Regional inequality in health and its determinants: evidence from China

Does the impact of economic inequality on maternal and child health inequality exhibit a threshold effect? Evidence from China

When the economy (economic inequality) develops to a certain level, does the impact of economic inequality on health inequality change? Through threshold regression, this study analyses the impact of city-level economic inequality on the absolute and economic-related inequality in under-5 child mortality rate (U5MR) (2001-2012) and maternal mortality rate (MMR) (2001-2015), along with the threshold values for economic development stages and economic inequality. Findings show: For the relationship between economic inequality and absolute inequality in U5MR, as well as economic-related inequality, there exists an economic development threshold effect. For the relationship between economic inequality and absolute inequality in MMR, an economic inequality threshold effect is illustrated. The improvement of economic conditions contributes to alleviating inequality in U5MR. Economic development inequality has a significant impact on the equality of maternal health development, but for enhancing the equality of women's health, health promotion policies may be more feasible.

A Political-Economic Model of Community and Societal Health Resources: A 92-Country Global Analysis

The quality and access to healthcare systems depend on community health resources, infrastructure, and funding; however, a significant disparity in these resources persists globally. The effectiveness of national health systems depends on a balanced approach to health spending, access to facilities and a skilled local health workforce. What accounts for country-level differences in those critical community and societal health resources? We proposed and tested a model that leverages political and socioeconomic factors to predict various health resources and services in countries. Data, including community health training, research, and support, universal health coverage, healthcare infrastructure, and per capita health expenditure, were collected and analysed by statistical methods, like bivariate correlations and hierarchical multiple linear regressions from 105 countries. Countries with more grassroots activism, fiscal decentralisation, freedom, and globalisation and less perceived corruption and inequality had more community and societal health resources. In multivariate analyses, stronger community health training and research is associated with the globalisation index, freedom score, government fiscal decentralisation, and income inequality. The strongest predictor of health insurance coverage and hospital beds was the country's population education index, and of nurses and midwives-per-capita and health expenditures-per-capita was GDP-per-capita. These insights could guide policymaking to reduce global health inequalities.

Impact of regional medical self-sufficiency on mortality from cancer, stroke and myocardial infarction

OBJECTIVES

This study aimed to explore the impact of regional medical self-sufficiency on mortality from cancer, stroke and myocardial infarction (MI), and make policy suggestions to address regional health disparities and promote national health outcomes.

STUDY DESIGN

A multilevel analysis of nationwide data.

METHODS

This study employed the Korean National Health Insurance Service-National Sample Cohort database at the individual level and the Korean Medical Utilization Statistics at the regional level. The study population included 31,862 individuals who were newly diagnosed with cancer, 16,793 with stroke and 2936 with MI between 2011 and 2019. Multilevel logistic regression was used to address the clustered structure of regional-level data with individual-level data on demographics and health details nested within it.

RESULTS

Regional medical self-sufficiency did not significantly impact 1-year mortality in cancer patients. For patients with stroke and MI, a low level of medical self-sufficiency in the residential area was associated with a notably increased likelihood of dying within 1 month by 1.03 (95 % confidence interval [CI]: 1.02-1.07) and 1.44 (95 % CI: 1.08-2.01) times, respectively. Stratified analysis by region of residence showed that even if cancer patients lived in Seoul and metropolitan areas, they had an increased risk of death within 1 year if the medical self-sufficiency of their treatment areas was low (adjusted odds ratio [aOR]: 1.19, 95 % CI: 1.03-1.38). Moreover, for patients with MI living in medically underserved areas, the risk of death tended to increase with lower income.

CONCLUSIONS

The findings demonstrated that for acute stroke or MI patients, living in areas with low self-sufficiency of medical care had a higher likelihood of dying within 1 month. To improve national health outcomes and address regional medical disparities, it is crucial to prioritise policies such as establishing specialised centres dedicated to managing acute cardio-cerebrovascular conditions in each region.

Unraveling the drivers of inequality in primary health-care resource distribution: Evidence from Guangzhou, China

Background

Primary health-care (PHC) resource plays a critical role in addressing challenges related to healthcare accessibility and costs, as well as implementing a graded diagnosis and treatment system. This study aims to analyze the extent and components of inequality in PHC resource allocation in Guangzhou.

Methods

By utilizing data from the Annual Report on Healthcare Institutions for community and township health centers in Guangzhou from 2012 to 2020, this paper analyses the distribution of human, material and financial resources. It examines inequities in health resource allocation using the Gini coefficient. Additionally, it investigates the internal structure of overall inequality through the two-stage nested Theil decomposition method and explores the influencing mechanisms of inequality using the concentration index decomposition method.

Results

The findings indicate that between 2012 and 2020, except for beds in 2018 and 2019, the Gini coefficients for resource allocation relative to population size remained below 0.3. Moreover, the Gini coefficient for geographical area ranged from 0.1228 to 0.3481. The two-stage nested Theil decomposition results reveal that within-district disparity contributes the most to the overall inequality, exceeding 46 %. The Concentration indexes show negative values, and the decomposition analysis highlights the significant contribution of the number of individuals served (over 72 %) to the inequality in health resource allocation.

Conclusion

At the administrative district level, the allocation of PHC resources in Guangzhou demonstrates overall equity, with within-district inequality identified as the primary contributor to the overall inequality. The distribution of PHC resources in Guangzhou follows a pro-poor pattern. The key factors influencing equity enhancement in PHC resource allocation in Guangzhou include the number of individuals served, the presence of township health centers among institution types, the number of hospital admissions per capita, and the proportion of children aged 0-3.

Accessing the Impact of TikTok's Algorithm on Regional Inequality in Health Information

This study aims to audit the potential algorithmic bias in TikTok's health-related video recommendation toward geographically diverse groups in China. We employed 120 cloud phones and conducted two agent-based testing experiments simulating users' geographical locations and online behaviors. The results indicated significant regional inequality in video sources recommended by the TikTok algorithm, t(118) = 3.02, p = .003, with users from developed cities encountering a higher proportion of professional videos than those from underdeveloped cities. However, when users from both regions expressed a similar preference for the same type of information, an equal proportion of professional videos was recommended. Our findings suggest that widely used algorithms may covertly perpetuate social inequities and reinforce preexisting class-based inequalities, particularly affecting vulnerable population from low-income regions. This study also highlights the importance of enhancing eHealth literacy among disadvantaged users to mitigate problematic outcomes in the AI-based communication landscape.

The geography of healthcare: Mapping patient flow and medical resource allocation in China

The misallocation of medical resources leads to interregional patient flow in search of better healthcare. Using out-of-pocket medical expenditure data and a delineating method, this paper identifies spatial clusters of medical services in China based on patient flow across cities. Our findings indicate that healthcare resources are more concentrated in northern China, while southern China is divided into several large healthcare clusters at the same threshold. The provincial capital and economically significant cities are more likely to serve as medical cluster centers. We further apply the gravity model to examine the effects of healthcare disparity on cross-city medical expenditure. The results reveal that geographic disparities in high-quality medical resources encourage remote healthcare-seeking behavior, and the shorter the distance between locations, the higher the level of medical consumption. Patients are inclined to seek medical services within their own province and within specific medical clusters identified through delineation methods. This effect is more pronounced among patients from non-central cities. This study highlights healthcare inequality by examining cross-regional medical expenditure, providing valuable insights for future healthcare policy.

GIS-based assessment of spatial and temporal disparities of urban health index in Shenzhen, China

Purpose

To explore the inter-regional health index at the city level to contribute to the reduction of health inequalities.

Methods

Employed the health determinant model to select indicators for the urban health index of Shenzhen City. Utilized principal component analysis, the weights of these indicators are determined to construct the said health index. Subsequently, the global Moran's index and local Moran's index are utilized to investigate the geographical spatial distribution of the urban health index across various administrative districts within Shenzhen.

Results

The level of urban health index in Shenzhen exhibits spatial clustering and demonstrates a positive spatial correlation (2017, Moran's I = 0.237; 2019, Moran's I = 0.226; 2021, Moran's I = 0.217). However, it is noted that this clustering displays a relatively low probability (90% confidence interval). Over the period from 2017 to 2019, this spatial clustering gradually diminishes, suggesting a narrowing of health inequality within economically developed urban areas.

Conclusion

Our study reveals the urban health index in a relatively high-income (Shenzhen) in a developing country. Certain spatially correlated areas in Shenzhen present opportunities for the government to address health disparities through regional connectivity.

Assessment of national reimbursement anticancer medications availability in China: based on a medical institution perspective

BACKGROUND

High clinical value national reimbursement anticancer medications (NRAMs) are pivotal treatments for patients with cancer. However, the availability of NRAMs in medical institutions is unknown. This study aimed to assess the availability of NRAMs in national and provincial medical institutions.

