Person:

Su, Yanfang

Background: The phenomenon of inequitable healthcare utilization in rural China interests policymakers and researchers; however, the inequity has not been actually measured to present the magnitude and trend using nationally representative data. Methods: Based on the National Health Service Survey (NHSS) in 1993, 1998, 2003, and 2008, the Probit model with the probability of outpatient visit and the probability of inpatient visit as the dependent variables is applied to estimate need-predicted healthcare utilization. Furthermore, need-standardized healthcare utilization is assessed through indirect standardization method. Concentration index is measured to reflect income-related inequity of healthcare utilization. Results: The concentration index of need-standardized outpatient utilization is 0.0486[95% confidence interval (0.0399, 0.0574)], 0.0310[95% confidence interval (0.0229, 0.0390)], 0.0167[95% confidence interval (0.0069, 0.0264)] and −0.0108[95% confidence interval (−0.0213, -0.0004)] in 1993, 1998, 2003 and 2008, respectively. For inpatient service, the concentration index is 0.0529[95% confidence interval (0.0349, 0.0709)], 0.1543[95% confidence interval (0.1356, 0.1730)], 0.2325[95% confidence interval (0.2132, 0.2518)] and 0.1313[95% confidence interval (0.1174, 0.1451)] in 1993, 1998, 2003 and 2008, respectively. Conclusions: Utilization of both outpatient and inpatient services was pro-rich in rural China with the exception of outpatient service in 2008. With the same needs for healthcare, rich rural residents utilized more healthcare service than poor rural residents. Compared to utilization of outpatient service, utilization of inpatient service was more inequitable. Inequity of utilization of outpatient service reduced gradually from 1993 to 2008; meanwhile, inequity of inpatient service utilization increased dramatically from 1993 to 2003 and decreased significantly from 2003 to 2008. Recent attempts in China to increase coverage of insurance and primary healthcare could be a contributing factor to counteract the inequity of outpatient utilization, but better benefit packages and delivery strategies still need to be tested and scaled up to reduce future inequity in inpatient utilization in rural China.

Objective: With a quasi-experimental design, this study aims to assess whether the Zero-markup Policy for Essential Drugs (ZPED) reduces the medical expense for patients at county hospitals, the major healthcare provider in rural China. Methods: Data from Ningshan county hospital and Zhenping county hospital, China, include 2014 outpatient records and 9239 inpatient records. Quantitative methods are employed to evaluate ZPED. Both hospital-data difference-in-differences and individual-data regressions are applied to analyze the data from inpatient and outpatient departments. Results: In absolute terms, the total expense per visit reduced by 19.02 CNY (3.12 USD) for outpatient services and 399.6 CNY (65.60 USD) for inpatient services. In relative terms, the expense per visit was reduced by 11% for both outpatient and inpatient services. Due to the reduction of inpatient expense, the estimated reduction of outpatient visits is 2% among the general population and 3.39% among users of outpatient services. The drug expense per visit dropped by 27.20 CNY (4.47 USD) for outpatient services and 278.7 CNY (45.75 USD) for inpatient services. The proportion of drug expense out of total expense per visit dropped by 11.73 percentage points in outpatient visits and by 3.92 percentage points in inpatient visits. Conclusion: Implementation of ZPED is a benefit for patients in both absolute and relative terms. The absolute monetary reduction of the per-visit inpatient expense is 20 times of that in outpatient care. According to cross-price elasticity, the substitution between inpatient and outpatient due to the change in inpatient price is small. Furthermore, given that the relative reductions are the same for outpatient and inpatient visits, according to relative thinking theory, the incentive to utilize outpatient or inpatient care attributed to ZPED is equivalent, regardless of the 20-times price difference in absolute terms.

Measuring health through surveys is challenging. Participants may respond in a socially favorable but untruthful way, and responses across respondents may be difficult to compare. List experiments and anchoring vignette techniques have been proposed to improve survey measures, and this dissertation applied qualitative and quantitative methods to evaluate either the usefulness or validity of those techniques. The first paper explored how list-based questions perform compared to direct questions when measuring two behaviors, smoking and intravenous infusion use. The difference-in-differences between the two survey methods and two behaviors was non-significant. List experiments might introduce downward biases rather than alleviate them due to cognitive difficulty in responding. The second paper applied cognitive interviewing to the design of vignettes among Chinese students with objectively different visual acuities. Ten major problems were identified regarding vignette comprehension, judgment, and responses. Respondents rated vignette character’s vision differently from their own, demonstrating a norm of being “strict with oneself and lenient towards others” in an Asian context.
The third paper assessed the validity of three vignette survey methods (i.e., indirect comparison between self and vignettes, direct comparison between self and vignettes, and self-assessment primed by vignettes) in measuring distance vision. Surprisingly, it was found that vignette methods were not improvements over self-assessment, and indirect comparison performed the worst.
These three studies shed light on a series of cognitive difficulties related to advanced survey techniques. Traditional self-assessment may be as useful as the list experiment and more valid than some anchoring vignette techniques in these studies’ context.