Publication: Health Shocks in China : Are the Poor and Uninsured Less Protected?
Loading...
Published
2005-10
ISSN
Date
2012-06-19
Author(s)
Editor(s)
Abstract
Health shocks have been shown to have important economic consequences in industrial countries. Less is known about how health shocks affect income, consumption, labor market outcomes, and medical expenditures in middle- and low-income countries. The authors explore these issues in China. In addition to providing new evidence on the general impact of health shocks, they also extend previous work by assessing the extent of risk protection afforded by formal health insurance, and by examining differences in the impact of health shocks between the rich and poor. The authors find that health shocks are associated with a substantial and significant reduction in income and labor supply. There are indications that the impact on income is less important for the insured, possibly because health insurance coverage is also associated with limited sickness insurance, but the effect is not significant. They also find evidence that negative health shocks are associated with an increase in unearned income for the poor but not the non-poor. This effect is however not strong enough to offset the impact on overall income. The loss in income is a consequence of a reduction in labor supply for the head of household, and the authors do not find evidence that other household members compensate by increasing their labor supply. Finally, negative health shocks are associated with a significant increase in out-of-pocket health care expenditures. More surprisingly, there is some evidence that the increase is greater for the insured than the uninsured. The findings suggest that households are exposed to considerable health-related shocks to disposable income, both through loss of income and health expenditures, and that health insurance offers very limited protection.
Link to Data Set
Citation
“Lindelow, Magnus; Wagstaff, Adam. 2005. Health Shocks in China : Are the Poor and Uninsured Less Protected?. Policy Research Working Paper; No. 3740. © World Bank. http://hdl.handle.net/10986/8499 License: CC BY 3.0 IGO.”
Associated URLs
Associated content
Other publications in this report series
Publication Intergenerational Income Mobility around the World(Washington, DC: World Bank, 2025-07-09)This paper introduces a new global database with estimates of intergenerational income mobility for 87 countries, covering 84 percent of the world’s population. This marks a notable expansion of the cross-country evidence base on income mobility, particularly among low- and middle-income countries. The estimates indicate that the negative association between income mobility and inequality (known as the Great Gatsby Curve) continues to hold across this wider range of countries. The database also reveals a positive association between income mobility and national income per capita, suggesting that countries achieve higher levels of intergenerational mobility as they grow richer.Publication International Activity and Female Labor Participation: New Evidence for Services Firms in Developing Countries(Washington, DC: World Bank, 2025-09-03)Using a cross-section of more than 33,000 services firms in 104 low- and middle-income countries from the World Bank’s Enterprise Surveys, this paper examines whether the female labor share premium of international firms relative to non-international firms in manufacturing also holds for services firms. Unlike the manufacturing sector, the paper finds a negative relationship between exporting and global value chain participation and the female labor share for services firms, while no relationship is found for importing or foreign ownership status, controlling for firm output, productivity, technology intensity, and fixed effects. The female labor share gap for exporters was larger before COVID-19, and the gap for global value chain participants is no longer significant after COVID-19. Controlling for sectoral relative wages between men and women does not change the findings in a smaller subsample of economies. Controlling for female top management and ownership reveals a female labor share gap for exporters, global value chain participants, and importers. Using an alternative estimator and data set confirms the female labor share gap in services firms. This may be attributed to the sectoral segregation between women and men, with women tending to pursue work opportunities in less skill- and export-intensive services sectors compared to men.Publication Children in Monetary Poor Households: Global, Regional, and Select National Trends in the Progress against Child Poverty(Washington, DC: World Bank, 2025-09-05)This