scheme (NCMS) is a volun- tary programme based on cost sharing between government and farmers and covers mostly inpatient services and a few outpatient services.7 However, despite China’s great strides in health insurance coverage,4,8 in a more comprehensive sense such coverage is not universal. It falls short when held up to the definition of universal coverage put forth by the World Health Organization (WHO), which includes equitable ac- cess to health services for all at an affordable cost and has three dimensions: breadth, depth and height. Breadth refers to population coverage, depth refers to the range of services covered and height refers to the extent to which health service costs are covered.9,10 Despite China’s repeated rounds of health sector reform over the last three decades, increasing public dissatisfaction, particularly with health-care costs, motivated a new round in 2009. Although it had some positive effects, to what extent in- creased public spending and expanded coverage have reduced people’s financial barriers, if at all, remains unclear. The per- centage of total health expenditure paid out of pocket in China increased from 20% in 1978 to 60% in 2001, then dropped to 40% in 2008.11 With weak expenditure controls in place, the increased breadth of coverage, combined with low benefit levels, may have actually contributed to higher utilization rates and hence to a higher burden of out-of-pocket payments. Under such circumstances increasing the breadth of coverage may not be enough to protect people from catastrophic health expenditure or impoverishment from medical expenses. The vicious circle linking poverty and disease has been regarded as the biggest hindrance to government efforts to fight absolute poverty. Although the number of people living Objective To assess the degree to which the Chinese people are protected from catastrophic household expenditure and impoverishment from medical expenses and to explore the health system and structural factors influencing the first of these outcomes. Methods Data were derived from the Fourth National Health Service Survey. An analysis of catastrophic health expenditure and impoverishment from medical expenses was undertaken with a sample of 55 556 households of different characteristics and located in rural and urban settings in different parts of the country. Logistic regression was used to identify the determinants of catastrophic health expenditure. Findings The rate of catastrophic health expenditure was 13.0%; that of impoverishment was 7.5%. Rates of catastrophic health expenditure were higher among households having members who were hospitalized, elderly, or chronically ill, as well as in households in rural or poorer regions. A combination of adverse factors increased the risk of catastrophic health expenditure. Families enrolled in the urban employee or resident insurance schemes had lower rates of catastrophic health expenditure than those enrolled in the new rural corporative scheme. The need for and use of health care, demographics, type of benefit package and type of provider payment method were the determinants of catastrophic health expenditure. Conclusion Although China has greatly expanded health insurance coverage, financial protection remains insufficient. Policy-makers should focus on designing improved insurance plans by expanding the benefit package, redesigning cost sharing arrangements and provider payment methods and developing more effective expenditure control strategies. a Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, Heilongjiang,150086, China. b Centre of Health Statistics and Information, Ministry of Health, Beijing, China. c School of Public Health, La Trobe University, Melbourne, Australia. d Beijing Ditan Hospital, Beijing, China. Correspondence to Qunhong Wu (e-mail: wuqunhong@163.com). (Submitted: 11 January 2012 – Revised version received: 17 May 2012 – Accepted: 23 May 2012 – Published online: 13 June 2012 ) Bull World Health Organ 2012;90:664–671 | doi:10.2471/BLT.12.102178 665 Research Catastrophic health expenditure in ChinaYe Li et al. in absolute poverty in China dropped from 250 million in 1978 to 27 million in 2011, impoverishment from medical expenses has not disappeared.12–14 In 2004, 23.3% of rural households were impoverished by medical expenses.15,16 In this article, we analyse the rates of catastrophic health expenditure and of impoverishment from medical expenses in China and how they are distributed throughout the country and in the population, and we try to identify the structural factors that underlie the risk of the first of these outcomes. We