| BackgroundAs the development of social economy and the improvement of living standard, the changes in life style and diet structure, environmental deterioration, accelerating ageing etc. bring about significant changes in the spectrum of diseases in our country. Non-communicable chronic diseases (NCDs) are becoming the main threat to the health of rural residents. In2008, the number of chronic cases was260million and was increasing by10million new cases each year. Among them, cases with hypertension and diabetes increased by2times. Due to high prevalence, multi-complications, long duration of treatment and bad prognosis, NCDs patients and families need to pay substantial medical expenses, resulting in heavy economic burdens. The World Health Organization estimated that the direct medical expenses will exceed500billion US Dollars. Especially for rural households, NCDs'medical expenditure increases much faster than their income, which further magnifies economic shocks of disease risk towards rural residents, so that their families face tremendous NCDs'financial risk. Against this risk, rural residents and their households have already formed a serious of risk management strategies, one of which is rural cooperative medical care system (NCMS), the principal medical scheme in rural areas. Its core function is to protect farmers from being inflicted by disease financial risk.The generation and development of the disease financial risk is a successive process, which will be affected by all kinds of risk factors in this process, so that researches on disease financial risk and its management should be based on this whole process. However, most researches on disease financial risk management stand in the perspective of responding after risk happened. So far, there has been no systematic research on the generating path, level, distribution and determinants of rural resident and their households'financial risk due to NCDs, as well as influencing factors on each part of the whole process. Besides, it lacks empirical analysis of NCD's financial risk management strategies from risk prevention, mitigation and coping with the application of Social Risk Management framework.At the background of continuously increasing NCDs prevalence and medical expenses in rural areas of our country, inadequacy of capacity to respond to disease financial risk, and farmers'being into or back into poverty by illness, it's of great significance to explicit generating path of rural resident's NCDs financial risk, measure financial risk level resulted by NCDs, analyze influencing factors on risk and inspect the risk management strategies of rural residents/households, NCMS's function to reduce disease financial risk in particular.ObjectivesGeneral objective of this study is to systematically research on rural residents'NCDs financial risk, disentangle its generating path, explicit its level and influencing factors among rural residents and their households by means of reviewing, summarizing domestic/abroad research results and analyzing data from field survey, in order to propose policy implications reducing rural residents'financial risk due to NCDs. Specific objectives includes:to build the theoretical framework of NCDs financial risk's generating path and its management; to analyze the influencing factors of each part of this path, to measure the level of rural residents and their households'financial risk due to NCDs, explore the determinants of NCDs financial risk; investigate NCDs financial risk management strategies of rural residents, especially NCMS's function to reduce risk; to make policy suggestions for managing rural residents'NCDs financial risk.Data and MethodsThe data source of this study relied mainly on literature review and field investigation. Through the review of the literature, this analysis introduced the concept of financial risks due to NCDs, summarized its commonly used evaluation indicators and summed up the affecting factors and analytical methods. In addition, the study proposed the theoretical framework of generation path and risk management of the NCDs based on the conceptual frame of social risk management. The study employed a stratified random sampling method, with3counties of Jinan selected. Within each county,18villages spread across3townships were selected to participate in the survey. About20households were randomly selected per village, resulting in a total sample of3458rural residents in984households as respondents. This survey mainly included family general information, basic situation of family members and situation of health service demand and utilization of chronic diseases of the previous year before survey. Data analysis methods were mainly descriptive analysis, univariate analysis and multivariate analysis (including Two-part model, Non-conditional Binary Logistic regression analysis, Multivariate Linear Regression Analysis). The Statistical analysis software used was SPSS15.0for windows.Results1. Rural Residents'NCDs Prevalence, Treatment, Costs and their Determinants The prevalence rates calculated on the basis of number of NCDs patients and number of cases was19.38%and23.34%, respectively, both of which were higher than the NCDs prevalence rate from the national health services survey in2008. Rural residents in the sampled areas were facing higher risk of NCDs. Circulatory system diseases were the most important constitute of NCDs among sampled population (47.21%), in which the prevalence rate of hypertension was the highest. Multivariate analysis of NCDs prevalence rate indicated that advanced age and alcohol abusing were risk factors, while higher income, higher education level were protective factors. During the year before survey, the treatment rate of NCDs cases was88.23%, self treatment rate was48.17%, non-treatment rate was11.77%, and the rate of non-hospitalization was1.73%. Financial hardship is the main factor of non-treatment and non-hospitalization for chronic cases. The average annual treatment costs on NCDs was1534.79RMB, among which per capita inpatient and outpatient treatment cost were648.75and624.44RMB, respectively, while the medicine cost in drugstore was the least (261.60RMB).The two-part model analysis of NCDs treatment rate and cost indicated that perceived health status and the type of system diseases were significant affecting factors. The treatment rate and cost of patients whose perceived health status was poorer were higher than those with better health status. The treatment rate and cost in circulatory system diseases, digestive system diseases, endocrine system disease and other system diseases were higher than musculoskeletal system diseases and connective tissue diseases. In addition, health service accessibility (whether the nearest medical institution was within200meters) had a significant effect on the NCDs treatment rate, while no significant effect on the treatment cost.2. Rural Residents'Financial Risk due to NCDs and its Determinants(1) Financial risk of chronic cases and their familiesThe income of chronic patients and their families was lower than the average level of the sample while health expenditure was higher than the average. The relative financial risk of chronic cases is2.50times of the total sample (adjusted RR=2.50), and the low-income group had the highest relative risk (adjusted RR=5.71). During the past year,50.28%of the chronic cases who had treatment were in the higher financial risk due to costs of treatment;20.68%of the households with chronic patients had experienced catastrophic health payments due to the cost of NCDs treatment, while the mean gap and mean positive gap were10.28%and49.73%, respectively, the concentration index of catastrophic health payments was-0.314, which indicated that catastrophic health payments were more likely to occur in families with lower income.