Evaluating the effect of health insurance reform on health equity and financial protection for elderly in low- and middle-income countries: evidences from China

Wang and Xiang Globalization and Health (2024) 20:57 https://doi.org/10.1186/s12992-024-01062-8 Globalization and Health Open Access RESEARCH Evaluating the effect of health insurance reform on health equity and financial protection for elderly in low- and middleincome countries: evidences from China Hongzhi Wang1 and Xin Xiang2* Abstract Background To achieve Universal Health Coverage (UHC), China have implemented health system reform to expend health coverage and improve health equity. Scholars have explored the implementing effect of this health reform, but gaps remained in health care received by elderly. This study aims to assess the effect of implementing health insurance payment reform on health care received by elderly, as well as to evaluate its effect on cost sharing to identify whether improve financial protection of elderly under this reform. Methods We identified hospitalization of 46,714 elderly with cerebral infarction from 2013 to 2023. To examine the determinant role played by DRGs payment reform in healthcare for elderly and their financial protection, this study employs the OLS linear regression model for analysis. In the robustness checks, we validated the baseline results through several methods, including excluding the data from the initial implementation of the reform (2021), reducing the impact of the pandemic, and exploring the group effects of different demographic characteristics. Results The findings proposed that implementing DRGs payment reduces drug expenses but increases treatment expense of chronic disease for elderly in China. This exacerbates healthcare costs for elderly patients and seems to be contrary to the original purpose of health care reform. Additionally, the implementation of DRGs payment reduced the spending of medical insurance fund, while increased the out-of-pocket of patients, revealing a shift in health care expenses from health insurance fund to out-of-pocket. Conclusions This study shares the lessons from China’s health reform and provides enlightenment on how to effective implement health reform to improve health equity and achieve UHC in such low- and middle-income countries facing challenges in health financing. Keywords Health insurance reform, Elderly, Health equity, Financial protection, Out-of-pocket *Correspondence: Xin Xiang 1 Research Center of Hospital Management and Medical Prevention, Guangxi Academy of Medical Sciences, The People’s Hospital of Guangxi Zhuang Autonomous Region), Nanning, China 2 Institute of Fiscal and Finance, Shandong Academy of Social Sciences, 56 Shungeng Road, Jinan 250000, Shandong, China © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it.The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.To view a copy of this licence, visit http:// creativecommons.org/licenses/by-nc-nd/4.0/. Wang and Xiang Globalization and Health (2024) 20:57 Introduction Universal Health Coverage (UHC) which means individuals have obtain the high quality health care they need without suffering financial hardship, is the key to achieving the World Bank Group’s (WBG) twin goals of ending extreme poverty and increasing equity and shared prosperity, as well as the core element of Sustainable Development Goals (SDGs) adopted by the United Nations [1–4]. World Health Organization (WHO) and World Bank are calling on governments to prioritize investments in building resilient health systems to safeguard the health and well-being of all people and establish the UHC targeting that at least 80% health coverage of essential health care and 100% of financial projection by 2030 for all countries [5]. To achieve UHC, many countries, especially low- and middle-income countries (LMICs), implement health system reform to expend health coverage and improve health equity [6–10]. One of the most significant reform initiatives is that health systems in LMICs are undergoing reforms from retrospective payment to prospective payment systems by implementing Diagnosis related groups (DRGs) [11]. Such vulnerable populations as elderly, children and low-income groups, were paid more attention in those reforms. DRGs payment, as the most popular payment system, originated in the United States and first implemented in the 1980s [12], is essentially a case mix classification scheme, which comprehensively considers the main diagnosis, additional, surgical operation, complications, age and other factors of each case to classify and combine the cases into categories, and the fixed payment of each category is payable in advance to hospital based on the DRGs classifications [13–15]. Early stages of DRGs payment were implemented in high-income settings with rich health resources [12] and showed evidences to stimulate healthcare providers towards greater efficiency through controlling costs, improving financial protection, reducing length of stay and enhancing healthcare quality in those countries [15–17]. In the recent years, to improve the efficiency and quality of healthcare, health systems in many LMICs have undergone reforms from retrospective payment to prospective payment systems by implementing DRGs such as Thailand, Ghana, Serbia, and China [11, 18–20]. However, empirical evidences in LMICs reported mixed outcomes. For example, study from Thailand indicated DRGs payment system significant reduce health cost and admission to higher level institutions, while Ghana’s evidence suggested implementing DRGs payment has the potential risk of guiding patients to over-treat and enter higher payment groups [19, 20]. Hence, more evidences directly related to health equity and financial protection from LMICs should receive significant attention, especially for vulnerable populations. Page 2 of 14 Elderly populations, due to their health and socioeconomic status, have higher rates of health care utilization than other age groups, and also suffer more health inequities and financial hardship [21–24]. China has the world’s largest and most rapidly-ageing population and is facing ongoing unique challenges in addressing elderly population health [25, 26]. The mismatch between large population and limited medic (...truncated)