Trends in access to health services, financial protection and satisfaction between 2010 and 2016: Has China achieved the goals of its health system reform?

Health insurance and subjective well-being: evidence from integrating medical insurance across urban and rural areas in China

Health insurance coverage and the risk protection it provides may improve enrollees' subjective well-being (SWB), as demonstrated, e.g. by Oregon Medicaid's randomized expansion significantly improving enrollees' mental health and happiness. Yet little evidence from low- and middle-income countries documents the link between insurance coverage and SWB. We analyse individual-level data on a large natural experiment in China: the integration of the rural and urban resident health insurance programmes. This reform, expanded nationally since 2016, is recognized as a vital step towards attaining the goal of providing affordable and equitable basic healthcare in China, because integration raises the level of healthcare coverage for rural residents to that enjoyed by their urban counterparts. This study is the first to investigate the impact of urban-rural health insurance integration on the SWB of the Chinese population. Analysing 2011-18 data from the China Health and Retirement Longitudinal Study in a difference-in-difference framework with variation in the treatment timing, we find that the integration policy significantly improved the life satisfaction of rural residents, especially among low-income and elderly individuals. The positive impact of the integration on SWB appears to stem from the improvement of rural residents' mental health (decrease in depressive symptoms) and associated increases in some health behaviours, as well as a mild increase in outpatient care utilization and financial risk protection. There was no discernible impact of the integration on SWB among urban residents, suggesting that the reform reduced inequality in healthcare access and health outcomes for poorer rural residents without negative spillovers on their urban counterparts.

Factors associated with patients' healthcare-seeking behavior and related clinical outcomes under China's hierarchical healthcare delivery system

Introduction

The hierarchical healthcare delivery system is an important measure to improve the allocation of medical resources and promote equitable distribution of basic medical and health services. It is one of the key factors in the success or failure of China's medical reform. This study aims to analyze the factors influencing patients' healthcare-seeking behaviors, including socioeconomic and clinical outcomes, under China's hierarchical healthcare delivery system, and to provide potential solutions.

Methods

Patients receiving outpatient treatment in the past 14 days and inpatient care in the past 1 year were investigated. The multivariate logistic regression was used to analyze the influencing factors of patient's medical treatment behavior selection, and to compare whether the clinical outcomes of primary medical institutions and grade A hospitals are the same.

Results

Nine thousand and ninety-eight person-times were included in the study. Of these, 4,538 patients were outpatients, 68.27% of patients were treated in primary medical institutions; 4,560 patients were hospitalized, 58.53% chose to be hospitalized in grade A hospitals. Provinces and cities, urban and rural areas, occupation, education level, medical insurance type, income, whether there are comorbid diseases, and doctors' medical behavior are the factors affecting the choice of medical treatment behavior. Patients who choose primary medical institutions and grade A hospitals have different control levels and control rate for the blood pressure, blood lipids, blood glucose.

Conclusion

Under the hierarchical diagnosis and treatment system, the patients' choice of hospital is mainly affected by their level of education, medical insurance types, and the inpatients are also affected by whether there are comorbid conditions. Clinical outcomes of choosing different levels of hospitals were different.

Neighborhood safety perception and depressive symptoms in China: a moderated mediation relationship

PURPOSE

Despite rich data on neighborhood safety perception's role in shaping depressive symptoms, a comprehensive view of this dynamic interplay remains a frontier. This study seeks to unravel the intricate interplay of neighborhood safety perception and depressive symptoms, utilizing the lens of social safety theory.

METHODS

Employing the 2016 and 2020 waves of the China Family Panel Studies (CFPS), this study utilized ordered logistic regression (ologit) for statistical analysis. The approach encompassed descriptive analysis of variables, Spearman's correlation analyses to explore associations between variables, and a moderated mediation analysis. Sensitivity analyses were also conducted to affirm the robustness of findings against model assumptions and data processing techniques.