review catastrophic health expenditure and impoverishment within the wider socioeconomic context to provide guid- ance for the next phase of health reform. Methods Data source and sampling method The primary data used to calculate catastrophic health expenditure rates were obtained from the Fourth National Health Service Survey (NHSS, 2008). The NHSS is organized by the Chinese government every five years under the direction of the Ministry of Health. For the fourth NHSS, the ministry used a multi-stage, stratified cluster sampling method with systematic random sam- pling at each stage.17 The stages were as follows: All cities – i.e. political, eco- nomic, social and cultural centres hav- ing a non-agricultural population above 100 000 – in 31 provinces were ranked into five groups according to their so- cioeconomic, educational, demographic and health indicators. From these five groups, 94 sample cities were selected, and in each city five townships were se- lected, for a total of 470 townships. Two administrative villages were selected in each township (940 villages in total) and 60 households were selected in each vil- lage. This gave a final sample of 56 400 households across China.18 Data collection and quality control The survey questionnaire covered the following: general status of the house- hold based on income and household consumption expenditure (out-of- pocket health expenditure and food consumption expenditure); health status of the head of household based on his/ her socio-demographic characteristics (age, sex, education, employment and insurance), overall household health status and health service utilization (ill- ness of a household member in previous two weeks, presence of chronic disease in a household member over the past six months, and outpatient and inpatient service utilization by household mem- bers during the past year). After use in four national surveys, this questionnaire has been shown to be consistent and reli- able. Face-to-face household interviews were conducted by qualified investiga- tors. Quality control was implemented by supervisors charged with guiding and inspecting every step of the survey. Of sampled households, 5% were revisited to check the accuracy of the data, which was > 95%.17 Data consistency was tested and no age bias was detected (Myer’s Index: 3.48%).17 The DELTA dissimilar- ity coefficient and the GINI concentra- tion ratio showed good consistency in household size between the surveyed population and the general population.17 Statistical analysis After the data cleaning process – a small number of households with incomplete or anomalous data were excluded – a sample of 55 556 households (175 577 people) remained and the correspond- ing data were entered into a database for analysis using SAS (SAS Institute Inc., Cary, United States of America). WHO’s method was employed to calculate cata- strophic health expenditure, which was defined as an out-of-pocket payment for health care ≥ 40% of a household’s capacity to pay.2 Monthly household consumption expenditure was ranked into quintiles after adjustment for stan- dard household size. This adjustment, recommended by WHO, allows any differences in health spending across countries to be attributed to factors other than the differential composition of their populations. The poverty line was defined by subsistence spending, i.e. the average monthly food expenditure of the household whose food expenditure as a share of total household consump- tion expenditure fell between the 45th and 55th percentiles of the entire sam- ple. The subsistence spending of each household was calculated as the poverty line multiplied by standard household size. If a household’s total expenditure was less than this figure, the household was categorized as poor. Household non-subsistence spending was used as a proxy for capacity to pay. However, whenever food expenditure was less than subsistence spending, capacity to pay was defined as total expenditure minus food expenditure. A descriptive analysis was under- taken to identify morbidity, service utilization and health-care spend- ing. Logistic regression was used to predict determinants of catastrophic health expenditure. The independent variables included head of household’s sex, education, employment and health insurance status, and several household characteristics, namely expenditure quintile, household size, having at least one member older than 60 or younger than 5 years, having at least one member with tuberculosis or any chronic, non- communicable condition and having at least one hospitalized member. Results Health-care needs