中国全民健康覆盖改革前后医疗保健利用水平的不平等：来自四川省家庭调查的证据。
Inequity in level of healthcare utilization before and after universal health coverage reforms in China: evidence from household surveys in Sichuan Province.
作者信息
Flatø Hedda, Zhang Huafeng
机构信息
Fafo Research Foundation, PO Box 2947, Tøyen, NO-0608, Oslo, Norway.
出版信息
Int J Equity Health. 2016 Jun 22;15:96. doi: 10.1186/s12939-016-0385-x.
BACKGROUND
China has since the beginning of this millennium engaged in substantial Universal Health Coverage (UHC) reforms. This paper adds evidence on how equity in level of health service utilization changed after UHC reforms.
METHODS
Our study was based on household survey data from 30 counties in Sichuan province in 2004 and 2011. We introduce an unusual outcome variable, namely level of healthcare utilization. Concentration index (CI) was used to measure income based inequality in level of healthcare utilization. Horizontal index (HI) was used to assess whether inequalities are inequitable. We decomposed the concentration index to measure the factors contributing to inequality in level of utilization. Oaxaca type decomposition was applied to control whether identified changes were attributable to changed inequality or to other factors.
RESULTS
Pro-rich inequity in level of healthcare utilization increased after UHC reforms. Overall, a higher proportion of users sought services at county hospitals or higher in 2011 compared with 2004. Richer users were considerably more likely than the poor to seek care at hospitals rather than at clinics or health centers, and the pro-rich inequality in level of healthcare utilization was highly inequitable. Insurance enrollment became the main driver of pro-rich inequity in level of healthcare utilization after reforms, while health needs became less important for determining level of care, all disfavoring low income groups.
CONCLUSIONS
Assessments of equity should pay attention to inequalities in level of healthcare utilization. Our results indicate that in China, wide insurance coverage is insufficient to ensure equity in level of healthcare utilization. On the contrary, type of insurance enrollment has become a main driver of inequity in level of utilization. Hence, equalizing health insurance schemes would be of crucial importance in order to improve health equity in China. Moreover, UHC reforms should strengthen the primary sector and limit non-needs based use of high-level hospitals in order to promote equitable use of healthcare services.
背景
自本世纪初以来，中国一直在大力推进全民健康覆盖（UHC）改革。本文补充了有关UHC改革后卫生服务利用水平公平性如何变化的证据。
方法
我们的研究基于2004年和2011年四川省30个县的家庭调查数据。我们引入了一个不同寻常的结果变量，即医疗保健利用水平。集中度指数（CI）用于衡量医疗保健利用水平中基于收入的不平等。横向指数（HI）用于评估不平等是否不公平。我们对集中度指数进行分解，以衡量导致利用水平不平等的因素。应用奥克塔维亚类型分解来控制所确定的变化是否归因于不平等的变化或其他因素。
结果
UHC改革后，医疗保健利用水平上有利于富人的不平等有所增加。总体而言，与2004年相比，2011年寻求县级及以上医院服务的使用者比例更高。富裕的使用者比贫困者更有可能在医院而不是诊所或卫生中心寻求治疗，并且医疗保健利用水平上有利于富人的不平等非常不公平。改革后，参保成为医疗保健利用水平上有利于富人的不平等的主要驱动因素，而健康需求对确定医疗水平的重要性降低，所有这些都不利于低收入群体。
结论
公平性评估应关注医疗保健利用水平的不平等。我们的结果表明，在中国，广泛的保险覆盖不足以确保医疗保健利用水平的公平性。相反，参保类型已成为利用水平不平等的主要驱动因素。因此，均衡医疗保险计划对于改善中国的健康公平至关重要。此外，UHC改革应加强基层部门，并限制基于非需求的高水平医院的使用，以促进医疗服务的公平利用。
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