Empirical essays on the evaluation of health care reforms in rural China
This thesis is comprised of three empirical studies on health care reforms in rural China. It specifically examines the determinant of enrolment in the social health insurance program, the effects of the insurance on health care utilization, and the extent of income-related inequity in the use of health care before and after the reforms. Chapter 2 analyses the determinant of enrolment in the New Rural Cooperative Medical Scheme (NRCMS) from 2004 to 2006. The results show that people who use low-level public health facilities (village clinics or town hospitals) are more likely to be insured while people who use high-level public health facilities (county or city hospitals) are less likely to be covered. The relationship remains strong and significant after controlling for various groups of independent variables, such as demographics, socio-economic characteristics and health variables. The results may be attributed to generous reimbursements for health services delivered by low-level health facilities, making insurance more attractive for people who use primary care. However, the fact that people who use high-level facilities are less likely to purchase the NRCMS may indicate problems related to weak health systems at the primary level and a breakdown in the referral system. Chapter 3 provides evidence on the effectiveness of the NRCMS on health care utilization to explore whether the insurance has helped patients to obtain more and better quality health services. As the program is a non-random policy initiative rolled out nationally, various matching methods with difference-in-difference (DID) models are employed based on data from the China Health and Nutrition Survey (CHNS). The results show that the introduction of the NRCMS was not clearly related to the overall use of medical care, but it may have directed patients from town hospitals towards village clinics and county hospitals. On the one hand, the NRCMS appears to partly rationalise the use of health services, with some increase in the use of primary care. On the other hand, the insurance may also alleviate financial barriers to accessing higher levels of medical facilities and help patients to obtain better quality health care. Chapter 4 examines how the income-related inequity of health care utilization in China develops from 2000 to 2009, the period before and after the health care reforms. The first part of the analysis uses Concentration Indices and Erreygers’ Indices of the need-standardized use of different types of health services and different levels of health facilities. Pro-rich inequity emerges with respect to the use of preventive care and county hospitals, and pro-poor inequity is found in the use of folk doctors and village clinics. The results indicate that the rich are more likely to obtain formal and better quality health services. The second part of the analysis assesses the contribution of various need and non-need factors to total inequity in health care use and shows that inequity is mainly driven by income. Therefore, policies that address the unequal distribution of income would help to reduce the degree of horizontal inequity in the use of health services.
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