Social Insurance Schemes Research Articles

Willingness to pay for a National Health Insurance Scheme in The Gambia: a contingent valuation study.

In pursuit of universal health coverage, many low- and middle-income countries are reforming their health financing systems and introducing health insurance schemes. As part of these reforms, lawmakers in The Gambia enacted 'The National Health Insurance Bill, 2021'. The Act will establish a National Health Insurance Scheme (NHIS) that pays for the cost of healthcare services for its members. This study assessed Gambians' willingness to pay (WTP) for a NHIS. Using multistage sampling design with no replacement, head/co-head of households were presented with a hypothetical health insurance scheme from July to August 2020. Their WTP and factors influencing WTP were elicited using a contingent valuation method. Descriptive statistics were used to describe sample characteristics. Lopez-Feldman's modified ordered probit model and linear regression were applied to estimate respondents' WTP as well as identify factors that influence their WTP. More than 90% of the respondents-677 (94.4%) were willing to join and pay for the scheme. Half of these respondents-398 (58.8%) agreed to pay the first bid of US dollars (US$) 20.78 or Gambian dalasi (GMD) 1000. The average WTP was estimated at US$23.27 (GMD1119.82), whereas average maximum amount to pay was US$26.01 (GMD1251.16). Results of the two models together showed that gender, level of education and household income were statistically significant, with the latter showing negative influence on WTP. The study found that Gambians were largely receptive to the scheme and have stated their willingness to contribute. Our findings can inform policymakers in The Gambia and other sub-Saharan countries when establishing contribution rates and exemption criteria during social health insurance scheme implementation.

Presentation and subsequent care of dental injuries sustained by New Zealand adults.

Injuries to permanent teeth are common and can have lasting effects, but knowledge of their consequences is deficient because there is a lack of information from longitudinal follow-up studies of adult populations. The aim of this study was to use routinely collected adult dental trauma data from New Zealand's no-fault, Government-run social insurance scheme-the Accident Compensation Corporation-to investigate the presentation and subsequent care of dental injuries sustained by adults. Cross-sectional analysis of all new dental injuries recorded during 2008 was followed by prospective analysis of all treatment claimed in the following five years for all new injuries recorded in June 2008 for adults aged 18+ years. Those injuries were categorised into five clinically meaningful, ordinal groups of dental injuries, ranging from least severe (Minor injury) to most severe (Severe displacement). The prospective post-injury treatment information was summarised as (1) restorations; (2) crowns and veneers; (3) completed root canal treatment (preparation and obturation of root canal[s]); (4) extraction (extraction; surgical removal); and (5) implant placement. Orofacial trauma details were recorded for 32 110 individuals (of all ages) in 2008; males predominated in all age groups, except for those aged 65+ years. Of the 68 890 separate injuries to permanent teeth recorded, 74.9% involved maxillary teeth, with almost 50% involving teeth 21 and 11. Some 66.9% of the dental injuries were classified as Minor; 21.7% involved Fractures or loosening, and 8.2% were Severe fractures. Displacement and Severe displacement injuries comprised 1.8% and 2.5% respectively. During June 2008, dental injuries were recorded for 1325 adults. More than 80% of those dental injuries underwent treatment during the subsequent five years, and more severe initial trauma required more complicated treatment. Minor injuries accounted for 33.5%, fractures/loosening for 50.8%, severe fractures for 1.2%, displacements for 8.8%, and severe displacements for 5.8% of the total cost of treatment provided over that five-year period. Although most injuries sustained were minor, their subsequent treatment burden is not only high but also greater with more severe initial trauma. The ongoing societal cost of orofacial trauma appears to be high.

Is the criminalization of informal payment a good idea? The role of the free choice of physician in the elimination of the phenomenon