METHODS

This cross-sectional study utilized national health insurance data to access the availability of NRAMs in national and provincial medical institutions. Further statistical analyses and visualizations were conducted in terms of medical institution level and daily cost. Using the Spearman's rank correlation test (α = 0.05), we calculated the correlation between the availability rates of NRAMs and their negotiation access time, daily cost, per capita disposable income, provincial gross product, and number of policy releases.

RESULTS

Overall, 81 NRAMs, with an average availability rate of approximately 1.01% nationwide, were included. There were significant differences between provinces for each drug, and the availability of NRAMs gradually decreased in tertiary (13.41%), secondary (1.58%), and primary medical institutions (< 0.05%). Differences were also observed in the availability rate of NRAMs in various daily drug cost ranges. Among the factors examined, negotiation access time (r1 = 0.425), daily cost (r2 = - 0.326), per capita disposable income (r3 = 0.645), provincial gross product (r4 = 0.433), and number of policy releases (r5 = 0.461) were all correlated with the availability of NRAMs.

CONCLUSIONS

The low availability of NRAMs in national and provincial medical institutions indicates that their willingness to equip NRAMs needs to be improved. All factors examined in this study affected the availability of NRAMs. Our findings can guide policymakers in improving relevant policies.

The impacts of basic medical insurance for urban-rural residents on the perception of social equity in China

BACKGROUND

Based on CSS 2019 data, this article analyzes the impact of Basic Medical Insurance for Urban and Rural Residents (BMIUR) on perceived social equity of residents.

METHOD

Using the CSS data of 2019, this article analyzes the influence of BMIUR on the perception of social equity of residents, on the basis of 2SLS model and mediating effect model.

RESULTS

We find that BMIUR has a significantly positive impact on the perception of social equity. That is to say, BMIUR can improve residents' evaluation of social equity and further promote the level of social equity, which makes residents more happiness. The conclusion remains valid after using robustness test and propensity score matching to conduct counterfactual reasoning. The discussion of mechanism indicates that the influence of BMIUR is mediated by enhancing social capital, improving satisfaction of income distribution and reducing self-paid medical expenses. This study also finds that the influence of BMIUR is more obvious in the low-income, low-skilled and mid-west groups.

CONCLUSION

The reform of the medical security system should be regarded as a foothold for improving people's well-being and promoting social equity; Expanding people's social capital through multiple channels and improving income distribution mechanisms; Strengthen vocational skills training, especially to provide more public services and social security for low-income groups, low-skilled groups, and groups in the western region of China, in order to improve the welfare and policy effectiveness of China's social security reform.

Dynamic distribution, regional differences and convergence of health workforce allocation in township health centers in China

This study evaluated the dynamic distribution, regional differences, and convergence of health workforce allocation in Township Health Centers in China during 2011-2020 using data obtained from the China Health Statistics Yearbook (2012-2021). The Gini coefficient and kernel density estimation were chosen to examine the dynamic distribution and regional differences in health workforce allocation in Township Health Centers in China and their components. σ convergence and β convergence were used to investigate the change trend of health workforce allocation in Township Health Centers. The results show that between 2011 and 2020, the number of licensed doctors and registered nurses per thousand population in Township Health Centers both increased largely and regional disparities still exist. In 2020, the largest differences in the density of licensed doctors and registered nurses were found in the eastern and central regions, respectively, and the intensity of trans-variation contributed the most to the overall disparities. The allocation of licensed doctors and registered nurses both exhibited σ convergence, absolute and conditional β convergence, indicating that the regional differences in health workforce in THCs among provinces will decrease. The growth of healthcare workforce was positively impacted by the urbanization rate, growth rate of government health expenditures and growth domestic product per capita, but negatively impacted by population density in rural areas and fiscal self-sufficiency.

Does the Healthy China 2030 Policy Improve People's Health? Empirical Evidence Based on the Difference-in-Differences Approach

Background

The Healthy China 2030 (HC2030) policy is currently recognized as China's most significant and influential national health policy. However, despite its implementation in 2016, the policy's impact has yet to be comprehensively evaluated, particularly in relation to its effectiveness in enhancing population health and promoting public health equity.

Methods

We utilized the Difference-in-Differences (DiD) method to evaluate the impact of the HC2030. Our analysis utilized a panel dataset derived from five longitudinal surveys conducted by the China Family Panel Studies (CFPS).

Results

The implementation of HC2030 has improved the overall health status of residents, particularly in urban areas and the western and eastern regions. Mechanistic analysis has further unveiled that the policy's beneficial impact on health outcomes is attributed to a rise in physical activity frequency and the betterment of mental health. Additionally, female, married, and medically insured individuals have demonstrated a significant positive impact of the policy on their health outcomes.

Conclusion

Although the HC2030 appears to have effectively improved overall population health, it needs to promote equity in public health adequately. The study suggests adjustments are needed to address the unequal distribution of health outcomes between urban and rural areas and among different regions.

Life expectancy inequalities between regions of China 2004-2020: contribution of age- and cause-specific mortality

Background

China's rapid economic and social development since the early 2000s has caused significant shifts in its epidemiological transition, potentially leading to health disparities across regions.

Objectives

This study employs Life Expectancy (LE) to assess health disparities and trends among China's eastern, central, and western regions. It also examines the pace of LE gains relative to empirical trends and investigates age and causes of death mortality improvement contributing to regional LE gaps.

Data and methods

Using a log-quadratic model, the study estimates LE in China and its regions from 2004 to 2020, using census and death cause surveillance data. It also utilizes the Human Mortality Database (HMD) and the LE gains by LE level approach to analyze China and its regions' LE gains in comparison to empirical trend of developed countries. The study investigates changes in LE gaps due to age and causes of death mortality improvements during two periods, 2004-2012 and 2012-2020, through the LE factor decomposition method.

Results

From 2000 to 2020, China's LE exhibited faster pace of gains compared to developed countries. While men's LE growth gradually aligns with empirical trends, women experience slightly higher growth rates. Regional LE disparities significantly reduced from 2004 to 2012, with a marginal reduction from 2012 to 2020. In the latter period, the changing LE gap aligns with expected trends in developed countries, with all Chinese regions surpassing empirical estimates. Cardiovascular diseases and malignant neoplasms emerged as the primary contributors to expanding regional LE gaps, with neurological disorders and diabetes playing an increasingly negative role.

Conclusion

LE disparities in China have consistently decreased, although at a slower pace in recent years, mirroring empirical trends. To further reduce regional LE disparities, targeted efforts should focus on improving mortality rates related to cardiovascular diseases, neoplasms, neurological disorders and diabetes, especially in the western region. Effective health interventions should prioritize equalizing basic public health services nationwide.

Decomposing income-related inequality in health-related quality of life in mainland China: a national cross-sectional study

INTRODUCTION

Health equity is an important indicator measuring social development and solidarity. However, there is a paucity in nationwide studies into the inequity in health-related quality of life (HRQoL) in mainland China, in particular using the most recent data measuring HRQoL using the EuroQol 5-Dimension-5 Level (EQ-5D-5L). This study aimed to address the gap in the literature by estimating and decomposing income-related inequality of the utility index (UI) of EQ-5D-5L in mainland China.

METHODS

Data were extracted from the Psychology and Behaviour Investigation of Chinese Residents (2022), including 19 738 respondents over the age of 18 years. HRQoL was assessed by the UI of the EQ-5D-5L. Concentration index (CI) was calculated to measure the degree of income-related inequality in the UI. The contributions of individual, behavioural and context characteristics to the CI were estimated using the Wagstaff decomposition method.

RESULTS

The CI of the EQ-5D-5L UI reached 0.0103, indicating pro-rich inequality in HRQoL. Individual characteristics made the greatest contribution to the CI (57.68%), followed by context characteristics (0.60%) and health behaviours (-3.28%). The contribution of individual characteristics was mainly attributable to disparities in the enabling (26.86%) and need factors (23.86%), with the chronic conditions (15.76%), health literacy (15.56%) and average household income (15.24%) as the top three contributors. Educational level (-5.24%) was the top negative contributor, followed by commercial (-1.43%) and basic medical insurance (-0.56%). Higher inequality was found in the least developed rural (CI=0.0140) and western regions (CI=0.0134).

CONCLUSION

Pro-rich inequality in HRQoL is evident in mainland China. Targeted interventions need to prioritise measures that aim at reducing disparities in chronic conditions, health literacy and income.

