Regional inequality in health and its determinants: evidence from China

All-cause mortality rate in China: do residents in economically developed regions have better health?

Background

Urban-rural disparities have been extensively investigated, while most investigators overlooked urban-suburban-rural variations in population health. Although regional disparities in East-West China have been largely discussed, limited attention has been directed to the interaction between regional differences and urban-suburban-rural disparities. This study aims to analyze urban-suburban-rural variations in all-cause mortality rates across four geographic regions in China.

Methods

Data came from China’s National Census Survey and public statistical yearbooks in 2000 and 2010. Urban districts, county-level cities, and counties were respectively defined as urban, suburban, and rural areas. We obtained 2322 areas, including 2148 areas with two observations and 174 areas with only one observation. Data visualization was performed to depict geographic variations and changes in all-cause mortality rates. Five hierarchical linear regression analyses with generalized estimating equations (GEE) were employed to analyze variations in all-cause mortality rates over time. Demographic and socioeconomic attributes were introduced as covariates.

Results

Despite an overall decline in all-cause mortality rate, rural residents generally achieved worse health than urban and suburban counterparts. In contrast, urban-suburban disparities could be fully explained by demographic and socioeconomic differences. In addition, Northeastern and Central residents achieved better health than Eastern and Western residents. Last, there existed urban/suburban-rural disparities in all regions, except Northeastern, where urban/suburban-rural disparities were eliminated after controlling for socioeconomic and demographic attributes.

Conclusion

Even though suburban and rural areas were often merged, there exist urban/suburban-rural disparities in population health. Furthermore, urban/suburban-rural disparities vary across regions.

Comparing socio-economic inequalities in healthy ageing in the United States of America, England, China and Japan: evidence from four longitudinal studies of ageing

Healthy ageing has become a popular topic worldwide. So far, a consensus measure of healthy ageing has not been reached; and no studies have compared the magnitude of socio-economic inequality in healthy ageing outside Europe. This study aims to create a universal measure of healthy ageing and compare socio-economic inequalities in healthy ageing in the United States of America (USA), England, China and Japan. We included 10,305 American, 6,590 English, 5,930 Chinese and 1,935 Japanese participants for longitudinal analysis. A harmonised healthy ageing index (HAI) was developed to measure healthy ageing multi-dimensionally. Educational, income and wealth rank scores were derived accounting for the entire socio-economic distribution and the sample size of each category of socio-economic indicator. Associations between socio-economic rank scores and HAIs were assessed using multi-level modelling to calculate the Slope Indices of Inequality. Healthy ageing trajectories were predicted based on the full-adjusted age-cohort models. We found that education was a universally influential socio-economic predictor of healthy ageing. Moving from the highest to the lowest educational groups was associated with a 6.7 (5.2–8.2), 8.2 (6.0–10.4), 13.9 (11.4–16.3) and 6.1 per cent (3.9–8.2%) decrease in average HAI at 60 years in the USA, England, China and Japan, respectively. After 60 years, the educational inequality in healthy ageing kept increasing in the USA and China. The educational inequality in healthy ageing in China was also greater than any other socio-economic inequality in the four countries. Wealth was more influential in predicting healthy ageing inequality among American, English and Japanese participants, while income was more influential among Chinese participants. The socio-economic inequality in healthy ageing in Japan was relatively small. Chinese and American participants had worse healthy ageing profiles than Japanese and English participants.

Ex-ante Inequality of Opportunity in Child Malnutrition: New Evidence from Ten Developing Countries in Asia

This study explores the inequality of opportunity in child malnutrition in ten developing countries in Asia, where a high proportion of children still remain vulnerable to food insecurity. This study takes account of multidimensional aspects of household and parental socio-economic status, and partitions children into distinct types through a data-driven clustering method. This is followed by a comparison of the malnutrition rates between types. Next, we decompose the observed disparity into the factors that are associated with the between-type disparity in malnutrition rates through a non-linear decomposition method. The results indicate that in all 10 countries, significant between-type disparities are found. We find the largest difference in Pakistan as 21.7 percentage points and the smallest difference in Maldives as 5.9 percentage points. In five of the ten countries, the difference in household affluence explains the largest part of the observed between-type disparity. All the results suggest that priority should be given to protecting children from marginalised households in order to mitigate the inequality in child health.

Health Inequality Among the Elderly in Rural China and Influencing Factors: Evidence from the Chinese Longitudinal Healthy Longevity Survey

Based on data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), this paper calculates the health distribution of the elderly using the Quality of Well-Being Scale (QWB) score, and then estimates health inequality among the elderly in rural China using the Wagstaff index (WI) and Erreygers index (EI). Following this, it compares health inequalities among the elderly in different age groups, and finally, uses the Shapley and recentered influence function-index-ordinary least squares (RIF-I-OLS) model to decompose the effect of four factors on health inequality among the elderly in rural China. The QWB score distribution shows that the health of the elderly in rural China improved with social economic development and medical reform from 2002 to 2014. However, at the same time, we were surprised to find that the health level of the 65-74 years old group has been declining steadily since 2008. This phenomenon implies that the incidence of chronic diseases is moving towards the younger elderly. The WI and EI show that there is indeed pro-rich health inequality among the rural elderly, the health inequality of the younger age groups is more serious than that of the older age groups, and the former incidence of health inequality is higher. Health inequality in the age group of 65-74 years old is higher than that in other groups, and the trend of change fluctuated downward from 2002 to 2014. Health inequality in the age group of 75-84 years old is lower than that in the group of 65-74 years old, but higher than that in the other age groups. The results of Shapley decomposition show that demographic characteristics, socioeconomic status (SES), health care access, and quality of later life contributed 0.0054, 0.0130, 0.0442, and 0.0218 to the health inequality index of the elderly, which accounted for 6.40%, 15.39%, 52.41%, and 25.80% of health inequality index. From the results of RIF-I-OLS decomposition, this paper has analyzed detailed factors' marginal effects on health inequality from four dimensions, which indicates that the health inequality among the elderly in rural China was mainly caused by the disparity of income, medical expenses, and living arrangement.

An Overview of Tuberculosis-Designated Hospitals in China, 2009-2015: A Longitudinal Analysis of National Survey Data

Design

A national tuberculosis- (TB-) designated hospital survey was conducted in 2015 to identify significant changes since 2009 in implementation of TB-testing services within hospitals of various types and administrative levels in various regions in China.

Methods

In 2015, all TB-designated hospitals were required to complete questionnaires designed by the National Clinical Center for TB. Community hospitals also completed simplified questionnaires as part of the study.

Results

Overall, in 2015 there were 1685 TB-designated hospitals in China, consisting of 1335 (79.2%) county-level hospitals and 350 (20.8%) hospitals at the prefecture level and above. The percentage of counties with TB-designated hospitals in the western region (57.4%) was significantly lower than corresponding percentages for eastern and middle regions (70.3% and 96.5, respectively). Based on data recorded on hospital surveys in both 2009 and 2015, significant differences were noted between years in proportions of general hospitals with TB wards and of specialized infectious disease hospitals (P < 0.01). Of 1256 county-level laboratories conducting smear microscopy, only 979 (79%) performed external quality control evaluations of test results in 2015. For prefecture-level hospitals, 70% (234/334), 76% (155/203), and 67% (66/98) of hospitals obtained external quality control validations of smear microscopy, phenotypic DST, and molecular test results, respectively.

Conclusions

Although China's health reform efforts have resulted in improved TB patient access to quality health care, more attention should be paid to balancing the distribution of medical facilities across different regions. In addition, laboratory capabilities and quality control systems should be strengthened to ensure delivery of high-quality laboratory services by TB-designated hospitals throughout China.

General practice for the poor and specialist services for the rich: inequality evidence from a cross-sectional survey on Hangzhou residents, China

Background

Inequalities in health care services are becoming an increasing concern in the world including in China. This study measured the income-related inequalities of residents in Hangzhou of China in access to general practice and specialist care and identified socioeconomic factors associated with such inequalities.