In Hungary, the new act on the employment status of health workers aims at the elimination of informal payments by the strict separation of public and private care, by a significant increase of the salary of medical doctors and with the criminalization of giving and accepting informal payments. In this study, which is based on our former research, an analysis of the Hungarian judicial practice and an internet research focused on obstetrics, we examine whether the chosen tools are appropriate to achieve this goal, and if not, how the provisions of law should be modified. Both the theoretical considerations and the empirical evidence suggest that the approach the act took is wrong, because the majority of patients are not paying to compensate the doctors for their low salary. Patients pay because they think that they will not get the necessary care without it. This fee-for-service type informal payment is not corruption and it originates from health system shortages, which is not addressed by the act. On the contrary, the full implementation of the provisions of the act might even increase these shortages, which paradoxically can lead to the amplification of the phenomenon. According to the international experiences, long-term measures aiming at the easing of shortages, in themselves, are not sufficient to roll back this undesirable phenomenon, if they are not coupled with a short-term quick fix intervention, which creates a formal substitution mechanism allowing patients to buy the services associated with informal payments legally. The free choice of doctor is perceived to be an additional service to be paid for by the majority of patients and doctors, despite that, according to the current regulations, it is part of the public benefit package and should be available free of charge. Hence, informal payments could be formalized in the frame of the free choice of doctor and health care provider by making it a chargeable service. Such an approach is not unfamiliar in the Hungarian health policy, judicial practice, and even private obstetric care. Moreover, there is a government-supported obstetric model program in the public system in Hungary, where an explicit goal is to replace informal payments with formal fees to be paid by the patients for the free choice of the obstetrician who attends the delivery. All of these seem to be realistic starting points to introduce a technically and politically feasible pilot project, but the detailed regulations should be designed so that the involved health workers have no financial interest to discriminate against non-paying patients. To achieve this, we recommend that the attending physicians are also paid a fee even if they care for a patient, who did not choose them and pay them out of pocket, but live in the catchment area of the health service delivery organization, which is obliged to care for the local residents. Obviously, the source of this fee, which is eventually a performance-based component of the income of physicians, in this case, has to be the social health insurance scheme.

Changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes in Beijing, China

BackgroundChina expanded health coverage to residents in informal economic sectors by the rural new cooperative medical scheme (NCMS) for rural population and urban resident basic medical insurance scheme (URBMI) for non-working urban residents. Fragmentation of resident social health insurance schemes exacerbated the health inequity and China started the integration of urban and rural resident medical insurance schemes since 2016. Beijing finished the insurance integration in 2017 and has been implementing a unified urban and rural resident basic medical insurance scheme (URRBMI) since the beginning of 2018. This study aims to examine changes in health care utilization and financial protection after integration of the rural and urban social health insurance schemes.MethodsWe used household survey data from Beijing Health Services Survey in 2013 and 2018. Respondents who were 15 or older and covered by URBMI, NCMS or URRBMI were included in this study. Our study finally included 8,554 individuals in 2013 and 6,973 individuals in 2018, about 70% of which were rural residents in each year. Descriptive analysis was used to compare the healthcare utilization, healthcare expenditure and incidence of catastrophic health expenditure between different groups. A series of two-part regression models were used to analyze the changes of healthcare utilization, healthcare expenditure and incidence of catastrophic health expenditure.ResultsFrom 2013 to 2018, urban–rural disparity in outpatient care utilization seemed widened because urban residents’ utilization of outpatient care increased 131% while rural residents’ utilization only increased 72%; both rural and urban residents’ spending on outpatient care increased about 50%. Utilization of inpatient care changed little and poor residents still used significantly less inpatient care compared with the rich residents. Poor residents still suffered heavily catastrophic health expenditures.ConclusionFrom 2013 to 2018, residents’ utilization of healthcare, especially outpatient care, increased in Beijing. Health insurance reforms increased residents’ utilization of healthcare but failed to reduce their healthcare financial burden, especially for poor people. Our study advocates more pro-poor insurance policies and more efforts on the efficiency of health system.

Can decreased cost-sharing reduce the vulnerability of sick families to poverty? An analysis of the multi-level social health insurance scheme in China.

In recent years, China has been increasing social health insurance benefits to alleviate poverty due to illness. In 2015, China introduced the Critical Illness Insurance for patients with high out-of-pocket expenses as supplementary to the social health insurance, which categorized patients with different medical expenses into different cost-sharing policies. We conducted a survey on households with high-cost patients in rural Shandong in 2019 and employed the instrumental variables estimation approach to determine how different cost-sharing measures affect households' poverty vulnerability. We found that cost-sharing reduction significantly decreases the vulnerability of sick families to poverty. Moreover, we found that the positive effect is attributed to a reduction in health burden and household livelihood capital shocks. The vulnerability to poverty is still exceptionally high owing to the heavy health burden in rural China and other developing countries. The results of our study provide insights into poverty alleviation by improving social health insurance in developing economies.