Effects of the Implementation of Transport-Driven Poverty Alleviation Policy on Health Care-Seeking Behavior and Medical Expenditure Among Older People in Rural Areas: Quasi-Experimental Study

BACKGROUND

Improving the rural residents' accessibility to and affordability of health care is recognized as a common target globally. The Health in All Policies approach, from the Declaration of Helsinki to the United Nations' Decade Of Healthy Ageing, strengthened the far-reaching effect of large-scale public policies on health care-seeking behavior; however, the effects of national transport policy on health care-seeking behavior is unclear.

OBJECTIVE

This quasi-experimental study aimed to examine the effects of the implementation of transport-driven poverty alleviation (TPA) policy on health care-seeking behavior and medical expenditure among older adults in rural areas and the mechanism underlying these effects.

METHODS

We designed a quasi-experiment to estimate the effects of TPA policy implementation on health care-seeking behavior and medical expenditure among older adults in rural areas through a difference-in-differences (DID) analysis based on data from the China Health and Retirement Longitudinal Study in 2011, 2013, 2015, and 2018. The underlying mechanism was analyzed and effect modification patterns were further investigated by poor households, health status, and age.

RESULTS

Our findings validated a positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas. After the implementation of TPA policy, the number of inpatient visits increased by annually 0.35 times per person, outpatient medical expenditure increased by 192% per month, and inpatient medical expenditure increased by 57% annually compared with those of older adults in rural areas without the implementation of TPA policy. Further, there was a significant modification effect, with a positive effect among poor households, healthier older adults, and those aged 60-80 years. Additionally, the policy improved the patients' capabilities to seek long-distance care (β=23.16, 95% CI -0.99 to 45.31) and high-level hospitals (β=.08, 95% CI -0.02 to 0.13), and increased individual income to acquire more medical services (β=4.57, 95% CI -4.46 to 4.68).

CONCLUSIONS

These findings validate the positive contribution of TPA policy on health care-seeking behavior among older adults in rural areas; however, the medical expenditure incurred was also high. Concerted efforts are needed to address health care-seeking dilemmas in rural areas, and attention must be paid to curbing medical expenditure growth for older adults in rural areas during TPA policy implementation.

Disparity in hospital beds' allocation at the county level in China: an analysis based on a Health Resource Density Index (HRDI) model

BACKGROUND

As approximately 3/4 of the population lives in county-level divisions in China, the allocation of health resources at the county level will affect the realization of health equity. This study aims to evaluate the disparity in hospital beds at the county level in China, analyze its causes, and discuss measures to optimize the allocation.

METHODS

Data were drawn from the Chinese County/City Statistical Yearbook (2001-2020). The health resource density index (HRDI) was applied to mediate between the influence of demographic and geographical factors on the allocation of hospital beds. The trends of HRDI allocation were evaluated through the growth incidence curve and the probability density function. The regional disparity in the HRDI was examined through the Lorenz curve, and Dagum Gini coefficient. The contribution of the Gini coefficient and its change were assessed by using the Dagum Gini decomposition method.

RESULTS

From 2000 to 2019, the number of hospital beds per thousand people at the county level in China increased dramatically by 1.49 times. From the aspect of the HRDI, there were large regional disparities at the national level, with a Gini coefficient of 0.367 in 2019 and in the three subregions. In 2019, the Gini coefficient of the HRDI exhibited regional variations, with the highest value observed in the western region, followed by the central region and the eastern region. Decomposition reveals that the contribution of interregional disparity changed from the dominant factor to the least important factor, accounting for 29.79% of the overall disparity and the contribution of trans-variation intensity increased from 29.19% to 39.75%, whereas the intraregional disparity remained stable at approximately 31% and became the second most important factor.

CONCLUSION

The regional disparity in hospital beds allocation at the county level in China was large and has not improved substantially. Trans-variation intensity was the main reason for the overall disparity and changes, and the intraregional disparity was more important than the interregional disparity for the overall disparity.

Maternal Health Care Service Utilization in the Post-Conflict Democratic Republic of Congo: An Analysis of Health Inequalities over Time

This study assessed inequality in maternal healthcare service utilization in the Democratic Republic of the Congo, using the Demographic and Health Surveys of 2007 and 2013-2014. We assessed the magnitude of inequality using logistical regressions, analyzed the distribution of inequality using the Gini coefficient and the Lorenz curve, and used the Wagstaff method to assess inequality trends. Women were less likely to have their first antenatal care visit within the first trimester and to attend more antenatal care visits when living in eastern Congo. Women in rural areas were less likely to deliver by cesarean section and to receive postnatal care. Women with middle, richer, and richest wealth indexes were more likely to complete more antenatal care visits, to deliver by cesarean section, and to receive postnatal care. Over time, inequality in utilization decreased for antenatal and postnatal care but increased for delivery by cesarean sections, suggesting that innovative strategies are needed to improve utilization among poorer, rural, and underserved women.

The impact of government reimbursement negotiation on targeted anticancer medicines use and cost in China: A cohort study based on national health insurance data

Background

High prices of targeted anticancer medicines (TAMs) result in financial toxicity for patients and the health insurance system. How national price negotiation and reimbursement policy affect the accessibility of TAMs for cancer patients remains unknown.

Methods

In this population-based cohort study, we used national health insurance claims data in 2017 and identified adult patients with cancer diagnoses for which price-negotiated TAMs were indicated. We estimated the half-month prevalence of price-negotiated TAMs use before and after the policy implementation in September 2017. We calculated direct medical costs, out-of-pocket (OOP) costs, and the proportion of OOP cost for each cancer patient to measure their financial burden attributable to TAMs use. We performed segmented linear and multivariable logistic regression to analyse the policy impact.

Results

We included 39 391 of a total 118 655 cancer beneficiaries. After September 2017, the prevalence of price-negotiated TAMs use increased from 1.4%-2.1% to 2.9%-3.1% (P = 0.005); TAMs users' daily medical costs increased from US$261.3 to US$292.5 (P < 0.001), while median daily OOP costs (US$68.2 vs US$65.7; P = 0.134) and OOP costs as a proportion of daily medical costs persisted (28.5% vs 28.5%; P = 0.995). Compared with resident beneficiaries, the relative probability of urban employee beneficiaries on TAMs uses decreased after the policy (adjusted odds ratio (aOR) = 2.4 vs aOR = 2.2).

Conclusions

The government price negotiation and reimbursement policy improved patient access to TAMs and narrowed disparities among insurance schemes. China's approach to promoting the affordability of expensive medicines provides valuable experience for health policy decision-makers.

The impacts of altruism levels on the job preferences of medical students: a cross-sectional study in China

BACKGROUND

Rational allocation of human resources for health is crucial for ensuring public welfare and equitable access to health services. Understanding medical students' job preferences could help develop effective strategies for the recruitment and retention of the health workforce. Most studies explore the relationship between extrinsic incentives and job choices through discrete choice experiments (DCEs). Little attention has been paid to the influence of intrinsic altruism on job choice. This study aimed to explore the heterogeneous preferences of medical students with different levels of altruism regarding extrinsic job attributes.

METHODS

We conducted an online survey with 925 medical students from six hospitals in Beijing from July to September 2021. The survey combined job-choice scenarios through DCEs and a simulation of a laboratory experiment on medical decision-making behavior. Behavioral data were used to quantify altruism levels by estimating altruistic parameters based on a utility function. We fit mixed logit models to estimate the effects of altruism on job preference.

RESULTS

All attribute levels had the expected effect on job preferences, among which monthly income (importance weight was 30.46%, 95% CI 29.25%-31.67%) and work location (importance weight was 22.39%, 95% CI 21.14%-23.64%) were the most salient factors. The mean altruistic parameter was 0.84 (s.d. 0.19), indicating that medical students' altruism was generally high. The subgroup analysis showed that individuals with higher altruism levels had a greater preference for non-financial incentives such as an excellent work environment, sufficient training and career development opportunities, and a light workload. The change in the rate of the uptake of a rural position by individuals with lower levels of altruism is sensitive to changes in financial incentives.

CONCLUSIONS

Medical students' altruism was generally high, and those with higher altruism paid more attention to non-financial incentives. This suggests that policymakers and hospital managers should further focus on nonfinancial incentives to better motivate altruistic physicians, in addition to appropriate economic incentive when designing recruitment and retention interventions. Medical school administrations could attach importance to the promotion of altruistic values in medical education.

An investigation of body mass distributional changes in Australia, 1995-2017/18

This study investigates changes in the distribution of body mass for adult Australians between 1995 and 2017/18. Using three nationally representative health surveys, we first apply the parametric generalised entropy (GE) class of inequality indices to measure the level of disparity in the body mass distribution. Results from the GE measure reveal that, while growth of body mass inequality is a population-wide experience, demographic and socio-economic factors explain only a modest portion of total inequality. We then apply the relative distributions (RD) method to garner richer insights on changes to the body mass distribution. The non-parametric RD method reveals growth in the proportion of adult Australians falling into the upper deciles of the body mass distribution since 1995. Then, hypothetically keeping the shape of the distribution unchanged, we discern that body mass increases across all deciles of the distribution (location effect) is an important contributor to the observed distributional change. After removing the location effect, however, we find a non-trivial role for distributional shape changes (growth of the proportion of adults at the upper and lower parts of the distribution as the proportion in the middle diminish). While our findings support current policy directions that target the population as a whole, factors driving shape changes to the body mass distribution also need consideration when designing anti-obesity campaigns, especially when aimed at women.

