Academic journal article Bulletin of the World Health Organization

Giving Birth at a Health-Care Facility in Rural China: Is It Affordable for the poor?/Donner Naissance Dans Un Etablissement Medical En Chine Rurale: Les Pauvres Peuvent-Ils Se le permettre?/Dar a Luz En Un Centro Sanitario De Una Zona Rural De China: ?Resulta Asequible Para Los Mas Pobres?

Academic journal article Bulletin of the World Health Organization

Giving Birth at a Health-Care Facility in Rural China: Is It Affordable for the poor?/Donner Naissance Dans Un Etablissement Medical En Chine Rurale: Les Pauvres Peuvent-Ils Se le permettre?/Dar a Luz En Un Centro Sanitario De Una Zona Rural De China: ?Resulta Asequible Para Los Mas Pobres?

Article excerpt

Introduction

In China, the number of women giving birth at a health-care facility is used as a target indicator for measuring progress towards improved maternal health. (1) The proportion of deliveries attended in health-care facilities varies across geographical areas and according to family wealth: in 2003, about 94% of urban women in China gave birth at a health-care facility. This is 1.4 times the proportion in an average rural area and 3 times that in poor rural areas. (2) In addition, giving birth at a health-care facility was four times more common among the richest 20% of women than among the poorest 20% (Z Wu, unpublished data, personal archive, 2010).

A limited ability to pay and high hospital costs have been identified as the major barriers for the rural poor wishing to access healthcare in China. (3) Following the demise of the rural Cooperative Medical Scheme in the 1980s, which occurred with the marketization of the rural economy, large sections of the rural population were left without health insurance cover. (4) In addition, China's health-care system was decentralized in the 1980s and the central budget dropped to 10% of total expenditure. (5,6) Health-care facilities now rely on user fees to cover their running costs and the result has been a rapid increase in medical costs. (3)

Data from the Chinese Ministry of Health show that fee-for-service income accounted for 82% of the total revenue of maternal health-care institutions in rural China in 2002. (7) Delivery is the most costly part of maternal care, and expenditure can be especially high for emergency obstetric care. (8) Unexpectedly high expenditure on a delivery can push a family into poverty.

In 2003, a new rural health insurance programme, the New Cooperative Medical Scheme, was introduced with the aim of reducing the risk that health-care costs could become catastrophic for some individuals. The scheme operates on a voluntary basis and uses funds pooled from central and local government and from individual contributions. (4) The county (typical population: 0.5-1 million) forms the administrative unit of the scheme and the risks associated with illness are shared across the unit. The county government can decide the content, coverage and reimbursement model most appropriate for local conditions, although the Chinese Ministry of Health is responsible for developing overall strategies and policies. In 2008, 92% of the rural population were enrolled in the New Cooperative Medical Scheme. (9)

The New Cooperative Medical Scheme includes a maternal care benefit package that differs in design and implementation across counties. Usually this package provides reimbursement for delivery at a health-care facility, either as a fixed proportion of expenditure or as a fixed payment. Reimbursement may be the same or different for vaginal and Caesarean delivery.

The aims of this study were to investigate changes in expenditure on facility-based delivery in rural China between 1998 and 2007, to examine the financial burden on households, in particular on poor households, and to identify factors associated with out-of-pocket expenditure on facility-based delivery.

Methods

The study was based on cross-sectional data from national household health service surveys conducted in 2003 and 2008 by the Centre for Health Statistics and Information of the Chinese Ministry of Health. For our analysis, only the rural component of the data set was used. Both surveys employed the same four-stage, stratified, random sampling procedure involving counties, townships, villages and households. Ten indicators of socioeconomic development were used to classify each county's level of development as being in one of four categories: developed, relatively developed, less developed or poor. The probability proportional sampling method was used to randomly select counties for each development category; then, five townships were selected from each county and two villages from each township. …

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