Methods

A cross-sectional questionnaire survey was conducted on 1048 residents in ten urban communities in Hangzhou, China. The percentage and frequency of respondents visiting general practice (GP) and hospital specialist clinics over the past four weeks prior to the survey were estimated. Income-related inequalities in access to these services were measured by the concentration index. Logistic regression and Poisson regression models were established to decompose the contributions of socioeconomic factors (residency, income, education, marital status, and social health insurance) to the inequalities in the probability and frequency of accessing these services, respectively, after adjustment for the needs factors (age, sex and illness conditions).

Results

The GP services were in favor of the poor, with a concentration index of − 0.0464 and − 0.1346 for the probability and frequency of GP visits, respectively. In contrast, the specialist services were in favor of the rich, with a concentration index of 0.1258 and 0.1279 for the probability and frequency of specialist visits, respectively. Income is the biggest contributor to the inequalities, except for the frequency of visits to specialists in which education played the greatest role.

Conclusions

Income-related inequalities in GP and specialist care are evident in China. Policy interventions should pay increasing attention to the emergence of a two-tier system, potentially enlarging socioeconomic disparities in health care services.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0966-6) contains supplementary material, which is available to authorized users.

Community-Based Cognitive Social Capital and Depressive Symptoms Among Older Adults in Urban China: The Moderating Role of Family Social Capital

The present study examined the moderating role of family social capital in the relationship between community-based cognitive social capital and depressive symptoms among community-dwelling older adults in urban China. Cross-sectional data were derived from a community survey conducted in Suzhou, China, in late 2015. Data from 441 respondents were included in the final analysis. Multiple group analysis was used to test the hypotheses. The latent construct of community-based cognitive social capital was based on trust and reciprocity indicators. Measurement invariance was established across groups with high or low family social capital. The results show that family social capital had a moderation effect on the relationship between community-based cognitive social capital and depressive symptoms. The effects of community-based cognitive social capital on depressive symptoms were higher among those with low family social capital. The findings demonstrate the interplay between family and community-based cognitive social capital. Policy and intervention implications are discussed.

Air pollution inequality and health inequality in China: An empirical study

China's residents experience unequal exposure to air pollution in different regions, and the corresponding health consequences have increased remarkably. To ensure sustainable development, China should monitor health inequality and its potential determinants. This study empirically examines the health inequalities (represented by perinatal and tuberculosis mortalities) caused by air pollution inequalities (represented by SO₂ and NO_x emissions) from 31 Chinese provinces in the period 2006 to 2015, using the generalized method of moments (GMM) and quantile regression (QR). The GMM results reveal a strong positive relationship between SO₂/NO_x emission inequality and tuberculosis mortality inequality. In contrast, the QR results show that perinatal mortality inequality is closely related to emission inequality across all percentiles for SO₂ emission and at the 75th percentile for NO_x emission. Our findings help policymakers to identify health disparities and be mindful of air pollution inequality as a factor in the elimination of health inequality.

Multilevel Analysis of Individual, Organizational, and Regional Factors Associated With Patient Safety Culture: A Cross-Sectional Study of Maternal and Child Health Institutions in China

Supplemental digital content is available in the text.

The aim of this study was to assess patient safety culture (PSC) in maternal and child health (MCH) institutions in China and its individual, organizational, and regional variations.

Geographical variations in self-rated health and functional limitations among older Chinese in eight WHO-SAGE provinces

BACKGROUND

The proportion of population ageing in China will grow significantly in the next few decades but the pace of population ageing and social change vary considerably across regions. Notably, Eastern coastal areas are economically more advanced compared to the Western region. These economic disparities could result in differing adverse health outcomes.

METHODS

We investigate geographical variations in self-rated overall health and functional limitations in a national representative sample of Chinese aged 50 years and older (n = 13,175) using the WHO Study on global AGEing and adult health (WHO SAGE). We used multivariable logistic regression to investigate urban-rural inequalities across regions, adjusting for sociodemographic and health covariates. Two main outcomes were self-rated overall health and functional limitations based on the WHO Disability Assessment Schedule 2.0 for a range of daily activities.

RESULTS

The largest urban-rural differences in adverse health outcomes were in Shandong (AORs for urban versus rural of 6.32 [95% Confidence Interval 4.53-8.82] for poor or very poor self-rated overall health and 5.14 [CI 3.55-7.44] for functional limitations), followed by Jilin (AORs 2.71 [CI 2.04-3.61] and 4.72 [CI 3.43-6.49]), and Hubei (AORs 2.36 [CI 1.82-3.07] and 4.11 [CI 2.80-6.04]), respectively. Covariates significantly associated with both adverse health outcomes were older age, poor income, no health insurance, and increasing number of chronic diseases.

CONCLUSION

Our study reveals substantial disparities between urban and rural areas observed in both the well-developed areas (eg Shandong) and also the lower end of the economic spectrum (eg Hubei and Jilin). Targeted economic development policy and systematic health prevention and healthcare policies could be beneficial in improving health in later life whilst minimising geographical inequalities.

Maternal Health Behaviors and Outcomes in a Nomadic Tibetan Population

Introduction Despite significant global improvements in maternal health, large disparities persist. In China, rural women and women who live in western regions experience lower rates of maternal healthcare utilization and higher rates of maternal mortality than women elsewhere in the country. This paper examines maternal health care-seeking among nomadic Tibetan women in rural western China, a particularly understudied group. Methods Secondary data analysis was conducted with survey data collected in 2014 in Qinghai Province, China. Participants (rural, nomadic, adult women) provided birth histories and information on care received during antenatal, intrapartum and/or postpartum period(s). Using bivariate and multivariable logistic regression models, these outcomes were explored in relation to maternal characteristics (e.g., educational attainment and parity), use of health insurance, and time. Results Approximately half of all women had ever used antenatal care, institutional delivery, and/or skilled birth attendance. The utilization of these services has increased over time, from 10% of births prior to the year 2000, to approximately 50% since 2000. Utilization increased by year (odds ratios ranging from 1.1 to 1.3) even after controlling for covariates. Women with health insurance coverage were significantly more likely to use these services than women without insurance, although less than 20% of women reported that insurance paid for any antenatal and/or childbirth care. Discussion Utilization of maternal care is improving among this population but rates remain low in comparison to other women in rural, western China. Further targeted interventions may be needed to reach and adequately address the maternal health needs of this unique population.

The burden of stroke in China: Results from a nationwide population-based epidemiological survey

Stroke is a serious threat to human health that often leads to severe complications, and currently ranks first as leading cause of death in China. However, reliable data on stroke burden in China in the 21st century are lacking. We used the data from NESS-China (National Epidemiological Survey of Stroke in China) for assessing the adverse health effects of stroke in Chinese population. We carried out inter-regional comparative study in order to obtain regular burden related characteristics of stroke in China, as measured by YLLs (years of life lost due to premature mortality), YLDs (years lived with disability) and DALYs (disability adjusted life years). Amongst the nationwide population of 596,536 individuals of all ages in 2013, the YLLs for stroke was 1748, the YLDs was 262, and the DALYs was 2010(per 100,000). The gender subtype analysis of DALYs was 2171(male) and 1848(female). The YLLs, YLDs and DALYs in rural areas were higher compared to urban areas. Among the 18 age groups, the highest YLLs was observed in ≥ 80 years old group. The impact of stroke on Chinese population is more severe compared to the global average levels. Stroke results as the main cause of YLLs in China, while there is no significant difference for the YLDs. Nevertheless, DALYs caused by stroke rank 3th in global epidemiologic study territories, 1st in China.

Equity and efficiency of primary health care resource allocation in mainland China

BACKGROUND

China had proposed the unification of equity and efficiency since the launch of the new round of health system reform in 2009. And the central government gave priority to the development of primary health care (PHC) whilst ensuring its availability and improving its efficiency. This study aimed to evaluate the changes of equity and efficiency in PHC resource allocation (PHCRA) and explored ways to improve the current situation.