Availability and trend of dissemination of cardiac rehabilitation in China: report from the multicenter national registration platform between 2012 and 2021

The study aimed to evaluate the current status of cardiac rehabilitation programs in China by registering and tracking patients undergoing CR programs in the database. Data were extracted from the online registry platform of the China Society of Cardiopulmonary Prevention and Rehabilitation from February 2012 to December 2021. Overall, data on 19,896 patients with cardiovascular diseases (CVDs) from 159 hospitals in 34 provinces of China were extracted. From a time point of view, the number of patients who had undergone CR and institutions that perform CR showed the first decline in 2009 and then increased until 2021. From a geographic point of view, the degree of participation varied greatly among regions, most of which were concentrated in eastern parts of China. A higher population of patients who underwent CR were male, aged less than 60 years, with low-a risk for coronary heart disease (CHD), and tended to choose the hospital-based CR program among all cases registered in the database. The top three diseases in the patients who participated in CR were CHD, hypertension, and metabolic syndrome (MS). Centers with CR were more likely to be tertiary-level hospitals. After adjusting for baseline values, there were significant differences in post-CR exercise capacity among the three groups (home-based CR group, hospital-based CR group, and hybrid CR group), which were in favor of the hybrid CR group compared with other groups. The underutilization of CR is a global issue, not just in China. Despite the number of CR programs showing an increasing trend in the past years, CR in China is still in the preliminary stage of development. Furthermore, the participation of CR in China shows wide diversity across geography, disease, age, sex, risk stratification, and hospital-level factors. These findings reinforce the importance of the implementation of effective measures to improve the participation, enrollment in, and uptake of cardiac rehabilitation.

The Association Between Social Determinants of Health and Population Health Outcomes: Ecological Analysis

BACKGROUND

With the increased availability of data, a growing number of studies have been conducted to address the impact of social determinants of health (SDOH) factors on population health outcomes. However, such an impact is either examined at the county level or the state level in the United States. The results of analysis at lower administrative levels would be useful for local policy makers to make informed health policy decisions.

OBJECTIVE

This study aimed to investigate the ecological association between SDOH factors and population health outcomes at the census tract level and the city level. The findings of this study can be applied to support local policy makers in efforts to improve population health, enhance the quality of care, and reduce health inequity.

METHODS

This ecological analysis was conducted based on 29,126 census tracts in 499 cities across all 50 states in the United States. These cities were grouped into 5 categories based on their population density and political affiliation. Feature selection was applied to reduce the number of SDOH variables from 148 to 9. A linear mixed-effects model was then applied to account for the fixed effect and random effects of SDOH variables at both the census tract level and the city level.

RESULTS

The finding reveals that all 9 selected SDOH variables had a statistically significant impact on population health outcomes for ≥2 city groups classified by population density and political affiliation; however, the magnitude of the impact varied among the different groups. The results also show that 4 SDOH risk factors, namely, asthma, kidney disease, smoking, and food stamps, significantly affect population health outcomes in all groups (P<.01 or P<.001). The group differences in health outcomes for the 4 factors were further assessed using a predictive margin analysis.

CONCLUSIONS

The analysis reveals that population density and political affiliation are effective delineations for separating how the SDOH affects health outcomes. In addition, different SDOH risk factors have varied effects on health outcomes among different city groups but similar effects within city groups. Our study has 2 policy implications. First, cities in different groups should prioritize different resources for SDOH risk mitigation to maximize health outcomes. Second, cities in the same group can share knowledge and enable more effective SDOH-enabled policy transfers for population health.

The Effect of Ecological Management on Regional Health Inequality

Ecological management has been implemented to improve individual well-being. However, it remains unclear whether this management has improved health inequality over time. Aiming to examine whether health inequality is caused by ecological management in China, we harnessed a macro-level dataset from 2001 to 2019 across 31 Chinese provinces-combined with gene and dietary culture data-and utilized a bilateral approach to pair provincial data. Empirical results of system Generalized Method of Moments (sys-GMM) estimations in benchmark and extensive models which suggest a negative and statistically significant causal effect of ecological management on health inequality. Specifically, ecological management contributes to decreasing the inequality in the population death rate, the death rate among pregnant women, the underweight newborn rate, the child malnutrition rate, and the infectious disease mortality. The results are robust to weak instruments in the sys-GMM setting and a delayed effect of ecological management. Additionally, the heterogeneity analysis shows that the causal effect of ecological management on decreasing regional health inequality is more significant and higher for subsamples in identical regions than in different regions.

Regional disparities and influencing factors of high quality medical resources distribution in China

BACKGROUND

With the gradual increase of residents' income and the continuous improvement of medical security system, people's demand for pursuing higher quality and better medical and health services has been released. However, so far little research has been published on China's high quality medical resources (HQMR). This study aims to understand the spatiotemporal variation trend of HQMR from 2006 to 2020, analyze regional disparity of HQMR in 2020, and further explore the main factors influencing the distribution of HQMR in China.

METHODS

The study selected Class III level A hospitals (the highest level medical institutions in China) to represent HQMR. Descriptive statistical methods were used to address the changes in the distribution of HQMR from 2006 to 2020. Lorentz curve, Gini coefficient (G), Theil index (T) and High-quality health resource density index (HHRDI) were used to calculate the degree of inequity. The geographical detector method was used to reveal the key factors influencing the distribution of HQMR.

RESULTS

The total amount of HQMR in China had increased year by year, from 647 Class III level A hospitals in 2006 to 1580 in 2020. In 2020, G for HQMR by population was 0.166, while by geographic area was 0.614. T was consistent with the results for G, and intra-regional contribution rates were higher than inter-regional contribution rates. HHRDI showed that Beijing, Shanghai, and Tianjin had the highest allocated amounts of HQMR. The results of the geographical detector showed that total health costs, government health expenditure, size of resident populations, GDP, number of medical colleges had a significant impact on the spatial distribution of HQMR and the q values were 0.813, 0.781, 0.719, 0.661, 0.492 respectively. There was an interaction between the influencing factors.

CONCLUSIONS

China's total HQMR is growing rapidly but is relatively inadequate. The distribution of HQMR by population is better than by geography, and the distribution by geography is less equitable. Population size and geographical area both need to be taken into account when formulating policies, rather than simply increasing the number of HQMR.

Impact of COVID-19 on health services utilization in mainland China and its different regions based on S-ARIMA predictions

Global health services are disrupted by the COVID-19 pandemic. We evaluated extent and duration of impacts of the pandemic on health services utilization in different economically developed regions of mainland China. Based on monthly health services utilization data in China, we used Seasonal Autoregressive Integrated Moving Average (S-ARIMA) models to predict outpatient and emergency department visits to hospitals (OEH visits) per capita without pandemic. The impacts were evaluated by three dimensions:1) absolute instant impacts were evaluated by difference between predicted and actual OEH visits per capita in February 2020 and relative instant impacts were the ratio of absolute impacts to baseline OEH visits per capita; 2) absolute and relative accumulative impacts from February 2020 to March 2021; 3) duration of impacts was estimated by time that actual OEH visits per capita returned to its predicted value. From February 2020 to March 2021, the COVID-19 pandemic reduced OEH visits by 0.4676 per capita, equivalent to 659,453,647 visits, corresponding to a decrease of 15.52% relative to the pre-pandemic average annual level in mainland China. The instant impacts in central, northeast, east and west China were 0.1279, 0.1265, 0.1215, and 0.0986 visits per capita, respectively; and corresponding relative impacts were 77.63%, 66.16%, 44.39%, and 50.57%, respectively. The accumulative impacts in northeast, east, west and central China were up to 0.5898, 0.4459, 0.3523, and 0.3324 visits per capita, respectively; and corresponding relative impacts were 23.72%, 12.53%, 13.91%, and 16.48%, respectively. The OEH visits per capita has returned back to predicted values within the first 2, 6, 9, 9 months for east, central, west and northeast China, respectively. Less economically developed areas were affected for a longer time. Safe and equitable access to health services, needs paying great attention especially for undeveloped areas.

Does social capital buffer or exacerbate mental health inequality? Evidence from the China Family Panel Study (CFPS)

Background

Health inequality, including physical and mental health inequality, is an important issue. What role social capital plays in mental health inequality is still ambiguous, especially in developing countries. The aim of this study is to explore the relationship between social capital and mental health inequality in China.