Leveraging Innovative Financing Strategy to Increase Coverage and Resources Among Informal Sector for Social Health Insurance Within the Nigerian Context of Devolution: Evidence From Adoption Model Implementation

BackgroundEnrollment in sub-national social health insurance schemes (SSHIS) can be challenging in developing countries like Nigeria, particularly among people in the informal sector. This could be due to a lack of knowledge on its mode of operation and benefits, distrust in government, inimical religious and traditional beliefs, as well as constraining economic factors. A complementary and innovative financing strategy such as the philanthropist adoption model (ADM) could be beneficial in improving SSHIS coverage and financial resources among persons in the informal sector. The study provides new evidence on how ADM influenced health insurance coverage and resources within SSHIS among informal settings in Nigeria. It also highlights contextual factors influencing the implementation of ADM.MethodsThis study employed a mixed-methods case-study approach undertaken in Anambra State, Southeast Nigeria. Data were collected through in-depth interviews (n = 14), document review (n = 12), and quantitative (enrollment data) methods. The respondents were purposively selected based on their involvement with the implementation of the SSHIS. Data analysis for qualitative data was done using the manual thematic framework approach while descriptive analysis was performed for the quantitative data.ResultsThe implementation of ADM was a valuable and effective strategy for improving knowledge, coverage, and resource mobilization (annual premium pool) within the SSHIS in the informal sector. The main enablers of the implementation of ADM include strong political will and commitment, wider stakeholders' consultation and collaboration, numerous public-spirited philanthropists, and legal institutionalization of health insurance. Other enablers include organizational factors like good teamwork among Anambra State Health Insurance Agency (ASHIA) staff, enabling work environment (incentives, supervision, office space), and experienced marketers in the agency. However, ADM had several barriers that affected its implementation—acceptability issues due to distrust for government and the health system, health systems barriers including substandard health facilities and equipment, and inimical cultural and religious beliefs about health insurance.ConclusionThe study demonstrates a case for the implementation of innovative ADM as a strategy for enhancing SSHIS financial sustainability and coverage of persons in the informal sector. Hence, the strategy should be adopted in settings where philanthropy abounds for increasing access to quality healthcare delivery to poor beneficiaries toward achieving universal health coverage in developing countries.

Willingness to pay for social health insurance and its associated factors among public servants in Addis Ababa, Ethiopia: a cross-sectional study

BackgroundAs a means of establishing a sustained and fair health care financing system, Ethiopia has planned and ratified a legal framework to introduce a social health insurance program for employees of the formal sector to protect them against financial and health burdens. However, the implementation has been delayed due to the resistance of public servants to pay the proposed premium. The aim of this study was to estimate the magnitude of willingness to pay the proposed amount of premium set by the government for the social health insurance program and the factors associated with it among public servants in Addis Ababa, Ethiopia.MethodsAn institution-based cross-sectional study design was used to conduct the study. Multistage sampling was employed to select a total of 503 from 12 randomly selected public sectors. Data were collected using pretested, interviewer-administered structured questionnaires. A contingent valuation method with an iterative bidding game was used to elicit willingness to pay. Finally, logistic regression analysis was used to identify independent predictors of willingness to pay. Statistical significance was considered at P < 0.05 with adjusted odds ratios calculated at 95% CIs.ResultsOnly 35.4% were willing to pay the proposed premium (3% of their monthly salary). Those who had children from 6–18 years old (AOR = 3.252; 95% CI: 1.15, 9.22), had a history of unaffordable health service costs during the last 12 months (AOR = 9.631; 95% CI: 4.12, 22.52), and had prior information about the social health insurance program (AOR = 11.011, 95% CI. 3.735–32.462) were more likely to pay for the proposed social health insurance program compared to their counterparts.ConclusionThe willingness to pay the proposed amount premium for social health insurance among public servants in Addis Ababa was very low that implies the implementation will be challenging. Thus, the government of Ethiopia should consider reviewing the amount of premium contributions expected from employees before implementing the social health insurance scheme.

