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    THẠC SĨ Improving equitable access to cataract surgery in rural southern china: Using willingness to pay data to assess the feasibility of a tiered pricing model to subsidize surgeries to the poorest

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  6. Improving equitable access to cataract surgery in rural southern china: Using willingness to pay data to assess the feasibility of a tiered pricing model to subsidize surgeries to the poorest

    Đề tài: IMPROVING EQUITABLE ACCESS TO CATARACT SURGERY IN RURAL SOUTHERN CHINA: USING WILLINGNESS TO PAY DATA TO ASSESS THE FEASIBILITY OF A TIERED PRICING MODEL TO SUBSIDIZE SURGERIES TO THE POOREST
    TABLE OF CONTENTS

    1 STUDY AIM AND OBJECTIVES 1

    1.1 OBJECTIVE 1 3

    1.2 OBJECTIVE 2 3

    1.3 OBJECTIVE 3 4

    2 BACKGROUND 5

    2.1 EPIDEMIOLOGY OF CATARACT AND CATARACT SURGERY 5

    2.2 RURAL HEALTH CARE IN CHINA 6

    2.3 HKI, CHINA AND TIERED PRICING 10

    2.4 THE ARAVIND EYE HOSPITAL, INDIA 11

    2.5 HKI, CHINA AND CATARACT SURGERY 13

    3 CONCEPTUAL FRAMEWORK 14

    3.1 DEFINING EQUITY IN TERMS OF WILLINGNES S TO PAY 14

    3.2 SOCIAL WELFARE AND THE EQUITY-EFFICIENCY TRADE-OFF 16

    3.3 THE ECONOMICS OF TIERED PRICING 18

    4 CONTINGENT VALUATION AND WILLINGNESS TO PAY 20

    4.1 CONTINGENT VALUATION 20

    4.2 WTP AND 'DEMAND ' 23

    4.3 WTP AND SOCIAL WELFARE 25

    4.4 WTP AND EXTERNALITIES 27

    4.5 WTP AND ALTRUISM 29

    5 THE USE OF WTP IN DEVELOPING COUNTRY RESEARCH 31

    5.1 WTP FOR INSECTICIDE TREATED BEDNET S IN EASTERN NIGERIA 31

    5.2 WTP FOR COMMUNITY-BASED INSURANCE IN BURKINA FASO 32
    5.3 WTP FOR CATARACT SURGERY IN NEPAL 33

    5.4 WTP FOR CATARACT SURGERY IN TANZANIA 33

    5.5 FINDINGS AND IMPLICATIONS 34

    5.6 BEST PRACTICE FOR WTP SURVEY ADMINISTRATION 37

    6 DATA COLLECTION 42

    6.1 SAMPLING FRAMEWORK 42

    6.2 SAMPLE SIZE 43

    6.3 SURVEY DESIGN 44

    6.4 SURVEY ADMINISTRATION 50

    7 STATISTICAL METHODS 53

    7.1 CATEGORICAL OUTCOME S - INTERVAL REGRESSION 53

    7.2 CONCENTRATION CURVE AND INDEX ESTIMATION 58

    8 RESULTS 63

    8.1 SAMPLE SIZE AND RESPONSE RATE 63

    8.2 SAMPLE CHARACTERISTICS 65

    8.3 BIVARIATE ASSOCIATIONS WITH WTP ANYTHING FOR CATARACT SURGERY 75

    8.4 MAXIMUM WILLINGNES S TO PAY FOR CATARACT SURGERY 79

    8.5 OBJECTIVE 1 PATIENTS WILLINGNES S TO PAY 86

    8.6 OBJECTIVE 2 CAREGIVERS WILLINGNES S TO PAY 99

    8.7 EQUITY OF ACCES S USING CAREGIVER' S WTP 104

    8.8 OBJECTIVE 3 WILLINGNESS TO PAY FOR AMENITIES 105

    9 DISCUSSION 109

    9.1 FACTORS AFFECTING PATIENT' S WTP 109

    9.2 PATIENT' S WILLINGNESS TO PAY 113

    9.3 FACTORS AFFECTING CAREGIVER' S WTP 115
    9.4 HOUSEHOLD CHARACTERISTICS' IMPACT ON WTP ON PAIRED RESPONDENTS 116

    9.5 CAREGIVERS' PREDICTED WILLINGNES S TO PAY 118

    9.6 EQUITY OF ACCES S 122

    9.7 POLICY IMPLICATIONS FOR HKI 124

    9.8 POLICY IMPLICATIONS FOR CHINA' S RCMS 127

    9.9 WA S THE METHODOLOGY APPROPRIATE FOR OUR OBJECTIVES? 128

    9.10 WA S THE METHODOLOGY APPROPRIATE FOR THIS POPULATION? 128

    9.11 BEST PRACTICE FN PRACTICE 133

    9.12 STUDY LIMITATIONS 137

    9.13 CONCLUSION 140

    10 APPENDICES 151

    10.1 WTP SURVEY FOR PATIENTS 151

    10.2 WTP SURVEY FOR CAREGIVERS 171

    11 CURRICULUM VITAE - ELAINE MONISOLA BARUWA 190

    1 Study Aim and Objectives

    This study was designed to evaluate whether access to cataract surgery is equitable in the

    Guangdong Province of the People's Republic of China (PRC) and to explore the feasibility

    of using a tiered pricing model to increase uptake by the poorest, using data from a

    willingness to pay survey administered to a rural population in this region.