Method

Both family-level and community-/village-level social capitals are included in our analysis. Data is mainly extracted from the China Family Panel Studies in 2018, and lagged term of social capital in CFPS 2016 was used to link with other variables in 2018. Depressive symptoms and subjective well-being are set as indicators of mental health. A series of OLS regression models were conducted to estimate the effects of social capital on mental health and mental health inequality.

Results

Higher levels of social capital and income are related to a lower level of depressive symptoms and a higher level of subjective well-being. The positive coefficient of interaction term of family-level social capital and income level in the urban area indicates that the inhibiting effect of social capital on depressive symptoms is pro-poor. The negative coefficient of interaction term of village-level social capital and income level in the rural area suggests that the promoting effect of social capital on subjective well-being is pro-poor, too.

Conclusion

The results show that severe mental health inequality exists in China; family-level social capital can buffer depressive symptom inequality, and village-level social capital can buffer SWB inequality. Although the amount of social capital of the poor is less than the rich, the poor can better use social capital to improve their mental health. Our study advocates enhancing social participation and communication for the poor to reduce mental health inequality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01642-3.

Does air pollution contribute to urban-rural disparity in male lung cancer diseases in China?

It remains unknown whether exposure to ambient air pollution can be a mediator linking socioeconomic indicator to health outcome. The present study aims to examine the mediation effect of PM2.5 air pollution on the association between urban-rural division and the incidence (mortality) rate of male lung cancer. We performed a nationwide analysis in 353 counties (districts) of China between 2006 and 2015. A structural equation model was developed to determine the mediation effect of exposure to PM2.5. We also tested whether the findings of the mediation effect of exposure to PM2.5 are sensitive to the controls of smoking factors and additional air pollutant, and PM2.5 exposures with different lag structures. According to the results, we found that exposure to PM2.5 significantly mediated the association between urban-rural division and the incidence rate of male lung cancer. Specifically, there were significant associations between urban-rural division, exposure to PM2.5, and the incidence rate of male lung cancer, with PM2.5 exposure accounting for 29.80% of total urban-rural difference in incidence rates of male lung cancer. A similar pattern of results was observed for the mortality rate of male lung cancer. That is, there was a significant mediation effect by PM2.5 on the association of the mortality rate with urban-rural division. The findings of exposure to PM2.5 as a mediator were robust in the three sensitivity analyses. In conclusion, urban-rural difference in exposures to PM2.5 may be a potential factor that contributes to urban-rural disparity in male lung cancer diseases in China. The findings inform that air pollution management and control may be effective measures to alleviate the great difference in male lung cancer diseases between urban and rural areas in China.

The Impact of Multidimensional Health Levels on Rural Poverty: Evidence from Rural China

Poor health and poverty interact and restrict each other. While this relationship is acknowledged, little is known about the extent of its impact. By integrating multisource data, this study used spatial econometric models to quantitatively reveal the relationship between health and rural poverty and explore its intrinsic mechanisms. The results indicated that health-care system input, individual health status, and individual health-seeking behavior have a significantly positive effect on the eradication of rural poverty. The health-care system input is characterized by spatial spillover, significantly contributing to rural poverty alleviation in the region and neighboring regions, as well. However, the effect of health-care system services’ capability was negative. Thus, it is necessary to increase investment in the health-care system and pay attention to both the health status and healthy behaviors of rural residents. Moreover, further effort should be given to the supply-side reform of health services as a breakthrough point.

Inequity in the Access to eHealth and Its Decomposition Case of Poland

The aim of this research is to analyze the disparities in the distribution of information and communication technologies and skills across geographically determined population groups and to identify the source of the inequity. Literature showed that the nature of e-Health has the potential to resolve health inequalities. However, its successful implementation depends on such factors as the accessibility of required technologies to all people, the existence of technical infrastructure as well as people having the necessary information and communication skills. Employment of the Theil index allowed us to measure and decompose the national inequality into both: between and within macro-regions differences. Data was collected from Statistics Poland. The results showed the existence of inequity and its drivers. The novelty of this research results from application of the Theil index in the field of eHealth and identification of the barrier in access to e-Health, which can be a basis for improvement in government policy.

Urban-rural lifespan disparities and cause-deleted analysis: evidence from China

OBJECTIVES

To examine the length and dispersion level of lifespan for the subnational populations in China, identify the urban-rural gap and sex differences, and analyse the contribution made by causes of death.

SETTING

Cause-specific mortality data extracted from the Chinese Disease Surveillance Points system, grouped by sex and urban/rural residence.

PRIMARY OUTCOME MEASURES

Life expectancy and lifespan disparity are used to measure the length and dispersion level of lifespan, respectively. Cause-specific contributions are obtained by contrasting cause-deleted life expectancy and lifespan disparities with observed values.

PARTICIPANTS

Aggregated national data gathered from over 605 surveillance points across China, covering over 264 million people by 2016 (about 19.14% of the total Chinese population).

RESULTS

In the decade under observation, all subpopulations in China, by area and sex, experienced increases in life expectancy and decreases in lifespan disparity, while causes of deaths contributed differently. For example, based on the 2016 data, if cardiovascular diseases were deleted, there would be an increase in life expectancy that ranges from 5.59 years for urban males to 6.69 years for rural females. However, also lifespan disparity would increase, ranging from 0.81 years for urban females to 1.37 years for rural males.

CONCLUSIONS

In China, the urban-rural gaps in both life expectancy and lifespan disparity are shrinking as the rural residents are catching up fast, while the gender gaps remain large, and even widening. Causes of death with different age distribution patterns contribute differently to the level and direction of the urban-rural and sex differentials in life expectancy and lifespan disparity. Sex differentials were observed in cardiovascular diseases, respiratory diseases, lung and liver cancers, and external causes, while urban-rural differences were found in lung and breast cancers, and external causes.

The Temporal and Spatial Changes of Health Inequality in Rural China

This article estimates the temporal and spatial changes of health inequality in rural China from 2010 to 2018. Based on a panel database of 29,616 rural residents, the Health Utility Index (HUI) and a spatial econometric model are used for analysis. The results show that, on the temporal dimension, the health inequality of rural China first expands and then deflates. On the spatial dimension, the health inequality gradually deflates from eastern to western China. Furthermore, from 2010 to 2018, the high and low-value areas constantly changed among different provinces. After decomposing the causes of health inequality, it is found that behind the health inequality is the difference of socioeconomic-related status. Moreover, narrowing the difference in socioeconomic-related status is the key to improving health inequality.

Income-related health inequality in urban China (1991-2015): The role of homeownership and housing conditions

Unprecedented economic growth has been experienced over the several decades worldwide, but such rapid economic growth wasn't accompanied by equally-substantial improvement in health, especially health inequalities between the rich and poor. This study examines the role of housing in income-related health inequalities (income-health gradient) in urban China. We here analyze 1991-2015 China Health and Nutrition Survey data to ask how housing affects income-related health inequalities in urban China. We find pro-poor inequalities in self-reported bad health but pro-rich inequalities in objective bad health (general overweight/obesity, central obesity and high blood pressure). Housing conditions serve to reduce the health gradient, especially for objective health. On the contrary, homeownership exacerbates the health gradient. Improving housing conditions thus appears to be an effective way of reducing the income-health gradient in urban China.

Assessing Spatial Accessibility to Primary Health Care Services in Beijing, China

Primary health care has been emphasized as a pillar of China’s current round of health reforms throughout the previous decade. The purpose of this study is to analyze the accessibility of primary health care services in Beijing and to identify locations with a relative scarcity of health personnel. Seven ecological conservation districts, which are relatively underdeveloped, were selected in the study. The Gini coefficient and Lorenz curve, as well as the shortest trip time and modified two-step floating catchment area (M2SFCA) approach, are used to quantify inequalities in primary health care resources and spatial accessibility. The Gini coefficient of primary medical services was calculated as high as 0.705, showing a significant disparity in primary care services. A total of 81.22% of communities reached the nearest primary care institution within 15 min. The average accessibility of primary healthcare services, as measured by the number of health professionals per 1000 population, was 2.34 in the 1715 communities of seven ecological conservation districts. Three hundred and ninety-one communities (22.80%) were identified with relatively low accessibility. More primary health professionals should be allocated to Miyun, Mentougou, and Changping Districts. Overall, the primary healthcare resources were distributed unevenly in most districts. According to our study, expanding primary healthcare institutions, increasing the number of competent health professionals, and enhancing road networks will all be effective ways to increase spatial accessibility and reduce primary healthcare service disparity in Beijing.