Does direct settlement of intra-province medical reimbursements improve financial protection among middle-aged and elderly population in China? Evidence based on CHARLS data

In low- and middle-income countries, social health insurance schemes are the main focus of efforts to achieve universal health coverage (UHC) by promoting access to health care and financial protection. Problems with financial protection in China are caused mainly by health insurance fragmentation and a rapid rise in medical expenditure. In this context, China implemented a policy of direct settlement of intra-provincial medical reimbursement in 2014. We evaluated the impact of the policy on financial protection with a population aged 45 and above based on the China Health and Retirement Longitudinal Study from 2011 to 2018. We estimated the policy effects using the difference-in-differences method, based on coarsened exact matching. We found that the policy significantly reduced the catastrophic health expenditures (CHEs) rate by approximately 10% in the population, whether middle-aged or elderly. Subgroup analyses indicated that middle-aged and elderly people living in western China and with lower household incomes received greater protection from the policy. The CHEs rate for the two age groups in western China was reduced by 16.26% and 20.12%, respectively. The CHEs rate was reduced by 24.51% and 17.32% for middle-aged individuals in the lowest and second household income quartiles, respectively, and by 21.31% for older adults in the second household income quartile. The new rural cooperative medical scheme exerted a smaller protective effect than urban medical insurance among the participants aged 60 and older. We found that in addition to optimizing health insurance schemes, more health care reform measures, such as adopting more efficient payment methods and rationalizing medical expenditures, should be combined to help reduce health inequities and accelerate progress toward achieving UHC and the Sustainable Development Goals.

Intergenerational contract in Ageing Democracies: sustainable Welfare Systems and the interests of future generations.

As the assumptions of perpetual economic and population growth no longer stand, the welfare systems built on such promises are in peril. Policymakers must reallocate the responsibility for providing care between generations. Democratic theories can help establish procedures for finding solutions, particularly in ageing democratic countries. By analysing existing representative and deliberative democratic theories, this paper explores how the interests of future generations could be included in such procedures. A hypothetical social health insurance scheme with the pay-as-you-go financial arrangement is selected as an illustrative case. This paper argues that due to the intrinsic bias towards the current generation, both representative and deliberative democratic health policymaking are limited in making decisions that account for future generations. Instead, their interests could be at best represented by benevolent representatives.

Influence of sub-national social health insurance scheme on enrollees’ health seeking behaviour in Anambra state, Nigeria: a pre and post study

BackgroundAppropriate health-seeking behaviour (HSB) is crucial for improving health outcomes and achieving universal health coverage (UHC). Accessing healthcare through the state social health insurance scheme (SSHIS) could lead to improved HSB. The study explores the influence of access to healthcare through health insurance on the HSB of the enrollees of the SSHIS in southeast, Nigeria.MethodsA descriptive cross-sectional study undertaken in twelve health facilities in Anambra state using quantitative and qualitative research methods. Data were collected through a facility-based survey (n = 447) and sex-disaggregated focus group discussions (n = 12) of health insurance enrollees. Univariate and bivariate analyses were performed for quantitative data, while qualitative data were analyzed using a manual content approach.ResultThe findings revealed a positive change in enrollee’s HSB post-health insurance enrollment. Majority (83%) of the respondents reported that they immediately take action when ill post-health insurance enrollment as against 34% (pre-health insurance) resulting in a 49% increase, with a statistically significant difference (p < 0.02). There was a statistically significant association between positive HSB and marital status (p < 0.04); educational level (p < 0.00); occupation (p < 0.03) and ownership of health facility (p < 0.00). There was an increase in the percentage of enrollees who use the hospital as their first choice of provider during an illness episode post-health insurance enrollment. This increased from 37.4% to 90.2% (post-health insurance enrollment), representing a 52.8% increase, which is statistically significant (p < 0.03), in seeking care in hospitals. Similarly, the percentage (46%) of enrollees using patent medicine vendors (PMVs) as their first choice of provider when ill prior to enrollment in health insurance decreased to 8.1% post-health insurance enrollment, representing a 38% decline with a statistically significant (p < 0.00) drop in PMV patronage. Reasons for positive HSB include low cost of services and availability of quality care such as quality drugs, presence of doctors, and other skilled health workers by the health insurance facilities.ConclusionHealth insurance has been established as an effective strategy for improving appropriate HSB. Hence, increasing coverage of health insurance among the uninsured is crucial in improving access to quality and affordable health care towards achieving UHC, particularly in developing countries.

