| BackgroundNational Health Accounts (NHA), an internationally endorsed framework for tracking the flow of all health funds (public, private, and donor) in a health system, from their financing sources to their end uses. NHA is a tool designed to assist policy-makers in their efforts to understand their health systems and to improve health system performance. NHA constitute a systematic, comprehensive and consistent monitoring of resource flows in a country’s health system for a given period and reflect the main functions of health care financing:resource mobilization & allocation, pooling and insurance, purchasing of care and the distribution of benefits. The purpose and significance of the total health expenditure (THE) study are to provide information on macroeconomic in the development and implementation of health development strategy, to serve the formulation and adjustment of economic policies on health services, to adapt to the need of economic development and structural adjustment. It also provides macroeconomic information of health for policy makers. The total amount and composition of THE will affect the economic development capacity, health development and the degree of personal disease burden. If the THE’s ratio of GDP is too high, it would beyond the affordability of socio-economic development. If the ratio is too low, it would limit the health system development, resulting to not meet the residents’ health service demand. Out-of-pocket payment (OOP) is the key factor to influence the impoverishment. The higher proportion of OOP, the residents’ disease burden would be much heavy. It will lead to the problem of ’spending much in medical care’ and ’being poverty caused by diseases’.’No universal health, no overall well-off society’. With the development of economic, the pace of urban and rural residents’ consumption concept and structure changes or improvement have accelerated. Shandong is facing many health challenges amid its demographic and epidemiological transition of rapid economic growth, urbanization and industrialization, population ageing, diseases and risk factors related to lifestyle and environmental pollution. But previous health financing was heavily relied on OOP, people’s health services need increased, and must to bear the high cost of medical treatment, so disease burden is heavy, which results in ’medical treatment is difficult and expensive to see a doctor’and these situation has become a serious problem. Since the new health system reform in 2009, especially since 2012, in order to solve the problem of ’medical treatment is difficult and expensive to see a doctor’, in terms of health financing, the relevant policies of new medical reform require to increase government health expenditures and reduce the OOP proportion of THE. Under the influence of the binary structure of urban and rural areas, there are also outstanding gaps between the urban and rural residents’ income, health services demand and health ability-to-pay, which leads to the health inequities.However, the background of facing the goal to build a comprehensive well-off society in the period of the ’13th Five-Year Plan’, achieving universal health coverage, reducing people’s economic burden of diseases and preventing the impoverishment from illness are the prioritized works for the whole health system and health investment. Based on the above backgrounds, it is necessary to study on account and prediction of THE. Systematic analysis of financing structure change and growth of THE before and after health care reform, status and future ratio trends of government health spending, social health expenditure and private expenditure on health, urban and rural residents’ health status, OOP equity and the situation of catastrophic health payment among urban and rural residents.Research ObjectivesBased on the data of THE and health services survey in Shandong Province, we analyzed the status quo of population health and health service, THE and financing proportions and characteristics of flow state of the institution before and after the new health reform. From the perspective of personal health expenditure, this study analyzed the features of urban and rural household consumption on health, comparisons on fairness and differences of urban and rural residents’ health spending and catastrophic health payment. The prediction of health financing structure in ’13th Five-Year Plan’ would be made. Based on’applied research’ principle, this study aimed at providing data analysis and policy recommendations for the future health financing policy formulation and adjustment, narrowing the gap between urban and rural residents health spending and providing implications of urban and rural residents in health-related equity. Thus, the establishment of ’healthy Shandong’ and the goal of comprehensive well-off society would be achieved.Data SourcesThe information and data sources are authoritative, comprehensive and accurate in this study. It consists of three parts:Firstly, the data of economic and population health status in Shandong Province from 2003 to 2014. Data sources from Statistical Yearbook of Shandong Province, Shandong Provincial Health Statistics Yearbook (IPPF Health Statistics Yearbook),2004-2015. Secondly, the data of THE (source method and mechanism