A Multilevel Logit Estimation on the Determinants of Utilization of Preventive Health Care and Healthy Lifestyle Practice in China

• Author: Lida Fan,Nazim N. Habibov,Jianye Liu
• DOI: http://doi.org/10.1002/wmh3.160
• Published date: 01 December 2015
• Date: 01 December 2015

A Multilevel Logit Estimation on the Determinants of

Utilization of Preventive Health Care and Healthy

Lifestyle Practice in China

Lida Fan, Jianye Liu, and Nazim N. Habibov

The purpose of this study is to provide policy implications by estimating the individual and

community level determinants of preventive health-care utilization in China based upon data from

the China Health and Nutrition Survey. Two different frameworks, a human capital model and

a psychological-behavioral model, are tested using a multilevel logit estimation. The results

demonstrate different patterns for medical and nonmedical preventive activities. There is a strong

correlation between having medical insurance and utilizing preventive health services. For the usage

of medical-related preventive health care (MP), age, gender, education, urban residence, and medical

insurance are strong predictors. High income did not provide much of an increase in the usage level

of MP, but the lack of income was a huge obstacle for low-income people to overcome. Community

variation in number of facilities accounted for about one third of the total variation in the utilization

of MP. The utilization of MP in China remains dependent upon the individual’s social-economic

conditions.

KEY WORDS: determinants, preventive health care, China

Introduction

How do people deal with threats to their health? In the developed world, the

answers to this long-standing question tend to be either behaviorally or

cognitively oriented (Kirscht, 1983; Prentice-Dunn & Rogers, 1986). However, the

utilization of preventive health care in developing countries can be substantially

different from that in the developed world (Dupas, 2011). Preventive health-care

activities are associated with socioeconomic conditions, and their use depends on

the types of activities involved; for example, whether they require medical

facilities or can be done by individuals. In this study, we will investigate the

determinants of both medical preventive health care and healthy lifestyle practice

in China, using a data set from a nationally representative survey.

“Prevention f‌irst” has been one of the major health-care policies in China

since the 1950s. This policy was considered a success in improving the health

World Medical & Health Policy, Vol. 7, No. 4, 2015

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status of the Chinese people in pre-reform China (Sidel & Sidel, 1982; World

Health Organization, 1975). The merit of the pre-reform Chinese medical system

was characterized by an emphasis on prevention: “low-cost, locally controlled

health services and promoting accessible primary health care in rural areas”

(Hillier & Shen, 1996, p. 258). The pre-reform era’s health-care system was

eff‌icient in terms of the control of infectious diseases; despite pervasive low

productivity and shortage of services in almost every area, Chinese people’s

health status improved throughout the 1980s and 1990s (Fang & Bloom, 2010; Shu

& Yao, 1997). During the economic reform, the utilization of preventive health

care became challenging for many people, especially people living in rural areas

and people without medical insurance, because of decentralization and marketi-

zation. Financial decentralization limits the role of the government in providing

public health programs. During the reform, the urban medical scheme has been

f‌inanced mainly through municipal-level risk pooling for employees with basic

medical insurance. The rural “New Cooperative Medical Scheme” (NCMS)

initiated in 2003 focuses “almost exclusively on medical care and funds only a

few preventive services” (Fang & Bloom, 2010, p. 32). This policy may lead

individuals to a more curative care focus, since one of the fundamental changes

lies in increasing out-of-pocket expense. Thus spending on preventive health care

becomes more of a personal choice for future well-being, rather than a public

policy arrangement as it was before the reform. Although the ongoing health-care

reform initiated in 2009 aims to provide comprehensive universal health coverage

for all citizens by 2020, individuals’ incentives would remain an important

element in the new system (Yip et al., 2012). In this way, it becomes more about

the individual’s investment in their own human capital, impacted both by the

individual’s understanding of the importance of preventive care, and their

economic ability to carry the associated costs.

In recent years, an increasing literature has focused on various key factors

affecting the utilization of health care in China (Gao, Raven, & Tang, 2007; Liu,

Zhang, Lu, Kwon, & Quan, 2007; Qian, Pong, Yin, Nagarajan, & Meng, 2009;

Wagstaff, Lindelow, & Hsiao, 2009; Zhang & Kanbur, 2005; Zhang, Wang, &

Zhang, 2014). However, although early studies explored the preventive health-

care system before and after the reform (Hillier, 1986; Hillier & Shen, 1996;

Kaufmana & Jing, 2002), if we limit our searching area to the determinants or

factors affecting the utilization of preventive health care, we still have the

impression that we know little in this area. Among the very few studies on the

determinants of preventive health care in China, van Dalen (2006) estimated a

few socioeconomic variables, including insurance and wealth, using probit-

estimation and instrumental variables (IV) based on the data of the China Health

and Nutrition Survey 2004. Using probit-estimation he found that possessing

health insurance increased the probability of using preventive health care by 3

percent, but this effect was not statistically signif‌icant per the results of the IV

probit-estimation. He also found that being in the lowest 40 percent of population

wealth would reduce the likelihood of using preventive health care by 1 percent.

However, being in the top 20 percent wealth group did not have any effect when

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