Urban Employee Basic Medical Insurance Research Articles

Trend and Geographic Variation in Incidence and Prevalence of Inflammatory Bowel Disease in Regions Across China: A Nationwide Employee Study Between 2013 and 2016.

BackgroundIncidence and prevalence rates and trends of inflammatory bowel disease (IBD) in China remain largely unknown.ObjectiveThis study aimed to estimate the nationwide prevalence and incidence of IBD and identify its noticeable trends in China between 2013 and 2016.MethodsWe conducted a population-based analysis using data from the National Urban Employee Basic Medical Insurance database. Patients with at least three claims of IBD diagnosis were identified. A Joinpoint regression model was used to analyze the annual percent change (APC) of the age-standardized incidence and prevalence.ResultsThe age-standardized prevalence of Crohn's disease (CD) increased from 1.59/100,000 in 2013 to 3.39/100,000 (p < 0.05) in 2016, and that of ulcerative colitis (UC) increased from 8.72/100,000 to 17.24/100,000 (p < 0.05) during the period, with a UC/CD ratio of 5.09 in 2016. The age-standardized incidence of CD varied between 0.82/100,000 and 0.97/100,000 (p = 0.9), whereas that of UC slightly increased from 4.54/100,000 to 4.85/100,000 (p = 0.7). The eastern region of China had the highest incidence and prevalence, and the western region had the lowest rates, in both UC and CD, showing an east-to-west gradient.ConclusionThe incidence and prevalence of IBD in most urban regions in China had an emerging trend over the study period, and an east-to-west gradient was observed, which indicated a greater burden in eastern China. Efforts to improve prevention strategies and promote awareness of IBD are needed, particularly in young men who are at higher risk for CD.

The Different Classification of Hospitals Impact on Medical Outcomes of Patients in China.

BackgroundIn China, different classification of hospitals (COH) provide treatment for patients with different degrees of illness. COH play an important role in Chinese medical outcomes, but there is a lack of quantitative description of how much impact the results have. The objective of this study is to examine the correlation between COH on medical outcomes with the hope of providing insights into appropriate care and resource allocation.MethodsFrom the perspective of the COH framework, using the Urban Employee Basic Medical Insurance (UEBMI) data of Chengdu City from 2011 to 2015, with a sample size of 512,658 hospitalized patients, this study used the nested multinomial logit model (NMNL) to estimate the impact of COH on the medical outcomes.ResultsThe patients were mainly elderly, with an average age of 66.28 years old. The average length of stay was 9.61 days. The female and male gender were split evenly. A high level of hospitals is positively and significantly associated with the death and transfer rates (p < 0.001), which may be related to more severe illness among patients in high COH.ConclusionThe COH made a difference in the medical outcomes significantly. COH should be reasonably selected according to disease types to achieve the optimal medical outcome. So, China should promote the construction of a tiered delivery system.

The Effects of Environmental Regulations on Medical Expenses: Evidence from China.

In this study, we examine the effects of a special period regulation (SPR), implemented in the Chang-Zhu-Tan (Changsha City, Zhuzhou City, and Xiangtan City; CZT) region, regarding medical expenses paid by the Urban and Rural Resident Basic Medical Insurance (URRBMI) and Urban Employee Basic Medical Insurance (UEBMI) programs, using a difference-in-differences (DID) design. We find that the SPR significantly reduces medical expenses in the CZT region, which appears to be driven by improved air quality. Furthermore, this regulation has a significantly negative and positive impact on medical expenses paid by the UURBMI and UEBMI, respectively. In summary, our results provide empirical evidence for the orderly implementation of command-and-control environmental regulation policies from the perspective of health benefits.

Concomitant Medication Use With Xiyanping Injection and the Risk of Suspected Allergic Reactions: A Nested Case-Control Study Based on China's National Medical Insurance Database.

