Urban–rural inequalities in health care delivery in South Africa

Urban–rural inequalities in access to health care services continue to persist in South Africa, and in almost all cases discriminate against the poor. In certain cases disparities are even worse in urban areas, although levels of service delivery admittedly are consistently worse in rural areas. People in rural areas are generally more dependent on public and other health care services than on private services, compared with people living in urban areas. There is limited evidence of substantial intra-urban disparities, with inequality being worse in smaller urban settlements (i.e. towns) as opposed to larger ones (i.e. small cities and metropolitan areas). The article emphasises the important role the envisaged future decentralisation of selected health services to local government is likely to play in addressing these inequalities and the lack of service delivery at this level.     

中国农村基本健康保障体系的重组

I. IntroductionDuring the two decades since the end of the 1970s, China's market-oriented economicreform has exerted a robust effect in improving the overall efficiency of the national economyas manifested in rapid economic growth. This achievement is also seen in an apparentincome increase for the entire Chinese population and a dramatic reduction in poverty.However, the process of introducing market mechanisms has also engendered a wideningrural-urban gap, increasing regional disparities an…     

Impact of urban-rural health insurance integration on health care: Evidence from rural China

In recent years, Chinese local governments have experimented with integrating the social health insurance system segmented between rural and urban areas to unify the administration, policy, and funds of various health insurance programs. In this study, we take advantage of the staggered implementation of the urban-rural health insurance integration across cities over time to examine the impacts of the integration on rural residents' health care utilization and health outcomes. Based on an original city-year level policy dataset and the China Health and Retirement Longitudinal Study (CHARLS) for the years 2011, 2013, and 2015, we find that the integration significantly increases the middle-aged and older rural residents' inpatient care utilization and this positive effect is particularly salient in poor areas. Moreover, we find that the positive policy effect of integration is attributed to enhanced health insurance benefits, such as a higher reimbursement rate for inpatient care. However, the integration has limited impacts on the middle-aged and older rural residents' health outcomes. This study reveals the partial success of urban-rural health insurance integration to reduce health care inequality in China.     

Equity in health-care financing in China during the progression toward universal health coverage

Financing equity has become a major policy goal in China's progression toward universal health coverage since the beginning of the 21st century. In this study, we examine the equity characteristics of health-care financing in a province in the middle of China, comparing the equity performance between urban and rural areas at two different points in time. Progressivity and the corresponding Kakwani index were used to assess four health-care financing sources: indirect and direct taxes, public health insurance, and out-of-pocket payments. Two rounds of surveys were conducted in 2008 (5650 individuals in 1800 households) and 2013 (11,250 individuals in 3598 households). Household socioeconomic status, health-care payments, and utilization information were recorded during household interviews. Total health-care financing was near proportional in 2008 and slightly progressive in 2013 in urban areas, whilst it was marginally progressive in both 2008 and 2013 in rural areas. The health-care financing system was more equitable in 2013 than in 2008. Overall, the performance of China's health-care financing has improved over the period 2008–2013. Using flat-rate contributions to fund health care is not equitable to the poor. Key measures to achieve equitable health-care financing distribution include improvements in the benefit packages offered by health-insurance schemes and provision of essential health services.     

Analysis of dynamics of public and private expenditures on health care and education in contemporary Russia

This paper provides an estimate of the dynamics in expenditures on health care and education made from all sources in Russia in the 1995–2012 and viewed as investments in human capital. These data from Russia are compared with those from other countries. The problems of efficiency in the functioning of these systems and different affordability of these services are considered.     

Health Status and Earnings of Migrant Workers from Rural China

The migration of rural laborers into cities for employment has been one of the main driving forces of China's economic growth over the past three decades. Based on a dataset collected by the Ministry of Agriculture of China from 2003 to 2007, this paper examines the impact of health on the earnings of migrant workers engaging in physically‐intensive work requiring good health. Our findings indicate that a poor health status not only weakens the incentive of rural laborers to participate in the migrant labor force but also significantly reduces their earnings. A migrant worker in poor health only earns 67 percent of what a healthy worker makes. Among all the human capital characteristics and family economic factors, health status is the most influential on earnings for less educated workers. Labor productivity has a greater impact on earnings than the annual number of days that a person works. Ongoing health‐care reforms aimed at the improvement of the health‐care services available to rural laborers are urged to help reduce poverty in rural China.     

