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Research
Social health insurance coverage and financial protection among rural-to-urban internal migrants in China: evidence from a nationally representative cross-sectional study
  1. Wen Chen1,
  2. Qi Zhang2,
  3. Andre M N Renzaho3,
  4. Fangjing Zhou4,
  5. Hui Zhang5,
  6. Li Ling1
  1. 1Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-Sen University, Guangzhou, China
  2. 2School of Community and Environmental Health, Old Dominion University, Norfolk, Virginia, USA
  3. 3School of Social Science and Psychology, Humanitarian and Development Research Initiative, Western Sydney University – Penrith Campus, Kingswood, New South Wales, Australia
  4. 4Department of Prevention and Treatment, Center for Tuberculosis Control of Guangdong Province, Guangzhou, China
  5. 5Faculty of Health Policy and Management, School of Public Health, Sun Yat-Sen University, Guangzhou, China
  1. Correspondence to Professor Li Ling; lingli{at}mail.sysu.edu.cn

Abstract

Introduction Migrants are a vulnerable population and could experience various challenges and barriers to accessing health insurance. Health insurance coverage protects migrants from financial loss related to illness and death. We assessed social health insurance (SHI) coverage and its financial protection effect among rural-to-urban internal migrants (IMs) in China.

Methods Data from the ‘2014 National Internal Migrant Dynamic Monitoring Survey’ were used. We categorised 170 904 rural-to-urban IMs according to their SHI status, namely uninsured by SHI, insured by the rural SHI scheme (new rural cooperative medical scheme (NCMS)) or the urban SHI schemes (urban employee-based basic medical insurance (UEBMI)/urban resident-based basic medical insurance (URBMI)), and doubly insured (enrolled in both rural and urban schemes). Financial protection was defined as ‘the percentage of out-of-pocket (OOP) payments for the latest inpatient service during the past 12 months in the total household expenditure’.

Results The uninsured rate of SHI and the NCMS, UEBMI/URBMI and double insurance coverage in rural-to-urban IMs was 17.3% (95% CI 16.9% to 17.7%), 66.6% (66.0% to 67.1%), 22.6% (22.2% to 23.0%) and 5.5% (5.3% to 5.7%), respectively. On average, financial protection indicator among uninsured, only NCMS insured, only URBMI/UEBMI insured and doubly insured participants was 13.3%, 9.2%, 6.2% and 5.8%, respectively (p=0.004). After controlling for confounding factors and adjusting the protection effect of private health insurance, compared with no SHI, the UEBMI/URBMI, the NCMS and double insurance could reduce the average percentage share of OOP payments by 33.9% (95% CI 25.5% to 41.4%), 14.1% (6.6% to 20.9%) and 26.8% (11.0% to 39.7%), respectively.

Conclusion Although rural-to-urban IMs face barriers to accessing SHI schemes, our findings confirm the positive financial protection effect of SHI. Improving availability and portability of health insurance would promote financial protection for IMs, and further facilitate achieving universal health coverage in China and other countries that face migration-related obstacles to achieve universal coverage.

  • health insurance
  • cross-sectional survey
  • health systems

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjgh-2017-000477

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    Footnotes

    • Handling editor Seye Abimbola

    • Contributors LL got the access to data from the ‘2014 National Internal Migrant Dynamic Monitoring Survey (NIMDMS)'. WC developed analytical strategy, analysed data and drafted the manuscript. QZ and AMNR participated in critically revising the manuscript. FZ contributed to data analysis. All authors contributed to the data interpretation, manuscript writing and final approval of the manuscript.

    • Funding The NIMDMS was funded by the National Health and Family Planning Commission of China. The funding agency played no role in data analysis, writing of the manuscript, interpretation of the results or submission for consideration of publication. QZ was supported by the 111 Project, grant number B16031.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Ethics approval This was secondary analysis of publicly available data, and no participant consent forms were required to access this data set. This study was approved by the Ethics Committee of School of Public Health, Sun Yat-Sen University.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The data controller of the data analysed is the National Health and Family Planning Commission of China. The 2014 NIMDMS data are available subject to authorised researchers who have been permitted by the National Health and Family Planning Commission of China.