Trends in socio-economic, sex and geographic disparities in childhood underweight in Mauritania: evidence from Multiple Indicator Cluster Surveys (2007-2015)

Background

Underweight is one of the largest contributors to child morbidity and mortality and is considered to be the largest contributor to the global burden of diseases in low-and middle-income countries. In Mauritania, where one-fifth of children are underweight, there is a dearth of evidence on socio-economic, sex and geographic disparities in childhood underweight. As a result, this study aimed at investigating the socio-economic, sex and geographic disparities in childhood underweight in Mauritania.

Methods

Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the Mauritania Multiple Indicator Cluster Surveys (MICSs) conducted between 2007 and 2015 were analysed. Childhood underweight was disaggregated by five equity stratifiers: education, wealth, residence, region and sex. In addition, absolute and relative inequality measures, namely difference (D), population attributable risk (PAR), ratio (R) and population attributable fraction (PAF) were calculated to understand inequalities from wider perspectives. Corresponding 95% confidence intervals (CIs) were computed to measure statistical significance.

Results

Substantial absolute and relative socio-economic, sex and geographic disparities in underweight were observed from 2007 to 2015. Children from the poorest households (PAR=−12.66 [95% CI −14.15 to −11.16]), those whose mothers were uneducated (PAF=−9.11 [95% CI −13.41 to −4.81]), those whose mothers were rural residents (R=1.52 [95% CI 1.37 to 1.68]), residents of HodhCharghy (PAF=−66.51 [95% CI −79.25 to −53.76]) and males (D=4.30 [95% CI 2.09 to 6.52]) experienced a higher burden of underweight. Education-related disparities decreased from 2007 to 2015. The urban–rural gap in underweight similarly decreased over time with the different measures showing slightly different reductions. Wealth-driven disparities decreased marginally from 2011 to 2015. The sex-based and regional disparities increased, at least on average, over the 8-y intersurvey period.

Conclusions

The burden of underweight was significantly higher among children from disadvantaged subpopulations, those with uneducated and poorest/poor mothers, those living in rural areas and those living in HodhCharghy. Special nutrition intervention and efforts focused on these deprived subpopulations are required to reduce childhood morbidity and mortality associated with underweight and help achieve the Sustainable Development Goals.

Will high-speed railway influence the healthcare seeking behaviour of patients? Quasi-experimental evidence from China

This study examines the impacts of high-speed railway (HSR) transportation on the healthcare-seeking behaviour of patients along newly integrated areas of Sichuan province, China. The opening of the Cheng-Mian-Le intercity HSR is considered as quasi-experimental evidence from China, and we make a propensity score matching the difference in differences research design, using data from the monthly report database of the Sichuan Province health statistical data collection and Decision Support System from 2014 to 2015. We find that, first, the opening of the HSR resulted in significant healthcare-seeking behaviour with great heterogeneity. Second, patients are more likely to go to areas with high-density healthcare resources, in which case HSR may mitigate the diagnostic inaccuracies that patients face locally. Third, the 'distance enhancement effect' was present, and its marginal effect is more significant for long-distance patients. Fourth, the tiered-network healthcare policy has no significant restrictive impact on patients seeking high-level medical services. Our results show that HSR establishment has a substantial impact on the behaviour of people seeking medical treatment and medicine. Furthermore, we discuss the results' policy implications for the allocation and integration of China's healthcare market, and the accessibility of medical and health services.

Association between socioeconomic status and dental caries among Chinese preschool children: a cross-sectional national study

OBJECTIVES

Socioeconomic inequalities in oral health are often neglected in oral health promotion. This cross-sectional study assessed the association between dental caries and socioeconomic status (SES) among preschool children in China.

DESIGN

Cross-sectional study.

SETTING

Data from the Fourth National Oral Health Survey of China (2015), comprising of 40 360 children aged 3-5 years was used.

METHODS

Dental caries indicators including prevalence of dental caries, dental pain experience and number of decayed, missing and filling teeth (dmft). SES indicators included parental education and household income. The associations between SES and dental caries were analysed by using negative binomial regression or Poisson regression models according to data distribution. Relative and absolute inequalities in dental caries were quantified by using the Relative Index of Inequality (RII) and Slope Index of Inequality (SII), respectively.

RESULTS

There were significant associations between SES and prevalence of dental caries and dmft (p<0.001). Children from lower educated (RII 1.36, 95% CI 1.3 to 1.43; SII 0.97, 95% CI 0.81 to 1.13) and lower household income (RII 1.17, 95% CI 1.11 to 1.24; SII 0.55, 95% CI 0.35 to 0.75) families had higher dmft than those from well-educated and most affluent families. Relative and absolute inequalities in dental caries were larger in urban areas by household income, and in rural areas by parental education.

CONCLUSIONS

Association between dental caries and SES was demonstrated and socioeconomic inequalities in dental caries existed among Chinese preschool children.

Nomadic Tibetan women's reproductive health: findings from cross-sectional surveys with a hard-to-reach population

Background

Western China has undergone substantial sociodemographic change, yet little is known about the health status of ethnic minority populations living in these areas.

Methods

We report findings from two cross-sectional surveys conducted with female Tibetan nomads living in rural areas of Western China/Eastern Tibet. We present results of descriptive analyses of data collected from reproductive-aged females who attended community health fairs in 2014 (n = 193) and 2016 (n = 298).

Results

On average, sexual debut preceded marriage among study participants, with fertility near replacement levels (2.7 and 2.1 in 2014 and 2016, respectively). Contraceptive use was common, and dominated by use of IUDs and female sterilization. Although over three-quarters (76%) of 2016 survey participants reported ever having at least one sexually transmitted infection (STI) symptom, there was low awareness of STIs (59%) and action to prevent STIs (21%). Younger women (< 40) were more likely to report having had had an STI symptom, as compared to older women (84% versus 71%; p < 0.05).

Conclusions

We demonstrate feasibility of collecting data with this hard-to-reach population. Reporting of STI symptoms warrants further investigation to identify and address health conditions in this population of Tibetan nomadic women, especially amidst broader social and contextual changes that may affect the Tibetan population.

Western China has undergone substantial sociodemographic change, yet little is known about the health status of ethnic minority populations living in these areas. We report findings from two cross-sectional surveys conducted with female Tibetan nomads living in rural areas of Western China/Eastern Tibet. We present results of descriptive analyses of data collected from reproductive-aged females who attended community health fairs in 2014 (n = 193) and 2016 (n = 298). On average, sexual debut preceded marriage among study participants, with fertility near replacement levels (2.7 and 2.1 in 2014 and 2016, respectively). Contraceptive use was common, and dominated by use of IUDs and female sterilization. Although over three-quarters (76%) of 2016 survey participants reported ever having at least one sexually transmitted infection (STI) symptom, there was low awareness of STIs (59%) and action to prevent STIs (21%). Younger women (less than 40 years old) were more likely to report having had had an STI symptom, as compared to women over 40 years old (84% versus 71%; p < 0.05). We demonstrate feasibility of collecting data with this hard-to-reach population. Reporting of STI symptoms warrants further investigation to identify and address health conditions in this population of Tibetan nomadic women, especially amidst broader social and contextual changes that may affect the Tibetan population.

Effects of drought on infant mortality in China

This study focuses on Guizhou Province, a region with difficult geographical conditions and poor economic development, to examine the effect of rainfall shocks on contemporaneous infant health and long-run socioeconomic outcomes in China. The study results indicate that negative rainfall shocks are robustly correlated with higher infant mortality and lower birth weight. In the long run, early life rainfall shortages limit an individual's income and housing conditions. The study findings indicate a significant interaction of rainfall shock with the severity of water scarcity. This result implies that drinking water safety is an essential channel through which early life rainfall shocks influence individual health endowments. However, agriculture production is not a likely channel for rainfall effects despite its association with infant mortality. Accordingly, our empirical results suggest that improving public facility coverage will reduce the vulnerability of infant health to adverse rainfall shocks in Guizhou and other developing areas.

Regional Disparity and Patients Mobility: Benefits and Spillover Effects of the Spatial Network Structure of the Health Services in China

BACKGROUND

The distribution of medical resources in China is seriously imbalanced due to imbalanced economic development in the country; unbalanced distribution of medical resources makes patients try to seek better health services. Against this backdrop, this study aims to analyze the spatial network characteristics and spatial effects of China's health economy, and then find evidence that affects patient mobility.

METHODS

Data for this study were drawn from the China Health Statistical Yearbooks and China Statistical Books. The gravitational value of China's health spatial network was calculated to establish a network of gravitational relationships. The social network analysis method was used for centrality analysis and spillover effect analysis.