paper presents the first estimates of extreme child poverty and child poverty using the World Bank’s recently revised international poverty lines. Using the international poverty line of $3.00 per day and the higher $8.30 per day poverty line (both expressed in 2021 purchasing power parity), the paper provides new results of the global and regional trends over 2014–24. The estimates show that 19.2 percent of children, approximately 412 million children, were living on less than $3.00 (2021 PPP) per day as of 2024, a reduction from 507 million children in 2014. This long-term decrease was slower than that for the general population. At the higher line of $8.30, the child poverty rate in 2024 was 65.9 percent, representing around 1.4 billion children, a drop from the 73.1 percent registered in 2014. At the regional level, the East Asia and Pacific and South Asia regions witnessed significant reductions in child poverty and extreme child poverty between 2014 and 2024, and the Europe and Central Asia and Latin America and the Caribbean regions showed reductions mostly in child poverty. In the same period, there was an increase in extreme child poverty in the Middle East and North Africa region. Sub-Saharan Africa experienced a “lost decade” of child poverty reduction between 2014 and 2024, increasing its concentration of global poverty. In 2024, Sub-Saharan Africa hosted more than three-quarters of children in extreme poor households (more than 311 million children), although its share of the global child population was around 23 percent. Country-level results show evidence of regional heterogeneity in progress against extreme child poverty.Publication Engineering Ukraine’s Wirtschaftswunder(Washington, DC: World Bank, 2025-07-29)As Ukraine emerges from the devastation of war, it faces a historic opportunity to engineer its own Wirtschaftswunder—a productivity-driven economic transformation akin to post-war West Germany. While investment-led growth may offer quick wins, it is efficiency, innovation, and institutional reform that will determine Ukraine’s long-term economic trajectory. Drawing on rich micro-level firm data spanning 25 years, this paper uncovers deep structural distortions that have suppressed creative destruction and productivity in Ukraine. It finds that business dynamism is on the decline, alongside rising market concentration among incumbent businesses, including low productivity state owned enterprises. To inform priorities for reviving business dynamism, this study develops a model of creative destruction drawing on Acemoglu et al. (2018) and Akcigit et al. (2021). The quantitative assessment highlights that policies that discipline entrenched incumbents are the bedrock for reviving business dynamism and engineer Ukraine’s Wirtschaftswunder. Policies targeting specific types of firms have limited efficacy when incumbents run wild.Publication The Macroeconomic Implications of Climate Change Impacts and Adaptation Options(Washington, DC: World Bank, 2025-05-29)Estimating the macroeconomic implications of climate change impacts and adaptation options is a topic of intense research. This paper presents a framework in the World Bank's macrostructural model to assess climate-related damages. This approach has been used in many Country Climate and Development Reports, a World Bank diagnostic that identifies priorities to ensure continued development in spite of climate change and climate policy objectives. The methodology captures a set of impact channels through which climate change affects the economy by (1) connecting a set of biophysical models to the macroeconomic model and (2) exploring a set of development and climate scenarios. The paper summarizes the results for five countries, highlighting the sources and magnitudes of their vulnerability --- with estimated gross domestic product losses in 2050 exceeding 10 percent of gross domestic product in some countries and scenarios, although only a small set of impact channels is included. The paper also presents estimates of the macroeconomic gains from sector-level adaptation interventions, considering their upfront costs and avoided climate impacts and finding significant net gross domestic product gains from adaptation opportunities identified in the Country Climate and Development Reports. Finally, the paper discusses the limits of current modeling approaches, and their complementarity with empirical approaches based on historical data series. The integrated modeling approach proposed in this paper can inform policymakers as they make proactive decisions on climate change adaptation and resilience.
Journal
Journal Volume
Journal Issue
Collections
Related items
Showing items related by metadata.