METHODS

The data of this study came from the China Health Statistical Yearbook (2013-2017) and China Statistical Yearbook (2017). Three and five indicators were used to measure equity and efficiency, respectively. The Lorenz curve, Gini coefficient (G), Theil index (T) and health resource density index (HRDI) were used to assess equity in demographic and geographical dimensions. Data envelopment analysis (DEA) and the Malmquist productivity index (MPI) were chosen to measure the efficiency and productivity of PHCRA.

RESULTS

From 2012 to 2016, the total amount of PHCR had increased year by year. The Gs by population size were below 0.2 and that by geographical area were between 0.6 and 0.7. T had the same trend with G, and intra-regional contribution rates were higher than inter-regional contribution rates, which were all beyond 60%. From 2012 to 2016, the numbers of provinces that achieved an effective DEA were 4, 3, 4, 5 and 5, respectively. The mean of the total factor productivity index was 0.994.

CONCLUSION

The equity of PHCRA in terms of population size is superior in the geographical area. Intra-regional differences are the main source of inequality. The eastern region has the highest density of PHCR, whereas the western region has the lowest. In addition, PHC institutions in more than 80% of the provinces are inefficient, and the productivity of the institutions decline by 0.6% from 2012 to 2016 because of technological retrogression.

Individual- and state-level factors associated with functional limitation prevalence among Colombian elderly: a multilevel analysis

This study aimed to identify the main regional factors associated with variations in the prevalence of functional limitation on the older adult in Colombia adjusted by individual characteristics. This multilevel study used cross-sectional data from 23,694 adults over 60 years of age in the SABE, Colombia nationwide survey. State-level factors (poverty, development, inequity, violence, health coverage, and access to improved water sources), as well as individual health related, socioeconomic and demographic characteristics, were analyzed. The overall prevalence of functional impairment for the basic activities of daily living (ADL) was 22%. The presence of comorbidities, low educational level, physical inactivity, no participation in social groups, mistreatment and being over 75 years old were associated with functional limitation. At the group level, the analysis showed significant differences in the functional limitation prevalence across states, particularly regarding the socioeconomic status measured according to the Human Development Index (median OR = 1.22; 95%CI: 1.13-1.30; p = 0.011). This study provides evidence on the impact of socioeconomic variation across states on FL prevalence in the Colombian elderly once adjusted for individual characteristics. The findings of this study, through a multilevel approach methodology, provide information to effectively address the conditions that affect the functionality in this population through the identification and prioritization of public health care in groups with economic and health vulnerability.

Effect of characteristics and life in cities in China on residents' smoking behaviour

Objective

This study aimed to identify the relationship between city-level economic development and smoking behaviour.

Methods

Using multilevel mixed-effects logistic methods, we examined the relationship between smoking/passive smoking and respondents’ lifestyles in the city.

Results

We found that respondents living in cities with higher per capita gross domestic product (GDP) were less likely to smoke than those living in cities with lower per capita GDP (odds ratio [OR] = 0.977, 95% confidence interval [CI]: 0.958–0.997). Further, respondents with higher levels of life satisfaction and subjective social status were less likely to smoke than those with lower levels of these variables (OR = 0.942, 95% CI: 0.893–0.994; OR = 0.955, 95% CI: 0.928–0.983, respectively). In terms of passive smoking, respondents with higher levels of subjective social status in their cities were less likely to smoke than those with lower levels (OR = 0.972, 95% CI: 0.948–0.996). Smoking and exposure to second-hand smoke were more common among those with lower socioeconomic status.

Conclusions

Smoking is one of the most serious public health hazards in China. People’s smoking behaviour is significantly related to characteristics of their cities and their socioeconomic status. Improved smoking-prevention measures are urgently required in China.

Inter-provincial inequality of public health services in China: the perspective of local officials' behavior

Background

After economic reform, China experienced rising public health services inequality between the eastern developed and mid-west undeveloped provinces. The fiscal transfer payment system which aims to shape the disparities was considered inefficient. However, there are only a few studies that address the political reason when analyzing the inter-provincial public health services inequality. And the previous studies did not consider a possible non-linear relationship between the fiscal transfer payments and the inter-provincial public health services equalization.

Methods

This paper argues that the local officials’ fanatical pursuit of local economic growth which driven by the Political Promotion Tournament and the polarized fiscal self-sufficiency (fiscal capacities) of local governments are responsible for the inter-provincial inequality of public health services and the inefficiency of fiscal transfer payments. By constructing panel threshold regression models with fiscal self-sufficiency of local governments as threshold variable, this study tries to empirically investigate the optimal level of the local governments’ self-sufficiency at which the fiscal transfer payments can effectively promote equalization.

Results

Threshold effects exist between fiscal transfer payments and inter-provincial public health services equalization. The effects on inter-provincial public health services equalization show trends that first increase and then decrease as the fiscal self-sufficiency of local governments increases. And there exist a range of fiscal self-sufficiency between 29.236 and 43.765% or between 28.575 and 45.746% for local governments where the fiscal transfer payments can effectively achieve equalization. Currently, the vast majority of provinces in China remain in the ineffective regime where the fiscal transfer payments are inefficient in shaping inequality.

Conclusions

This paper explains the reason of inequality in public health services and the inefficiency of fiscal transfer payment system from Chinese local officials’ behavior aspect, and try to find out an effective solution by focusing on the local government’s fiscal capacity. The effective way to narrow the inequality is to establish a flexible tax-sharing system to adjust local governments’ fiscal capacities and give local governments with low fiscal self-sufficiency more fiscal resources. The new policy measures recently launched by Chinese central government coincide with our recommendations.

Trends in injury morbidity in China, 1993-2013: A longitudinal analysis of population-based survey data

Understanding long-term trends in injury morbidity is critical to prevention and intervention planning. The aim of this study was to assess long-term trends in injury morbidity rates in China from 1993 to 2013. Using data from the National Health Service Survey (NHSS), which is conducted every five years, crude and age-standardized prevalence during the previous two weeks and hospitalization rates in the last 12 months with 95% confidence intervals (CI) were calculated. The Rao-Scott Chi-square test examined injury morbidity differences across the five survey years by location (urban/rural), sex, age group, and household income. Percent changes in morbidity rate were approximated using logistic regressions. Sampling weights were applied to all analyses. In 2013, crude two-week injury prevalence in China was 0.46% (95% CI: 0.40%, 0.52%) and 12-month crude hospitalization rate was 0.70% (95% CI: 0.63%, 0.77%). Age-standardized injury prevalence increased 31.4% (95% CI: 7.6%, 60.6%) between 1993 and 2013 (29.4%, 95% CI: 6.7%, 56.9% from 1993-2003; 1.6%, 95% CI: -14.8%, 21.0% from 2003-2013), and age-standardized hospitalization rates rose 107.2% (95% CI: 75.1%, 145.2%) from 1993 to 2013 (-9.5%, 95% CI: -24.6%, 8.6% from 1993-2003 and 129.0%, 95% CI: 93.9%, 170.4% from 2003-2013). Subgroup analyses showed similar trends over time. The leading cause of injury was dislocation, sprain or strain for prevalence, and fractures for hospitalization. In conclusion, injury morbidity increased substantially from 1993 to 2013 in China. Inconsistent changes in two-week prevalence and 12-month hospitalization rate merit attention from researchers and policy-makers.

Household income, income inequality, and health-related quality of life measured by the EQ-5D in Shaanxi, China: a cross-sectional study

Background

In advanced economies, economic factors have been found to be associated with many health outcomes, including health-related quality of life (HRQL), and people’s health is affected more by income inequality than by absolute income. However, few studies have examined the association of income inequality and absolute income with HRQL in transitional economies using individual data. This paper focuses on the effects of county or district income inequality and absolute income on the HRQL measured by EQ-5D and the differences between rural and urban regions in Shaanxi province, China.