and service utilization The rate of morbidity during the two most recent weeks was 17.9% overall: 17.0% in rural areas and 19.3% in urban areas. The total prevalence of chronic, non-communicable disease was 15.8%. Among rural households, 6.8% had a hospitalized member, compared with 7.1% of urban households and 6.8% of all households. The “non-admission rate”, defined as the percentage of patients needing hospitalization who were not hospital- ized, was 27.9%. Of these patients, 70.2% were not hospitalized because of finan- cial difficulties. The lowest expenditure quintile had the highest non-admission rate: 39.1%, a rate twice as high as that of the wealthiest group. People without insurance had the highest rate of non- admission (35.4%), followed by those covered by the MIUR (30.5%) and by the NCMS (27.6%). In 2008 the average cost of inpatient care per year was 721.9 United States dollars (US$) (exchange rate: 6.9451 yuan to US$ 1.00). The average reimbursement rate was 43.2% but varied among different insurance schemes. The MIUE offered the highest reimbursement rate (55.0%), followed by the MIUR (40.0%) and by the NCMS (30.4%). Catastrophic health expenditure in different groups Catastrophic health expenditure rates were inversely associated with the Bull World Health Organ 2012;90:664–671 | doi:10.2471/BLT.12.102178666 Research Catastrophic health expenditure in China Ye Li et al. household’s economic level. The aver- age catastrophic health expenditure was 13.0%. The average out-of-pocket pay- ment and capacity to pay rose steadily with rising expenditure quintile; the wealthier the quintile, the higher the out-of-pocket payment and capacity to pay. Conversely, the out-of-pocket pay- ment occupied a progressively smaller fraction of capacity to pay with rising expenditure quintile. Thus, the eco- nomic burden borne by the wealthier population segments is proportionately smaller because their capacity to pay is higher (Table 1). Catastrophic health expenditure distribution We compared catastrophic health expenditure rates among urban and rural households with different health- related characteristics located in China’s eastern, middle and western provinces (corresponding to affluent, middle- income and poor regions) (Table 2). Rural households were at greater risk of experiencing catastrophic health expenditure than urban households. Households located in the wealthier provinces were at lower risk of cata- strophic health expenditure than poorer regions. Household characteristics, such as having health insurance or having chronically ill, elderly or hospitalized members, were associated with the risk of catastrophic health expenditure in ur- ban and rural households in all regions. The catastrophic health expenditure rate for households covered by the MIUE and MIUR was lower than the national average; the rates for households cov- ered by the NCMS (range: 13.8–16.0%) were above the national average. A combination of several family- level risk factors with location-related factors, such as living in a rural area, increased household vulnerability to catastrophic health expenditure. House- holds with hospitalized members and located in rural areas had the highest catastrophic health expenditure rate (35.0%), followed by those with hos- pitalized members (32.8%), Noncom- municable diseases (NCDs) (23.1%) and elders above 60 (19.7%). When these vulnerabilities existed together, the risk of catastrophic health expenditure increased. Households with NCD members who were hospitalized had catastrophic health expenditure rates of 39.3%, which was two times higher than households with NCD but not hospitalized and eight times higher than the rate for households without either characteristic. Poverty levels and impoverishment analysis In our study, the poverty line was US$ 449.40 per year. Without taking out-of-pocket payments into consider- ation, poor households accounted for 18.2% of all households and for 86.0% of the households in the poorest quintile. After out-of-pocket payments, 7.5% of non-poor households became poor. As expected, impoverishment from medi- cal expenses was more common in the poorest quintile. Rural households had higher rates of poverty and of im- poverishment than urban households (Table 3). The rural poverty rate was almost eight times higher than the rate in urban areas and the rate of impover- ishment was about three times higher. Determinants of catastrophic health expenditure Logistic regression yielded a wide range of determinants linked with cata- strophic health expenditure (Table 4). Households headed by a female, an unemployed person