Introduction: Xiyanping injection (XYP), a type of Traditional Chinese Medicine, is widely used and often applied in combination with other medications in treating bronchitis, tonsillitis, and bacillary dysentery in China. In recent years, an elevated risk of allergic reactions has been observed following XYP, but whether concomitant medication use contributes to this risk is still unknown. Objective: This study aims to investigate the association between the concomitant use of XYP and the 25 most frequently co-applied medications with suspected allergic reactions for China’s patients receiving XYP. Methods: A nested case–control study was conducted using the sampling data from 2015 China’s Urban Employees Basic Medical Insurance and Urban Residents Basic Medical Insurance database. Four anti-allergic marker drugs were used to evaluate suspected allergic reactions. Univariate analyses and multivariable conditional logistic regression were conducted, and results were reported as odds ratios (ORs) with a 95% confidence interval (CI). Sensitivity analyses were performed on the expanded sample by including those prescribed with anti-allergic marker drugs on the same day as XYP and then stopped XYP on the next day. Results: Out of 57,612 participants with XYP prescription, we obtained 949 matched case–control pairs. Multivariable conditional logistic regression revealed that seven concomitant medications including gentamicin [OR = 4.29; 95% CI (2.52, 7.30)], cefoperazone-sulbactam [OR = 4.26; 95% CI (1.40, 13.01)], lidocaine [OR = 2.76; 95% CI (1.79, 4.25)], aminophylline [OR = 1.73; 95% CI (1.05, 2.85)], ribavirin [OR = 1.54; 95% CI (1.13, 2.10)], potassium chloride [OR = 1.45; 95% CI (1.10, 1.91)], and vitamin C [OR = 1.32; 95% CI (1.03, 1.70)] were associated with increased risk, while cefathiamidine [OR = 0.29; 95% CI (0.16, 0.51)] was associated with reduced risk. Sensitivity analysis on 2,438 matched pairs revealed similar findings. Conclusion: Increased risks for suspected allergic reactions were found for the concomitant use of XYP with seven medications. Our data suggest that gentamicin, cefoperazone-sulbactam, lidocaine, and ribavirin should be applied with precautions for patients receiving XYP, and further studies on drug interactions and allergy mechanisms are warranted.

Effectiveness of influenza vaccination on in-hospital death and recurrent hospitalization in older adults with cardiovascular diseases

ObjectivesThere is limited evidence on the effectiveness of influenza vaccination on hospitalization outcomes by cardiovascular disease (CVD) subtypes or comorbidities. MethodsThis study involved 713,488 records of hospitalization of adults ≥60 years with CVD from the Beijing Urban Employee Basic Medical Insurance database. Logistic regression with generalized estimating equations was conducted to estimate the effectiveness of influenza vaccination on in-hospital death and recurrent hospitalization, adjusting for unmeasured confounders. ResultsThe coverage of influenza vaccination was only 13.3% among older adults hospitalized for CVD. Influenza vaccination was associated with 15% (odds ratios 0.85 [0.74, 0.99]) lower risk of in-hospital death among patients with CVD, with stronger associations in patients with stroke. Influenza vaccination was associated with 6% (0.94 [0.88, 0.99]) and 28% (0.72 [0.56, 0.93]) lower risks of recurrent hospitalization for ischemic heart disease (IHD) and respiratory disease in patients with IHD, but there were no clear associations in patients with stroke. For in-hospital death, the protective association of influenza vaccination was stronger in patients with fewer comorbidities and was similar to that of joint vaccinations of influenza and pneumococcal vaccinations. ConclusionThe protective association of influenza vaccination on CVD hospitalization outcomes serves as the evidence base to increase the uptake of influenza vaccination among older adults in China.

Late career participation of late retirees in the age of the silver tsunami: understanding the influencing mechanism of health status and employment-based health insurance participation

BackgroundThe delayed retirement initiative and population aging have led to a growing group of late retirees. However, it remains unclear whether the existing employment-based health insurance system can effectively match the recently proposed initiative and support late retirees, especially those with pre-existing function limitations. Thus, this study aims to investigate the influencing mechanism of China’s Urban Employee Basic Medical Insurance (UEBMI), physical functioning limitation (PFL) and difficulty in instrumental activities of daily living (IADLs) on labour participation of late retirees in China.MethodsThis study uses data from the China Health and Retirement Longitudinal Study (CHARLS) survey, which tracks the quality of life among older adults in China (valid sample size = 5560).ResultsEmpirical results show that China’s employment-based health insurance (i.e. UEBMI) and health conditions (i.e. PFL and difficulty in IADLs) are positively associated with late retirees’ withdrawal from late career participation. In addition, a higher level of difficulty in IADLs could strengthen the effect of PFL on late retirees’ withdrawal from late career participation, which could be further buffered by UEBMI beneficiary status.ConclusionIn the formulation of delayed retirement policies, it is necessary to consider the influencing mechanism of the social health insurance system and health conditions on late career participation of older workers to ensure policy effectiveness.