Methods

Data were collected from the 2008 National Health Service Survey conducted in Shaanxi, China. The EQ-5D index based on Japanese weights was employed as a health indicator. The income inequality was calculated on the basis of self-reported income. The special requirements for complex survey data analysis were considered in the bivariate analysis and linear regression models.

Results

The mean of the EQ-5D index was 94.6. The EQ-5D index of people with low income was lower than that in the high-income group (for people in the rural region: 93.2 v 96.1, P < 0.01; for people in the urban region: 95.5 v 96.8, P < 0.01). Compared with people with moderate inequality, the EQ-5D index of those with high inequality was relatively lower (for people living in the rural region: 91.1 v 95.8, P < 0.01; for people living in the urban region: 95.6 v 97.3, P < 0.01). Adjusted by age, gender, education, marital status, employment, medical insurance, and chronic disease, all the coefficients of the low-income group and high income inequality were significantly negative. After stratifying by income group, all the effects of high income inequality remained negative in both income groups. However, the coefficients of the models in the high income group were not statistically significant.

Conclusion

Income inequality has damaging effects on HRQL in Shaanxi, China, especially for people with low income. In addition, people living in rural regions were more vulnerable to economic factors.

Urban-rural disparities in health care utilization among Chinese adults from 1993 to 2011

BACKGROUND

Despite economic growth and improved health outcomes over the past few decades, China still experiences striking urban-rural health inequalities. Urban and rural residents distinguished by the hukou system may experience profound disparities because of institutional effect. The aim of this study is to estimate trends in urban-rural disparities in self-care, outpatient care, and inpatient care utilization from a perspective of the hukou system.

METHODS

Data were extracted from the seven latest waves of the China Health and Nutrition Survey (CHNS). We used the hukou system to distinguish between urban and rural residents. Chi-square tests were performed to examine urban-rural gaps in self-care, outpatient care, and inpatient care utilization. Multinomial logistic regression was employed to confirm these disparities and to explore whether the urban-rural gaps have narrowed or widened from 1993 to 2011 once known determinants of utilization are taken into account according to Andersen/Aday's Health Behaviour Model.

RESULTS

The urban-rural disparities were evident after controlling for confounding variables: urban adults were 3.24 (p < 0.05), 2.23 (p < 0.1), and 4.77 (p < 0.01) times more likely to choose self-care vs. no care, outpatient care vs. no care, and inpatient care vs. no care than their rural counterparts, respectively. The results showed upward trends in self-care, outpatient care, and inpatient care utilization from 2004 to 2011. The urban-rural gaps in health care utilization gradually narrowed during the period of 1993-2011. The hukou distinctions of self-care, outpatient care, and inpatient care in 2011 were only 33.3%, 35.5%, and 9.6% of that in 1993, respectively.

CONCLUSIONS

Although rural residents were underutilizing health care when compared to their urban counterparts, the significant decrements in urban-rural disparities reflect the positive effect of the on-going health system reform in China. To maintain an equitable distribution of health care utilization, policy makers need to be aware of challenges due to aging problems and health expenditure increment.

The cost of Alzheimer's disease in China and re-estimation of costs worldwide

INTRODUCTION

The socioeconomic costs of Alzheimer's disease (AD) in China and its impact on global economic burden remain uncertain.

METHODS

We collected data from 3098 patients with AD in 81 representative centers across China and estimated AD costs for individual patient and total patients in China in 2015. Based on this data, we re-estimated the worldwide costs of AD.

RESULTS

The annual socioeconomic cost per patient was US $19,144.36, and total costs were US $167.74 billion in 2015. The annual total costs are predicted to reach US $507.49 billion in 2030 and US $1.89 trillion in 2050. Based on our results, the global estimates of costs for dementia were US $957.56 billion in 2015, and will be US $2.54 trillion in 2030, and US $9.12 trillion in 2050, much more than the predictions by the World Alzheimer Report 2015.

DISCUSSION

China bears a heavy burden of AD costs, which greatly change the estimates of AD cost worldwide.

Factors affecting patient satisfaction with ecdemic medical care: a cross-sectional study in Nanchang, China

PURPOSE

This study aimed to determine the factors that influence patient satisfaction with ecdemic medical care.

MATERIALS AND METHODS

Eight hundred and forty-four face-to-face interviews were conducted between October and November 2017 in two high-profile hospitals in Nanchang, China. Patient satisfaction was divided into lowest and highest satisfaction groups according the 80/20 rule. Demographic factors associated with patient satisfaction were identified by logistic regression models.

RESULTS

Respondents' main reasons for choosing a non-local hospital were "high level of medical treatment" (581/844), "good reputation of the hospital" (533/844), and "advanced medical equipment" (417/844). The top three items that dissatisfied the ecdemic patients were "long time to wait for treatment" (553/844), "complicated formalities" (307/844), and "poor overall service attitude" (288/844). Fewer female patients (adjusted odds ratio [AOR] =1.47, 95% confidence interval [CI] =1.03-2.11), patients with a family per-capita monthly income (FPMI) between 3,001 and 5,000 CNY (AOR =1.40, 95% CI =1.01-2.17), inpatients (AOR =1.46, 95% CI =1.01-2.13), and more patients with an FPMI >7,000 CNY (AOR =0.43, 95% CI =0.20-0.92) were detected in the lowest satisfaction group. Fewer patients with an associate's or bachelor's degree (AOR =2.40, 95% CI =1.37-4.20) and patients with an FPMI >7,000 CNY (AOR =3.02, 95% CI =1.10-8.33) were detected in the highest satisfaction group. Moreover, more inpatients (AOR =0.70, 95% CI =0.54-0.97) and those aged 46-65 years (AOR =0.63, 95% CI =0.33-0.98) were detected in the highest satisfaction group.

CONCLUSION

Findings suggested that managers of the medical facilities should note the importance of increasing their publicity through a rapidly developing media, as well as the necessity of creating a more patient-friendly medical care experience. Hospitals should also focus on the medical care experience of patients with relatively lower and higher income levels, male ecdemic patients, and ecdemic outpatients.

Identifying patterns of non-communicable diseases in developed eastern coastal China: a longitudinal study of electronic health records from 12 public hospitals

OBJECTIVE

Few studies have examined the spectrum and trends of non-communicable diseases (NCDs) in inpatients in eastern coastal China, which is transforming from an industrial economy to a service-oriented economy and is the most economically developed region in the country. This study aimed to dynamically elucidate the spectrum and characteristics of severe NCDs in eastern coastal China by analysing patients' longitudinal electronic health records (EHRs).

SETTING

To monitor the spectrum of NCDs dynamically, we extracted the EHR data from 12 general tertiary hospitals in eastern coastal China from 2003 to 2014. The rankings of and trends in the proportions of different NCDs presented by inpatients in different gender and age groups were calculated and analysed.

PARTICIPANTS

We obtained a total sample of 1 907 484 inpatients with NCDs from 2003 to 2014, 50.05% of whom were men and 81.53% were aged 50 years or older.

RESULTS

There was an increase in the number of total NCD inpatients in eastern coastal China from 2003 to 2014. However, the proportion of chronic respiratory diseases and cancer inpatients decreased over the 12-year period. Compared with men, women displayed a significant increase in the proportion of mental and behavioural disorders (p<0.001) over time. Additionally, digestive diseases and sensory organ diseases significantly decreased among men, but not women. The older group accounted for a larger and growing proportion of the NCD inpatients, and the most common conditions in this group were cerebral infarctions, coronary heart disease and hypertension. In addition, the proportion of 21-year-old to 50-year-old inpatients with diabetes, blood diseases or endocrine diseases skyrocketed from 2003 to 2014 (p<0.001).

CONCLUSIONS

The burden of inpatients' NCDs increased rapidly, particularly among women and younger people. The NCD spectrum observed in eastern coastal China is a good source of evidence for developing prevention guides for regions experiencing transition.