RESULTS

A gravity correlation matrix was constructed among provinces by calculating the gravitational value, indicating the spatial relationships of different provinces in the health economic network. Economically developed provinces, such as Shanghai and Jiangsu, are at the center of the health economic network (centrality degree = 93.333). These provinces also play a strong intermediary role in the network and have connections with other provinces. In the CONCOR analysis, 31 provinces are divided into four blocks. The spillover effect of the blocks indicates provinces with medical resource centers have beneficial effects, while provinces with insufficient resources have obvious spillover effects.

CONCLUSION

There is a significant gap in the geographical distribution of medical resources, and the health economic spatial network structure needs to be improved. Most medical resources are concentrated in economically developed provinces, and these provinces' positions in the health economic spatial network are becoming more centralized. By contrast, economically underdeveloped regions are at the edge of the network, causing patients to move to provinces with medical resource centers. There are health risks of the increasing pressure to seek medical treatment in developed provinces with abundant medical resources.

Equity and efficiency of health care resource allocation in Jiangsu Province, China

Background

Jiangsu was one of the first four pilot provinces to engage in comprehensive health care reform in China, which has been on-going for the past 5 years. This study aims to evaluate the equity, efficiency and productivity of health care resource allocation in Jiangsu Province using the most recent data, analyse the causes of deficiencies, and discuss measures to solve these problems.

Methods

Data were extracted from the Jiangsu Health/Family Planning Statistical Yearbook (2015–2019) and Jiangsu Statistical Yearbook (2015–2019). The Gini coefficient (G), Theil index (T) and health resource density index (HRDI) were chosen to study the fairness of health resource allocation in Jiangsu Province. Data envelopment analysis (DEA) and the Malmquist productivity index (MPI) were used to analyse the efficiency and productivity of this allocation.

Results

From 2014 to 2018, the total amount of health resources in Jiangsu Province increased. The G of primary resource allocation by population remained below 0.15, and that by geographical area was between 0.14 and 0.28; additionally, the G of health financial resources was below 0.26, and that by geographical area was above 0.39. T was consistent with the results for G and Lorenz curves. The HRDI shows that the allocated amounts of health care resources were the highest in southern Jiangsu, except for the number of health institutions. The average value of TE was above 0.93, and the DEA results were invalid for only two cities. From 2014 to 2018, the mean TFPC in Jiangsu was less than 1, and the values exceeded 1 for only five cities.

Conclusion

The equity of basic medical resources was better than that of financial resources, and the equity of geographical allocation was better than that of population allocation. The overall efficiency of health care resource allocation was high; however, the total factor productivity of the whole province has declined due to technological regression. Jiangsu Province needs to further optimize the allocation and increase the utilization efficiency of health care resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01320-2.

Reduction in healthcare services during the COVID-19 pandemic in China

INTRODUCTION

The COVID-19 pandemic caused a healthcare crisis in China and continues to wreak havoc across the world. This paper evaluated COVID-19's impact on national and regional healthcare service utilisation and expenditure in China.

METHODS

Using a big data approach, we collected data from 300 million bank card transactions to measure individual healthcare expenditure and utilisation in mainland China. Since the outbreak coincided with the 2020 Chinese Spring Festival holiday, a difference-in-difference (DID) method was employed to compare changes in healthcare utilisation before, during and after the Spring Festival in 2020 and 2019. We also tracked healthcare utilisation before, during and after the outbreak.

RESULTS

Healthcare utilisation declined overall, especially during the post-festival period in 2020. Total healthcare expenditure and utilisation declined by 37.8% and 40.8%, respectively, while per capita expenditure increased by 3.3%. In a subgroup analysis, we found that the outbreak had a greater impact on healthcare utilisation in cities at higher risk of COVID-19, with stricter lockdown measures and those located in the western region. The DID results suggest that, compared with low-risk cities, the pandemic induced a 14.8%, 26.4% and 27.5% reduction in total healthcare expenditure in medium-risk and high-risk cities, and in cities located in Hubei province during the post-festival period in 2020 relative to 2019, an 8.6%, 15.9% and 24.4% reduction in utilisation services; and a 7.3% and 18.4% reduction in per capita expenditure in medium-risk and high-risk cities, respectively. By the last week of April 2020, as the outbreak came under control, healthcare utilisation gradually recovered, but only to 79.9%-89.3% of its pre-outbreak levels.

CONCLUSION

The COVID-19 pandemic had a significantly negative effect on healthcare utilisation in China, evident by a dramatic decline in healthcare expenditure. While the utilisation level has gradually increased post-outbreak, it has yet to return to normal levels.

Prevalence and health correlates of anaemia among community-dwelling Chinese older adults: the China Health and Retirement Longitudinal Study

OBJECTIVES

To identify the prevalence of anaemia among older adults in China by sociodemographic and geographical regions, and cross-sectionally examine the associations between anaemia and several geriatric outcomes.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Participants were 6656 older adults aged at least 60 years with haemoglobin data from the 2015 to 2016 wave of the China Health and Retirement Longitudinal Study.

METHODS

We examined the prevalence of anaemia by sociodemographics (age, sex, residence, education, marital status) and geographical regions, adjusting for age. We investigated the associations between anaemia and geriatric conditions.

RESULTS

The prevalence of anaemia was 20.6% among adults ≥60 years and was higher at advanced ages, among those who were females, living in rural areas, and those who were unmarried. The southern region of China had a higher burden of anaemia than the north. Anaemic adults had a higher age-adjusted prevalence of falls, activities of daily living (ADL) disability, instrumental ADL disability, lower extremely functional limitation, upper extremely functional limitation, low gait speed, low grip strength and low self-reported memory.

CONCLUSIONS

Anaemia affected approximately one in five older adults in China, particularly in those with disadvantaged sociodemographics, and anaemia was associated with a higher burden of geriatric conditions. Huge geographical disparities of anaemia prevalence between northern and southern regions reflected the dietary variations in different regions. Efforts on preventing anaemia and reducing regional disparities of anaemia were needed to improve older adults' health in China.

The cream-skimming effect in China's health care services: A mixed methods study

OBJECTIVE

One of the greatest inequities in China's health care service is that between senior cadres, high-level bureaucrats, and the general public in terms of hospital access and payment. We aim to demonstrate this inequity and to explore its connection with the regional inequity of different levels of health care facilities.

METHODS

In a content analysis of official websites of provincial health bureaus and national top hospitals, we determine whether senior cadres enjoy priority in health services with fewer payments. Then, we employ multiple regression analyses to explore the correlation of the local economy, the local population as well as the regional power and different levels of health care facilities.

RESULTS

The content analysis suggests that senior cadres indeed enjoy priority in health care services. According to the regression results, the local population has a positive correlation with every level of health care facilities except the highest one, which is responsive only to the local power index.

CONCLUSION

We demonstrate a demand-side cream-skimming effect in China's health care service. Senior cadres have taken the 'cream', the best services, and the individual inequity between senior cadres and the general public is related to the regional inequity of different-level health care facilities.

Double Jeopardy in Contemporary China: Intersecting the Socioeconomic Gradient and Geographic Context on Early Childhood Development

Family socioeconomic status (SES) differences in early childhood development (ECD) are well documented, as are the neighborhood effects in early development outcomes. However, little is known about whether the SES gradient in ECD outcomes varies across geographic contexts by county-level variables in contemporary China. This study examines the effects of county-level socioeconomic background on inequalities in the developmental outcomes of young Chinese children. Individual-level child development data based on four early development milestones—taking a first step, first sentences, counting 10 objects, fully independent toileting—were combined with family- and county-level socioeconomic data from the China Family Panel Studies (CFPS). Using a hierarchical linear model (HLM) to examine how the broader socioeconomic context plays a role in the attainment of developmental milestones at expected times as young children grow and develop, we have found significant cross-level interaction effects between family SES and county-level variables in relation to developmental milestone attainment. The family SES gradient in the achievement of children’s developmental milestones is steeper for those in the under-developed regions than their counterparts in the more developed regions. Our findings suggest that low-SES children who are living in socioeconomically deprived regions suffer from a double disadvantage in terms of early development outcomes. Further research would be needed to contextualize the observed interactions and better explain the underlying mechanisms.

Imbalance in the geographical distribution of practicing dentists in postgraduate dental training institutions in Taiwan

Background/purpose

Postgraduate year training program for dentists (PGYD) in Taiwan started since 2010. This study tried to assess the geographical distribution of practicing dentists in postgraduate dental training institutions in Taiwan.

Materials and methods

This study utilized the secondary data analysis to measure and compare the numbers of practicing dentists in each type of dental training institution and the numbers of overall practicing dentists among different cities and counties in Taiwan.