    China and Cataract

    Cataract is the leading cause of blindness in the PRC in people aged 50 and over.

    Prevalence rates of cataract blindness have been estimated to be up to 4.37%, with rates of

    low vision being even higher in this age group (Hsu, Cheng, Liu, Tsai, & Chou, 2004; Li, Xu,

    He, Wu, Munoz, & Ellwein, 1999a). Combined with a low cataract surgery rate of 230 per

    million per year the result is that China has a severe burden of curable blindness and low

    vision (Apple, Ram, Foster, & Peng, 2000).

    Helen Keller International, Chin a

    Helen Keller International (HK.I), in conjunction with the privately owned Guangming Eye

    Hospital (GEH) and the Yang Jiang local government health department set up a cataract

    screening and surgery program in 2001 . The program now provides about 1800 surgeries a

    year which translates roughly to a rate of at least 720 per million if we do not include the

    surgeries performed by other providers. A cross sectional willingness to pay study conducted

    three months after the program began, suggested that income would be a limiting factor for

    access to cataract surgery even with the service priced at cost (He M et al., 2007) . Now the

    program would like to determine whether or not it is feasible to use a tiered pricing structure

    to increase its revenues in order for it to provide cataract surgery at a lower price to those
    unable to pay the current fee of 500 - 630 Renminbi (RMB) where 1 US$=8RMB.

    Access : Inequality and Inequity

    In the 200 1 study it was found that there were significant differences in the amount that

    respondents were willing to pay across income groups, specifically, those in higher income

    groups were willing to pay higher amounts. This finding highlights an inequality in

    willingness to pay that is not necessarily inequitable - there is nothing 'unfair' about

    individuals with a higher income being willing to spend more than individuals with lower

    income. However it was also found that only 37% of the respondents would be willing to pay

    500RMB or more to obtain cataract surgery. This result suggests that even though the service

    is now available to this population, there may remain access limitations for some individuals

    due to the pricing and this outcome is inequitable. The combination of these findings suggests

    that, with enough income variation, it might be possible to induce those with higher incomes

    who may be willing to pay more for surgery, to actually do so and then to use the increased

    revenue to subsidize a lower price that improves access for those with lower incomes and

    willingness to pay. In other words we could take advantage of an existing income inequality

    and provide somewhat unequal services to reduce an access inequity for the most basic level

    of service.

    This study will utilize data from a willingness to pay survey to obtain a valuation of

    cataract surgery by respondents and their caregivers which, when combined with the known

    prices, will determine whether or not access is equitable. It will then determine whether or

    not a large enough number of respondent s value additional amenitie s highly enough to enable

    higher pricing. Such amenities could include having a senior surgeon perform their surgery,

    having an improved intra-ocular lens implanted or having food and transport provided for
    them. With estimates of revenue, a range of possible subsidized prices can be determined and

    used to predict the impact of the model on the equity of access to cataract surgery.

    1.1 Objective 1

    To determin e whethe r access to cataract surgery is equitable in this population
    using willingness to pay survey dat a from respondents wit h cataract

    Empirical Analysis : The results from a survey administered to respondents who are

    cataract blind in at least one eye will be used to explore how willingness to pay for cataract

    surgery may differ by demographic and socioeconomic characteristics, vision status and

    potential sources of payment. Following this exploration, an appropriate model to estimate

    willingness to pay will be proposed and tested. From these results an 'incidence rate' for

    cataract surgery at current pricing levels will be determined and combined with the income

    data to construct a concentration index that describes the equity of access.

    1.2 Objective 2

    To determin e whether willingness to pay differs between respondents with
    cataract and their households/caregivers and what impact this has upon the
    willingness to pay estimates

    Empirical Analysis : The results from a survey administered to the caregivers who

    accompany respondents will be used to explore how willingness to pay for cataract surgery

    may differ between patients and another member of their household and to determine how

    much care the patient needs because of their impaired vision. Specifically this comparison

    will be used :

    l) To determine why there may be differences in WTP from respondents who come from
    the same household and are subject to the same income constraint. It could be important if

    sources other than own savings and insurance are used to pay for surgery

    2) To determine if there are intergenerational differences in the perceived need for surgery

    3) To determine whether there are differences in perceived control of household resources

    4) To determine whether a societal valuation of cataract surgery might be significantly

    higher or lower than the patients' valuation of cataract surgery

    1.3 Objective 3

    To estimate the revenue that can be expected from a tiered pricing model and
    to determin e the potential of the model to improve equity of access to surgery

    Empirical Analysis : The willingness to pay data will be used to assess the potential

    demand for the additional amenities that GEH/HKI could provide at minimal cost. These

    amenities are having a senior surgeon perform the surgery, an improved intraocular lens,

    transport to/from the clinic and the provision of meals. Subsequently, the projected revenue

    from the provision of such services will be estimated and used to determine the feasibility of a

    tiered pricing and cross subsidization model. To avoid having to determine patients' choices

    between amenities, revenues will be determined from the provision of a single amenity at a

    time. Finally a concentration index will be estimated at each feasible subsidized price to see

    what impact this model may have on the equity of access.

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