Misconceived equity? Health care resources, contextual poverty, and child health disparities in Peru

Although many studies have examined determinants of child health, fewer have explored factors explaining regional disparities in child health outcomes. In the Peruvian context, we examined the relationship between regional disparities in child malnutrition and local variation in health resources (health care resources and the socioeconomic environment). Using the Peruvian 2007-2008 Continuous Demographic and Health Survey (N = 8020) and governmental administrative data, our analyses show that 1) only selected types of health care resources (medical professionals and outpatient visits) are related to child nutritional status, 2) local poverty predicts nutritional status net of household characteristics, and, most importantly, 3) a significant portion of regional differences in child malnutrition are explained by local poverty, whereas health care resources are not associated with regional disparities. These findings suggest that the local socioeconomic environment is a key determinant of both child health outcomes and regional disparities in these outcomes.

Evaluation on equality and efficiency of health resources allocation and health services utilization in China

Background

China is faced with a daunting challenge to equality and efficiency in health resources allocation and health services utilization in the context of rapid economic growth. This study sought to evaluate the equality and efficiency of health resources allocation and health services utilization in China.

Methods

Demographic, economic, and geographic area data was sourced from China Statistical Yearbook 2012–2016. Data related to health resources and health services was obtained from China Health Statistics Yearbook 2012–2016. Furthermore, we evaluated the equality of health resources allocation based on Gini coefficient. Concentration index was used to measure the equality in utilization of health services. Data envelopment analysis (DEA) was employed to assess the efficiency of health resources allocation.

Results

From 2011 to 2015, the Gini coefficients for health resources by population ranged between 0.0644 and 0.1879, while the Gini coefficients for the resources by geographic area ranged from 0.6136 to 0.6568. Meanwhile, the concentration index values for health services utilization ranged from −0.0392 to 0.2110. Moreover, in 2015, 10 provinces (32.26%) were relatively efficient in terms of health resources allocation, while 7 provinces (22.58%) and 14 provinces (45.16%) were weakly efficient and inefficient, respectively.

Conclusions

There exist distinct regional disparities in the distribution of health resources in China, which are mainly reflected in the geographic distribution of health resources. Furthermore, the people living in the eastern developed areas are more likely to use outpatient care, while the people living in western underdeveloped areas are more likely to use inpatient care. Moreover, the efficiency of health resources allocation in 21 provinces (67.74%) of China was low and needs to be improved. Thus, the government should pay more attention to the equality based on geographic area, guide patients to choose medical treatment rationally, and optimize the resource investments for different provinces.

'Seeking affluent neighbourhoods?' a time-trend analysis of geographical distribution of hospitals in the Megacity of Tehran

OBJECTIVE

Access to hospitals in megacities in low and middle income countries might be hampered by travel barriers and distance. We assessed the 'inverse care law' hypothesis: whether hospitals tended to be built in the relatively better-off areas through the time.

METHODS

A longitudinal time-series study (1966 to 2011) in Tehran to measure inequality in the distribution of hospital beds. We assessed correlations between the district socioeconomic status and availability of hospital beds via regression analyses, estimated correlation, Gini and concentration indices, and used GIS models to map hospital distributions through time.

FINDING

We found a clear relationship between socioeconomic status and number of hospital beds per capita ( P -values <0.05). Gini coefficients were about 0.6 and 0.8 for public and private beds, respectively. A third of the variations in hospital bed distribution was explained by the welfare status of the district. For every extra residential room per capita, 130 to 280 extra beds were observed per ten thousand population at the district level. In 2011, out of 162 hospitals, 110 were located in six districts around the centre and northern part of the city. During the time period only two private hospitals were built in relatively disadvantaged districts.

CONCLUSION

Over a period of about fifty years new hospitals had been established in the relatively affluent areas of the city and the relationship between socioeconomic status of district with total, private and public beds were direct and intensive. Results indicate the problem of inequality may remain over time and be resistant to policy initiatives and major political changes.

Inequality in the distribution of health resources and health services in China: hospitals versus primary care institutions

BACKGROUND

Equity is one of the major goals of China's recent health system reform. This study aimed to evaluate the equality of the distribution of health resources and health services between hospitals and primary care institutions.

METHODS

Data of this study were drawn from the China Health Statistical Year Books. We calculated Gini coefficients based on population size and geographic size, respectively, for the indicators: number of institutions, number of health workers and number of beds; and the concentration index (CI) for the indicators: per capita outpatient visits and annual hospitalization rates.

RESULTS

The Gini coefficients against population size ranged between 0.17 and 0.44 in the hospital sector, indicating a relatively good equality. The primary care sector showed a slightly higher level of Gini coefficients (around 0.45) in the number of health workers. However, inequality was evident in the geographic distribution of health resources. The Gini coefficients exceeded 0.7 in the geographic distribution of institutions, health workers and beds in both the hospital and the primary care sectors, indicating high levels of inequality. The CI values of hospital inpatient care and outpatient visits to primary care institutions were small (ranging from -0.02 to 0.02), indicating good wealth-related equality. The CI values of outpatient visits to hospitals ranged from 0.16 to 0.21, indicating a concentration of services towards the richer populations. By contrast, the CI values of inpatient care in primary care institutions ranged from -0.24 to -0.22, indicating a concentration of services towards the poorer populations. The eastern developed region also had a high internal inequality compared with the other less developed regions.

CONCLUSION

Significant inequality in the geographic distribution of health resources is evident, despite a more equitable per capita distribution of resources. Richer people are more likely to use well-resourced hospitals for outpatient care. By contrast, poorer people are more likely to use poorly-resourced primary care institutions for inpatient care. There is a risk of the emergence of a two-tiered health care delivery system.

The equity of China's emergency medical services from 2010-2014

Background

With the depth development of health care system reform in China, emergency medical services (EMS) is confronted with challenges as well as opportunities. This study aimed to analyze the equity of China’s EMS needs, utilization, and resources distribution, and put forward proposal to improve the equity.

Method

Three emergency needs indicators (mortality rate of cardiovascular and cerebrovascular diseases, harm, and digestive system disease), two utilization indicators (emergency outpatient visits and rate of utilization) and one resource allocation indicator (number of EMS facilities) were collected after the review of the China Statistical Yearbook and the National Disease Surveillance System. Next, EMS related indicators were compared among 31 provinces from the eastern, central, and western regions of the country. Concentration Index (CI) were used to measure the equity of EMS needs and utilization among the western, central, and eastern regions. The Gini coefficient of demographic and geographic distribution of facilities represented the equity of resource allocation.

Result

During 2010–2014, the CI of cardiovascular and cerebrovascular disease mortality changed from positive to negative, which indicates that the concentrated trend transferred from richer regions to the poorer area. Injury mortality (CI: range from − 0.1241to −0.1504) and digestive disease mortality (CI: range from − 0.1921 to − 0.2279) consistently concentrated in the poorer region, and the inequity among regions became more obviously year-by-year. The utilization of EMS (CI: range from 0.1074 to 0.0824) showed an improvement; however, the inequity reduced gradually. The EMS facilities distribution by population (Gini coefficient: range from 0.0922 to 0.1200) showed high equitability but the EMS facilities distribution by geography (Gini coefficient: range from 0.0922 to 0.1200) suggested a huge gap between regions because the Gini coefficients were greater than 0.5 in the past 5 years.

Conclusion

There are some inequities of needs, utilization, and resource allocation in the China EMS. The government needs to stick to the principle of increasing investment in poorer regions, perfecting ambulance configuration and improving health workers’ professional skills to improve the equity and quality of EMS.

Determinants of Catastrophic Dental Health Expenditure in China

This study explored catastrophic health expenditure in China, due to out-of-pocket payments for dental care, and its associated individual- and contextual-level factors. We pooled data from 31,566 adults who participated in the third National Oral Health Survey with province-level data from different sources. We defined catastrophic dental health expenditure (CDHE) as payments for dental services and/or medication for dental problems during the last year that exceeded the 10% and 20% of the household income. The association of individual and contextual factors with catastrophic dental health expenditure was evaluated using two-level logistic regression models with individuals nested within provinces. Socioeconomic position (education and household income), household size and dental status (pain in teeth or mouth and number of teeth) were the individual-level factors associated with CDHE among the full sample of participants; and, also, among those who used dental services in the past year. Greater gross domestic product per capita was the only contextual factor associated with CDHE, and only at the lower income threshold. This study shows that out-of-pocket expenses for dental services may put a considerable, and unnecessary, burden on households' finances. Our findings also help characterise those households more likely to face catastrophic expenditure on health if they have to pay for dental services.