method) in Shandong Province, a total of 16 years of accounting data from 1998-2013, which comes from the Center for Health Statistics, Shandong Province. Thirdly, Shandong Provincial Health Services Survey data included urban and rural residents’family income, consumption expenditure structure, health service demand, health service utilization, health care expenditure and other indicators in 2008 and 2013 surveys.Research Contents and Methods1. The overview of demography and health service development in Shandong province.The method of descriptive Statistics analysis of the economic development, population trend and public health of Shandong Province in 2003-2004 by the means of annual growth rate and composition ratio was used. The inferential statistical analysis method of chi-square tests and correlation analysis to research the differences and changes of urban and rural residents’ health service needs (two-week morbidity rate, two-week chronic illness rate, etc.), health services utilization (two week consultation rate, hospitalization rate) in the dimensions of the areas, age and years was used.2. The Analysis of current status and characteristics of THE.The descriptive Statistics analysis of the current status of Shandong Provincial financing compositions and institutional distribution was made. We measured the actual growth rate and health consumption elastic coefficient of THE. After having the data of THE adjusted by GDP deflator, we made the use of Q cluster analysis and gray correlation analysis on the characteristics of the THE from 2003 to2013.3. ELES model and fairness analysis of the urban and rural residents’ personal health spending.We used the extended linear expenditure model (ELES model) to analyze the urban and rural residents’ marginal propensity to consume, the satisfaction degree of health service and the difference of health payment ability. We also analyzed the health equity, health expenditure fairness and catastrophic health payment among different income groups of urban and rural areas.4. Prediction research on THE of Shandong province in the period of 13th Five-Year Plan.We used logistic advantage analysis and cointegration tests to check out how demographic, economic, and health service technology-intensive degree affects THE were, used ARIMA (2,2,1) model and GM (1,1) forecasting method to predict the THE and its components in 2014-2020.Research Results1. Status of population health and health service in Shandong Province.(1)From 2003-2014, the total population of Shandong province increased from 91.25 million to 97.89 million. In 2014, the birth rate of the population increased to 14.23‰, 2.82%o more than 2013. The elderly population (aged 65 and above) as proportion of total population increased from 9.1% to 11.6%.(2)From 2008-2013, the residents’two-week morbidity increased froml2.67% to 30.25%. Outpatient visits within two weeks were increased from10.47% to 12.75%, so as the hospitalization rate increased from 61.79‰ to 91.78‰. Health service demand and utility of children under the age of 15 years and elder older than 65 years were stronger than other age groups. The health utilization rate of rural residents was higher than that of urban residents.(3)The total number of patients increased by 101%, which was doubled from 301 million in 2003 to 632 million in 2014. From 2003 to 2014, the number of inpatient raised by 213.87%, raised from 4.78 million to 15.01 million.(4)The number of outpatient and beds per day per doctor had an uptrend, which raised from 4.09 and 1.53 respectively in 2003 to 5.67 and 2.34 respectively in 2014.(5)Medical costs accounted for a decline in the proportion, but the outpatient hospital costs still grew too fast. In 2004, The average hospitalization costs Y7917.40, which occupied 27.09% of Disposable income of urban residents (38.51% in 2003) and 66.63% of rural per capital net income (102.66% in 2003), at the same time, the economic burden of disease had reduced but still relatively heavy.2. Analysis on the source and allocation of THE.(1)From 2003 to 2013, annual growth of THE and per capita health expenditure reached 18%, increased by a factor of 5. Both the growth rate had slowed down by the impact of an economic slowdown. But compared with the OECD, BRIC countries and some other provinces, Shandong provincial THE funding level was still low. The stage characteristic of THE was obviously before and after the new medical reform. The proportion of Government expenditure, social expenditure and OOP was optimized to 25:40:35 in 2013, compared with 15:30:55 in 2003. In 2013, the OOP as proportion of THEs was 35.61%, there was a great gap with the target of less than 30%.(2)The growth of government health expenditure was fast, mainly in medical and health services, health care expenditures. After the new health reform, total amount of the social health expenditure was rising, the growth was slowing, mainly used to social medical insurance expenditure, the development of private hospitals and commercial insurance, but the composition of medical insurance expenditure was not reasonable.(3)After the reform of medical system, the growth of individual health expenditure in rural residents was accelerating and faster than the growth rate of urban residents, the burden of health expenditure was heavier than urban residents.