or a person having little education, and households having at least one member who was elderly, ill from tuberculosis or any chronic non-communicable illness, or hospi- talized were more likely to experience catastrophic health expenditure. House- holds without insurance were at higher risk of catastrophic health expenditure Table 1. Distribution of household health expenditure across consumption expenditure quintiles, China, 2008 Indicator Expenditure quintilea 1 2 3 4 5 All Average monthly out-of-pocket health expenditure (US$)b 6.8 11.6 15.7 22.6 50.8 21.7 Average capacity to pay (US$)b 32.0 56.6 84.2 135.2 327.6 129.2 Out-of-pocket share of monthly household expenditure (%) 12.7 12.0 11.6 11.6 12.3 12.1 Capacity to pay out of pocket (%) 22.2 20.5 18.5 16.6 14.9 18.5 Households with catastrophic health expenditure (%) 15.8 14.3 12.7 11.3 10.7 13.0 US$, United States dollars. a Quintile 1 is the poorest and quintile 5 the wealthiest. b Based on a currency exchange rate of 6.9451 yuan to US$ 1.00. Table 2. Catastrophic health expenditure distribution among different households and areas, China, 2008 Household characteristic Area (%) All Urban Rural Eastern Middle Western Member with chronic disease 23.1 17.1 26.0** 19.8 23.9 25.9** Member > 60 years of age 19.7 15.1 21.9** 17.8 20.5 21.0** Member < 5 years of age 14.3 7.9 15.8** 13.5 14.6 14.6 Hospitalized member 32.8 26.6 35.0** 31.9 32.8 33.4** Health insurance status MIUE 9.4 9.2 10.8 8.5 9.6 10.5* MIUR 8.5 8.9 6.4 7.9 12.1 7.2 NCMS 14.8 9.3 14.9** 13.8 14.1 16.0** Other insurance plan 12.2 11.6 13.6 10.6 18.5 9.5 None 11.7 10.8 13.0* 8.8 12.5 13.1** MIUE, Medical Insurance for Urban Employees; MIUR, Medical Insurance for Urban Residents; NCMS, New Cooperative Medical Scheme; *P < 0.05; **P < 0.01. Bull World Health Organ 2012;90:664–671 | doi:10.2471/BLT.12.102178 667 Research Catastrophic health expenditure in ChinaYe Li et al. compared with those covered by the MIUE and MIUR. Economic status was inversely associated with catastrophic health expenditure, that is, wealthier households were more protected against catastrophic health expenditure. Urban households were more likely to escape catastrophic health expenditure than rural households. Having a large family and at least one young member appeared to be protective factors. Discussion Rates of catastrophic health expenditure and impoverishment from medical expenses provide insight into the level of financial protection that a health- care financing system provides for its citizens. It reflects the financial burden Table 3. Percentage of poor households and of households impoverished by medical expenses, by household location and expenditure quintile, China, 2008 Characteristic Poor Impoverished Location Urban 3.1 3.3 Rural 24.6 9.3 Eastern province 11.3 5.5 Middle province 17.4 7.9 Western province 25.2 9.0 Expenditure quintilea 1 86.0 10.6 2 0 19.1 3 0 4.2 4 0 2.2 5 0 1.6 Total 18.2 7.5 a Quintile 1 is the poorest and quintile 5 the wealthiest. Table 4. Determinants of catastrophic health expenditure,a China, 2008 Determinant β SE Wald P OR (95% CI) Gender of household head (male vs female) −0.147 0.035 17.278 < 0.0001 0.863 (0.805–0.925) Educational level of head of household None vs university or above 1.073 0.141 57.600 < 0.0001 2.924 (2.216–3.857) Primary school vs university or above 0.806 0.139 33.745 < 0.0001 2.239 (1.706–2.939) Junior high school vs university or above 0.488 0.138 12.467 < 0.0001 1.629 (1.242–2.135) Senior high school vs university or above 0.385 0.143 7.251 0.007 1.469 (1.110–1.943) Technical secondary school vs university or above 0.385 0.161 5.681 0.017 1.469 (1.071–2.016) Junior college vs university or above −0.090 0.177 0.259 0.611 0.914 (0.646–1.292) Employment status of head of household Employed vs unemployed −0.567 0.040 206.000 < 0.0001 0.567 (0.525–0.613) Retired vs unemployed −0.119 0.068 3.089 0.079 0.888 (0.778–1.014) Student vs unemployed −0.805 0.376 4.595 0.032 0.447 (0.214–0.933) Insurance status of head of household MIUE vs none −0.365 0.075 23.937 < 0.0001 0.694 (0.600–0.804) MIUR vs none −0.462 0.105 19.514 < 0.0001 0.630 (0.513–0.773) NCMS vs none 0.012 0.057 0.044 0.834 1.012 (0.905–1.131) Other vs none −0.080 0.194 0.171 0.679 0.923 (0.631–1.35) Household having: Member with chronic disease (yes vs no) 1.047 0.030 1247.289 < 0.0001 2.848 (2.687–3.018) Hospitalized member (yes vs no) 1.525 0.032 2248.972 < 0.0001 4.597 (4.316–4.896) Member with tuberculosis (yes vs no) 0.575 0.109 27.697 < 0.0001 1.778 (1.435–2.203) No. of household members (≥ 5 vs ≤ 4) −0.728 0.034 448.930 < 0.0001 0.483 (0.451–0.516) Members