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      Catastrophic health expenditure incidence and its equity in China: a study on the initial implementation of the medical insurance integration system


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          By 2013, several regions in China had introduced health insurance integration policies. However, few studies addressed the impact of medical insurance integration in China. This study investigates the catastrophic health expenditure and equity in the incidence of catastrophic health expenditure by addressing its potential determinants in both integrated and non-integrated areas in China in 2013.


          The primary data are drawn from the fifth China National Health Services Survey in 2013. The final sample comprises 19,788 households (38.4%) from integrated areas and 31,797 households (61.6%) from non-integrated areas. A probit model is employed to decompose inequality in the incidence of catastrophic health expenditure in line with the methodology used for decomposing the concentration index.


          The incidence of catastrophic health expenditure in integrated areas is higher than in non-integrated areas (13.87% vs. 13.68%, respectively). The concentration index in integrated areas and non-integrated areas is − 0.071 and − 0.073, respectively. Average household out-of-pocket health expenditure and average capacity to pay in integrated areas are higher than those in non-integrated areas. However, households in integrated areas have lower share of out-of-pocket expenditures in the capacity to pay than households in non-integrated areas. The majority of the observed inequalities in catastrophic health expenditure can be explained by differences in the health insurance and householders’ educational attainment both in integrated areas and non-integrated areas.


          The medical insurance integration system in China is still at the exploratory stage; hence, its effects are of limited significance, even though the positive impact of this system on low-income residents is confirmed. Moreover, catastrophic health expenditure is associated with pro-poor inequality. Medical insurance, urban-rural disparities, the elderly population, and use of health services significantly affect the equity of catastrophic health expenditure incidence and are key issues in the implementation of future insurance integration policies.

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          The bounds of the concentration index when the variable of interest is binary, with an application to immunization inequality.

          When the health sector variable whose inequality is being investigated is binary, the minimum and maximum possible values of the concentration index are equal to micro-1 and 1-micro, respectively, where micro is the mean of the variable in question. Thus as the mean increases, the range of the possible values of the concentration index shrinks, tending to zero as the mean tends to one and the concentration index tends to zero. Examples are presented on levels of and inequalities in immunization across 41 developing countries, and on changes in coverage and inequalities in selected countries. Copyright (c) 2004 John Wiley & Sons, Ltd.
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            Health service delivery in China: a literature review.

            We report the results of a review of the Chinese- and English-language literatures on service delivery in China, asking how well China's health-care providers perform and what determines their performance. Although data and methodological limitations suggest caution in drawing conclusions, a critical reading of the available evidence suggests that current health service delivery in China leaves room for improvement, in terms of quality, responsiveness to patients, efficiency, cost escalation, and equity. The literature suggests that these problems will not be solved by simply shifting ownership to the private sector or by simply encouraging providers -- public and private -- to compete with one another for individual patients. By contrast, substantial improvements could be (and in some places have already been) made by changing the way providers are paid -- shifting away from fee-for-service and the distorted price schedule. Other elements of 'active purchasing' by insurers could further improve outcomes. Rigorous evaluations, based on richer micro-level data, could considerably strengthen the evidence base for service delivery policy in China.
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              Inequality in household catastrophic health care expenditure in a low-income society of Iran.

              We assessed change in household catastrophic health care expenditures (CHE) and inequality in facing such expenditures in south-west Tehran. A cluster-sampled survey was conducted in 2003 using the World Health Survey questionnaire. We repeated the survey on the same sample in 2008 (635 and 603 households, respectively). We estimated the proportion of households facing CHE using the 'household's capacity to pay'. We identified the determinants of the household CHE using regression analysis and used the concentration index to measure socio-economic inequality and decompose it into its determinants factors. Findings showed that the proportion of household facing CHE had no significant change in this period (12.6% in 2003 vs 11.8% in 2008). The key determinants of CHE for both years were health care utilization and health care insurance status. Socio-economic status was the main contributor to inequality in CHE, while unequal utilization of dentistry and outpatient services had reduced the inequality in CHE between socio-economic groups. We observed no significant change in the CHE proportion despite policy interventions aimed at reducing such expenditures. Any solution to the problem of CHE should include interventions aimed at the determinants of CHE. It is essential to increase the depth of social insurance coverage by expanding the basic benefit package and reducing co-payments.

                Author and article information

                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central (London )
                30 December 2019
                30 December 2019
                : 19
                : 1761
                ISNI 0000 0001 2204 9268, GRID grid.410736.7, Department of Social Medicine, Health Management College, , Harbin Medical University, ; Harbin, China
                Author information
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                : 25 June 2019
                : 23 December 2019
                Funded by: FundRef http://dx.doi.org/10.13039/501100001809, National Natural Science Foundation of China;
                Award ID: 71333003
                Award ID: 71804036
                Award Recipient :
                Funded by: Natural Science Foundation of Heilongjiang Province
                Award ID: YQ2019G003
                Research Article
                Custom metadata
                © The Author(s) 2019

                Public health
                catastrophic health expenditure,medical insurance integration system,equity,influencing factors


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