(2) Determinants of financial risk of chronic patients and their familyMultivariate analysis showed that income, perceived health status, hospitalization and the category of diseases are significant factors influencing NCDs cases'financial risk. The probability of higher financial risk decreased with the increase of income; cases with worse and normal perceived health status have higher probability of financial risk than better health status (Odds Ratio=2.256). Cases who had hospitalization in the past year had higher probability than non-hospitalization cases. The probability is significantly different among different types of system diseases, and cases with musculoskeletal system and connective tissue diseases had lower risk. Significant factors influencing the probability of catastrophic health expenditures in households with chronic patients were the household's total population, the number of chronic patients in the family, whether hospitalized or not, household income, county and the occupation of the household head. Headcount of catastrophic health payments decreased with the increase of the household's total population and income, and increased with the number of chronic patients in households. Those households with patients who had hospitalized in the past year had higher probability of catastrophic health payments. The incidence of catastrophic health expenditures was different among counties and Zhangqiu had the lowest incidence. Those households which the head of household is farmer had higher incidence than non-farmers.3. Rural Residents'Risk Management Strategies of Financial Risk due to NCDs(1)Risk Prevention Strategies:smoking rate of NCDs cases (18.98%) and excessive alcohol consumption rate (16.98%) was slightly higher than the average rate of sample population (18.28%,14.40%). Sanitation situation of households with NCDs cases was inferior to that of sample households. Proportion of tap water (76.88%) and clean energy (47.43%) of households with NCDs was lower than sample households. During the year before the survey, only29.06%(1005) of the sampled population and33.21%of NCDs cases received free medical examination from NCMS.(2)Risk Mitigation Strategies:Income resource diversification index of households with NCDs (0.570) was slightly lower than that of sampled households (0.585).The proportion of chronic disease household with deposit (34.21%) was lower than that of sample households (36.59%). The average household population of households with NCDs was slightly higher than that of sample households, but the number of working age population and the self-inductance of health status was lower than that of sampled households. Treatment of chronic disease cases in the past year was88.23%, self-medication was48.17%, no treatment was11.77%; the rate of chronic disease families joining NCMS was99.06%, slightly higher than that of sample households (98.48%).72.62%of the cases were compensated by NCMS, the actual compensation rate of NCMS was10.42%; NCMS made4.77%of cases of chronic disease get rid of the high-risk status, the degree of incidence of high economic risk level decreased by9.49%;the NCMS compensation let3.20%of chronic disease families flee from catastrophic health expenditure, and the incidence of catastrophic health expenditure dropped by15.47%, the average gap and the relative gap declined by1.44%and6.95%, respectively, a drop of13.97%.(3)Risk Coping Strategies:Using cash or deposits of their own family (informal mechanisms) was the main strategy of households with NCDs patients to cope with NCDs treatment costs (96.78%of households with NCDs paid for medical expenses by cash or deposit), the use of other formal and informal coping strategies was less than5%. The main source of NCDs treatment costs was Out-of-pocket of the households, accounting for77.13%of total costs. Only3%of the costs were from the formal risk coping mechanism, including medical assistance and commercial insurance.Conclusions and Policy ImplicationsRural residents'NCDs prevalence rates and treatment rates were higher in the sample region. NCDs treatment costs and its financial risks to NCDs cases and families were high; Advanced age, excessive drinking were risk factors of NCDs prevalence; Higher education level and higher income were protective factors; Perceived health status and types of system disease were significant factors which affected NCDs treatment probability and costs; Health service accessibility was also affecting factor of NCDs treatment rates, and economic hardship was an important reason for NCDs cases not to use health services. Income level, whether using hospitalization services, perceived health status and types of system disease were significant factors affecting chronic cases'financial risk; While household income, the household's total population, the number of NCDs patients, whether there were hospitalized patients in the household and the career of householders were significant factors of the probability of households'catastrophic health expenditure. As to rural residents'financial risk management strategies for chronic disease, prevention strategies were not emphasized, mitigation strategies had a limited effect, and the compensation capacity of NCMS, which is the main formal means in coping strategies, is inadequate for sharing the NCDs cases of and their families'financial risk. Based on the above findings, we propose a three-level management model for NCDs financial risk which includes prevention, mitigation and coping strategies:Risk prevention:(1) to strengthen publicity and education of chronic disease-related knowledge, to promote active and healthy lifestyle to minimize the prevalence of NCDs, to fundamentally prevent financial risks caused by NCDs;(2) to include physical examination in NCMS compensation range, to conduct physical examination for residents and establish health records, and undergo systematic management for chronic patients, to prevent exacerbations and prevent complications.Risk mitigation:(1) to continue to expand the NCMS coverage, further improve the NCMS funding levels, and change the "first pay, then get reimbursement" process;(2) to gradually incorporate NCDs into NCMS arrangement for serious diseases, to further improve the standard of chronic disease hospital compensation;(3) to guide patients to a reasonable medical treatment, full use of primary health services, reduce chronic disease treatment costs;(4) to promote the development of formal mitigation mechanisms based on market, e.g. commercial insurance;(5) to encourage rural residents to engage in multiple income sources and increase their income to disperse financial risk due to NCDs.Risk coping:(1) to fulfill the joint development and effective interface of medical assistance system and NCMS;(2) to promote the development of formal coping mechanisms based on market, e.g. credit institutions;(3) to expand the role of informal risk-coping mechanisms of social networks.
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