The impact of limiting long term illness on internal migration in England and Wales: New evidence from census microdata

Previous research has suggested that poor health is associated with reduced migration; this knowledge stems from models based on past censuses, or longitudinal studies which imply that the factors influencing migration are the same between those in good and poor health. This paper addresses these issues by utilising health-stratified analyses on the 2011 Census Individual Secure Sample for England and Wales. Multilevel models predict the odds of moving for working age adults, controlling for key predictors of migration, estimating the effect of health status on the odds of moving and the destination-specific variance in migration. We find that those in poor health are less likely to move, after controlling for individual level characteristics. In contrast with expectations, economic inactivity, marriage and being in African, Caribbean, Black, Other or Mixed ethnic groups were not significant predictors of migration among the unhealthy sample, but were for the healthy sample. We conclude that migration is health-selective and propose implications for understanding area level concentrations of poor health in England and Wales.

The geographic pattern of Belgian mortality: can socio-economic characteristics explain area differences?

Background

Country averages for health outcomes hide important within-country variations. This paper probes into the geographic Belgian pattern of all-cause mortality and wishes to investigate the contribution of individual and area socio-economic characteristics to geographic mortality differences in men aged 45–64 during the period 2001–2011.

Methods

Data originate from a linkage between the Belgian census of 2001 and register data on mortality and emigration during the period 2001–2011. Mortality rate ratios (MRRs) are estimated for districts and sub-districts compared to the Belgian average mortality level using Poisson regression modelling. Individual socio-economic position (SEP) indicators are added to examine the impact of these characteristics on the observed geographic pattern. In order to scrutinize the contribution of area-level socio-economic characteristics, random intercepts Poisson modelling is performed with predictors at the individual and the sub-district level. Random intercepts and slopes models are fitted to explore variability of individual-level SEP effects.

Results

All-cause MRRs for middle-aged Belgian men are higher in the geographic areas of the Walloon region and the Brussels-Capital Region (BCR) compared to those in the Flemish region. The highest MRRs are observed in the inner city of the BCR and in several Walloon cities. Their disadvantage can partially be explained by the lower individual SEP of men living in these areas. Similarly, the relatively low MRRs observed in the districts of Halle-Vilvoorde, Arlon and Virton can be related to the higher individual SEP. Among the area-level characteristics, both the percentage of men employed and the percentage of labourers in a sub-district have a protective effect on the individual MRR, regardless of individual SEP. Variability in individual-level SEP effects is limited.

Conclusions

Individual SEP partly explains the observed mortality gap in Belgium for some areas. The percentage of men employed and the percentage of labourers in a sub-district have an additional effect on the individual MRR aside from that of individual SEP. However, these socio-economic factors cannot explain all of the observed differences. Other mechanisms such as public health policy, cultural habits and environmental influences contribute to the observed geographic pattern in all-cause mortality among middle-aged men.

Electronic supplementary material

The online version of this article (doi:10.1186/s13690-016-0135-y) contains supplementary material, which is available to authorized users.

Inequalities in the Distribution of Health Care Facilities

Inequality in the distribution of health care facilities is one of the main barriers to health care access. The purpose of this study was to assess the regional differences in health care facilities across the Kohgiluyeh and Boyer-Ahmad (KBA) province in order to reduce the gap between different regions. The study was carried out in the KBA province in the southwest of Iran. Fifteen health indices were selected based on their availability in the 2011 Statistical Centre of Iran (SCI) annual report. Data analysis was conducted through using numerical taxonomy. The findings obtained showed a huge gap between the different counties of the province. Yasouj had the highest (0.73) health indicator level, while Charam (0.982) had the lowest. Our findings can provide a big picture of the inequalities that exist in this province for policy-makers. Consequently, it enables policy-makers to make greater efforts for understanding the present conditions and moving towards a more equal distribution of health care services and facilities.

Correlates of unequal access to preventive care in China: a multilevel analysis of national data from the 2011 China Health and Nutrition Survey

BACKGROUND

Preventive care has an essential role in reducing income-related health inequalities. Despite a general consensus of the need of shifting focus from disease treatment to wellness and prevention, little is known about inequalities in access to preventive care in China. Our study aimed to explore the inequalities in preventive care usage and factors that were associated with such inequalities among Chinese adults.

METHODS

Multilevel logistic regression analyses were performed using national data from the 2011 Chinese Health and Nutrition Survey. The study sample comprised 13,483 adults who were covered by Basic Social Medical Insurance (BSMI). We analyzed individual socioeconomic status (marital status, education attainment, annual household income per capita, and medical insurance) and contextual factors for their influence on preventive care usage (region of residence and type of community) after controlling for health needs (age, sex, and health condition).

RESULTS

Out of the participants, 6.9 % received preventive care services over the past four weeks and 3.9 % went for a general physical examination prior to the survey. We noted regional disparities in the overall use of preventive care and specific use of general physical examination, with residents from central and northeastern regions less likely to use preventive care including general physical examination than in the more affluent eastern region. Lower levels of education and income were associated with reduced use of preventive care. Subscriptions to less generous social medical insurance programs such as Urban Resident-based Medical Insurance Scheme or New Rural Cooperative Medical Scheme were associated with decreased specific use of general physical examinations, but not overall use of preventive care.

CONCLUSIONS

Inequalities in preventive care usage were evident in China, and were associated with health needs and socioeconomic characteristics. Current health insurance arrangements may fail to reduce inequalities relating to preventive care. A fair and more coherent policy across all BSMI schemes is needed.

Correlates of unequal access to preventive care in China: a multilevel analysis of national data from the 2011 China Health and Nutrition Survey

Background

Preventive care has an essential role in reducing income-related health inequalities. Despite a general consensus of the need of shifting focus from disease treatment to wellness and prevention, little is known about inequalities in access to preventive care in China. Our study aimed to explore the inequalities in preventive care usage and factors that were associated with such inequalities among Chinese adults.

Methods

Multilevel logistic regression analyses were performed using national data from the 2011 Chinese Health and Nutrition Survey. The study sample comprised 13,483 adults who were covered by Basic Social Medical Insurance (BSMI). We analyzed individual socioeconomic status (marital status, education attainment, annual household income per capita, and medical insurance) and contextual factors for their influence on preventive care usage (region of residence and type of community) after controlling for health needs (age, sex, and health condition).

Results

Out of the participants, 6.9 % received preventive care services over the past four weeks and 3.9 % went for a general physical examination prior to the survey. We noted regional disparities in the overall use of preventive care and specific use of general physical examination, with residents from central and northeastern regions less likely to use preventive care including general physical examination than in the more affluent eastern region. Lower levels of education and income were associated with reduced use of preventive care. Subscriptions to less generous social medical insurance programs such as Urban Resident-based Medical Insurance Scheme or New Rural Cooperative Medical Scheme were associated with decreased specific use of general physical examinations, but not overall use of preventive care.

Conclusions

Inequalities in preventive care usage were evident in China, and were associated with health needs and socioeconomic characteristics. Current health insurance arrangements may fail to reduce inequalities relating to preventive care. A fair and more coherent policy across all BSMI schemes is needed.

Who benefits most from influenza vaccination policy: a study among the elderly in Beijing, China

Background

Influenza continues to have a major impact on vulnerable populations worldwide, particularly among the elderly (≥60 years of age). Vaccination for targeted groups is recommended by the WHO as the most effective way to control influenza infections. Since 2009, the Beijing municipal government has provided influenza vaccination to the elderly at no out-of-pocket cost to reduce influenza threats and improve related health equality. The study aims to evaluate the equality of the policy, and to analyze factors that bring influences to equality.