aged > 60 years (yes vs no) 0.627 0.033 367.713 < 0.0001 1.872 (1.755–1.995) Five or more members (yes vs no) −0.211 0.064 10.925 0.001 0.810 (0.715–0.918) Area Rural vs urban 0.054 0.007 54.468 < 0.0001 1.055 (1.040–1.07) Expenditure quintileb Quintile 1 vs 5 0.306 0.052 34.728 < 0.0001 1.358 (1.227–1.504) Quintile 2 vs 5 0.269 0.052 27.084 < 0.0001 1.309 (1.183–1.449) Quintile 3 vs 5 0.141 0.051 7.567 0.006 1.151 (1.041–1.272) Quintile 4 vs 5 0.006 0.049 0.015 0.903 1.006 (0.914–1.108) CI, confidence interval; MIUE, Medical Insurance for Urban Employees; MIUR, Medical Insurance for Urban Residents; NCMS, New Cooperative Medical Scheme; OR, odds ratio; SE, standard error. a Out-of-pocket payment divided by capacity to pay ≥ 40%. b Quintile 1 is the poorest and quintile 5 the wealthiest. Bull World Health Organ 2012;90:664–671 | doi:10.2471/BLT.12.102178668 Research Catastrophic health expenditure in China Ye Li et al. shouldered by families and the finan- cial barriers that reduce their access to health care. In our study, the rates of catastrophic health expenditure and impoverishment were 13.0% and 7.5%, respectively. Such rates are higher than those found in other low-income coun- tries.19–21 The drivers of catastrophic health expenditure are summarized in subsequent sections. Health-care needs, utilization and capacity to pay Our logistical results show that health- care needs and service utilization are key determinants of catastrophic health expenditure. The risk of households with NCD is 2.8 times higher than those without. Households experiencing hos- pitalization are 4.6 times more likely to suffer catastrophic health expenditure. The financial protection provided by the present mix of insurance schemes is inadequate. The risk of catastrophic health expenditure and impoverishment are closely linked with economic status. Households in poorer quintiles are more at risk of suffering catastrophic health expenditure and their impoverishment is more common, which is similar to other studies.22,23 The capacity to pay of the wealthiest population quintile is around 10 times higher than that of the poorest. Disparities in social, economic and environmental conditions in differ- ent regions of China also play a part in the risk of experiencing catastrophic health expenditure. Demographic factors Logistic regression showed that demo- graphic factors such as age, sex, educa- tion, household size, employment status of the head of household and location exert an influence on the risk of cata- strophic health expenditure. Households headed by a male or by someone with higher education or employment are less likely to suffer catastrophic health expenditure. Larger household size and the presence in a household of a member less than 5 years of age are protective factors, as reported in studies from Argentina and Turkey.24,25 The high rate of catastrophic health expenditure in households with elderly members is of special relevance in view of China’s age- ing demographic profile. An integrated, poverty-oriented social policy approach is needed to address these factors. Health insurance coverage In 2008, 87% of China’s population was covered by various insurance schemes, which suggests that the breadth of coverage needs to be expanded further to achieve universal coverage. Cata- strophic health expenditure rates varied across affiliates of the different insur- ance schemes. They were lower among MIUE and MIUR affiliates (9.4% and 8.5%, respectively) than among NCMS enrolees (14.8%). Catastrophic health expenditure rates among MIUE and MIUR enrolees are higher than rates in other developing countries.26 The depth and height of coverage are still insuffi- cient; service coverage is inadequate and out-of-pocket payments remain high. Benefit packages and cost sharing A comprehensive benefit package includes not only services, but also cost-sharing mechanisms.27 China’s medical insurance schemes rely on high co-payments to control the financial risk carried by the insurer. Net co-payment rates are 45%, 60% and 70% for MIUE, MIUR and NCMS enrolees, respectively, even though Chinese policy stipulates that the reimbursement rate for inpa- tients should be above 60%.28 China’s medical insurance schemes are designed to protect against cata- strophic expenses during episodes of major illness and hospitalization rather than to prevent such episodes. Because of the limited coverage of pharmaceuti- cals and outpatient services, households having a chronically ill member may refrain from seeking care until advanced illness sets in. Extending insurance cov- erage to long-term care for