published_or_final_version / Community Medicine / Master / Master of Research in Medicine

In 2009 China launched an ambitious health care reform to ensure equal and affordable access to basic health care for all by 2020. The reform was not only a response to changing patterns of disease, rising health expenditures, and widening regional inequalities, but part of a wider strategy to improve the social security system covering residents in order to increase domestic consumption. Its success will be defined by the efficient use of funds in financing and delivering health care. Against this backdrop, this dissertation evaluates the importance of health insurance characteristics on measures of financial risk protection, household saving and consumption, and preference for health care providers. It uses an experimental design to study the effect of more generous outpatient coverage and a tiered reimbursement structure that sets rates higher at primary care facilities than tertiary hospitals. While middle income households benefitted most in terms of financial risk protection, poorer and sicker households increased utilization at primary care facilities and food consumption – two pathways by which health insurance can improve health outcomes. This suggests that as outpatient coverage improves those most vulnerable will increase their access to health care, where there was previous underutilization, but not necessarily see an improvement in financial risk protection. The increased cover would also offer greater protection for those already using healthcare, but on its own not necessarily change their utilization patterns or reduce household savings. Looking at the quality-price trade-off in choice of provider reveals that, while at lower levels of household consumption demand for outpatient care is elastic with respect to price, as living standards rise past subsistence, individuals begin to value other provider characteristics. Together, these findings highlight the importance of benefit design and quality improvements at lower levels of care to shift patterns of utilization and ensure health services are accessed cost-effectively.

published_or_final_version / Public Administration / Master / Master of Public Administration

The background variables, GDP per capita, marketization, industrialization and urbanization are used to control different levels of development across provinces. The role of the state is measured in the following ways. First, financial capacity, administrative capacity and coercive capacity are used to measure the role of state capacity in BMI extension. The study examines whether there is a difference in choosing different agencies to collect social insurance premiums: one is local taxation agency and the other is social insurance agency. Third, the performance of BMI is measured through the deposit rates of BMI funding which reflects governments' ability to manage the BMI program. In the current policy, employers are charged largely the social insurance fees. So their willingness and capabilities to pay will affect BMI coverage. The study investigates two kinds of employers: loss making State-Owned-Enterprises (SOE hereafter) and Foreign Invested Enterprises (FIE