Publication Are Health Shocks Different? Evidence from a Multi-Shock Survey in Laos(2010-06-01)In Laos health shocks are more common than most other shocks and more concentrated among the poor. They tend to be more idiosyncratic than non-health shocks, and are more costly, partly because they lead to high medical expenses, but also because they lead to income losses that are sizeable compared with the income losses associated with non-health shocks. Health shocks also stand out from other shocks in the number of coping strategies they trigger: they are more likely than non-health shocks to trigger assistance from a nongovernmental organization and other households, dis-saving, borrowing, asset sales, an early harvest, the pawning of possessions, and the delaying of plans; by contrast, they are less likely to trigger assistance from government. Consumption regressions point to only limited evidence of households not being able to smooth consumption in the face of any shock. However, these results contrast with households' own assessments of the welfare impacts of shocks. The majority said they had to cut back consumption following a shock and that shocks considerably affected their welfare. Only health shocks are worse than a drought in terms of the likelihood of a family being forced to cut back consumption and in terms of the shock affecting a family's well-being "a lot." The poor are especially disadvantaged in terms of the greater damage that health shocks inflict on household well-being. Health shocks stand out too in leading to a loss of human capital: household members experiencing a health shock did not recover their former subjective health following the health shock, losing, on average, 0.6 points on a 5-point scale. The wealthier and better educated are better able to limit the health impacts of a health shock; the data are consistent with this being due to their greater proximity to a health facility.Publication Can Insurance Increase Financial Risk? The Curious Case of Health Insurance in China(World Bank, Washington, DC, 2005-10)The most basic argument for insurance is that it reduces financial risk. But since insurance opens up new opportunities for consuming expensive high-technology care which permits health improvements that are valued by the insured, and because in many settings the provider is able and has an incentive to exploit the informational advantage he has over the patient, it is not immediately obvious that insurance will in practice reduce financial risk. The authors analyze the effect of insurance on the probability of an individual incurring "high" annual health expenses using data from three household surveys-one a cross-section survey, the other two panel surveys. All come from China, a country where providers have until recently largely been paid fee-for-service (often according to a schedule that encourages the overprovision of high-technology care and the underprovision of basic care) and who are only lightly regulated. The authors define annual spending as "high" if it exceeds 5 percent of average income in the sample and as "catastrophic" if it exceeds 10 percent of the household's own per capita income. The estimates of the effect of insurance on financial risk allow for the possible endogeneity of health insurance in the panel datasets by allowing for a time-invariant fixed effect capturing unobserved risk that may be correlated with insurance status, and in the cross-section dataset by using instrumental variables, where availability of and eligibility for health insurance are used as instruments. The results suggest that during the 1990s China's government and labor insurance schemes increased financial risk associated with household health care spending, but that the rural cooperative medical scheme significantly reduced financial risk in some areas but increased it in others (though not significantly). From the results, it appears that China's new health insurance schemes (private schemes, including coverage of schoolchildren) have also increased the risk of high levels of out-of-pocket spending on health. Where the authors find evidence of health insurance increasing the risk of "high" out-of-pocket expenses, the marginal effect is of the order of 15-20 percent; in the case of "catastrophic" expenses, it is even larger.Publication Reforming China's Rural Health System(World Bank, 2009)This book began in 2003 during the initial formulations of China's 11th five-year plan, which covers the period 2006-10. During the entire period, the rural health Analytic and Advisory Activities (AAA) team analyzed the sector and debated reform options with government officials and scholars. It is helped the government in its extensive reform efforts over the past few years. The publication can serve two important functions: to provide an analytical framework for thinking about what happened in China's rural health system and why, and to present a global perspective on the options for further strengthening the sector. China is well on its way to achieving a modern, equitable, and well-functioning rural health sector, but this is not an easy task for any country. This book can provide a useful reference for policy makers in the next phase of health reform and beyond.Publication Extending Health Insurance to the Rural Population : An Impact Evaluation of China's New Cooperative Medical Scheme(World Bank, Washington, DC, 2007-03)In 2003, after over 20 years of minimal health insurance coverage in rural areas, China launched a heavily subsidized voluntary health insurance program for rural residents. The authors use program and household survey data, as well as health facility census data, to analyze factors affecting enrollment into the program and to estimate its