Increasing prevalence and burden of bronchiectasis in urban Chinese adults, 2013–2017: a nationwide population-based cohort study

BackgroundWhile the prevalence and disease burden of bronchiectasis are increasing, data in the world’s largest population are lacking. We aimed to investigate the prevalence and disease burden of bronchiectasis in Chinese adults.MethodsWe conducted a population-based study using data between 2013 and 2017 from the national databases of Urban Employee Basic Medical Insurance and Urban Resident Basic Medical Insurance in China. Data from over 380 million patients aged 18 years and older during the study period were analyzed, and a total of 383,926 bronchiectasis patients were identified. Primary outcomes included the age- and sex-specific prevalence of bronchiectasis. Annual visits and hospitalizations, as well as annual costs were also calculated.ResultsThe prevalence of bronchiectasis in Chinese adults increased 2.31-fold, from 75.48 (62.26, 88.69) per 100,000 in 2013 to 174.45 (137.02, 211.88) per 100,000 in 2017. The increase was more remarkable for patients aged over 50 years in both genders. The per-capita total cost and hospitalization cost of patients with bronchiectasis increased 2.18-fold and 1.83-fold from 2013 to 2017, respectively, mostly driven by non-bronchiectasis costs. The average annual hospitalization ranged from 1.20 to 1.24 times during the 5 years.ConclusionThe prevalence and disease burden of bronchiectasis in Chinese urban adults ≥ 18 years had increased significantly between 2013 and 2017.

Unmet Healthcare Needs and Their Determining Factors among Unwell Migrants: A Comparative Study in Shanghai.

The purpose of this study was to analyze the health status and unmet healthcare needs, and the impact of related factors, of unwell migrants in Shanghai. A total of 10,938 respondents, including 934 migrants and 10,004 non-migrants, were interviewed in Shanghai’s Sixth Health Service Survey. Descriptive statistics were utilized to present the prevalence of health status and unmet healthcare needs. Binary logistic regression analysis was performed to explore the relationships between predisposing factors, enabling factors, need factors, and health-related behavior and unmet healthcare needs in the Anderson health service utilization model. This study indicated the percentages of migrants having a fair or poor self-evaluated health status (21.09%) and suffering from chronic diseases (72.91%) were lower than those of non-migrants (28.34% and 88.64%, respectively). Migrants had higher percentages of unmet hospitalization needs (88.87%), unmet outpatient care needs (44.43%), and self-medication (23.98%) than those of non-migrants (86.24%, 37.95%, 17.97%, respectively). Migrants enrolled in Urban Employee Basic Medical Insurance were more likely to utilize hospitalization services (OR = 1.457) than those enrolled in other health insurances or uninsured. Need factors had impacts on unwell migrants’ unmet healthcare needs. Other factors, including age and health behavior, were also found to significantly affect unwell migrants’ unmet health service needs. Specific gaps continue to exist between unwell migrants and non-migrants regarding the accessibility of local health services. Flexible policies, such as enhancing the health awareness of migrants and eliminating obstacles for migrants to access medical services, should be implemented to provide convenient and affordable healthcare services to unwell migrants.

The impact of retirement on inpatient healthcare utilization in Guangzhou,\xa0China: a regression discontinuity analysis of 189,031 health insurance claims