RESULTS

The study uncovered a significant negative correlation between neighborhood safety perception and depressive symptoms (Direct effect =  - 0.338, Z =  - 2.564, p = 0.010). A key finding was the steeper slope of the relationship between neighborhood safety perception and neighborhood relation perception among individuals with a higher perception of neighborhood environment quality. As neighborhood environment quality perception increases, the strength of the mediated negative impact on depressive symptoms intensifies (- 0.102 >  - 0.132 >  - 0.162).

CONCLUSION

This study offers a comprehensive moderated mediation model that establishes a novel connection between neighborhood safety perception and depressive symptoms. It integrates the complexities of social safety theory and social information processes, revealing key strategies such as enhancing perceived neighborhood environment quality and neighborhood relationship quality.

Research on collaborative development mechanism of multiple stakeholders in medical institutions based on rough set

Reducing doctor-patient conflict is an important part of coordinating doctor-patient disputes and easing doctor-patient relationship, which is conducive to building a harmonious medical environment and promoting the healthy development of medical undertakings. This paper constructs a multi-decision-maker mixed conflict model based on rough set theory, puts forward the matrix operation expression of the conflict degree theory in the Pawlak model, and gives a more objective and scientific evaluation function. Combined with hot issues of doctor-patient conflict, the proposed multi-decision-maker mixed conflict model is applied to doctor-patient conflict, examines the doctor-patient relationship in the medical institution system from multiple internal perspectives, and calculates feasible solutions in the conflict system. The results show that high medical quality, high standardize medication, high institutional efficiency, high staff efficiency, high hospital benefits, high hospital revenue, medium employee development, medium equipment development, or high medical quality, high standardize medication, high institutional efficiency, medium staff efficiency, medium hospital benefits, high hospital revenue, high employee development, and high equipment development are important conditions for building a harmonious medical environment and reducing doctor-patient conflicts.

An analysis of the trend towards universal health coverage and access to healthcare in Morocco

OBJECTIVE

We aim in this study to investigate the association between access to health care services and various components of universal health coverage in Morocco, controlling for socioeconomic, demographic, and cultural factors.

DATA AND METHODS

The study employed a logistic regression method to model the relationship between access to health care as binary outcome variable and health coverage, using the longitudinal data collected from the Household Panel Survey of the National Observatory of Human Development (ONDH) spanning the period from 2013 to 2019.

RESULTS

The study reveals a significant association between access to health care services and having medical coverage taking into consideration socioeconomic and demographic characteristics as the main determinants of access to health care services.

CONCLUSION

The study investigates the impact of demographic and socioeconomic factors on medical care utilization. The econometric model reveals that individuals with medical coverage, particularly through AMO and RAMED, are more likely to seek health care services, emphasizing the positive influence of universal health coverage. Additionally, demographic and socioeconomic characteristics such as gender, education, employment, and living environment significantly affect health care-seeking behavior. Urban residents, women, and those with higher standards of living are more inclined to access health care services.

Coupling coordination of the provision of medical services and high-quality economic development in the Yangtze River Economic Belt

Background

Promoting high-level coupling coordination between the provision of medical services (PMS) and high-quality economic development (HED) has emerged as a critical issue in China's pursuit of high-quality development and is now a significant subject of concern in the area of welfare economics.

Materials and methods

Based on panel data from 11 provinces and municipalities in the Yangtze River Economic Belt, covering the period from 2010 to 2020, this study conducted an empirical analysis of the coupling coordination between PMS and HED and its influencing factors. Methods combined a comprehensive evaluation model, a coupling coordination model, and a panel Tobit model.