hereafter). On the employee's part, the percent of informal employment in total urban employment is used to measure the effect of adverse employment conditions on BMI coverage. Trade union density is used to estimate the labor organization strength. / The complicated process of extending coverage is related to three major stakeholders: state, employers and employees. These three stake-holders influence BMI progress. Also, the background factors (such as the economic growth) should be taken into account for the regional variations in development level. Since BMI is a typical social policy field, this study reviews major theories about social policy development: logic of industrialism, power resource theory and state-centered approach and so on. These theories help organize pieces of phenomena into a unified framework and testable hypotheses are also derived. / The contributions of this study can be twofold. First, from the theoretical aspect, this research tests several welfare state development theories using Chinese data. In this way, it does not only expand the scope conditions of theories, but also improves our understanding of the social policy development in China, an outlier of traditional western democracies. Second, this study tests some controversial issues on BMI development and the research findings provide knowledge support for the policy practice in the real world. / The low coverage of social health insurance is one of the causes of the problems in Chinese health care system which is criticized for the rising health cost, large share of out-of-pocket payments and health inequality issue. The Basic Medical Insurance for Urban Employees (BMI hereafter) was chosen as the subject of my investigation. It was established in 1998 for the working population and till now it has not achieved universal coverage yet. The Basic Medical Insurance for Urban Residents (BMI-R hereafter) was started in 2007 and it is still in pilot stage, therefore data are still inadequate. In rural areas, the New Cooperative Medical Scheme (NCMS hereafter) achieved almost full coverage in 2008. Thus extending coverage is not issue at concern for NCMS. Besides, the NCMS data at province level are quite limited. Considering the stages of policy development and data access, BMI-R and NCMS are not included in this study. / The proportion of winning lawsuit in labor disputes is used to measure the function of labor protection system. This study adopts the panel method. Data is ranging from the year 1999 to 2005 and the unit of analysis is province/year. They were collected from various official statistics and constructed into a panel database which can trace the development of BMI from its origin to most recent situation. / The research question is what are the determinants of BMI's coverage? It is originated from some puzzling observations: the NCMS achieved full coverage in four years and it is a voluntary participation insurance program. On the contrary, why the mandatory BMI did not reach universal coverage after almost ten years' development? Besides, the progress of BMI across different provinces varied greatly. Given the policy designing and starting points are rather similar, how can we explain