BackgroundPrevious studies suggest that retirement, a major life event, affects overall healthcare utilization. We examine, the effects of retirement on inpatient healthcare utilization, including effect heterogeneity by gender, disease category, and type of health service.MethodsWe used routine health insurance claims data (N = 87,087) spanning the period 2021 - September 2013 from the Urban Employee Basic Medical Insurance (UEBMI), a mandatory social health insurance for working and retired employees in urban China. We applied a non-parametric fuzzy regression discontinuity design using the statutory retirement age in urban China as an exogenous instrument to measure the causal effect of retirement on six measures of inpatient healthcare utilization.ResultsRetirement reduced total hospital costs (-84.71 Chinese Yuan (CNY), 95% confidence interval (CI) -172.03 – 2.61), shortened length of hospital stays (-44.59, 95% CI -70.50 – -18.68), and increased hospital readmissions (0.06, 95% CI 0.00 – 0.12) and primary hospital visits (0.06, 95% CI 0.02 – 0.09) among women. Retirement did not significantly change inpatient healthcare utilization among men. The retirement effects among women varied by disease category. Specifically, retirement substantially increased hospitalizations for non-communicable diseases (NCDs), yet had only modest or no effect on hospitalizations for communicable diseases or injuries. Retirement effects among women also varied by the type of services. For relatively inexpensive services, such as nonoperative treatment, there were surges in the extensive margin (hospital readmission). For relatively expensive and invasive services, such as surgeries, retirement reduced the intensive margin (out-of-pocket expenditures and length of stay).ConclusionsRetirement decreases overall use of inpatient healthcare for women. The examination on the disease-related heterogeneous effects helps with the introduction and implementation of integrated healthcare delivery and appropriate incentive schemes to encourage better use of healthcare resources among older adults.

Financial toxicity and psychological distress in adults with cancer: A treatment-based analysis

ObjectiveTo evaluate disparities in financial toxicity and psychological distress in patients with cancer as a function of treatment and reveal the relationship between financial toxicity and psychological distress. MethodsThis was a multicenter cross-sectional study. Patients were recruited from March 2017 to October 2018, and questionnaires were completed regarding their demographics, financial toxicity, and psychological distress. A multiple linear regression model was used to examine factors associated with financial and psychological distress. ResultsSignificant financial toxicity and psychological distress occurred in 47.9% and 56.5% of patients, respectively. Financial toxicity (P ​= ​0.032) and psychological distress (P ​< ​0.001) were statistically different among the single chemotherapy, adjuvant therapy, and surgery groups. Multivariable analysis revealed that patients aged 50–59 years (P ​= ​0.035), 60–69 years (P ​= ​0.007), and 70 years or older (P ​= ​0.002) had higher the Comprehensive Score for financial Toxicity (COST) scores compared with patients less than 50 years old. Patients with personal annual income > 40,000 CNY reported higher COST scores than those who had < 20,000 CNY (P ​< ​0.001). Patients who had Urban Resident Basic Medical Insurance (URBMI) (P ​= ​0.030) or New Rural Cooperative Medical Scheme (NRCMS) (P ​= ​0.006) compared with Urban Employee Basic Medical Insurance (UEBMI) presented lower COST scores than patients with UEBMI. The multiple analysis model of psychological distress showed that an age of more than 70 years (P ​= ​0.010) was significantly associated with low the Distress Thermometer (DT) scores, and patients with colorectal cancer (P ​= ​0.009), the surgery group (P ​< ​0.001) and adjuvant therapy group (P ​< ​0.001) were significantly associated with high DT scores. The correlations between financial toxicity and psychological distress were mild but statistically significant in the chemotherapy-related treatment groups. ConclusionsThe research highlights the high rates of financial and psychological distress in adult patients. Multidimensional distress screening and psychosocial interventions should be provided for patients with cancer according to related factors.

China Stroke Statistics: an update on the 2019 report from the National Center for Healthcare Quality Management in Neurological Diseases, China National Clinical Research Center for Neurological Diseases, the Chinese Stroke Association, National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention and Institute for Global Neuroscience and Stroke Collaborations

China faces the greatest challenge from stroke in the world. According to results from the Global Burden of Disease Study 2019, there were 3.94 million new stroke cases, 28.76 million...

Investing in health capital: Does medical insurance matter?

Health capital investment is a component of human capital and can increase labor productivity in the economy. This study analyzes the returns on health investment based on the perspective of medical insurance. China’s basic medical insurance system provides a suitable institutional setting, which comprises three schemes: Urban Employee Basic Medical Insurance, Urban Resident Basic Medical Insurance, and New Rural Cooperative Medical Scheme. Using the China Health and Retirement Longitudinal Study and various econometric models, we find that medical insurance significantly impacts health outcomes of Chinese population aged 45 years and more. The result differs by the types of medical insurance, health indicators, and age groups. Furthermore, the convenience of obtaining medical insurance benefits, rarely mentioned in academic literature, is a significant factor affecting population health. From the perspective of health capital investment, investment in medical insurance must target younger groups.