impact on households and health facilities. They obtain estimates by combining differences-in-differences with matching methods. The authors find some evidence of lower enrollment rates among poor households, holding other factors constant, and higher enrollment rates among households with chronically sick members. The household and facility data point to the scheme significantly increasing both outpatient and inpatient utilization (by 20-30 percent), but they find no impact on utilization in the poorest decile. For the sample as a whole, the authors find no statistically significant effects on average out-of-pocket spending, but they do find some-albeit weak-evidence of increased catastrophic health spending. For the poorest decile, by contrast, they find that the scheme increased average out-of-pocket spending but reduced the incidence of catastrophic health spending. They find evidence that the program has increased ownership of expensive equipment among central township health centers but had no impact on cost per case.Publication Vulnerability and Safety Nets in Lao PDR(World Bank, Washington, DC, 2009-12)Lao PDR has experienced high levels of economic growth in recent years and the incidence of poverty has fallen dramatically since the 1990s. Yet, this report shows that Lao households continue to be highly vulnerable to regular seasonal fluctuations, as well as agricultural shocks and natural disasters. The report also highlights the importance of health shocks, injury and death for household welfare. Households adopt a variety of strategies to cope with these shocks, but in many cases are unable to fully smooth consumption, with negative short and long term consequences. Overall, the report points to a number of important vulnerable groups. The chronic poor in remote rural areas, including ethnic minority groups, remain highly vulnerable to seasonal fluctuations and natural disasters. However, households in urban areas, particularly the poor and near-poor, are vulnerable to future increases in food prices if they are not accompanied by increases in real wages. Moreover, as the Lao economy develops, more households will rely on off-farm work or migrant remittances, making them increasingly vulnerable to domestic and global macro-shocks. Finally, particular groups, including children, women, the disabled and the elderly are likely to be particularly badly affected by these shocks. The report goes on to discuss the potential value of social safety nets. Safety nets can reduce poverty and alleviate suffering for households who are unable to fully smooth their consumption after a shock. But effective safety nets don't just contribute to reducing poverty in the short term; they can also prevent long term poverty traps from arising (e.g. due to households being forced to sell productive assets, withdraw children from school, or reduce consumption below nutritionally adequate levels), and enable households to pursue riskier but more productive livelihood strategies. The report reveals important gaps in current policies and programs and suggests some potential directions towards implementing a comprehensive and institutionalized safety net program in Lao PDR. This will require substantial investments, not only to finance the actual programs, but also to develop the required capacity and knowledge at both local and central levels. While there are no easy solutions, reaching consensus on priorities and policy options for addressing vulnerability in Laos is essential if recent progress in poverty reduction and economic growth is to be sustained and deepened.
Users also downloaded
Showing related downloaded files
Publication Argentina Country Climate and Development Report(World Bank, Washington, DC, 2022-11)The Argentina Country Climate and Development Report (CCDR) explores opportunities and identifies trade-offs for aligning Argentina’s growth and poverty reduction policies with its commitments on, and its ability to withstand, climate change. It assesses how the country can: reduce its vulnerability to climate shocks through targeted public and private investments and adequation of social protection. The report also shows how Argentina can seize the benefits of a global decarbonization path to sustain a more robust economic growth through further development of Argentina’s potential for renewable energy, energy efficiency actions, the lithium value chain, as well as climate-smart agriculture (and land use) options. Given Argentina’s context, this CCDR focuses on win-win policies and investments, which have large co-benefits or can contribute to raising the country’s growth while helping to adapt the economy, also considering how human capital actions can accompany a just transition.Publication Firm-Level Technology Adoption in Vietnam(World Bank, Washington, DC, 2021-03)This paper describes the results of a new firm survey to measure technology use and adoption implemented prior to the COVID-19 pandemic in Vietnam. It analyzes the use and adoption of technology among Vietnamese firms and identifies some of the key barriers to adoption and diffusion. The analysis offers new and important stylized facts on firm-level use of technologies. First, although access to the internet is almost universal in Vietnam, firms had low digital readiness to face the COVID-19 pandemic; and the share of establishments with their own website, social media, and cloud computing is still small. Second, the use of Industry 4.0 technologies is incipient. Third, the technology gap with the use of frontier technologies in some general business functions, such as quality control, production planning, sales, and sourcing and procurement, is large. Fourth, the manufacturing sector faces the largest technological gap, larger