these variations? / The research yields several interesting results. First, the roles of financial capacity and administrative capacity in BMI development are supported by data, especially the social insurance agency. Second, results show that using local taxation to collect social insurance premiums has better effects in extending coverage than the alternative approach. This result will give an end to the decade-long debate on choice of social insurance premiums collection agencies. Third, the deposit rates of BMI funding are negatively related with BMI coverage. It implies that governments should improve the performance of BMI so as to attract more people to enroll in this program. Fourth, the union density in the private sector is positively related with BMI coverage. This result disagrees with the conventional wisdom that the Chinese trade unions are useless. It implies that strengthening the organization of employees (even through the official channel) can protect the rights of employees in some degree. / 劉軍強. / Adviser: Cheek-Kie Wong. / Source: Dissertation Abstracts International, Volume: 73-03, Section: A, page: . / Thesis (Ph.D.)--Chinese University of Hong Kong, 2009. / Includes bibliographical references (p. 198-222) / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [201-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in Chinese and English. / Liu Junqiang.

伴隨著改革開放開始的中國醫療改革由於受到過度市場化的影響，一直在質疑聲中前行。進入21世紀，社會醫療保障制度改革標誌著中國醫改「健康公平」之路的回歸。然而，在公平正義不斷被強調的口號背後，對「健康公平」的理論界定與實證研究仍然相對匱乏。 / 本研究從「弱者優先」的社會公義理論出發，重新將「健康公平」理論界定為「基於社會公義的健康平等」。研究員立於足后實證主義研究範式，綜合運用質化與量化研究方法，結合一手與二手數據分析，以浙江省為研究場域，探索以社會醫療保險改革為核心的醫療福利制度改革，對老年人「健康公平」所造成的影響。最終，確立了「底層健康公平」的價值選擇，並發展了多元健康公平的理論框架。 / 透過量化研究的主要發現，研究員的結論是要將健康公平問題從「機會公平」視角轉換為健康「結果公平」。另一重要的結論是不要單一關注社會醫療保險改革覆蓋面的擴大，更應關注不同保險項目之間福利待遇的公平性。透過多元線性回歸分析，研究員發現了醫療保險改革之後影響老年人健康水平的顯著因素：微觀層面的社會經濟地位與慢性病特徵，宏觀層面的保險因素與中觀層面的社會支持網絡。質化研究的採用將「健康公平」的討論從關注客觀的「健康結果」擴展為利益相關者主觀的公平性體驗。質化研究補充了政策制定者、基層醫生與弱勢老年人各自對「健康公平」的理解，進一步回答了「什麽是健康公平」，確立了本研究的底層視角。 / 混合研究進一步回答了社會醫療保險改革對老人「健康公平」的影響：雖然醫療保險改革提高了老人的「機會公平」，但這只是形式公平，改革在推動「過程公平」與「結果公平」這些實質公平的維度尚待探索。在醫療保險改革之後，進一步的路徑分析評估了「醫療服務使用」作為mediator的作用，呈現了與「健康水平」之間的負向因果關係。交互作用分析表明，如若改變弱勢老年人社群在「健康公平」中的弱勢地位，就需要社會醫療保險改革調節「醫療服務使用」與「健康水平」的關係；且澄清了不同社會醫療保險項目作為moderator的差別：城鎮職工基本醫療保險可以改善使用較多醫療服務的老人的健康水平，而新型農村合作醫療則起到相反的作用。在這些變量之間的關係背後，站在「弱者優先」的底層立場上，深入的質化研究補充了社會醫療保險改革對弱勢老人接受醫療服務與享受醫療福利待遇「過程公平」的缺失與「結果公平」的不足。 / 結合以上量化與質化研究發現，本研究識別出了「健康公平」多維度的影響因素（經濟地位、健康地位、社會關係網絡、身份地位、福利地位），建立了包括機會、結果和過程公平在內的多元的健康公平理論框架。並且綜合討論了「健康公平」理論的反思與重構，混合研究方法在評價醫療保障改革公平性實證研究中運用的可行性，並且倡導在政策制定中改變福利觀念，提出了如何進行公平的「全民醫保」政策改革，以及如何實現「以社區為中心的綜合健康服務與長期照顧體系」的政策創新。 / Along with the reform and opening up, the health reform in China had been continously challenged due to its excessive marketization. As the pioneer of a new round of health reform since 21st century, social health insurance reform reiterated ‘health equity’. Nevertheless, neither theoretical nor empirical studies were abundant behind the slogans for the advancement of equity and justice. / This thesis began with theory of social justice based on ‘give priority to the disadvantaged group’, redefining the concept of ‘health equity’ by ‘health equality on the basis of social justice’. Adopting of the paradigm of post-positivism, researcher