How viable is social health insurance for financing health in Zambia? Results from a national willingness to pay survey

In an era of considerable uncertainty about future prospects for development assistance to fund major health programmes in Sub-Saharan Africa, social health insurance is increasingly being considered as an alternative mechanism for increasing financing health. However, empirical support for social health insurance in sub-Saharan Africa remains sparse. The main aim of this study was to examine the viability of increasing health financing through social health insurance in Zambia. The paper uses a large nationally representative household survey to estimate the expected mean and total willingness to pay for social health insurance. The revenue potential of social health insurance for health sector funding is assessed. The results show that despite a high level of public support for social health insurance, with 80% willing to join a social insurance scheme, the estimated mean monthly willingness-to-pay is relatively low at Zambian Kwacha 55 (US$8.8 in 2014 dollars) per household. The evidence presented in this paper suggests that the revenue potential of social health insurance would not be sufficient to fund major improvements in quality of care for insured members, let alone cross-subsidize benefits to non-members.

Price elasticity of demand for voluntary health insurance plans in Colombia

BackgroundSince 1993, Colombia has had a mandatory social health insurance scheme that aims to provide universal health coverage to all citizens. However, some contributory regime participants purchase voluntary private health insurance (VPHI) to access better quality health services (i. e., physicians and hospitals), shorter waiting times, and a more extensive providers’ network. This article aims to estimate the price elasticity of demand for the VPHI market in Colombia.MethodsWe use data from the 2016–2017 consumer expenditure national survey and apply a Heckman selection model to address the selection problem into purchasing private insurance. Using the estimation results to further estimate the price semi-elasticity for VPHI, we then calculate the price elasticity for the households’ health expenditure and acquisition of VHPI.ResultsOur main findings indicate that a 1% VPHI price increase reduces the proportion of households affiliated to a VPHI in the country by about 2.32% to 4.66%, with robust results across sample restrictions. There are relevant differences across age groups, with younger households’ heads being less responsive to VPHI price changes.ConclusionsWe conclude that the VPHI demand in Colombia is noticeably elastic, and therefore tax policy changes can have a significant impact on public health insurance expenditures. The government should estimate the optimal VPHI purchase in order to reduce any welfare loss that the current arrangement might be generating.

The compensation law and its antagonistic administration: The Indian coalfield of Raniganj, 1923-71

ABSTRACT This article elaborates on the stipulation and administration of the compensation law, in the Indian coalfield of Raniganj, between 1923 and 1971. It shows how enacting the Workmen’s Compensation Act of 1923–24 formed a major social insurance scheme in colonial and post-colonial India. Notwithstanding this, the litigious and antagonistic administration became its defining feature. This feature lowered the utility of the compensation law as a restitution measure for grieving families, and as an incentive for investment in workers’ safety, during its half- century-long operation. Grief-stricken families registered an increasing number of claims to avail of compensation benefits from the later 1920s. Concomitantly, the number of employers’ contestation against workers’ claims also remained significantly high till the 1950s. The cumbersome procedure of law enforcement for administering compensation benefits, alongside an array of discursive-cum-legal techniques devised by the colliery management, caused hurdles in the workers’ attempt to secure their claims. The favourable turnaround in workers’ effort to secure compensation benefits from the late 1950s resulted from an enabling simplification and streamlining brought to the compensation law. However, the complication and expenses of the legal procedure that workers endured in the Compensation Office and Civil Courts generally added to their miseries.

How well are Indonesia's urban poor being provided access to quality reproductive health services?

Accommodating the needs of Indonesia’s rapidly growing urban population is essential to reaching national reproductive health goals and international commitments. As in other rapidly urbanizing low- and middle-income countries, satisfying the needs of Indonesia’s urban poor is both a high priority and a significant challenge. In this study, we assessed both how being from urban poor or near-poor households affects the quantity and quality of family planning and maternal health services received and the extent to which differentials had narrowed during the 2012–2017 period. This time interval is significant due to the introduction of a national social health insurance scheme in 2014, establishing the foundation for universal health care in the country. Data from the 2012 and 2017 Indonesian Demographic and Health Surveys were analyzed using logistic and multinomial logit regression. Poverty status was measured in terms of urban household wealth quintiles. For family planning, although urban poor and near-poor women made different method choices than non-poor women, no substantial 2017 differences in contraceptive prevalence, unmet need for family planning or informed choice were observed. However, urban poor women and to a lesser extent near-poor women systematically lagged non-poor urban women in both the quantity and quality of maternal health services received in connection with recent pregnancies. Significant maternal health service gains were observed for all urban women during the study reference period, with gains for poor and near poor urban women exceeding those for non-poor on several indicators. While the deployment of pro-poor interventions such as the national social health insurance scheme is likely to have contributed to these results, evidence suggesting that the scheme may not be influencing consumer health-seeking behaviors as had been anticipated along with continued limitations in public health sector supply-side readiness resulting in service quality issues suggest that more will have to be done.