Results

The study found that: (1) Regarding the overall situation in the Yangtze River Economic Belt, the overall PMS demonstrates a fluctuating upward trend, while HED fluctuates within the lower range of 0.3 to 0.4. The coupling coordination degree between PMS and HED fluctuates within the moderate range of 0.5 to 0.6. (2) In terms of the spatiotemporal evolution trends, there still exists substantial spatial disparity among provinces and municipalities within the Yangtze River Economic Belt regarding PMS; nonetheless, this gap is gradually narrowing. Significant regional disparities are also observed in HED, with Shanghai, Jiangsu, and Zhejiang leading among the provinces and municipalities in the Yangtze River Economic Belt. The coupling coordination degree between PMS and HED displays notable spatial discrepancies, where downstream areas of the Yangtze River Economic Belt such as Shanghai, Jiangsu, and Zhejiang exhibit a higher coupling coordination degree compared to other provinces and municipalities. However, most provinces and municipalities outside this group remain at a moderately coordinated stage concerning the degree of coupling coordination between PMS and HED. (3) Economic development level and local government competition had a significant negative impact on coupling coordination between PMS and HED, whereas there was a significantly positive impact on the degree of fiscal autonomy and urbanization.

Discussion

This study contributes to comprehensively understanding the coupling and coordination relationship between the PMS and HED across provinces and municipalities in the Yangtze River Economic Belt. It provides empirical evidence for the collaborative evolution of PMS and HED.

Public satisfaction with health system after healthcare reform in China

BACKGROUND

The Chinese central government launched the third phase of health system reforms in 2009. After a decade since the initiation of the reform, the health system has witnessed noteworthy gains. However, there is no concurrent improvement in public satisfaction with the health system. This study analysed various factors that influence public satisfaction with the system and examined whether perceived quality of care affects public satisfaction.

METHODS

A longitudinal nationally representative survey was used for this study. We used five waves of China Family Panel Studies (CFPS) survey data. The final sample consisted of 145 843 observations. A two-way fixed-effects ordered logistic model was used for the analysis.

RESULTS

The results indicate that perceived good quality of care was positively associated with public satisfaction in health system regardless of rural-urban residence. Older adults and individuals with more than 3 years of college education were less likely to be satisfied with the system in rural areas. Personal income and the density of medical professionals in the geographic area tend to improve public satisfaction in rural areas. Having medical insurance coverage and fair or good self-rated health improved the probability of reporting public satisfaction in urban areas. Married people and individuals who lived in the West region were less likely to be satisfied with the health system in urban areas.

CONCLUSIONS

Knowledge and skills of healthcare providers or physical quality of facilities are not sufficient in improving public satisfaction in the health system. Policymakers need to identify options to influence the important factors that affect public perception of the system. This analysis identified several policy-amenable factors to improve public perception of the health system in rural and urban China.

Universal health coverage in China part 1: progress and gaps

Over the past 2 decades, China has made remarkable progress in health-care service coverage, especially in the areas of reproductive, maternal, newborn, and child health, infectious diseases, and service capacity and access. In these areas, coverage is comparable to those in high-income countries. Inequalities of service coverage in these areas have been reduced. However, there remain large gaps in the service coverage of chronic diseases. There has been little progress in controlling risk factors of chronic diseases in the past 10 years. Service coverage for most chronic conditions is lower than in high-income countries. Moreover, China has disproportionately high incidences of catastrophic health expenditure compared with countries with similar economic development. This paper comprehensively evaluates China's progress towards universal health coverage by identifying the achievements and gaps in service coverage and financial risk protection that are crucial to achieve universal health coverage goals by 2030.

Simplified functioning assessment for low back pain: ICF-based item response theory modelling

BACKGROUND

Despite the growing interest of the item response theory (IRT) in assessment of person abilities and functioning difficulties in screening tools, there is scarcity of research using IRT on ICF-based tools for persons with low back pain (LBP).

AIM

To generate and validate a parsimonious core set of ICF (PCSI) for LBP based on the IRT modelling.

DESIGN

A cross-sectional study.

SETTING

Nine hospitals in Jiangsu Province, China.

POPULATION

We recruited patients with LBP.