Small is beautiful,but growth is inevitable: experiences of apex institutions in Senegal and Tanzania

This article examines the experiences of two national apex institutions in two sub-Saharan African countries, Senegal and Tanzania, which channel funds to retail microfinance institutions (MFIs). These two national apexes are the Dyna-Enterprises Project and the Small Entrepreneurs Loan Facility (SELF) project, which are functioning in Senegal and Tanzania respectively. Both Dyna and SELF initially started as small-scale apex MFIs and had been conceived with the same vision in mind – facilitation of access to financial services for the poor. The initial implementation focused on provision of credit through MFIs as well as capacity building. The targeted groups of clients are similar, i.e. the disadvantaged, and mostly are women groups in urban or peri-urban areas carrying out general petty trade activities. Like many apex institutions in sub-Saharan Africa, both SELF and Dyna have stimulated demand for more financial support to the poor and have shown potential to be transformed into viable commercial MFIs. This entails expansion in terms of increased number of staff, branches, cost-effective microfinance services, the number and quality of financial products, capacity building, outreach and information services. The current vision of these national apex institutions is to transform into effective, transparent and efficient corporate entities for addressing poverty issues through harnessing and targeting funds to needy areas, while incorporating microfinance best practices.     

Looking back: Government politics and trust in rural developments in Tanzania and Zimbabwe 1980–1990

Trust is assigning the right to act to others. Trust is therefore building community. But trust can increase and wane with complex consequences. Community was built differently in Tanzania and Zimbabwe. Tanzania reached independence already in 1961; Zimbabwe in 1980. Both were subjected to British colonialism. Both experienced liberation movements more harshly suppressed in Zimbabwe than in Tanzania. Both had large rural populations. It can be argued that some level of generalised trust among people within the state’s formal boundaries is a condition for a functioning democracy. Distrust that makes a citizen, a group or a whole category of people exit from the state’s basic institutions fragments the state. The question here is how government politics in rural affairs, both policy-making and the organisation of implementation, affected trust relations between rulers and rural citizens in the two countries. The assumption is the less positive meaning policy has, the less trust, a reduced willingness to assign authority to policy maker and implementers.     

医疗保险是否改善了老年人的慢性病医疗状况? ——基于CHARLS数据的实证分析

本文基于中国健康与养老追踪调查(CHARLS)数据,利用Heckman样本选择模型、二阶段最小二乘模型(2SLS)等方法,在高血压、糖尿病等慢性病纳入医保门诊报销的背景下,实证检验了医疗保险对我国城乡老年人慢性病医疗状况的影响.研究发现:(1)医疗保险显著增加了老年人慢性病的门诊和住院医疗费用,且城市和男性老年人的支出明显高于农村和女性老年人,但医疗保险对老年人慢性病住院医疗支出增长的影响呈减弱趋势;(2)医疗保险显著提高了老年人慢性病医疗服务利用率,增加了老年人及时就医的概率;(3)医疗保险显著降低了老年人慢性病的自付比例,减轻了老年人的医疗负担.     

Does health insurance promote people's consumption? New evidence from China

In order to change the situation that reimbursement rate of the new rural cooperative medical care system (NCMS) was too low to alleviate farmers medical burden, in August 2012, China began to expand the coverage of the NCMS to include the treatment of critical illnesses. Could more effective health insurance promote the consumption of rural residents? We studied the impact of the critical illness insurance (CII) on rural household consumption, and find that the CII increases per capita household daily consumption by >15%. But healthcare and medical expenditures have not been affected. Our comparison of outcomes for households with different levels of consumption and income shows the CII mainly promote the consumption of rural affluent family, but no incentive for poor family, resulting in deterioration of consumption inequality of rural households. The finding is robust to various alternative hypotheses and specifications.     

农民对农村公共服务投资的意愿分析——基于陕西关中地区24个乡镇102个村的调查

文章运用2007年7-9月陕西省关中地区24个乡镇102个村的调研数据分析了农民对农村公共服务投资的满意程度以及农民的投资意向。研究表明,农民对农村医疗卫生保健服务的满意度最低,但农民对农村医疗卫生保健服务的投资意愿却是很高的,仅次于农民对农村道路的投资意愿;而农民对文化娱乐公共项目投资的满意度和投资意愿都很低。因此,政府部门应该根据目前农民对农村公共服务项目的投资意愿,加大对农民不满意但又有强烈投资需求的项目的投入力度;对农民既不满意也不愿投资但与新农村建设相关的项目也应给予鼓励和支持。     

Sub-Saharan Africa in depression: The impact on the welfare of children

This paper analyses the impact of the economic crisis on the welfare of children in Sub-Saharan Africa, an area which includes most of the least developed and most severely affected countries. These countries are characterized by: low levels of skilled personpower, dependency on their primary product exports, small industrial sectors, a lagging food production growth, a high proportion of rural population and a child dependency ratio that is virtually 1 to 1. The situations of Nigeria, Zambia and Tanzania are examined in detail. In Zambia where there is substantial evidence of worsening of the condition of children in the 1970s, the most urgent requirement is additional resources, particularly foreign exchange. Such is also the case with Tanzania, while Nigeria does have the resources to develop a more coherent economy and finance basic services adequately.     