chronically ill patients, outpatient services, routine essential drugs and rehabilitation ser- vices should be a priority. Provider payment methods and cost containment In China, the main payment method for hospital charges is fee-for-service. In the absence of effective expenditure controls and with limited risk sharing by hospitals, the financial risk has been shifted to the insurer and the patients. Hospitals have no incentives for cost control under an environment of maxi- mum profit-seeking. Bonus payments to medical staff, tied to service volume and revenue, comprise a large fraction of medical remuneration. This consti- tutes an internal incentive to maximize volume, particularly of high-margin services. The price-cost margin is low for labour-intensive services, but it is higher for drugs and high-technology services, which further intensifies hos- pitals’ dependency on revenue from provider-induced demand. Hospitals receive less than 8% of their revenues from government support.29 This con- junction of factors contributes to esca- lating health-care costs. In response, the Chinese Government has promoted a series of pilot studies of alternative pay- ment methods, such as episode-based payment.30 High out-of-pocket payments such as those seen in China (40% of total health expenditure in 2008) and Viet Nam (53.5% of total health expendi- ture in 2010)17,31 are a risk factor for impoverishment.32 Basing health-care financing largely on out-of-pocket pay- ment is regarded as both inefficient and inequitable.33–36 The high out-of-pocket and high rates of catastrophic health expenditure and impoverishment in China suggest that the support provided by insurance has been surpassed by increased service volumes and charges. More worrying is the possibility that, without effective cost controls, the in- creased flow of government subsidies to insurance companies has actually helped increase service volumes and charges through provider-induced demand. Health insurance design To reduce the risk of catastrophic health expenditure, the current mix of insur- ance schemes will need to be redesigned to include a mandatory essential ben- efit package, an essential component of universal coverage.36 Coverage should be extended. Cost- and risk-sharing ar- rangements need to be reformed. Cost sharing in China favours the insurers rather than the patients. Insurers use exclusions, up-front deductibles and item ceilings to contain costs, and once a medical expenditure surpasses the ceiling, patients take over the remain- ing burden. This explains the disparity between reimbursement rates as stipu- lated in policy and actual rates in China. The main risk for hospitals is posed by uncollected debts. The insurers carry some risk with respect to volume, but most of the risk is borne by the enrolee. Insurance arrangements free of the per- Bull World Health Organ 2012;90:664–671 | doi:10.2471/BLT.12.102178 669 Research Catastrophic health expenditure in ChinaYe Li et al. verse incentives associated with these arrangements can be designed. The fee-for-service payment to health-care providers offers an incentive for reducing unit costs while increasing service volumes; it encourages provider- induced demand with over-servicing and over-prescription. This enables hospitals to shift the financial risk to in- surers and patients and has implications in terms of service quality and of the financial burden borne by households and the government. Conclusion China’s health sector reform has achieved unprecedented progress, but protecting vulnerable groups from health-care-related impoverishment remains a challenge. Health insurance, intended to reduce inequities and in- crease access to services, does not always accomplish these aims. As shown by our study, expanded coverage doesn’t always translate into improved health-service coverage or better protection against health-care costs. Designing health insurance appropriately is critical; if the benefit package is small and cost sharing inadequate, universal coverage will be difficult to achieve. Provider payment methods can have different outcomes; under China’s unique circumstances, fee-for-service payment creates perverse incentives that exacerbate catastrophic health expenditure. More systematic monitoring of catastrophic health expenditure will assist in steering the development of health financing policies in China. The country should focus on address- ing the financial access barriers facing vulnerable groups and on developing effective cost-control measures. A more integrated reform strategy is needed to enhance the breadth, depth and