Methods

Based on data from a household survey, concentration index (CI) was calculated to measure the socioeconomic inequality in influenza vaccination. A Logit regression model was used to decompose CI, in which the contribution of each determinant was calculated and the percentages of these contribution were obtained.

Results

Free influenza vaccination at point of use shows significant pro-poor distribution among the elderly in Beijing (CI = −0.115). After the decomposition of CI, the elderly with lower income, higher education, and living in rural areas were more likely to get the influenza vaccination, in which place of residence (contribution percentage = 57 %) held the most contribution of variance.

Conclusions

Beijing’s free influenza vaccination strategy at point of use could provide the poor elderly with equal opportunities to receive preventive health service, showing a significant pro-poor distribution. The poor elderly, who live in rural areas with high education, benefit most from the policy. Further policy interventions should target the population living in urban areas in order to improve the utilization of public health services and health equality.

The impact of economic factors on treatment results for tumor inpatients in the under-developed Western region of China

OBJECTIVE

To discuss the influences of economic factors on the treatment outcomes of cancer patients and the relaxation effects of medical insurance policies on the influences of economic factors.

METHOD

The concentration index (CI) and horizontal inequality (HI) of treatment outcomes of cancer patients were calculated and the role of the economy, disease, and other factors to HI was analyzed by describing the influence of treatment expense on the treatment outcomes of different cancer patients.

RESULTS

The study showed that the equity of the death rate and the effective rate of six types of cancer patients was good. The HI of the cure rate was 0.225, indicating a strong, pro-rich inequity of the cancer inpatient cure rate, while the contribution of the economic factors to HI was 0.158. The uncured rate in the low-cost group represented the rate of patients who discontinued the treatment; the HI was -0.324, indicating a strong, pro-poor inequity. The relaxation effect on the HI of the cured rate by medical insurance was 14.9%, while the effect on the HI of the uncured rate was 18.7%.

CONCLUSION

At present, medical insurance has demonstrated relaxation effects on the fairness of treatment outcomes to some extent. The main reason for this inequity comes from the payment of the items at present. To relieve such inequity to a greater extent, the payment system should be changed and diagnosis-related groups should be implemented.

Analysis of the equity of emergency medical services: a cross-sectional survey in Chongqing city

Background

Due to reform of the economic system and the even distribution of available wealth, emergency medical services (EMS) experienced greater risks in equity. This study aimed to assess the equity of EMS needs, utilisation, and distribution of related resources, and to provide evidence for policy-makers to improve such services in Chongqing city, China.

Methods

Five emergency needs variables (mortality rate of maternal, neonatal, cerebrovascular, cardiovascular, injury and poisoning) from the death surveillance, and two utilisation variables (emergency room visits and rate of utilisation) were collected from Chongqing Health Statistical Year Book 2008 to 2012. We used a concentration index (CI) to assess equality in the distribution of needs and utilisation among three areas with different per-head gross domestic product (GDP). In each area, we randomly chose two districts as sample areas and selected all the medical institutions with emergency services as subjects. We used the Gini coefficient (G) to measure equity in population and geographic distribution of facilities and human resources related EMS.

Results

Maternal-caused (CI: range −0.213 to −0.096) and neonatal-caused (CI: range −0.161 to −0.046)deaths declined in 2008–12, which focusing mainly on the less developed area. The maternal deaths were less equitably distributed than neonatal, and the gaps between areas gradually become more noticeable. For cerebrovascular (CI: range 0.106 to 0.455), cardiovascular (CI: range 0.101 to 0.329), injury and poisoning (CI: range 0.001 to 0.301) deaths, we documented a steady improvement of mortality; the overall equity of these mortalities was lower than those of maternal and neonatal mortalities, but distinct decreases were seen over time. The patients in developed area were more likely to use EMS (CI: range 0.296 to 0.423) than those in less developed area, and the CI increased over the 5-year period, suggesting that gaps in equity were increasing. The population distribution of facilities, physicians and nurses (G: range 0.2 to 0.3) was relatively equitable; the geographic distribution (G: range 0.4 to 0.5) showed a big gap between areas.

Conclusions

In Chongqing city, equity of needs, utilization, and resources allocation of EMS is low, and the provision of such services has not met the needs of patients. To narrow the gap of equity, improvement in the capability of EMS to decrease cerebrovascular, cardiovascular, injury and poisoning cases, should be regarded as a top priority. In poor areas, allocation of facilities and human resources needs to be improved, and the economy should also be enhanced.

Mobility and health sector development in China and India

China and India are both attempting to create comprehensive healthcare systems in the context of rapid but uneven economic growth and rapidly changing burdens of disease. While in each country the referencing of international policies and work experience abroad have been part of this process, research has yet to examine the kind of knowledge that is exchanged or the various actors involved in knowledge circulation. Based on a study of two sub-national contexts, this article focuses on the role Chinese and Indian health professionals who have studied and worked overseas play in introducing ideas and practices about healthcare provision and health education. We found that experience abroad influenced individuals, institutions, and each society differently and with some contradictory effects. International experience clearly contributed to personal growth and led individuals to support the adoption of new institutional practices, such as more egalitarian relations between doctors and patients and between students and teachers. However, the content of what individuals learned overseas and the mechanisms through which this knowledge was introduced back into homeland settings often reinforced rather than ameliorated institutional hierarchies and social inequalities. While the scope of this research was limited, we suggest that more explicit analysis of the role professional migrants play in transferring ideas and practices within the health sector would be valuable for policymakers and funders seeking to support a more productive interaction between local and global knowledge.

Patients with dementia syndrome in public and private services in southern Brazil

Dementia is characterized by deficits in more than one cognitive domain, affecting language, praxis, gnosis, memory or executive functions. Despite the essential economic growth observed in many developing countries, especially over the last century, huge differences remain in health care, whether among nations themselves or across different regions of the same country.

China's three-year health reform program and equity in sanitation improvement: a panel analysis

BACKGROUND

Accessible improved sanitation is critical to child health, and inequities in improved sanitation can be interpreted as health inequities across socio-economic groups. From 2009 to 2011, the Chinese government invested 4.448 billion yuan for rural sanitation improvement through a 3-year health reform program. This study assesses the inequity of sanitation improvement in rural China from 2003 to 2011 and examines whether the 3-year health reform program promoted equity in sanitation improvement.

METHODS

Data from the China Health Statistics Yearbooks of 2004 to 2012 and the National Bureau of Statistics of China were used to create the concentration curve (CC), concentration index (CI), and absolute concentration index (ACI) of improved sanitation. Data of central investment for sanitation improvement in each province of China for 2009, 2010, and 2011 was gained through correspondence and used to create the CC and CI for investment.

RESULTS

Although the CIs of improved sanitation are lower than the CIs of the net income of rural residents, the latter have an obvious downtrend. The CIs of improved sanitation increased from 2003 until 2008 and started to drop in 2009. As a result, by 2011, the CIs of improved sanitation had reached their 2003 levels. The ACI of improved sanitation decreased slightly from 2003 to 2008, but declined sharply from 2009 to 2011. The CIs of central investment for 2009, 2010, and 2011 are negative and the CCs of central investment are above the line of absolute equality, indicating that investments had been concentrated more on poorer provinces and regions.

CONCLUSIONS

The equality of rural residents' net income has been improving each year, whereas equity in sanitation improvement deteriorated from 2003 to 2008. However, equity in sanitation improvement has increased since 2009 due to central investment in sanitation improvement during the 3-year health reform program that benefits low-income areas more. It is clear that the 3-year health reform program played an important role in promoting the level and equity of sanitation improvement.

Individual and province inequalities in health among older people in China: evidence and policy implications

This paper uses multi-level modelling to analyse data from the nationally-representative Chinese Health and Retirement Longitudinal Study (CHARLS) in order to investigate the characteristics associated with poor health among older people, including individual and household characteristics as well as the characteristics of the provinces in which the older person lives (contextual effects). The results show that older Chinese women, rural residents, those with an education level lower than high school, without individual income sources, who are ex-smokers, and those from poor economic status households are more likely to report disability and poor self-rated health. Differentials in the health outcomes remain substantial between provinces even after controlling for a number of individual and household characteristics.

