全民健康覆盖内涵下城乡居民卫生支出现状及其公平性差异研究

Status and Equity of Health Expenditure in Urban and Rural Residents among the Process toward Achieving Universal Health Coverage

目的基于全民健康覆盖内涵,分析城乡居民卫生支出现状及其公平性差异,提出政策建议。方法利用国家第五次卫生服务调查(山东省部分)居民数据(12 006户家庭,居民33 060例,其中城市家庭6 006户,居民10 391例,农村家庭6 000户,居民22 669例),结合收入5分法,按城乡、不同收入组类别对居民卫生支出现状及其公平性进行分析。结果农村中位家庭医药卫生支出低于城市,中位个人门诊支出、中位个人住院支出高于城市,差异有统计学意义(P<0.05)。农村不同收入居民中位家庭医药卫生支出、个人中位门诊支出比较,差异无统计学意义(P>0.05);农村不同收入居民中位家庭住院支出比较,差异有统计学意义(P<0.05)。城市不同收入居民中位个人门诊支出比较,差异无统计学意义(P>0.05);家庭收入越高中位家庭医药卫生支出、中位个人住院支出越高,差异有统计学意义(P<0.05)。2003—2016年,农村居民恩格尔系数由41.81%波动下降到29.76%,2016年城市居民恩格尔系数为27.58%;农村居民医疗保健支出占收入比重由4.41%上升到7.36%,而城市居民由5.29%下降到4.73%。农村家庭医药卫生支出集中曲线几乎与45°测量线相重合,集中指数(CI)值为0.016 4;城镇家庭医药卫生支出集中曲线在45°测量线下方,CI值为0.092 1;整体上城乡居民家庭医药卫生支出集中曲线在45°测量线下方,CI值为0.039 0。农村、城市、城乡居民个人门诊支出集中曲线均在45°测量线上方,城乡居民个人门诊支出CI值为-0.064 2、农村为-0.094 1、城市为-0.393 3。城乡居民整体上住院费用支出是集中于高收入居民,CI值为0.013 0;农村居民次均住院支出费用曲线基本和45°测量线重合,CI值为-0.002 6;城市居民住院费用集中曲线基本在公平线下方,CI值为0.047 1。结论城市居民中位家庭医药卫生支出高于农村、中位个人门诊/住院支出低于农村。城市居民卫生支出公平性好于农村居民,农村居民在家庭医药卫生支出、个人门诊/住院支出上均呈现为集中于低收入人群的不公平现象。应从全面健康覆盖内涵出发,将农村地区、低收入人群作为全民健康覆盖工作的重点人群,改善卫生筹资策略,完善医疗保险制度设计,加强农村中低收入居民的疾病风险保护,进而提高全民卫生服务可负担性。

ObjectiveTo analyze the status and equity of health expenditure among urban and rural residents in the process of achieving universal health coverage,giving policy suggestions.MethodsFrom the results of National Health Services Survey in China,2013,data of Shandong Province were collected,involving a total of 33 060 individuals from 12 006 families （10 391 from 6 006 urban families,and 22 669 from 6 000 rural families）.Quinquepartite method was adopted to classify the annual household income.The status and equity of health expenditure of the participants were analyzed by residency place and level of income.ResultsThe rural families had lower median annual healthcare expenditure but higher median total cost peroutpatient visit,and median total cost per hospitalization compared with the urban families （P〈0.05）.The median total cost per hospitalization differed significantly between rural families by level of annual household income （P〈0.05）,but median annual healthcare expenditure and median total cost per outpatient visit did not （P〉0.05）.The median total cost per outpatient visit did not vary significantly between the urban families by level of annual household income （P〉0.05）.Higher median annual healthcare expenditure and median cost per hospitalization were positively associated with higher annual household income in the urban families （P〈0.05）.From 2003 to 2016,the Engel coefficient of rural residents dropped from 41.81% to 29.76%,and that of urban residents was 27.58% in 2016.The ratio of annual health expenditure to income rose from 4.41% to 7.36% in rural residents while it dropped from 5.29% to 4.73% in urban residents during this period.The concentration curve of median annual rural household health expenditure almost coincided with the 45-degree line （CI=0.016 4）,while that of median annual urban household health expenditure was below the egalitarian line （CI=0.092 1）,the concentration curve of median annual urban and rural household health expenditure was below the 45-degree line （CI=0.039 0）.The concentration curves of median annual cost of outpatient expenditure of rural residents,urban residents and all the residents were all above the 45-degree line.The CI value of paying outpatient expenditure with cash was -0.064 2,-0.094 1,-0.393 3,respectively,for all the residents,rural residents and urban residents.The hospitalization expenditure of the urban and rural residents with high income occupied most of the total hospitalization expenditure （CI=0.013 0）.The concentration curve of the median total cost per outpatient visit in rural residents almost coincided with the 45-degree line （CI=-0.002 6）.The concentration curve of the median annual hospitalization expenditure of urban residents was below the egalitarian line on the whole （CI=0.047 1）.ConclusionCompared with urban areas, the median household healthcare expenditure is lower and median outpatient/inpatient expenditure per capita is higher in rural areas. In general, the equity of health expenditure in rural residents is worse than that of urban residents. Moreover, low income rural residents are found with higher ratio of annual household healthcare expenditure to annual household income, and higher ratios of annual outpatient and inpatient expenditure per family member to annual household income. In order to achieve universal health coverage, rural residents, especially those with low income, should be placed into priority groups whose health coverage should be enhanced, and the affordability of healthcare should be increased by improving the healthcare financing strategies and health insurance systems, and strengthening the interventions for reducing disease risks in low-income and middle-income rural residents.