The Impact of Economic Accessibility of Healthcare Services on the Health ‎of Elderly Individuals in China

Honglin Deng; Somchai  Bovornkitti; Sarisak  Soontornchai; Xiaoqiang  Qiu

ผู้แต่ง

Honglin Deng Hospital of Guangxi Medical University
Somchai Bovornkitti Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Sarisak Soontornchai Thammasat University, Bangkok, Thailand
Xiaoqiang Qiu Guangxi Medical University, China

คำสำคัญ:

economic accessibility, healthcare services, elderly health, China, aging population

บทคัดย่อ

Abstract

Background: China is undergoing rapid population aging, with the share of citizens aged 65 and older projected to rise from 9.6% in 2015 to 27.6% by 2050. Despite expanding insurance coverage under the National Basic Public Health Service Program, out-of-pocket (OOP) healthcare expenditure remains substantial, raising concerns about whether economic barriers to care undermine the health of older adults. Evidence on how affordability translates into physical and mental health outcomes in the Chinese elderly population and through which behavioral mechanisms is limited.

Objective: To examine the association between economic accessibility of healthcare services and physical health, life satisfaction, and depressive symptoms among elderly individuals in China, and to identify behavioral mechanisms underlying this association.

Materials and Methods: This was a longitudinal panel study using secondary data from the China Family Panel Studies (CFPS), a nationally representative biennial household survey conducted by the Institute of Social Science Survey, Peking University. Four survey waves were analyzed (2016, 2018, 2020, and 2022). Participants were respondents aged 60 years and older at each wave (N = 7,524 unique individuals; total panel observations = 19,847). Inclusion criteria were age ≥ 60 years and non-missing healthcare expenditure data; observations with missing values on key variables were excluded using listwise deletion. Economic accessibility was measured as the household-level ratio of out-of-pocket medical expenditure to total healthcare spending in the previous 12 months (continuous variable; lower ratio = greater accessibility). Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize sample characteristics. Associations between economic accessibility and health outcomes were estimated using panel fixed-effects regression, with mediation analysis (Baron and Kenny approach) for exercise, smoking, and alcohol consumption. Statistical significance was set at p < 0.05.

Results: Of 7,524 elderly respondents, 51.9% were female and 39.8% resided in urban areas (full descriptive characteristics in Table 1). Greater economic accessibility to healthcare was associated with better physical health (β = −0.142, 95% CI: −0.218 to −0.066, p < 0.001), higher life satisfaction (β = 0.098, 95% CI: 0.045 to 0.151, p < 0.001), and fewer depressive symptoms (β = −0.185, 95% CI: −0.267 to −0.103, p < 0.001). Exercise frequency mediated approximately 34% of the association with physical health and 28% with life satisfaction (β = 0.246, p < 0.01), while mediation through smoking and alcohol was weak. Stronger associations were observed among women, individuals in the lowest income quartile, those aged 80 and above, and urban residents.

Conclusion: Improved economic accessibility of healthcare services is associated with better physical and mental health among elderly individuals in China, with increased physical activity acting as the principal behavioral mechanism. Healthcare policies should prioritize reducing out-of-pocket burdens, narrowing urban–rural disparities, and promoting preventive behaviors to support equitable healthy aging.

Keywords: economic accessibility, healthcare services, elderly health, China, aging population

เอกสารอ้างอิง

References

Byrne A, Barber R, Lim C. Impact of the COVID‐19 pandemic – a mental health service perspective. Progress in Neurology and Psychiatry 2021; 25(2): 27-33. doi: 10.1002/pnp.708.

National Bureau of Statistics of China. China Statistical Yearbook 2023. Beijing: China Statistics Press; 2023.

Fang EF, Xie C, Schenkel JA, Wu C, Long Q, Cui H, et al. A research agenda for ageing in China in the 21st century (2nd edition): focusing on basic and translational research, long-term care, policy and social networks. Ageing Res Rev 2020; 64: 101174. doi: 10.1016/j.arr.2020.101174. PubMed PMID: 32971255.

Yip W, Fu H, Chen AT, Zhai T, Jian W, Xu R, et al. 10 years of health-care reform in China: progress and gaps in Universal Health Coverage. Lancet 2019; 394(10204): 1192–204. doi: 10.1016/S0140-6736(19)32136-1. PubMed PMID: 31571602.

Li X, Lu J, Hu S, Cheng KK, De Maeseneer J, Meng Q, et al. The primary health-care system in China. Lancet 2017; 390(10112): 2584–94. doi: 10.1016/S0140-6736(17)33109-4. PubMed PMID: 29231837.

Zhang T, Liu C, Ni Z. Association of access to healthcare with self-assessed health and quality of life among old adults with chronic disease in China: urban versus rural populations. Int J Environ Res Public Health 2019; 16(14): 2592. doi: 10.3390/ijerph16142592. PubMed PMID: 31330818.

Tao Z, Cheng Y. Modelling the spatial accessibility of the elderly to healthcare services in Beijing, China. Environ Plan B Urban Anal City Sci 2021; 48(8): 2017–34. [UPDATED 2021]

Wang X, Yang H, Duan Z, Pan J. Spatial accessibility of primary health care in China: a case study in Sichuan Province. Soc Sci Med 2018; 209: 14–24. doi: 10.1016/j.socscimed.2018.05.023. PubMed PMID: 29778934.

Shao S, Wang M, Jin G, Zhao Y, Lu X, Du J. Analysis of health service utilization of migrants in Beijing using Anderson's health service utilization model. BMC Health Serv Res 2018; 18(1): 462. doi: 10.1186/s12913-018-3271-y. PubMed PMID: 29914464.

Prentice JC, Pizer SD. Delayed access to health care and mortality. Health Serv Res 2007; 42(2): 644–62. doi: 10.1111/j.1475-6773.2006.00626.x. PubMed PMID: 17362211.

Chen S, Li J. Economic accessibility and healthcare utilization in China. BMC Health Serv Res 2022; 22: 541.

Meng Q, Mills A, Wang L, Han Q. What can we learn from China's health system reform? BMJ 2019; 365: l2349. doi: 10.1136/bmj.l2349. PubMed PMID: 31217222.

Fu XZ, Sun QW, Sun CQ, Xu F, He JJ. Urban-rural differences in catastrophic health expenditure among households with chronic non-communicable disease patients: evidence from China family panel studies. BMC Public Health 2021; 21(1): 874. doi: 10.1186/s12889-021-10887-6. PubMed PMID: 33957893.

Zhao Y, Atun R, Oldenburg B, McPake B, Tang S, Mercer SW, et al. Physical multimorbidity, health service use, and catastrophic health expenditure by socioeconomic groups in China: an analysis of population-based panel data. Lancet Glob Health 2020; 8(6): e840–9. doi: 10.1016/S2214-109X(20)30127-3. PubMed PMID: 32446349.

Wagstaff A, Flores G, Hsu J, Smitz MF, Chepynoga K, Buisman LR, et al. Progress on catastrophic health spending in 133 countries: a retrospective observational study. Lancet Glob Health 2018; 6(2): e169–79. doi: 10.1016/S2214-109X(17)30429-1. PubMed PMID: 29248367.