Effective coverage: a metric for monitoring Universal Health Coverage

A major challenge in monitoring universal health coverage (UHC) is identifying an indicator that can adequately capture the multiple components underlying the UHC initiative. Effective coverage, which unites individual and intervention characteristics into a single metric, offers a direct and flexible means to measure health system performance at different levels. We view effective coverage as a relevant and actionable metric for tracking progress towards achieving UHC. In this paper, we review the concept of effective coverage and delineate the three components of the metric - need, use, and quality - using several examples. Further, we explain how the metric can be used for monitoring interventions at both local and global levels. We also discuss the ways that current health information systems can support generating estimates of effective coverage. We conclude by recognizing some of the challenges associated with producing estimates of effective coverage. Despite these challenges, effective coverage is a powerful metric that can provide a more nuanced understanding of whether, and how well, a health system is delivering services to its populations.

Understanding inequalities in child health in Ethiopia: health achievements are improving in the period 2000-2011

Objective

In Ethiopia, coverage of key health services is low, and community based services have been implemented to improve access to key services. This study aims to describe and assess the level and the distribution of health outcomes and coverage for key services in Ethiopia, and their association with socioeconomic and geographic determinants.

Methods

Data were obtained from the 2000, 2005 and 2011 Ethiopian Demographic and Health Surveys. As indicators of access to health care, the following variables were included: Under-five and neonatal deaths, skilled birth attendance, coverage of vaccinations, oral rehydration therapy for diarrhoea, and antibiotics for suspected pneumonia. For each of the indicators in 2011, inequality was described by estimating their concentration index and a geographic Gini index. For further assessment of the inequalities, the concentration indices were decomposed. An index of health achievement, integrating mean coverage and the distribution of coverage, was estimated. Changes from 2000 to 2011 in coverage, inequality and health achievement were assessed.

Results

Significant pro-rich inequalities were found for all indicators except treatment for suspected pneumonia in 2011. The geographic Gini index showed significant regional inequality for most indicators. The decomposition of the 2011 concentration indices revealed that the factor contributing the most to the observed inequalities was different levels of wealth. The mean of all indicators improved from 2000 to 2011, and the health achievement index improved for most indicators. The socioeconomic inequalities seem to increase from 2000 to 2011 for under-five and neonatal deaths, whereas they are stable or decreasing for the other indicators.

Conclusion

There is an unequal socioeconomic and geographic distribution of health and access to key services in Ethiopia. Although the health achievement indices improved for most indicators from 2000 to 2011, socioeconomic determinants need to be addressed in order to achieve better and more fairly distributed health.

Identifying determinants of socioeconomic inequality in health service utilization among patients with chronic non-communicable diseases in China

Background

People with chronic non-communicable diseases (NCD) are particularly vulnerable to socioeconomic inequality due to their long-term expensive health needs. This study aimed to assess socioeconomic-related inequality in health service utilization among NCD patients in China and to analyze factors associated with this disparity.

Methods

Data were taken from the 2008 Chinese National Health Survey, in which a multiple stage stratified random sampling method was employed to survey 56,456 households. We analyzed the distribution of actual use, need-expected use, and need-standardized usage of outpatient services (over a two-week period) and inpatient services (over one-year) across different income groups in 27,233 adult respondents who reported as having a NCD. We used a concentration index to measure inequality in the distribution of health services, which was expressed as HI (Horizontal Inequity Index) for need-standardized use of services. A non-linear probit regression model was employed to detect inequality across socio-economic groups.

Results

Pro-rich inequity in health services among NCD patients was more substantial than the average population. A higher degree of pro-rich inequity (HI = 0.253) was found in inpatient services compared to outpatient services (HI = 0.089). Despite a greater need for health services amongst those of lower socio-economic status, their actual use is much less than their more affluent counterparts. Health service underuse by the poor and overuse by the affluent are evident. Household income disparity was the greatest inequality factor in NCD service use for both outpatients (71.3%) and inpatients (108%), more so than health insurance policies. Some medical insurance schemes, such as the MIUE, actually made a pro-rich contribution to health service inequality (16.1% for outpatient and 12.1% for inpatient).

Conclusions

Inequality in health services amongst NCD patients in China remains largely determined by patient financial capability. The current insurance schemes are insufficient to address this inequity. A comprehensive social policy that encompasses a more progressive taxation package and redistribution of social capital as well as pro-poor welfare is needed.

The basic social medical insurance is associated with clinical outcomes in the patients with ST-elevation myocardial infarction: a retrospective study from Shanghai, China

OBJECTIVE

Several social economic factors play important roles in treatments of ST-elevation myocardial infarction (STEMI) and finally influence the clinical outcomes. The basic social medical insurance (BSMI) is an important economic factor in China's medical system. However, the impact of BSMI on clinical outcomes in STEMI patients has not been explored yet. The aim of this study is to investigate whether BSMI is a predictor of clinical outcomes in the patients with STEMI in Shanghai, China.

MATERIAL AND METHODS

In this retrospective study, 681 STEMI patients from different areas in Shanghai were classified into four groups: new rural cooperative medical scheme (NCMS) group, urban resident basic medical insurance scheme (URBMI) group, urban employee basic medical insurance scheme (UEBMI) group and UNINSURED group, major adverse events (cardiac death, nonfatal reinfarction, clinically driven target lesion revascularization/target vessel revascularization, stroke, heart failure) were regarded as study endpoints to determine whether BSMI was a prognostic factor.

RESULTS

During a mean follow-up of 36 months, the incidence of major adverse events was significantly higher in NCMS patients (64; 38.8%) compared with the other groups: URBMI (47; 24.6%); UEBMI (28; 15.6%); UNISURED (40; 27.6%). Similarly, cardiac mortality was also higher in NCMS group (19; 11.5%). A Kaplan-Meier survival analysis revealed significantly lower event-free survival rate for major adverse events (p < 0.001) and cardiac mortality (p = 0.01) in NCMS group. Multivariate Cox regression analysis revealed that BSMI was an important prognostic factor in STEMI patients.

CONCLUSION

These results demonstrate that BSMI is closely associated with the major adverse events-free survival rate at 36-month follow-up in the STEMI patients under the current policies in Shanghai, China.

EHR adoption across China's tertiary hospitals: a cross-sectional observational study

HEADING

EHR adoption across China's tertiary hospitals: a cross-sectional observation study

OBJECTIVES

To assess electronic health record (EHR) adoption in Chinese tertiary hospitals using a nation-wide standard EHR grading model.

METHODS

The Model of EHR Grading (MEG) was used to assess the level of EHR adoption across 848 tertiary hospitals. MEG defines 37 EHR functions (e.g., order entry) which are grouped by 9 roles (e.g., inpatient physicians) and grades each function and the overall EHR adoption into eight levels (0-7). We assessed the MEG level of the involved hospitals and calculated the average score of the 37 EHR functions. A multivariate analysis was performed to explore the influencing factors (including hospital characteristics and information technology (IT) investment) of total score and scores of 9 roles.

RESULTS

Of the 848 hospitals, 260 (30.7%) were Level Zero, 102 (12.0%) were Level One, 269 (31.7%) were Level Two, 188 (22.2%) were Level Three, 23 (2.7%) were Level Four, 5 (0.6%) was Level Five, 1 (0.1%) were Level Six, and none achieved Level Seven. The scores of hospitals in eastern and western China were higher than those of hospitals in central areas. Bed size, outpatient admission, total income in 2011, percent of IT investment per income in 2011, IT investment in last 3 years, number of IT staff, and duration of EHR use were significant factors for total score.

CONCLUSIONS

We examined levels of EHR adoption in 848 Chinese hospitals and found that most of them have only basic systems, around level 2 and 0. Very few have a higher score and level for clinical information using and sharing.