Health financing systems & drug use in rural China

Abstract: This thesis airns to study the association between health-care financing systems and health-care consumers' drug use and health providers' prescribing in six Chinese counties. In a cross-sectional study, a multistage sampling procedure was used to select provinces, counties, townships and villages. A simple random sampling rnethod was used to select health facilities. A quota sampling rnethod was used to select outpatients and a systematic sampling method to select providers. Face-to-face outpatient interviews and health provider survey were carried out in 1995. Outpatients were interviewed by trained interviewers using questionnaires. Health provider were asked to fill out self-administered questionnaires. The findings of this study suggest that there is an association between health-financing systems and patients' drug use, care-seeking behaviour, and health providers' prescribing. The uninsured patients had a significantly higher average number of drugs per visit. and were prescribed antibiotics to a significantly higher degree than the insured, a small proportion of them using newer antibiotics. The insured patients, however, had significantly higher average medical (drug) costs than the uninsured. Most health providers were of the opinion that the patients' insurance was related to their prescribing of treatment, that a bonus in relation to the revenue from drug prescriptions provided an incentive for providers to over-prescribe, and that the insured patients had a better access to expensive drugs and were to a greater extent referred to specialised health facilities. Health providers' choice and use of drugs were influenced by the market factors. In 1994, more insured patients than uninsured were hospitalised at the suggestion of a doctor. A logistic regression analysis showed that only 'out-of-pocket' payment influenced the proportion of hospitalised patients and that the influence was negative. The fee-for-service- based insurance led to a higher growth of health care cost, to a shift from preventive to curative medicine and to a higher level of tertiary Curative care cost. It also induced a higher per capita consumption of drugs. It was found that the uninsured patients received more drugs at lower drug Costs per visit than the insured. This implies that they received cheaper drugs than the insured. The insured patients, however, had a better access to expensive drugs and treatment. This implies that the uninsured patients do not have the same access to health care for similar needs. The findings from the health provider Survey and from tile patient interviews and prescription analyses in the same health facilities are consistent. In conclusion, the health-care financing systems appear to influence patients' drug use and health providers' prescribing. Insured patients have significantly higher average medical (drug) costs per visit, and better access to expensive drugs and treatment such as hospitalization than uninsured. Health providers' prescribing are influenced by patients' insurance status and financial abilities, bonus payment mechanism, and market factors. The fee- for-service-based insurance leads to a higher growth of health care cost, to a shift from preventive to curative medicine and to a higher level of tertiary curative care cost. It also induces a higher per capita consumption of drugs. Efficiency and equity in access to health caee are the two important aspects of China's new health policy. In order to realize the new policy China should finance health services by different benefitpackages within social insurance financed by general tax, employers and individuals in tile urban and also in the rural areas.