Social insurance schemes: foreign experience in the realities of Ukraine

The article is devoted to the justification of the role and importance of compulsory social insurance in developed countries. Special attention is paid to the importance of active orientation to public policy in social sphere. Foreign practices in the implementation of social protection of population and regulation of social development are analyzed. The priority directions for reforming the public social policy in Ukraine in the context of adaptation to the standards of highly developed countries are determined. Key institutional features of national social insurance systems are studied. Conceptual components of forming civilized social security institute, based on the advanced achievements. Substantiated mechanism for financing social protection and social security. Features of financing social services at the local level generally accepted for all developed foreign countries is a division of local budgets into two distinct functional types of local budgets. This local current (administrative) budget and local budgets Development (Investment Funds). Each of these types has its own budget expenditures and revenues. Experience in the development of public relations reveals that social security is an objective and necessary phenomenon. The objectivity of social insurance due to the risky nature of the market economy and the need to establish financial guarantees to ensure that persons who for certain reasons are unable to participate in the process of material production and to get paid for their work. The analysis of foreign experience and its comparison with state realities is allowed the author to make a number of proposals to improve the state practice of social insurance.

From each according to means, to each according to needs? Distributional effects of abolishing asset-based payments for residential care in Austria

BackgroundMost countries in Europe require out-of-pocket payments (OPPs) for nursing homes based on users’ income and often assets. This was also the case in Austria until 2018 when asset-based contributions to residential care —denoted the ‘Pflegeregress’ – were abolished, leaving a shortfall in revenue. We aim to determine how the Pflegeregress was distributed across different groups in Austria prior to 2018, what the distributional consequences of its abolishment were, and what the distributional impact of different financing alternatives would be.MethodsCircumventing data availability issues, we construct a micro-simulation model using a matched administrative dataset on residential care users receiving the Austrian care allowance (Pflegegeldinformation, PFIF, HVB, and Pflegedienstleistungsstatistik, Statistik Austria) and survey data (SHARE, wave 6). Using this model, we estimate the expected duration of residential care and OPPs under the Pflegeregress of a representative sample of older people aged 65 + in Austria, as well as OPPs under budgetary neutral financing alternatives to the abolished asset-based contribution, namely an inheritance tax and a social insurance scheme. The distributional impact of abolishing the Pflegeregress and these alternative scenarios is assessed through a number of measures, such as ability to pay, Concentration Indices (CI) and a needs-standardized measure.ResultsWe find that lower income individuals and homeowners disproportionately contributed to asset-based OPPs for residential care prior to 2018, due in large part to their higher use of residential care and the low asset-exemption thresholds. These groups were therefore the largest beneficiaries of its abolishment. The alternative financing scenarios tested would result in a more progressive distribution of payments (i.e. concentrated on more affluent individuals).ConclusionOur findings indicate the limited ability of asset-based OPPs to target those with higher assets, thus questioning the fairness of these instruments for financing residential care facilities for older people in Austria. Findings also suggest that the parameterization of such OPPs (such as asset exemption thresholds) and patterns of residential care use are key variables for assessing the distribution of asset-based OPPs for residential care use. Policy alternatives that decouple payments from use would entail greater transfers from healthy to less healthier individuals.

The promises and perils of predictive politics

Rachel Friedman’s Probable Justice and Jeffrey Friedman’s Power without Knowledge explore the promises and pitfalls of the application of predictive tools to the solution of social and political problems. Rachel Friedman argues that a fundamental duality in philosophical interpretations of probability allowed social insurance schemes to successfully accommodate two rival visions of liberal justice over the centuries. But in focusing on ideas around probability, she misses the limitations of the experts who put these ideas into practice and threatened to undermine them in the process. Jeffrey Friedman, by contrast, is centrally concerned with the limitations of experts. While he shows how these undermine one rather narrow conception of technocratic legitimacy, he avoids examining their implications for democratic legitimacy understood more broadly.

