Department of Global Health, School of Public Health, Wuhan University, Wuhan, China.
Global Health Institute, Wuhan University, Wuhan, China.
Front Public Health. 2022 Sep 30;10:989625. doi: 10.3389/fpubh.2022.989625. eCollection 2022.
Promoting equity in healthcare resource allocation (EHRA) has become a critical political agenda of governments at all levels since the ambitious Universal Health Coverage was launched in China in 2009, while the role of an important institutional variable-fiscal autonomy of subnational governments-is often overlooked. The present study was designed to determine the effect of FASG on EHRA and its potential mechanism of action and heterogeneity characteristics to provide empirical support for the research field expansion and relative policies making of EHRA.
From the start, we utilized the Theil index and the entropy method to calculate the EHRA index of 22 provinces (2011-2020) based on the medical resource data of 287 prefecture-level cities. Furthermore, we used the two-way fixed effects model (FE) to identify and analyze the impact of FASG on EHRA and then used three robustness test strategies and two-stage least squares (2SLS) regression to verify the reliability of the conclusions and deal with potential endogeneity problems, respectively. At last, we extend the baseline regression model and obtain the two-way FE threshold model for conducting heterogeneity analysis, which makes us verify whether the baseline model has nonlinear characteristics.
The static value and the trend of interannual changes in the EHRA values in different provinces are both very different. The regression results of the two-way FE model show that FASG has a significant positive impact on EHRA, and the corresponding estimated coefficient is - 0.0849 ( < 0.01). Moreover, this promotion effect can be reflected through two channels: enhancing the intensity of government health expenditure (IGHE) and optimizing the allocation of human resources for health (AHRH). At last, under the different economic and demographic constraints, the impact of FASG on EHRA has nonlinear characteristics, i.e., after crossing a specific threshold of per capita DGP (PGDP) and population density (PD), the promotion effect is reduced until it is not statistically significant, while after crossing a particular threshold of dependency ratio (DR), the promotion effect is further strengthened and still statistically significant.
FASG plays an essential role in promoting EHRA, which shows that subnational governments need to attach great importance to the construction of fiscal capability in the allocation of health care resources, effectively improve the equity of medical and health fiscal expenditures, and promote the sustainable improvement of the level of EHRA.
自 2009 年中国提出雄心勃勃的全民医保以来，促进医疗资源配置公平（EHRA）已成为各级政府的重要政治议程，而一个重要的制度变量——省级政府财政自主权——的作用往往被忽视。本研究旨在确定财政自主权对 EHRA 的影响及其潜在作用机制和异质性特征，为 EHRA 研究领域的拓展和相关政策制定提供实证支持。
本研究从省级财政自主权（FASG）的角度出发，利用 2011-2020 年 287 个地级市的医疗资源数据，采用泰尔指数和熵值法计算了 22 个省份的 EHRA 指数。在此基础上，利用双向固定效应模型（FE）对 FASG 对 EHRA 的影响进行识别和分析，然后采用三种稳健性检验策略和两阶段最小二乘法（2SLS）回归分别对结论的可靠性进行检验，并处理潜在的内生性问题。最后，扩展了基准回归模型，并获得了双向 FE 门限模型，以进行异质性分析，从而验证了基准模型是否具有非线性特征。
不同省份的 EHRA 值的静态值和年度变化趋势都非常不同。双向 FE 模型的回归结果表明，FASG 对 EHRA 具有显著的正向影响，对应的估计系数为-0.0849（<0.01）。此外，这种促进作用可以通过两条途径来体现：增强政府卫生支出强度（IGHE）和优化卫生人力资源配置（AHRH）。最后，在不同的经济和人口约束下，FASG 对 EHRA 的影响具有非线性特征，即人均 GDP（PGDP）和人口密度（PD）超过特定阈值后，促进效应会降低，直至不具有统计学意义，而在依赖比（DR）超过特定阈值后，促进效应会进一步增强，且仍具有统计学意义。
省级财政自主权在促进 EHRA 方面发挥着重要作用，这表明省级政府需要重视在医疗资源配置中财政能力的建设，切实提高医疗卫生财政支出的公平性，促进 EHRA 水平的持续提高。