Results

Our results found that the practicing dentists in each type of dental training institution showed a significantly greater imbalance in geographical distribution than the overall practicing dentists. It meant that the practicing dentists in postgraduate dental training institutions were more concentrated in northern part of Taiwan than in other parts of Taiwan, compared to the number of overall practicing dentists in different cities or counties in Taiwan. However, the disparities in the number of practicing dentists in dental training institutions could be compensated by cross-regional collaborating institutions under the joint training group system.

Conclusion

Because continuation of the current PGYD system may accelerate the imbalance in geographical distribution of practicing dentists in dental training institutions in Taiwan. To prevent this, further studies on yearly changes in the geographical distribution of dentists in postgraduate dental training institutions by city or county should be taken to monitor whether we should further modify the currently used PGYD system toward a better one to solve the problem of imbalance in the geographical distribution of dentists in postgraduate dental training institutions in Taiwan.

Outpatient Visits among Older Adults Living Alone in China: Does Health Insurance and City of Residence Matter?

This study aimed to examine the association between health insurance, city of residence, and outpatient visits among older adults living alone in China. A sample of 3173 individuals was derived from “Survey on Older Adults Aged 70 and Above Living Alone in Urban China” in five different cities. Logistic regression models indicated that older adults living alone who had urban employee basic medical insurance, urban resident basic medical insurance, and public medical insurance were more likely to have outpatient visits than those without any health insurance. After controlling the number of chronic diseases, only those with public medical insurance were more likely to have outpatient visits than uninsured older adults. Additionally, older adults who resided in Shanghai and Guangzhou were more likely to have outpatient visits than those in Chengdu, whereas older adults who were in Dalian and Hohhot were less likely to have outpatient visits. To improve the equity of outpatient visits among older adults living alone in China, policy efforts should be made to reduce fragmentation of different health insurance plans, expand the health insurance coverage for older adults, provide programs that consider the needs of this special group of older adults, and reduce the inequality in health resources and health insurance policies across cities.

Examining health disparities and characteristics in general practice utilization: based on outpatient data from 2014 - 2018 in Shanghai

BACKGROUND

Since 2000, China has been developing primary care institutions to serve as the gateway to the healthcare system. However, the investment of resources in primary care institutions is not based on the actual medical demands of the public. This study analysed primary care utilization to provide targeted guidance for the improvement of primary healthcare delivery in China.

METHODS

We extracted outpatient visit data from all community healthcare centres in Shanghai from 2014 to 2018. Diseases were then classified according to ICD-10 codes. The disease spectrum (frequency, proportion, rank) was stratified by sex, age, and region.

RESULTS

Most primary care outpatients were female (58.20%), 60-79 years old (57.91%), and in suburban regions (62.18%). Chronic diseases accounted for the majority (91.41%). Hypertension, chronic ischaemic heart disease, diabetes, and acute upper respiratory tract infections were the top four disorders for primary care visits regardless of sex. In the group aged 0-18 years, symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified accounted for 37.96% of the top 20 reasons. Acute upper respiratory tract infections were the most common diseases in the groups aged 0-18 (11.20%) and 19-39 (11.14%) years. However, hypertension was the most common disease in the group aged > 39 years old (> 20%). There were more outpatients with respiratory and digestive diseases in suburban areas than in urban areas. In addition, problems associated with medical equipment and other healthcare deficiencies were relatively more common in suburban areas (suburban: 4.13%, rank 5; urban: 2.29%, rank 10).

CONCLUSIONS

To meet the patients' needs and to develop the primary care system, the Shanghai government should focus on diseases with regionally high proportions. Disease diagnosis and treatment should be improved in the younger and suburban populations.

The Impact of Health Insurance on Healthcare Utilization by Migrant Workers in China

Health insurance is an essential instrument to ensure equal access to medical resources and promote the health of the general population. Robust evidence regarding whether migrant workers have benefited from available insurance schemes is limited. Drawing on survey data from the Rural Urban Migration in China (RUMiC) Project, this paper examines the effects of health insurance on migrant workers’ utilization of routine medical services, the medical burden, and the utilization of preventive medical services using a two-part model, the Heckman model, the Tobit model, and a probit model. Our findings indicate that, first, participating in medical insurance increases migrant workers’ probability of visiting a doctor. Unlike other medical insurance programs that positively affect migrant workers’ medical expenditure, the new rural cooperative medical system fails to play an effective role. Second, participation in any medical insurance program effectively reduces migrant workers’ medical burden and can improve the probability of preventive medical service utilization. Third, self-reported health and disease severity are pivotal to determining migrant workers’ medical expenditure. Fourth, high-income people have a good health status and a lower probability of becoming ill and can afford relatively higher medical expenses once they become ill. China’s medical insurance appears to mainly serve to reduce the financial burden for serious illnesses, reflecting important policy implications for policy-makers.

Comparing Regional Distribution Equity among Doctors in China before and after the 2009 Medical Reform Policy: A Data Analysis from 2002 to 2017

Background: Although China began implementing medical reforms in 2009 aimed at fair allocation of the regional distribution of doctors, little is known of their impact. This study analyzed the geographic distribution of doctors from 2002 to 2017. Methods: This study calculated the Gini coefficient and Theil index among doctors in the eastern, central, and western regions (Category 1) of China, and in urban and rural areas (Category 2). The statistical significance of fairness changes was analyzed using the Mann–Whitney U test. Results: The annual growth rates of the number of doctors for the periods from 2002 to 2009 and 2010 to 2017 were 2.38% and 4.44%. The Gini coefficients among Category 1 were lower than those in Category 2, and statistically decreased after the medical reforms (P < 0.01) but continued to increase in Category 2 (P = 0.463). In 2017, the Theil decomposition result of Category 1 was 74.33% for the between-group, and in Category 2, it was 95.22% for the within-group. Conclusions: The fairness among the regional distribution of doctors in Category 1 is now at a high level and is better than that before the reforms. While the fairness in Category 2 is worse than that before the reforms, it causes moderate inequality and is continually decreasing. Overall unfairness was found to be derived from the between-group.

Socioeconomic Inequalities in Child Malnutrition in Bangladesh: Do They Differ by Region?

Socioeconomic inequality in child malnutrition is well-evident in Bangladesh. However, little is known about whether this inequality differs by regional contexts. We used pooled data from the 2011 and 2014 Bangladesh Demographic and Health Survey to examine regional differences in socioeconomic inequalities in stunting and underweight among children under five. The analysis included 14,602 children aged 0–59 months. We used logistic regression models and the Concentration index to assess and quantify wealth- and education-related inequalities in child malnutrition. We found stunting and underweight to be more concentrated among children from poorer households and born to less-educated mothers. Although the poverty level was low in the eastern regions, socioeconomic inequalities were greater in these regions compared to the western regions. The extent of socioeconomic inequality was the highest in Sylhet and Chittagong for stunting and underweight, respectively, while it was the lowest in Khulna. Regression results demonstrated the protective effects of socioeconomic status (SES) on child malnutrition. The regional differences in the effects of SES tend to diverge at the lower levels of SES, while they converge or attenuate at the highest levels. Our findings have policy implications for developing programs and interventions targeted to reduce socioeconomic inequalities in child malnutrition in subnational regions of Bangladesh.

Regional disparities in health care resources in traditional Chinese medicine county hospitals in China

OBJECTIVE

We aimed to analyze regional disparities of health care resources in traditional Chinese medicine (TCM) county hospitals and their time trends, and to assess the changes of regional disparities before and after 2009 health care reforms.

METHODS

We used hospital-based, longitudinal data from all TCM county hospitals in China between 2004 and 2016. To measure the key development features of TCM county hospitals, data were collected on government hospital investment, hospital numbers (the average number of TCM hospitals per county), hospital scale (the number of medical staff and hospital beds) and doctors' workload (the daily visits and inpatient stays per doctor). We used segmented linear regression to test the time trend for outcome variables. We set a breakpoint at 2011, dividing the pre-reform (2004-2011) and post-reform (2012-2016) periods.

RESULTS

After the 2009 health reforms, TCM hospitals continued to display large disparities in the number, scale, and doctors' workload across the three regions. In the pre-reform period, yearly government subsidies for TCM hospitals in western area were roughly RMB0.6 million (US$89 thousand) more than those in central and eastern region, which increased under the 2009 reforms to roughly RMB2 million (US$298 thousand) more per yer in post-reform period. These increased subsidies saw an increase in the number of TCM hospitals in the western area, partly addressing regional disparities. But there was no improvement in the regional disparities in terms of scale (number of beds) and the doctors' workload (daily outpatient visits and inpatients per doctor) increased or remained unchanged between the western and other regions.

CONCLUSION

Although TCM hospital number, scale, and doctors' workload increased over the past 13 years, substantial regional disparities remained. The 2009 health reforms did not significantly change the regional disparities in health care resources, especially between the eastern and western regions.