(4)From health provider of the THE, after the reform average annual growth rate of pharmaceutical retail agency fees, outpatient expenses was faster, and the growth of expenditure in hospitals, public health, health administration and health insurance agency declined, so the proportion of the cost of drug retail institutions rose.(5)After the reform, proportion of drug in the expenditure of outpatient and inpatient decreased year by year, but the proportion of expenses of drug retail institutions in total drug expenses increased year by year, so there was a certain relationship between the excessive growth of the expenses of drug retail institutions and the implementation of the basic drug system. There was a need for relevant policy intervention on drug sales of drug retail institutions to control its excessive growth.3. Analysis on the Differences of Health Services Demand and OOP between Urban and Rural Households(1)From 2003 to 2013, urban and rural household consumption was divided into 3 stages,2003-2006,2007-2010 and 2011-2013. At every stage, the marginal expenditure of rural households was greater than that of urban Households. The marginal expenditure of urban households was mainly based on transportation and communication, housing and clothing, with rural households gave priority to live and health care.(2)The proportion of Urban (rural) household expenditure raised from 6.51%(7.32%) in 2003 to 9.99%(6.48%) in 2013. The marginal propensity to consume of health services in rural households increased with their income, however, urban families were decreasing at the same time. This indicates that the demand for health services of rural residents had not been met, and their income elasticity of demand was lower than that of Urban Households. In 2010-2013, the price elasticity of demand for rural family health services was-1.1139, which was greater than 1, meaning their need couldn’t be met.(3)The correlation between the amount of health expenditure and income was weak (the correlation coefficient was 0.066 in 2013), however, Income was an important cause for affecting the health of residents, health services utilization and payment capacity. In 2013,16.57% of rural households had no health payment capacity, about 2 times as much as urban households (8.61% in cities and towns), and the family which had no health payment capacity was mainly low-income families.(4)Two-week morbidity among residents overall focused on the poor, with rural concentrated in the poor (CI=-0.1179) and the urban focused on the rich (CI=0.0129). The outpatient service was concentrated in the rich (CI=0.0239), the inpatient service concentrated in the poor (CI=-0.0746). The health of rural residents and the fair of their two weeks outpatient visit were lower than that of the urban. The proportion of rural residents who were not treated and not in hospital due to financial difficulties was higher than that in urban areas.(5)The expenditure on medical and health of urban households was slightly higher than that of rural areas. In the rural area, the poor paid more, however, in the urban area, the rich paid more. The health status of rural residents and the use of health services were even worse. Outpatient expenditure focused on the poor, so the fairness of urban was poorer than that of rural areas. When it came to hospitalization expenses, in the rural area, the rural area was concentrated in the poor, and the urban area was concentrated on the rich, which means the fairness of rural area were worse.(6)Catastrophic health expenditures mainly occurred in households with annual income below 30 thousand. The lower the income, the higher the probability and intensity of catastrophic health expenditure. The probability and intensity of catastrophic health expenditure in rural households were 24.82% and 5.70%, higher than that of cities and towns (19%,3.30%).4. The prediction analysis on the influence factors of THE growth(1)The change of outpatient fee per time had the most influence on the THE. The indicators like the number of inpatient cases, population change of 65+and the GDP had weaker influence on THE. And outpatient visits had the weakest influence on THE. (The cointegration index were 29.95596,4.564916,1.175329,1.096597,0.026829 respectively). And indicators including GDP per capita, population, inpatient fee per time had no outstanding relationship with THE.(2)It is estimated that in’13th Five-Year Plan’ period, the growth of government health expenditure and social health expenditure in THE in health spending, financing structure of social health expenditure in the government will maintain a growth rate of 17.19% and 20.45% respectively, in the contrast, personal health spending growth will decline. From the change of these three proportions, government health spending rose significantly, which will occupy 32.94%-33.08% in 2020, and the proportion of public health spending rose slightly, which almost reaching the largest proportion of space will consistent 40%-40.83% in 2020, and the proportion of personal health expenditure maintain a downward trend which is excepted to 26.09%-27.51% in 2020. Total health costs are expected to grow at an average annual rate of 15%-16.9%, which is slightly higher than the average annual growth rate in 12th Five-Year, and the health consumption elasticity is about 2. In the context of economic development into the new normal, health total cost growth rate comparing to GDP growth rate will reach the maximum value of normal growth. In 2020, the proportion of total health cost in GDP will reach to 6%—6.28%, which up by 2% compared with 2013(4.11%), with average annual increase of 0.3 percentage points.Conclusions and policy recommendations1. The New Situation(1) The requirements for achieving comprehensive well-off need health, universal health care, elimination of burden of disease, prevention ’being into poverty by illness’ are the guarantee for the health.