Inequity in Health Services Utilization in Economically Underdeveloped Regions of Northeast China.

BackgroundThe Chinese health system has long been committed to eliminating inequalities in health services utilization. However, few studies have analyzed or measured these inequalities in economically underdeveloped regions in China.MethodsA total of 6,627 respondents from 3,000 households in Heilongjiang Province were extracted from the Sixth National Health Services Survey. We measured horizontal inequity in both 2-week outpatient rate and annual inpatient rate, and then identified the factors contributing to inequality.ResultsThe horizontal inequity indices of the 2-week outpatient and annual impatient rates in Heilongjiang Province were 0.0586 and 0.1276, respectively. Household income, health status, place of residence, basic medical insurance, and commercial health insurance were found to be the main factors affecting inequality in health services utilization. The contributions of household income to these two indices were 184.03 and 253.47%, respectively. Health status factors, including suffering from chronic disease, limitations in daily activities, and poor self-rated health, played positive roles in reducing inequality in these two indices. The contributions of place of residence to these two indices were 27.21 and −28.45%, respectively. Urban Employee Basic Medical Insurance made a pro-rich contribution to these two indices: 56.25 and 81.48%, respectively. Urban and Rural Resident Basic Medical Insurance, Urban Resident Basic Medical Insurance, New Rural Cooperative Medical Scheme, and other basic medical insurance made a pro-poor contribution to these two indices: −73.51 and −54.87%, respectively. Commercial health insurance made a pro-rich contribution to these two indices: 20.79 and 7.40%, respectively. Meanwhile, critical illness insurance made a slightly pro-poor contribution to these two indices: −4.60 and −0.90%, respectively.ConclusionsThe findings showed that the “equal treatment in equal need” principle was not met in the health services utilization context in Heilongjiang Province. To address this issue, the government could make policy changes to protect low-income populations from underused health services, and work to improve basic medical insurance, critical illness insurance, and social security systems.

KDE-OCSVM model using Kullback-Leibler divergence to detect anomalies in medical claims

Detecting and preventing unusual claims behavior in medical insurance can reduce the drawdown of a group medical insurance pool. Taking the case of the urban employee basic medical insurance (UEBMI) in China, this paper develops a method to detect unusual medical claim patterns in the UEBMI. We collect public domain records involving gastric malignancy as the experimental sample. A method to preprocess the experimental sample for data learning is provided. We present a feature selection method, involving variance analysis and similarity analysis, to determine the core features. Next, we establish an extended one-class support vector machine (OCSVM) model, the kernel density estimation (KDE)-OCSVM, which exploits the Kullback-Leibler divergence and the KDE method to estimate the parameter v of the OCSVM model, to improve model performance. An experiment and two analyses are performed to validate the proposed method.

Incidence and cost of haemolytic uraemic syndrome in urban China: a national population-based analysis

BackgroundHaemolytic uraemic syndrome (HUS) is a severe syndrome that causes a substantial burden for patients and their families and is the leading cause of acute kidney injury in children. However, data on the epidemiology and disease burden of HUS in Asia, including China, are limited. We aimed to estimate the incidence and cost of HUS in China. MethodsData about HUS from 2012 to 2016 were extracted from the Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI) databases. All cases were identified by ICD code and Chinese diagnostic terms. The 2016 national incidence rates were estimated and stratified by sex, age and season. The associated medical costs were also calculated.ResultsThe crude incidence of HUS was 0.66 per 100,000 person-years (95% CI: 0.35 to 1.06), and the standardized incidence was 0.57 (0.19 to 1.18). The incidence of HUS in males was slightly higher than that in females. The age group with the highest incidence of HUS was patients < 1 year old (5.08, 95% CI: 0.23 to 24.87), and the season with the highest incidence was autumn, followed by winter. The average cost of HUS was 2.15 thousand US dollars per patient, which was higher than the national average cost for all inpatients in the same period.ConclusionsThis is the first population-based study on the incidence of HUS in urban China. The age and seasonal distributions of HUS in urban China are different from those in most developed countries, suggesting a difference in aetiology.