than services and agricultural firms. The analysis of the main barriers and drivers to technology adoption and use shows the importance of good management quality for technology adoption, and that there is a technology premium associated with exporting activities. Finally, the analysis also shows that firms are largely unaware of the available public policy support for technology upgrading.Publication Ethnic Minority Development in Vietnam : A Socioeconomic Perspective(World Bank, Washington, D.C., 2002-05)The authors examine the latest quantitative evidence on disparities in living standards between and among different ethnic groups in Vietnam. Using data from the 1998 Vietnam Living Standards Survey and 1999 Census, they show that Kinh and Hoa ("majority") households have substantially higher living standards than "minority" households from Vietnam's other 52 ethnic groups. Subdividing the population into five broad categories, the authors find that while the Kinh, Hoa, Khmer, and Northern Highland minorities have benefited from economic growth in the 1990s, the growth of Central Highland minorities has stagnated. Disaggregating further, they find that the same ethnic groups whose living standards have risen fastest are those that have the highest school enrollment rates, are most likely to intermarry with Kinh partners, and are the least likely to practice a religion. The authors then estimate and decompose a set of expenditure regressions which show that even if minority households had the same endowments as Kinh households, this would close no more than a third of the gap in per capita expenditures. While some ethnic minorities seem to be doing well with a strategy of assimilating (both culturally and economically) with the Kinh-Hoa majority, other groups are attempting to integrate economically while retaining distinct cultural identities. A third group comprising the Central Highland minorities, including the Hmong, is largely being left behind by the growth process. Such diversity in the socioeconomic development experiences of the different ethnic minorities indicates the need for similar diversity in the policy interventions that are designed to assist them.Publication Classroom Assessment to Support Foundational Literacy(Washington, DC: World Bank, 2025-03-21)This document focuses primarily on how classroom assessment activities can measure students’ literacy skills as they progress along a learning trajectory towards reading fluently and with comprehension by the end of primary school grades. The document addresses considerations regarding the design and implementation of early grade reading classroom assessment, provides examples of assessment activities from a variety of countries and contexts, and discusses the importance of incorporating classroom assessment practices into teacher training and professional development opportunities for teachers. The structure of the document is as follows. The first section presents definitions and addresses basic questions on classroom assessment. Section 2 covers the intersection between assessment and early grade reading by discussing how learning assessment can measure early grade reading skills following the reading learning trajectory. Section 3 compares some of the most common early grade literacy assessment tools with respect to the early grade reading skills and developmental phases. Section 4 of the document addresses teacher training considerations in developing, scoring, and using early grade reading assessment. Additional issues in assessing reading skills in the classroom and using assessment results to improve teaching and learning are reviewed in section 5. Throughout the document, country cases are presented to demonstrate how assessment activities can be implemented in the classroom in different contexts.Publication Vietnam(World Bank, Hanoi, 2020-05-01)Following from Vietnam’s ratification of the Comprehensive and Progressive Agreement for Trans-Pacific Partnership (CPTPP) in late 2018 and its effectiveness from January 2019, and the European Parliament’s recent approval of the European Union-Vietnam Free Trade Agreement (EVFTA) and its subsequent planned ratification by the National Assembly in May 2020, Vietnam has further demonstrated its determination to be a modern, competitive, open economy. As the COVID-19 (Coronavirus) crisis has clearly shown, diversified markets and supply chains will be key in the future global context to managing the risk of disruptions in trade and in supply chains due to changing trade relationships, climate change, natural disasters, and disease outbreaks. In those regards, Vietnam is in a stronger position than most countries in the region. The benefits of globalization are increasingly being debated and questioned. However, in the case of Vietnam, the benefits have been clear in terms of high and consistent economic growth and a large reduction in poverty levels. As Vietnam moves to ratify and implement a new generation of free trade agreements (FTAs), such as the CPTPP and EVFTA, it is important to clearly demonstrate, in a transparent manner, the economic gains and distributional impacts (such as sectoral and poverty) from joining these FTAs. In the meantime, it is crucial to highlight the legal gaps that must be addressed to ensure that national laws and regulations are in compliance with Vietnam’s obligations under these FTAs. Readiness to implement this new generation of FTAs at both the national and subnational level is important to ensure that the country maximizes the full economic benefits in terms of trade and investment. This report explores the issues of globalization and the integration of Vietnam into the global economy, particularly through implementation of the EVFTA.