(2) The new normal economic development, raising funds for the total health expenses and the government health spending pressure require us must deal with the relationship between government health investment and economic growth.(3) With the trends of population aging, the new family planning policy, the higher requirements for the health service ability will be put forward.(4) Under the background of the new urbanization, the development of equity between the urban and rural areas is the key element to balancing urban and rural development.2. Research Conclusions(1) The macro environment:Slowing pace of economic development restricts the scale of fiscal revenue and expenditure, total expenditure on health financing. Facing the aging population and more retroflex trends, we asked for better health services for the aged, supply of health care and family childcare services. With the rapid growth of demand for health services utilization, medical personnel’s work load is increasing. We must strengthen the cultivation of medical talent and medical personnel training. Although the proportion of drug expenses in out-patient and hospitalization fees declined dramatically, compared with that before Health Care Reform, outpatient fee and inpatient fee per time remain relatively fast growth. It is necessary to rationally controlling medical costs.(2) The level of THE in Shandong province was still relatively low, however, the proportion of personal health expenditure in the financing structure was still high. Medical insurance cost and Social cost of government health spending and social health expenditure in Health Financing had raised fast after medical reform, but the distribution of medical insurance cost in different medical insurance system was not reasonable and the structure of the social cost of medical services need to be optimized. The proportion of the city hospital cost of fund flow in THE was down, with county hospital cost raised and drug retail agency cost grew too fast. Overall, the growth of THE was mainly influenced by the technology of health services and the economic growth, and the impact of population growth on it was still low. During’13th Five-Year Plan’, the composition and growth of THE is mainly based on the growth of government health expenditure, the proportion of social health expenditure is low and personal health spending will continue to decline, and the highest expenditure was social health in the total cost.(3)With the increase on income, rural household health services needs had been partially met, but the level of satisfaction was lower than that of urban households. After health care reform, the growth rate of personal health spending in rural areas was faster than that in urban areas. The health of rural residents, outpatient services, hospital services, medical and health expenditures and other aspects of fairness was worse than urban residents. Rural families, low-income urban and rural families had poor health payments, and the incidence and intensity of catastrophic health expenditure were high.3. Policy Suggestions(1) In order to deal with the situation of’children, ageing’, we need to pay attention to enhance the ability of health service supply.(2) We should improve the level of health financing and optimize the distribution of health expenditure. Firstly, facing the economic a new normal development, we need to keep the economic growth, raise spending and fiscal deficits appropriately, increase government health spending and raise the level of financing of health costs. Secondly, we should optimize the structure of government and social health expenditure, increase the health-care spending of government and social health expenditure and the structure of social medical insurance expenditure and social medical spending.(3) To enhance disease prevention and control, control the growth of health costs which is not reasonable and curb soaring retail drug price.(4) Under the influence of double-deck structure of urban and rural areas,’increase income and shake off poverty’ is the key to alleviate the residents’ economic burden of diseases, to promote health equity of urban and rural residents.(5) To improve healthcare system design, guarantee urban and rural residents share the fairness of public policy. Firstly, to narrow the unfairness among different health-insurance systems, reduce the funding gap and increase the individual proportion. Secondly, through the insurance policy of’financing and compensation by different cases’,we should raise the low-income’s level of basic medical insurance. |
PDF Full Text Request