Medical expenditure and its influencing factors of patients with hypertension in Shanxi Province, China: a study based on ‘System of Health Accounts 2011’ and multiple-layer perceptron neural network

ObjectivesTo study the medical expenditure and influencing factors of patients with hypertension in Shanxi Province, China.DesignA cross-sectional study.Setting1088 medical institutions, including general hospitals, traditional Chinese medicine hospitals, special hospitals, basic...

Multimorbidity and catastrophic health expenditure among patients with diabetes in China: a nationwide population-based study

IntroductionMultimorbidity is common among patients with diabetes and can lead to catastrophic health expenditure (CHE) for their families. This study aims to investigate the prevalence of multimorbidity and CHE among...

Incidence of neuromyelitis optica spectrum disorders in China: a large cohort study using claim data

ObjectivesPopulation-based studies estimating the incidence of neuromyelitis optica spectrum disorders (NMOSDs) in Asia are limited, and the relationship between latitude and incidence has been scarcely investigated. We aimed to estimate...

Loneliness Status and Related Factors among the Hakka Elderly in Fujian, China: Based on the Health Ecological Model.

There are few studies estimating the loneliness of the Hakka elderly in China. This study aims to examine the loneliness status and related factors among the Hakka elderly in Fujian, China. The short-form UCLA Loneliness Scale (ULS-8) was used to assess the loneliness of the Hakka elderly. Factors associated with loneliness were classified as individual indicators, behavioral indicators, interpersonal indicators, and social indicators according to the health ecological model (HEM). Hierarchical linear regression models were established to identify the main factors that were most predictive of loneliness. A sample of 1,262 Hakka elderly people was included in this study. Females (β = 0.631, P=0.012), those with ≥2 chronic diseases (β = 1.340, P < 0.001), those who were currently living in rural areas (β = 4.863, P < 0.001) or suburban areas (β = 2.027, P < 0.001), those with parents both died (β = 0.886, P=0.001), and those with the Urban Employees Basic Medical Insurance (UEBMI; β = 0.852, P=0.030) obtained a higher score of ULS-8. Those exercised regularly (β = −2.494, P < 0.001), those had leisure activities (β = −1.937, P < 0.001), those ate healthy (β = −1.270, P < 0.001), and those with better self-rated financial status and higher education level received a lower score of ULS-8. There are differences in loneliness among different Hakka elderly population subgroups, and healthy behaviors and lifestyles may reduce the loneliness of the Hakka elderly. Relevant interventions should be implemented in a targeted manner, focusing on susceptible populations. This is most evident among those who were female, living in rural areas, with parents both died, with lower education, and with multiple chronic diseases.

Comparison of inpatient spending and readmission rates for patients treated by male versus female physicians in China: An observational study.

To determine whether there are significant differences in costs of treatment and readmission rates for hospital consultations undertaken by female versus male physicians in China. Using data from the Urban Employee Basic Medical Insurance program from January 2018 through October 2019, we investigated spending patterns and clinical outcomes for patients at tertiary hospitals in one of the largest cities in China by the gender of the attending physician. Our sample included 79,085 hospitalizations treated by 3993 physicians in internal medicine departments. We examined the association between physician gender and visit cost using a multivariable linear model. We examined the association between physician gender and 30-days readmission rates using a multivariable probability model. We adjusted for a rich set of patient characteristics, primary diagnosis fixed effects, and hospital fixed effects. In addition, we used patient fixed effects in a robustness analysis. Adjusting for primary diagnosis fixed effects, spending per visit was 4.1% higher for patients treated by male physicians than for those treated by female physicians, a statistically significant difference (95% CI [1.5%, 6.7%]). This pattern persisted after further adjusting for hospital fixed effects (3.2% [1.2%, 5.2%]), patient characteristics (3.2% [1.2%, 5.1%]), and patient fixed effects (4.2% [1.8%, 6.7%]). The difference is mainly driven by higher spending on drugs (8.7% [3.9%, 13.6%]) and out-of-pocket costs (3.9% [1.7%, 6.0%]). No statistically significant differences were observed in the readmission rates of patients treated by male and female physicians in any of our three model specifications. Spending per visit was significantly higher among patients treated by male physicians than among those treated by female physicians, with the difference mainly driven by spending on drugs and out-of-pocket costs. No significant difference was observed in the hospital readmission rates of patients treated by male and female physicians. These findings have important implications for gender equality in medicine and health care quality and efficiency in developing countries.