城乡义务教育服务非均衡问题研究——基于“投入-产出-受益”三维视角的实证分析

本文基于“投入-产出-受益”的三维视角,通过构建结构方程模型,实证分析城乡义务教育服务投入差距、产出差距和受益非均衡的相互关系。结果显示：城乡地区普通初中和小学师资力量的差距以及义务教育服务的生产效率差距,是导致城乡义务教育服务产出差距的重要原因;而城乡义务教育服务的产出差距以及城乡居民义务教育服务的偏好差异,又是导致城乡义务教育服务受益非均衡的重要原因。据此,本文认为,应着力改善农村教师的工作和生活条件,吸引人才充实农村地区的师资队伍;同时,进一步提高农村教育资源的利用效率,并增强农村居民对义务教育服务的偏好强度,最终实现从多维的角度推进城乡义务教育服务的统筹和均等化。     

权利与公正:西部城乡基本公共服务均等化的哲学思考

推动城乡基本公共服务均等化,是西部大开发升级转型、维护社会公正、促进人全面发展的迫切需要。西部地区基本公共服务在交通基础建设、教育、医疗卫生、社会保障和社会治理等方面面临严峻挑战。要围绕以人的权利和公正推动西部城乡基本公共服务均等化,从公众需求出发,在强化政府基本公共服务职能、推动城乡制度衔接、完善农村基本公共服务体系、创新基本公共服务供给模式方面进行突破和创新,不断提升西部人的自我发展能力。     

Social capital as correlate,antecedent, and consequence of health service demand in China

Amid increasing interest in how social relationships play an important role in health and health behavior, it remains unclear whether social activities and social capital in general benefit individuals' health literacy and in turn affect their health care consumption. More specifically, this article proposes a research hypothesis to address the question: Do individuals who are strongly tied to other individuals within the social networks become more health conscious or literate and hence use more health services? This paper extends prior research on social support, health literacy and health care utilization to investigate the association between social interaction and health service demand. Using the China Health and Nutrition Survey, the paper provides cross-sectional evidence that people who are socially active and connected with their friends made more visits to health care providers. It also finds that people of male gender, being single, having more years of education, and no health insurance coverage tend to avoid seeking health services. The quasi-experimental study, which examines the events that exogenously intensified social interactions in some but not all Chinese provinces, indicates that social capital is more an antecedent than a consequence of health service needs.     

Community health service centers in China, not always trusted by the populations they serve?

Based on the idea that healthcare needs to be managed by individuals and that basic health services should be provided by the community, this paper examines the factors that impact urban outpatients' preferences for particular community health service centers (CHSCs) and hospitals. Rational consumption of healthcare is influenced by a patient's beliefs, beyond simple demographics and social structure. Ignorance of basic health issues leads to non-rational patient behavior, which also explains the confusion in Chinese health reform regarding people's mistrust of CHSCs. Health education in the form of self-managed care may increase personal health knowledge and encourage individuals to make use of the basic health services that are supplied by CHSCs.     

The role of for-profit hospitals in medical expenditures: Evidence from aggregate data in China

The health care delivery system in China, which is dominated by state hospitals, is being increasingly challenged by public concerns: it is too expensive and too inaccessible, a complaint commonly phrased as “kai bin nan, kan bin gui” in Chinese. As the penetration of for-profit hospitals has gradually increased, there is a growing need for policy research to assess their impact on medical spending from the patient perspective. Using panel data at the provincial level in China, this paper examines the impact of the penetration of for-profit hospitals on average medical expenditures for both outpatient and inpatient services in public general hospitals. Based on fixed-effect model estimates, the study shows that the penetration of for-profit hospitals has lowered the average medical expenditures for both inpatient and outpatient services across regions, especially for pharmaceuticals. Together with other results, this study finds no evidence that private for-profit hospitals drive up average medical expenditures while serving their profit-maximization objectives. Rather, they help increase the market supply of health care, which in turn better serves the increasing demand.     

改革开放三十年政府支出对城乡居民生活水平影响效应分析——基于TVP模型的实证研究

基于中国1978—2008年的时间序列数据,采用时变参数（TVP）模型对我国政府支出对城乡居民生活水平的影响效应进行比较分析。由实证结果可见：政府总支出促进了我国城乡居民生活水平的提高,但对城镇的影响大于农村。分类支出上,政府行政性支出对城市居民生活水平产生正向促进作用,对农村居民生活水平产生负向作用;政府基本建设支出对城市居民先产生正向作用,但最近几年,产生一定的负影响,而对农村居民生活水平从1990年后一直产生正向作用,且对城乡居民生活水平影响有逐渐趋同趋势;政府民生性支出对城乡居民生活水平一直有正向促进作用,但对农村居民生活水平的影响要高于城市。     

Mind the gaps: a political economy of the multiple dimensions of China's rural–urban divide

China's impressive growth has been accompanied by high inequality and a wide rural–urban divide. This paper identifies and examines some of the major dimensions of this divide: income, consumption, education, employment, health care, pensions, access to public services, and the environment. The paper attributes the main causes of the divide to China's urban‐biased development strategies and the resulting lack of social provision of public goods in rural areas. It also highlights the severe and multidimensional constraints on the Chinese peasantry and argues that increased equality and efficiency can now be pursued simultaneously.