Internal Migration and 'Rural/Urban‘ Households in China:
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Internal Migration and 'Rural/Urban‘ Households in China:

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Lunchtime seminar session on learning from the POVILL project in China.

Lunchtime seminar session on learning from the POVILL project in China.
www.povill.com

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Internal Migration and 'Rural/Urban‘ Households in China: Internal Migration and 'Rural/Urban‘ Households in China: Presentation Transcript

  • Internal Migration and Rural/Urban‘ Households in China: Implications for Health care 1
  • Origins of POVILL Research• Anecdotal evidence from poor villages:  Elderly + young children  High prevalence of chronic illness  Vulnerability• New Cooperative Medical Scheme (NCMS)  Government subsidy  Risk fund for inpatient care• ‘Catastrophic healthcare expenditure’  Model: Get sick – Buy care – Get well  Extreme reductionism (Dennett) 2
  • The Limits of ‘Catastrophic Healthcare Expenditure• High expenditure on healthcare (even relative to income) not necessarily ‘catastrophic’.• Adoption of approach by policy makers encouraged a excessive focus on hospital inpatient expenditures• Variety of mechanisms through which health shocks and poverty may interact:  Acute events requiring costly hospital care  Chronic illness requiring long-term medication  Less serious but often recurring acute illnesses  Long-term, possibly progressive, conditions that completely or partially disable the sufferer  Stigmatising illnesses may induce loss of status, isolation, rejection and persecution.• Poorest often cannot afford ‘catastrophic health expenditure’. 3 View slide
  • Illness-Poverty Links(China National Heath Service Survey 2008) Other Man made causes Unemployment Disease: treatment cost Disease: low productivity Natural conditions/disaster Lack labour 0 5 10 15 20 25 304 View slide
  • The POVILL project• Aims:  Understand the potentially complex impacts of major illness on household livelihoods for a substantial number of households  Select households using a probability sampling approach to make valid statistical inferences to the overall study area populations.• Major illness conceived very broadly: health problems which had the potential to seriously damage household livelihood strategies.• Primary causal pathways to impoverishment seen as:  Increased expenditures on healthcare  Limitations on household activities, linked to illness- induced changes in labour demand and supply. 5
  • Research Methods• Existing knowledge mainly derived from questionnaire surveys that collect information on illness, care seeking behaviour and expenditure, typically on the basis of a two-week recall for acute illness episodes and a one year recall for inpatient treatments.• Even panel surveys have limited ability to capture the step-by-step process whereby households cope, or fail to cope, with consequences of ill-health.• Alternatives:  Case studies: fascinating but limited scale  Monitoring surveys: increased reliability but limited to relatively simple data and modest sample size  Demographic surveillance sites: interesting possibility (if one exists), difficult ethical problems. 6
  • POVILL Approach• Rapid and reasonably large-scale household questionnaire survey using cluster sampling of households within selected study areas:  identify households substantially affected by different categories of serious health problem  estimate the proportions of such households in the population.• Sampled households stratified using survey data.• Probability sample of households within selected strata• In-depth studies (1-2 person days) of these household undertaken by teams of social scientists 7
  • In-Depth Studies• Collected both quantitative and qualitative data. Specific intention to derive reasonably reliable estimates of incomes, expenditures, health care cost, financial support received, duration of illness or disability, etc.• Underlying framework was an ‘illness narrative’ to document the history of each health problem addressed.• Four main components:  Narrative and construction of one year time line  Identification of ‘events’: start points for changes in health status, treatment, assistance, assets, other.  Detailed description of events  Dating/quantifying events to the extent possible 8
  • Illustrative One-Year Timeline 2006 2007 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Back Village Condition Township Borrow money County pain. Health worse. Unable Hospital to buy drugs. Hospital limits Station to farm. Son activity returns to help 9
  • Three Transitions• Demographic  Low mortality and low Fertility•Epidemiological  Acute infectious disease → chronic NCDs•Economic  Planned → ‘Socialist Market’ 10
  • Resident and Migrant Populations Total Resident at Absent more Population least 6 months than 6 months0-14 15.9 20.2 7.615-19 9.2 5.9 15.520-39 29.9 12.8 63.440-49 12.8 14.4 9.650-59 15.3 21.5 3.160-69 10.2 15.1 0.770+ 6.8 10.1 0.2 11
  • Resident and Migrant Populations Population and living away from home• Internal migration: 30% of 100 rural population. Male 90 Female• 90% of men and 70% of M-living away 80 women between the ages of F-living away 20 and 35 reported as living 70 away from home for part of 60 year (90% migrate 6 months age or longer). 40• So the resident population is 30 dominated by those under 15 20 (21%) or over 50 (48%). 10• 16.6% of rural residents aged 65 and over (UK:16%). 0 Population 600 500 400 300 200 100 100 200 300 400 500 600 12
  • The countryside is exporting goodhealth and re-importing ill-health.• First, young and healthy people are more likely to migrate than elderly people, leaving the weak and sick at home.• Second, more serious and incapacitating diseases and intensive-care conditions result in a migrant’s return to the home in the village to seek family support and to avoid the high medical and living costs in cities.
  • Reason given by migrants for returning home illhealth Too old take Care of family member Pregnancy, delivery & upbring cant find job % marriage investment 0 5 10 15 20 25 30 14
  • Self reported serious illness over previous year 10 15 20 25 30 35 40 45 50 migration left behind proportion of population(%) 5 0 15 20 25 30 35 40 45 50 15 age
  • ‘Rural/urban’ Households Elderly + children Parent + children Three generation Elderly only Nuclear Extended family family 14% 23% 11% 12% Members left- Reunited in 56% behind Rural/urban urban areaTraditionalhousehold household 40% 60% Return to care for others Migrants 44% couple single Return due to illness 16
  • Four main health insurance schemes in China• Government staff(free medical service,FMS)  5% population 100% coverage• Basic Medical Insurance (BMI)  Urban employees, 28% coverage 2006• Urban Basic Medical Insurance (UBMI)  Other urban residents, aim: 100% coverage by 2010• New Community Medical Scheme (NCMS)  Rural residents, 57% population, 87% coverage 2007 17
  • Heath insurance schemecoverage for migrants in Beijing BMIS FMS other 2% 2% 3% CI 6% none NCMS 46% 41% 18
  • Reimbursement of NCMS 19
  • Chronic illness healthcare costs 20
  • Urban/Rural and Decentralisation Poor county Shanghai Limited health insurance Well funded health insurance supplysupply Very limited govt revenue High government revenue Less enterprises and jobs More enterprises and jobs Healthy labor exported health Healthy labor imported demand Elderly less-healthy remain Ill-demand joined by returning ill migrants health Younger, healthier population 21
  • Shanghai compared to Western provinces• In Shanghai, the government plus personal financial contribution to the rural NCMS was around 450 yuan per person• Compared with only 50 yuan per person in most provinces in Western China. 22
  • Questions• Can segmented (urban/rural) and highly decentralised health care and health insurance systems cope with these new ways of constructing family units?• What happens next?• What are the implications for the Chinese economy?• How do we conduct research on these new ‘households’? 23