Do Health Sector Reforms Have Their Intended Impacts ? The World Bank'S Health VIII Project In Gansu Province, China

Abstract

The literature contains very few impact evaluations of health sector reforms, especially those involving broad and simultaneous changes on both the demand and supply sides of the sector. This paper reports the results of a World Bank-funded health sector reform project in China known as Health VIII. On the supply-side, the project combined infrastructure investments (especially at the township level) with improved planning and management, including a referral system between township health centers and county hospitals, and interventions aimed at improving the effectiveness and quality of care, including the introduction of clinical protocols and essential drug lists. On the demand-side, the project sought to resurrect community health insurance, and to introduce a safety net for the very poor to provide them with financial assistance with their health care expenses. The evaluation reported here concerns just one of the project's seven provinces, namely Gansu, the reason being that no suitable data are available to undertake a rigorous evaluation in all provinces. This paper makes use of a panel dataset collected for quite another purpose but whose timing (just around the time the project started and four years later) and location (covering both project and non-project counties) makes it well suited to the task. The paper compares estimates obtained using a variety of different estimators, including naïve single differences (before and after, and with and without the project), and differences in differences, adjusting for heterogeneity through both regression and matching methods. The results suggest that it makes a difference to the estimated impact of Health VIII which estimator is used, with the naïve single differences producing often markedly different estimates from the preferred approach of combining difference-in-differences with matching. The results suggest that Health VIII has been mostly successful in its goals. The preferred estimator suggests that the project reduced illness among children, improved self-assessed health and increased doctor visits among the population in general, and reduced the incidence of catastrophic health spending, defined as annual spending in excess of 10% of annual per capita income. However, the project appears to have increased the development and use of high-level facilities, hastened the demise of the village clinic, and may have reduced immunization rates.

How does the pharmaceutical industry influence prescription? A qualitative study of provider payment incentives and drug remunerations in hospitals in Shanghai

“…A number of quantitative studies explored the causal relationship between provider incentives and over-prescribing practice; however, due to the nature of quantitative research, these studies were not able to provide an in-depth analyses of the issue of over-prescription or to enunciate the root causes of it (Yip and Eggleston, 2004: 267-277;Wagstaff et al 2005;Lindelow, 2008: 990-1005;Yip and Hsiao, 2009: 613-619;Wagstaff et al, 2009: S7-S23;Babiarz et al, 2010;Babiarz et al, 2012Babiarz et al, : 1065Babiarz et al, -1074Yang and Wu, 2014). Several qualitative studies discussed the relationship between payment incentives and provider behaviours, but results by far are still anecdotal (Yip and Hsiao, 2008: 460-468;Blomqvist and Qian, 2008: 5-26;Yip and Hsiao, 2009: 613-619).…”

Health Insurance and Children in Low‐ and Middle‐income Countries: A Review

“…Results in Tables 2-4 are first listed for programs targeted at children and then for other programs. Seven out of 13 papers are concerned with health insurance expansion for the general population in Burkina Faso (Fink et al, 2013), China (Wagstaff & Yu, 2007;Chen & Jin, 2012), Colombia (Giedion & Uribe, 2009;Miller et al, 2013), Rwanda (Lu et al, 2012), and Thailand (Gruber et al, 2014). Five papers cover health insurance programs targeted at children in the Philippines (Kraft et al, 2009;Quimbo et al, 2011) and Vietnam (Wagstaff & Pradhan, 2005;Nguyen & Wang, 2013;Guindon, 2014;Palmer et al, 2015).…”

“…It should be noted that one paper (Guindon, 2014) deals with both a program targeted at children and a program for a larger population. 4 With respect to methodology, three articles used a difference-in-difference design (Nguyen & Wang, 2013;Gruber et al, 2014;Guindon, 2014), one paper used propensity score matching (Lu et al, 2012), four papers used difference-indifference and propensity score matching combined (Wagstaff & Pradhan, 2005;Wagstaff & Yu, 2007;Giedion & Uribe, 2009;Chen & Jin, 2012), three papers used a randomised controlled trial (Kraft et al, 2009;Quimbo et al, 2011;Fink et al, 2013), and two papers used a regression discontinuity design (Miller et al, 2013;Palmer et al, 2015). Note: * One study (Guindon, 2014) covers a program targeted at children and another program that is not targeted, hence the number of studies here sums to 14.…”

Health Insurance and Children in Low- and Middle-Income Countries: A Review

“…Increase by 12% for the general population of the overall inpatient utilisation rate Increase in overall utilisation rate is 2.5 times bigger for women and infants Substitution of public for private care for general population Lu et al (2012) Visits to health-care facilities for under-5 children with acute respiratory infection, diarrhoea, or fever increased two-to threefold due to insurance Reduction in OOP expenditures and in the probability of catastrophic health-care spending for overall population with health insurance Miller et al (2013) SR eligibility is associated with reductions in the variability* of inpatient medical spending Significant increase in use of preventive care (preventive physician visit and number of growth development checks last year) No change found for curative medical care among children Wagstaff and Pradhan (2005) The probability of contact with a health-care provider for a sick person increased for children 5 and over (+3.9%), but not for children under 5 Some reduction in OOP expenditures Increase in non-medical expenditures, by more than reduced OOP Wagstaff and Yu (2007) Little impact is found on the use of services (for instance, Increase in hepatitis B and polio immunisation at the county level, but negative impact on overall immunisations at the village level (although this result holds only for one specification) Reduced OOP spending, and the incidence of catastrophic spending and impoverishment through health expenses indicator of financial protection, five find that health insurance has a negative and significant effect (Wagstaff & Pradhan, 2005;Wagstaff & Yu, 2007;Lu et al, 2012;Fink et al, 2013;Nguyen & Wang, 2013). Only Palmer et al (2015) does not find evidence of a significant effect on out-of-pocket health expenditures for Vietnam's health insurance program for children under age 6.…”