METHODS

All participants completed the 78 items of the comprehensive ICF Core Set for LBP. The five-point scoring system was converted to dichotomous data with 1 as functioning/independent and 0 as impairment/dependent. Psychometric properties of the data were examined using Mokken Scale analysis and parametric item response modelling.

RESULTS

This study recruited 306 participants (185 females and 121 males) with LBP. The overall median age of the study participants was 50.28 (95% CI 23.34; 82.05) years. We constructed a three-parameter logistic model with 28 ICF categories (8 of body function, 18 of activities and participation, and two of body structures). The internal consistency was good with Cronbach's alpha = 0.927 and latent class reliability coefficient (LCRC) = 0.955. The model was validated by significant correlations (P<0.001) of its estimated person abilities with the Oswestry Disability Index (ODI, r=-0.41), the Roland-Morris Disability Questionnaire (RMDQ, r=-0.57), the Physical Component Summary (PCS, r=0.63), and the Mental Component Summary (MCS, r = 0.46) of 12-Item Short Form Survey (SF-12). The person abilities and item difficulties were integrated into a Wright map that offered a background for making individualized clinical decisions.

CONCLUSIONS

The PCSI of LBP with 28 categories has good construct validity and internal consistency, and is a convenient instrument for assessing functioning among persons with LBP. The IRT model provided theoretical and algorithmic support for deriving a simplified model for functioning assessment hence serving a basis for formulating rehabilitation plans in clinical practice and research.

CLINICAL REHABILITATION IMPACT

A parsimonious core set of ICF (PCSI) for LBP based on the IRT modelling provides a background for making individualized clinical decisions based on item difficulties.

Changing inequity in health service utilization and financial burden among patients with hypertension in China: evidence from China Health and Retirement Longitudinal Study (CHARLS), 2011-2018

BACKGROUND

China initiated a health system reform in 2009 to achieve Universal Health Coverage (UHC) by 2020. While the effectiveness of health-system reforms has been studied, equity in health-service utilization and financial burden remains underexplored. This study evaluated whether the health system reform has improved the equity in utilization and financial burden of health services among patients with hypertension in China.

METHODS

We obtained data from four waves of the China Health and Retirement Longitudinal Study (CHARLS) conducted between 2011 and 2018. The main outcome variables were outpatient and inpatient service utilization rates and catastrophic health expenditure (CHE) for patients with hypertension. The Standardized Concentration Index (CI) was used to measure the changing equity in health service utilization and affordability.

RESULTS

Outpatient service utilization was relatively equal among patients with varying socioeconomic statuses (SESs) (CI: 0.041 in 2011 and 0.064 in 2018). Inpatient service utilization inequity improved from CI 0.144 in 2011 to CI 0.066 in 2018. CHE incidence increased from 15.6% in 2011 to 24.2% in 2018. CI for CHE declined from -0.069 in 2011 to -0.012 in 2015 but increased to -0.063 in 2018.

CONCLUSIONS

Health insurance expansion and poverty alleviation policies promoted equity in inpatient service utilization for hypertensive patients. However, the financial burden for the poor requires further attention through reimbursement policy adjustments for outpatient services in primary care settings.

Health and health system impacts of China's comprehensive primary healthcare reforms: a systematic review