height of insurance coverage. In the long run, the various insurance schemes will need to be integrated and harmonized. ■ Acknowledgement We acknowledge the outstanding con- tributions from Lijun Gao and Ling Xu, who contributed equally as the first author to this article. Thanks for the insightful comments of representatives from Centre of Health Statistics and Information, Ministry of Health of the People’s Republic of China, especially to Yaoguang Zhang. Funding: This work was supported by the National Natural Science Fund (71073044) and the China Medical Board (08-929) and its distinguished professor- ship fund. Competing interests: None declared. صخلم ينمأتلل ةيسايسلا راثلآا :ينصلا في ةيبطلا تاقفنلا نع جتانلا راقفلإاو ةظهابلا ةيحصلا تاقفنلا لىع ةرثؤلما لماوعلا لماشلا يحصلا بعشلا ةياحم ىوتسم اهيلإ لصو يتلا ةجردلا مييقت ضرغلا تاقفنلا نع جتانلا راقفلإاو ظهابلا ليزنلما قافنلإا نم ينيصلا لىع ةرثؤلما ةيلكيلها لماوعلاو يحصلا ماظنلا فاشكتساو ةيبطلا .جئاتنلا هذه لىوأ تامدخلل عبارلا حسلما نم تانايبلا صلاختسا مت ةقيرطلا ةظهابلا ةيحصلا تاقفنلل ليلتح ءارجإ متو .ةينطولا ةيحصلا 55556 نم فلأتت ةنيع عم ةيبطلا تاقفنلا نع جتانلا راقفلإاو قطانم في ةيضرحو ةيفير تائيب فيو ةفلتمخ صئاصخ تاذ ةسرأ فيرعت ةيغب يتسيجوللا دادترلاا مادختسا متو .دلبلا نم ةفلتمخ .ةظهابلا ةيحصلا تاقفنلا تاددمح لدعم غلبو % 13.0 ةظهابلا ةيحصلا تاقفنلا لدعم غلب جئاتنلا ةظهابلا ةيحصلا تاقفنلا تلادعم تعفتراو .% 7.5 راقفلإا رابك وأ تايفشتسلما لىإ ملهاخدإ مت ًادارفأ مضت يتلا سرلأا ينب ةيفيرلا ميلاقلأا في سرلأا لىإ ةفاضلإاب ،يننمزم ضىرم وأ نس ةروطخ نم ةيبلسلا لماوعلا نم ةعوممج تدازو .ًارقف رثكلأا وأ ةيحصلا تاقفنلا تلادعم تناكو .ةظهابلا ةيحصلا تاقفنلا ينفظولما ىدل ينمأتلا ةمظنأ في ةلجسلما سرلأل ةبسنلاب ةظهابلا كترشلما ماظنلا في ةلجسلما كلت نع ةضفخنم ينميقلما وأ ينيضرلحا اهمادختساو ةيحصلا ةياعرلل ةجالحا تناكو .ديدلجا يفيرلا يمدقلم عفدلا ةقيرط عونو ايازلما ةمزح عونو تايفارغوميدلاو .ةظهابلا ةيحصلا تاقفنلا تاددمح يه تامدلخا يحصلا ينمأتلا ةيطغت عيسوتب ينصلا مايق نم مغرلا لىع جاتنتسلاا لىع ينعتيو .ةيفاك يرغ لازت لا ةيلالما ةيمالحا نأ لاإ ،يربك وحن لىع نم ةنسحلما ينمأتلا ططخ ميمصت لىع زيكترلا ةسايسلا عانص فيلاكتلا مساقت تابيترت ميمصت ةداعإو ايازلما ةمزح عيسوت للاخ ةيلاعف رثكأ تايجيتاترسا عضوو تامدلخا يمدقلم عفدلا قرطو .قافنلإا ةبقارلم 摘要 中国灾难性卫生支出和因病致贫影响因素分析 目的 评估中国居民在灾难性家庭卫生支出和因病致贫方面 的受保护程度。探究影响灾难性卫生支出发生的卫生系统 因素及结构性因素。 方法 利用第四次全国卫生服务调查数据。对中国不同地 区、城市和农村中具有不同特征的55556户家庭样本进行 灾难性卫生支出和因病致贫原因分析。运用逻辑回归的方 法确定灾难性卫生支出发生的影响因素。 结果 发生灾难性卫生支出的比率为13.0%；致贫比率为 7.5%。家庭成员中有住院病人、老年人或慢性病人，以 及在农村或贫困地区居住的家庭，其发生灾难性卫生支出 的比例较高。多种不利因素的组合增加了灾难性卫生支出 发生的风险。参加新型农村合作医疗的家庭比参加城镇职 工或居民基本医疗保险的家庭，发生灾难性卫生支出的比 例高。对卫生保健服务的需求和利用、人口学因素、医疗 保险的福利包类型以及供方支付方式，均是灾难性卫生支 出的影响因素。 结论 虽然中国已经大大拓展了医疗保险的覆盖面积，但 其对居民抵御疾病经济风险的保护能力仍然不足。决策 者今后的重点应该是：通过扩大医疗保险福利包的覆盖范 围、重新设计费用分摊方法和供方支付方式、并制定更加 有效的费用控制策略，进而设计出更好的医疗保险计划。 Bull World Health Organ 2012;90:664–671 | doi:10.2471/BLT.12.102178670 Research Catastrophic health expenditure in China Ye Li et al. Résumé Facteurs affectant les dépenses de santé catastrophiques et l’appauvrissement dû aux dépenses médicales en Chine: implications des politiques de l’assurance de santé universelle Objectif Évaluer dans quelle mesure le peuple chinois est protégé contre les dépenses catastrophiques et l’appauvrissement dû aux dépenses médicales, mais aussi étudier le système de santé et les facteurs structurels qui influencent le premier de ces résultats. Méthodes Des données ont été obtenues de la quatrième enquête nationale sur les services de santé. Une analyse des dépenses de santé catastrophiques et de l’appauvrissement dû aux dépenses médicales a été réalisée sur un échantillon de 55 556 ménages présentant diverses caractéristiques et vivant dans des environnements ruraux et urbains de différentes régions du pays. La régression logistique a été utilisée pour identifier les déterminants des dépenses de santé catastrophiques. Résultats Le taux des dépenses de santé catastrophiques s’élevait à 13,0 % et celui de l’appauvrissement à 7,5%. Les taux de dépenses de santé catastrophiques étaient supérieurs dans les familles dont certains membres étaient hospitalisés, souffraient de maladies chroniques ou étaient des personnes âgées, ainsi que dans les familles des régions rurales ou plus pauvres. Une combinaison de facteurs défavorables augmentait le risque de dépenses de santé catastrophiques. Les familles bénéficiant de régimes d’assurance de résident ou d’employé urbain présentaient des taux de dépenses de santé catastrophiques inférieurs aux familles bénéficiant du nouveau régime corporatif rural. Le besoin en soins de santé et leur utilisation, les données démographiques, le type d’assurance et le type de méthode de paiement des fournisseurs étaient