Trends in disparities in healthcare utilisation between and within health insurances in China between 2008 and 2018: a repeated cross-sectional study

BackgroundFragmentation in China’s social health insurance schemes and income gap have been recognised as important factors for the inequitable use of healthcare. This study assessed trends in disparities in healthcare utilisation between and within health insurances in China between 2008 and 2018.MethodsWe used data from the 2008, 2013, and 2018 China National Health Services Survey. Outpatient visit, inpatient admission and foregone inpatient care were chosen to measure healthcare utilisation and underutilisation by health insurances. Absolute differences and rate ratios were generated to examine disparities between and within health insurances, and changes in disparities were analysed descriptively. Pearson χ2 tests were used to test for statistical significance of differences.ResultsThe outpatient visit rate for respondents covered by the urban resident-based basic medical insurance scheme (URBMI) more than doubled between 2008 and 2018, increasing from 10.5% (9.7-11.2) to 23.5% (23.1-23.8). Inpatient admission rates for respondents covered by URBMI and the new rural cooperative medical scheme (NRCMS) more than doubled between 2008 and 2018, increasing by 7.2 (p < 0.0001) and 7.4 (p < 0.0001) percentage points, respectively. Gaps in outpatient visits and inpatient admissions narrowed across the urban employee-based basic medical insurance scheme (UEBMI), URBMI, and NRCMS through 2008 to 2018, and by 2018 the gaps were small. The rate ratios of foregone inpatient care between NRCMS and UEBMI fell from 0.9 (p > 0.1) in 2008 to 0.8 (p < 0.0001) in 2018. Faster increases in outpatient and inpatient utilisation and greater reductions in foregone inpatient care were observed in poor groups than in wealthy groups within URBMI and NRCMS. However, the poor groups within UEBMI, URBMI, and NRCMS were always more likely to forego inpatient care in comparison with their wealthy counterparts.ConclusionsRemarkable increases in healthcare utilisation of URBMI and NRCMS, especially among the poorest groups, were accompanied by improvements in inequality in healthcare utilisation across UEBMI, URBMI, and NRCMS, and in income-based inequality in healthcare utilisation within URBMI and NRCMS. However, the poor groups were always more likely to forego admission to hospital, as recommended by doctors. We suggest further focus on the foregoing admission care of the poor groups.

Advancing universal health coverage in the COVID-19 era: an assessment of public health services technical efficiency and applied cost allocation in Cambodia

BackgroundAchieving universal health coverage (UHC) is a global priority and a keystone element of the 2030 Sustainable Development Goals. However, COVID-19 is causing serious impacts on tax revenue and many countries are facing constraints to new investment in health. To advance UHC progress, countries can also focus on improving health system technical efficiency to maximize the service outputs given the current health financing levels.MethodsThis study assesses Cambodia’s public health services technical efficiency, unit costs, and utilization rates to quantify the extent to which current health financing can accommodate the expansion of social health protection coverage. This study employs Data Envelopment Analysis (DEA), truncated regression, and pioneers the application of DEA Aumann-Shapley applied cost allocation to the health sector, enabling unit cost estimation for the major social health insurance payment categories.ResultsOverall, for the public health system to be fully efficient output would need to increase by 34 and 73% for hospitals and health centers, respectively. We find public sector service quality, private sector providers, and non-discretionary financing to be statistically significant factors affecting technical efficiency. We estimate there is potential supply-side ‘service space’ to expand population coverage to an additional 4.69 million social health insurance beneficiaries with existing financing if the public health system were fully efficient.ConclusionsPublic health service efficiency in Cambodia can be improved by increasing utilization of cost-effective services. This can be achieved by enrolling more beneficiaries into the social health insurance schemes with current supply-side financing levels. Other factors that can lead to increased efficiency are improving health service quality, regulating private sector providers, focusing on discretionary health financing, and incentivizing a referral system.

The added-worker effect in the Netherlands before and during the Great Recession.

We study the added-worker effect in the Netherlands with large-scale administrative panel data for the period 1999–2015. Conditioning on samples with similar employment histories, we employ differences-in-differences to estimate the effect of a male partner’s unemployment shock on the female partner’s income. We find a modest added-worker effect of 2–5% of the male partner’s income loss, as compared to the much larger compensating effect from social insurance schemes. The added-worker effect largely disappeared at the beginning of the Great Recession, but resurfaced a few years later. Over the years, profits from self-employment have become more important in dealing with unemployment shocks.