chose quantitative-and-qualitative mixed method, and combined analysis of primary data and secondary data. This study has been located in Zhejiang province, intending to explore the impacts of health insurance reform along with health welfare system changes on health equity among the elderly. Researcher finally adopted the value choice of health equity for vulnerable groups, and developed a multi-dimension theoretical framework of ‘health equity’. / From the quantitative research findings, researcher modified the theory of health equity from concerning ‘equal opportunity’ to ‘equal outcome’. This research also contributed to a transition of health insurance studies from emphasis on expansion of ‘insurance coverage’ to the concerns with unequal benefit packages between different social insurance schemes. Multiple linear regression demonstrated significant predictors of older adults’ health outcome after health insurance reform, composing of socio-economic status and chronic disease in the micro-level, health insurance in the macro-level, and social support in the meso-level. Simultaneously, qualitative research explained diversive understandings of ‘health equity’ among policymakers, doctors who provide primary care and vulnerable older adults. The crucial question of ‘what is health equity’ has been answered, and that the ‘give priority to the disadvantaged group’ standpoint being reaffirmed. / Mixed method study further answered the research question of ‘what is impacts of health insurance reform on the health equity among the elderly’: Although health reform improved ‘opportunity equity’ for older adults as a kind of ‘form fairness’, it was still expected to explore other dimensions of ‘essential fairness’, such as ‘process equity’ and ‘result equity’. After health insurance reform, researcher employed path analysis to test mediator effects of ‘healthcare utilization’, which demonstrated negative causal relations with ‘health outcome’. Interaction effect analysis manifested a moderating effect of health insurance reform adjusting the relationship between ‘healthcare utilization’ and ‘health outcome’ with an attempt to improve social status for disadvantaged older groups. Interaction effects of different insurance schemes have been clarified as well: The Basic Medical Insurance for Urban Employees could improve health outcome of the elderly who use more health care services, whereas the New Rural Cooperative Medical Scheme played an opposite function. Under the background of these relations between variables, being standfast in vulnerabe groups’ stand, researcher adopted qualitative data to complement quantitative findings: The lack of ‘process equity’ and the short of ‘outcome equity’ during the process of interpreting accessibility to health care services and utilization. / In this dissertation, researcher also synthetically combined findings in quantitative and qualitative research, identified multiple predict factors of ‘health equity’ (economic status, health status, social networks, identity status and welfare status). All of above mentioned factors jointly composed and enriched multi-dimensional ‘health equity’ theoretical framework (including equitable opportunity, outcome and process). It also profoundly rethought and reconstructed ‘health equity’ theory, and evaluated efficiency and effectiveness of health insurance reform by using mixed research methods. Researcher advocated a transition of welfare ideology in the process of policy making, and recommended an ‘universal health insurance’ reform based on health equity, then initiated a ‘home and community based comprehensive health and long-term care service’ system. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / 劉曉婷. / "2013年3月". / "2013 nian 3 yue". / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 386-422). / Abstract in Chinese and English. / Liu Xiaoting. / 論文摘要 --- p.I / Abstract --- p.III / 致謝 --- p.VI / Chapter 第一部份 --- 研究背景 --- p.1 / Chapter 第一章 --- 導論 --- p.2 / Chapter 第一節 --- 研究的緣起 --- p.2 / Chapter 一、 --- 醫療改革中的公平性失守 --- p.3 / Chapter 二、 --- 醫改糾偏：重建社會公平的改革共識 --- p.6 / Chapter 三、 --- 聚焦老年人：醫療保障改革中的弱勢社群 --- p.10 / Chapter 四、 --- 研究場域：浙江醫改之路 --- p.12 / Chapter 第二節 --- 研究問題的提出 --- p.16 / Chapter 第三節 --- 研究的目標 --- p.19 / Chapter 一、 --- 從理論上對「健康公平」的界定與發展 --- p.19 / Chapter 二、 --- 從實證研究中識別「弱勢老年人」的社會結構、關係網絡與疾病風險特徵 --- p.20 / Chapter 三、 --- 通過混合研究方法探索醫療保險改革與老人健康公平的因果關係 --- p.21 / Chapter 四、 --- 探索建立「健康公平」研究的理論框架 --- p.21 / Chapter 第四節 --- 本文的結構 --- p.24 / Chapter 第二部份 --- 研究準備 --- p.27 / Chapter 第二章 --- 文獻回顧 --- p.28 / Chapter 第一節 --- 平等與公平 --- p.28 / Chapter 一、 --- 平等的主體與客體 --- p.29 / Chapter 二、 --- 公平的價值選擇 --- p.35 / Chapter 第二節 --- 基於社會公義的健康公平 --- p.41 / Chapter 一、 --- 健康公平的界定 --- p.41 / Chapter 二、 --- 健康公平的實現 --- p.48 / Chapter 三、 --- 底線公平 --- p.53 / Chapter 第三節 --- 醫療保險、醫療服務使用與健康水平的關係 --- p.58 / Chapter 一、 --- 文獻回顧與批評 --- p.58 / Chapter 二、 --- 對老年人健康水平認識的發展 --- p.64 / Chapter 第四節 --- 影響健康公平的社會決定因素 --- p.69 / Chapter 一、 --- 社會結構因素 --- p.69 / Chapter 二、 --- 社會網絡因素 --- p.78 / Chapter 第五節 --- 中國社會醫療保險制度改革 --- p.87 / Chapter 一、 --- 中國傳統醫療保障制度及其缺陷 --- p.87 / Chapter 二、 --- 社會醫療保險的道路選擇與發展 --- p.91 / Chapter 三、 --- 醫療保障制度改革對弱勢社群的排斥 --- p.102 / 本章小結 --- p.107 / Chapter 第三章 --- 方法論與反思 --- p.109 / Chapter 第一節 --- 研究範式：對後實證主義的理解 --- p.109 / Chapter 一、 --- 範式與範式轉移 --- p.109 / Chapter 二、 --- 證偽與後實證主義的運用 --- p.112 / Chapter 三、 --- 研究方法的層次與後實證主義的適用性 --- p.116 / Chapter 第二節 --- 混合研究方法 --- p.118 / Chapter 一、 --- 量化與質化研究各自的優缺點 --- p.118 / Chapter 二、 --- 選擇混合研究方法的理由 --- p.121 / Chapter 第三節 --- 分析單位：結構與能動者 --- p.124 / Chapter 一、 --- 結構與能動者 --- p.124 / Chapter 二、 --- 本研究的分析單位 --- p.128 / Chapter 第四節 --- 研究員的自我反省 --- p.130 / Chapter 一、 --- 對研究員個人社會特徵與經歷的反思 --- p.131 / Chapter 二、 --- 對研究員在學術場域中的位置的反思 --- p.135 / Chapter 三、 --- 對整個研究過程和研究方法的反思 --- p.137 / 本章小結 --- p.141 / Chapter 第四章 --- 研究框架與研究設計 --- p.142 / Chapter 第一節 --- 研究框架 --- p.142 / Chapter 第二節 --- 基本概念界定 --- p.146 / Chapter 一、 --- 社會醫療保險 --- p.146 / Chapter 二、 --- 弱勢老年人 --- p.148 / Chapter 三、 --- 醫療服務使用 --- p.149 / Chapter 四、 --- 健康水平 --- p.150 / Chapter 五、 --- 健康公平 --- p.151 / Chapter 第三節 --- 量化研究設計 --- p.153 / Chapter 一、 --- 研究假設 --- p.153 / Chapter 二、 --- 抽樣方法、問卷調查與二手數據分析 --- p.157 / Chapter 三、 --- 測量問題與分析模型 --- p.165 / Chapter 第四節 --- 質化研究設計 --- p.171 / Chapter 一、 --- 研究假設 --- p.171 / Chapter 二、 --- 樣本選擇與獲得進入 --- p.173 / Chapter 三、 --- 資料收集策略與分析方法 --- p.183 / Chapter 第五節 --- 研究的質素 --- p.190 / Chapter 一、 --- 量化與質化研究方法各自的信效度 --- p.190 / Chapter 二、 --- 混合研究方法的信效度：三角互證法 --- p.192 / 本章小結 --- p.197 / Chapter 第三部份 --- 研究發現 --- p.198 / Chapter 第五章 --- 量化研究發現 --- p.199 / Chapter 第一節 --- 改革前後被訪老人社會特徵的變化 --- p.199 / Chapter 一、 --- 基本特徵 --- p.200 / Chapter 二、 --- 社會經濟地位 --- p.204 / Chapter 三、 --- 社會支持網絡 --- p.208 / Chapter 第二節 --- 被訪老年人的健康水平與醫療服務使用情況 --- p.210 / Chapter 一、 --- 健康水平 --- p.210 / Chapter 二、 --- 醫療服務可及性及使用 --- p.220 / Chapter 第三節 --- 各保險項目參保老年人的健康不平等 --- p.227 / Chapter 一、 --- 各保險項目參保老年人的基本特徵 --- p.228 / Chapter 二、 --- 醫療保險類型與老年人的醫療服務使用 --- p.230 / Chapter 三、 --- 醫療保險類型與老年人的健康水平 --- p.233 / Chapter 第四節 --- 多元線性回歸分析：對健康水平的預測 --- p.236 / Chapter 一、 --- 建立多元線性回歸模型 --- p.239 / Chapter 二、 --- 多元線性回歸分析的結果 --- p.242 / 本章小結 --- p.248 / Chapter 第六章 --- 質化研究發現 --- p.250 / Chapter 第一節 --- 政策制定者：對形式公平與個人責任的強調 --- p.250 / Chapter 第二節 --- 基層醫生：因醫患矛盾和「付出-回報失衡」而產生的弱勢感 --- p.255 / Chapter 第三節 --- 弱勢老人：建立在「比較」基礎上的不公平感 --- p.259 / Chapter 一、 --- 農村老人與城鎮老人比較：社會福利不公平與弱勢地位的惡化 --- p.261 / Chapter 二、 --- 普通老人與離退休干部比較：身份地位差別引發的醫療服務不公平 --- p.264 / Chapter 三、 --- 只享受醫療保險的老人與低保對象比較：究竟誰更加弱勢？ --- p.266 / 本章小結：基於弱者優先的底線公平 --- p.271 / Chapter 第七章 --- 混合研究發現：醫療保險改革如何影響弱勢老人的健康公平 --- p.274 / Chapter 第一節 --- 浙江省社會醫療保障的改革實踐：機會公平 --- p.275 / Chapter 第二節 --- 路徑分析：醫療服務使用與健康水平的關係 --- p.279 / Chapter 一、 --- 醫療服務使用與健康水平的相關分析 --- p.280 / Chapter 二、 --- 路徑模型的建立、修正及結果 --- p.282 / Chapter 三、 --- 戶口-醫療服務使用-健康水平（最終的路徑模型） --- p.294 / Chapter 第三節 --- 交互作用分析：醫療保險的調節作用 --- p.299 / Chapter 一、 --- 「城鎮職工基本醫療保險」作為moderator --- p.299 / Chapter 二、 --- 「新型農村合作醫療」作為moderator --- p.302 / Chapter 第四節 --- 醫療保障制度改革中的過程公平與結果公平 --- p.306 / Chapter 一、 --- 過程公平：部門利益爭奪中「看病貴」問題喜憂參半的改革 --- p.306 / Chapter 二、 --- 結果公平：弱勢老人未被滿足的需要與不足夠的保障 --- p.310 / 本章小結 --- p.316 / Chapter 第四部份 --- 討論與結論 --- p.318 / Chapter 第八章 --- 討論 --- p.319 / Chapter 第一節 --- 「公平性」理論的反思與重構 --- p.319 / Chapter 一、 --- 反思醫療福利改革的理論基礎：對社會公義理論的發展 --- p.320 / Chapter 二、 --- 分析「底層健康公平」的理論機制：階層化身份地位差別的形成與變遷 --- p.325 / Chapter 第二節 --- 傳統微觀影響因素的再認識 --- p.332 / Chapter 一、 --- 健康水平：疾病風險變化與健康水平測量的發展 --- p.332 / Chapter 二、 --- 社會經濟地位：從關注收入轉向關注疾病的經濟負擔 --- p.334 / Chapter 三、 --- 戶籍狀況：影響的消除還是持續？ --- p.336 / Chapter 第三節 --- 結果公平的全民醫療保險制度改革 --- p.339 / Chapter 一、 --- 全民醫療保險的角色反思：從機會公平到結果公平 --- p.339 / Chapter 二、 --- 從醫療服務使用到健康結果：全民醫療保險的新路徑倡導 --- p.341 / Chapter 三、 --- 醫療保險改革與醫藥體制改革的互動 --- p.344 / Chapter 第四節 --- 以社區為中心的綜合健康服務與長期照顧體系初探 --- p.349 / Chapter 一、 --- 社會支持網絡：擴展的視角 --- p.349 / Chapter 二、 --- 美國社區健康中心與長期照顧服務的啟示 --- p.351 / Chapter 三、 --- 對中國建立社區綜合健康服務與長期照顧體系的啟示 --- p.355 / 本章小結 --- p.357 / Chapter 第九章 --- 結論與建議 --- p.359 / Chapter 第一節 --- 結論 --- p.359 / Chapter 一、 --- 「底層健康公平」價值選擇的特殊意涵 --- p.360 / Chapter 二、 --- 混合研究發現「過程公平」與「主觀公平」的重要性 --- p.362 / Chapter 三、 --- 健康公平社會影響因素的新變化與新發現 --- p.363 / Chapter 四、 --- 改革中醫療保險對健康公平的調節作用 --- p.364 / Chapter 第二節 --- 建議 --- p.367 / Chapter 一、 --- 醫療保障政策建議 --- p.367 / Chapter 二、 --- 醫療與醫藥政策的配合：推動「過程公平」的需要 --- p.371 / Chapter 三、 --- 社會醫療保險改革對醫療服務發展的啟示 --- p.373 / Chapter 第三節 --- 貢獻、局限與研究展望 --- p.375 / Chapter 一、 --- 本研究的貢獻 --- p.375 / Chapter 二、 --- 本研究的局限 --- p.379 / Chapter 三、 --- 未來的研究方向 --- p.381 / 結束語 --- p.384 / 參考文獻 --- p.386 / 附錄 --- p.423 / Chapter 附錄1. --- 調查問卷 --- p.423 / Chapter 附錄2. --- 數據使用協議 --- p.441 / Chapter 附錄3. --- 知情同意書 --- p.442 / Chapter 附錄4. --- 訪談提綱 --- p.443