les déterminants des dépenses de santé catastrophiques. Conclusion Bien que la Chine ait considérablement développé la couverture de son assurance-maladie, la protection financière reste insuffisante. L’objectif des responsables politiques doit être de créer des programmes d’assurance améliorés en étendant les prestations sociales, en redessinant les arrangements du partage des coûts et les méthodes de paiements des fournisseurs, mais aussi en développant des stratégies de contrôle des dépenses plus efficaces. Резюме Факторы, влияющие на катастрофические расходы на медицинское обслуживание и связанное с этим обнищание в Китае: выводы для экономической политики универсального медицинского страхования Цель Оценить степень защищенности населения Китая от катастрофических расходов домохозяйств и обнищания из-за расходов на медицинское обслуживание, а также изучить систему здравоохранения и структурные факторы, влияющие на первый из вышеназванных процессов. Методы Данные получены из 4-го исследования Государственной службы здравоохранения. Анализ катастрофических расходов на здравоохранение и обнищание из-за расходов на медицинское обслуживание был предпринят с выборкой 55 – 556 домохозяйств с разными параметрами и проводился в сельских и городских условиях в разных частях страны. Логистическая регрессия использовалась для установления определяющих факторов катастрофических расходов на здравоохранение. Результаты Уровень катастрофических расходов на здравоохранение составлял 13%; уровень обнищания – 7,5%. Уровни катастрофических расходов на здравоохранение были выше среди домохозяйств, имеющих госпитализированных, пожилых или хронически больных членов, а также в домохозяйствах в сельских или бедных регионах. Сочетание неблагоприятных факторов повысило риск катастрофических расходов на здравоохранение. Семьи, участвующие в системах страхования городских служащих или местных жителей, имели более низкие показатели катастрофических расходов на здравоохранение, по сравнению с зачисленными в новую сельскую корпоративную систему. Потребность в медицинской помощи, а также ее использование, демографические данные, тип страхового пакета и тип способа оплаты поставщика являлись детерминантами катастрофических расходов на здравоохранение. Заключение Несмотря на то, что Китай имеет весьма широкое страховое покрытие, финансовая защита остается неудовлетворительной. Ответственным за политику в области здравоохранения следует сконцентрироваться на разработке усовершенствованных планов страхования посредством расширения страховых пакетов, переработки соглашений о долевом участии и методов оплаты поставщикам услуг, а также разработки более эффективных стратегий по контролю за расходами. Resumen Factores que afectan a los gastos sanitarios catastróficos y el empobrecimiento provocado por los gastos médicos en China: repercusiones políticas de un seguro sanitario universal Objetivo Evaluar el grado de protección de los habitantes de China frente a los gastos familiares catastróficos y el empobrecimiento provocado por los gastos médicos y examinar el sistema sanitario y los factores estructurales que influyen en el primero de estos resultados. Métodos Los datos se obtuvieron de la 4ª Encuesta nacional sobre los servicios sanitarios. Se emprendió la tarea de analizar los gastos sanitarios catastróficos y el empobrecimiento provocado por los gastos médicos con una muestra de 55.556 hogares con características diferentes localizados tanto en entornos rurales como urbanos en distintas partes del país. Se empleó un modelo de regresión logística para identificar los determinantes del gasto sanitario catastrófico. Resultados La tasa del gasto sanitario catastrófico fue del 13.0% y la del empobrecimiento, del 7,5%. La tasa del gasto sanitario imprevisto fue superior en los hogares en los que alguno de los miembros estaba hospitalizado, era anciano o sufría una enfermedad crónica, así como en los hogares de zonas rurales o más pobres. Una combinación de factores adversos aumentó el riesgo de sufrir gastos sanitarios catastróficos. Las familias inscritas en los seguros urbanos para empleados o residentes presentaron una tasa menor de gastos sanitarios catastróficos que aquellas que estaban inscritas en el nuevo seguro corporativo rural. La necesidad y el uso de la atención sanitaria, la demografía, el tipo de prestaciones así como Bull World Health Organ 2012;90:664–671 | doi:10.2471/BLT.12.102178 671 Research Catastrophic health expenditure in ChinaYe Li et al. el método de pago al proveedor fueron los determinantes del gasto sanitario imprevisto. 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