China's comprehensive primary healthcare (PHC) reforms since 2009 aimed to deliver accessible, efficient, equitable and high-quality healthcare services. However, knowledge on the system-wide effectiveness of these reforms is limited. This systematic review synthesizes evidence on the reforms' health and health system impacts. In 13 August 2022, international databases and three Chinese databases were searched for randomized controlled trials, quasi-experimental studies and controlled before-after studies. Included studies assessed large-scale PHC policies since 2009; had a temporal comparator and a control group and assessed impacts on expenditures, utilization, care quality and health outcomes. Study quality was assessed using Risk of Bias In Non-randomized Studies of Interventions, and results were synthesized narratively. From 49 174 identified records, 42 studies were included-all with quasi-experimental designs, except for one randomized control trial. Nine studies were assessed as at low risk of bias. Only five low- to moderate-quality studies assessed the comprehensive reforms as a whole and found associated increases in health service utilization, whilst the other 37 studies examined single-component policies. The National Essential Medicine Policy (N = 15) and financing reforms (N = 11) were the most studied policies, whilst policies on primary care provision (i.e. family physician policy and the National Essential Public Health Services) were poorly evaluated. The PHC reforms were associated with increased primary care utilization (N = 17) and improved health outcomes in people with non-communicable diseases (N = 8). Evidence on healthcare costs was unclear, and impacts on patients' financial burden and care quality were understudied. Some studies showed disadvantaged regions and groups that accrued greater benefits (N = 8). China's comprehensive PHC reforms have made some progress in achieving their policy objectives including increasing primary care utilization, improving some health outcomes and reducing health inequalities. However, China's health system remains largely hospital-centric and further PHC strengthening is needed to advance universal health coverage.

Understanding financial risk protection in China's health system: a descriptive analysis using data from multiple national household surveys

BACKGROUND

Providing financial risk protection is one of the fundamental goals of health systems. Catastrophic health expenditure (CHE) and medical impoverishment (MI) are two common indicators in evaluating financial risk protection in health. As China continues its health system reform to provide accessible and affordable health care, it is important to have a clear understanding of China's progress in financial risk protection. However, past research showed discrepancies in the incidence of CHE and MI. In this article, using data from four national household surveys, we analyzed levels and characteristics of CHE and MI in China under different definitions.

METHODS

We used multiple conventional thresholds for CHE and MI to comprehensively describe the levels of financial risk protection in China. We used data from four national household surveys to measure the incidence of CHE and MI, and their inequalities by urban/rural status and by income quartiles. The Probit regression model was used to explore influencing factors of CHE and MI.

RESULTS

We found that the incidences of CHE and MI were largely consistent across four national household surveys, despite different sampling methods and questionnaire designs. At the 40% nonfood expenditure threshold, the incidence of CHE in China was 14.95%-17.73% across four surveys during the period of 2016-2017. Meanwhile, at the 1.9 US dollars poverty line, the incidence of MI was 2.01%-5.63%. Moreover, rural residents, lower-income subgroups, and smaller households were faced with higher financial risks from healthcare expenditures. Although positive progress in financial risk protection has been achieved in recent years, China has disproportionately high incidences of CHE and MI, compared to other countries.

CONCLUSION

China has large margins for improvements in risk financial protection, with large inequalities across subgroups. Providing better financial protection for low-income groups in rural areas is the key to improve financial protection in China.

How Can China's New Health Care Reform Promote the Balance of Interest Game?-Based on Game Evolution and Simulation Analysis

Purpose

The new round of medical reform is a significant exploration of reform in the public service sector in China. Health insurance regulatory departments, medical institutions, and patients, as critical stakeholders in China's medical reform, play a crucial role in the success of the reform through their strategic interactions.

Patients and Methods

Starting from the perspective of bounded rationality, applies evolutionary game theory to establish an evolutionary game model for the collaborative governance of health insurance regulatory departments, medical institutions, and patients and analyzes the stability of each party's strategy and the sensitivity of parameters in the tripartite game system.

Results

The study shows that an equilibrium point will be formed when medical institutions provide reasonable treatment, patients choose to accept treatment, and health insurance regulatory departments adopt a lenient regulatory strategy, maximizing the interests of all parties involved in the game. Factors such as the benefits of unreasonable treatment by medical institutions, fines, and regulatory costs impact the decision-making of health insurance regulatory departments. To maximize social welfare, health insurance regulatory departments should reform payment methods, adjust medical service behaviors of medical institutions, and guide the rational allocation of medical resources; the government should increase subsidies for the operation of medical institutions and the intensity of penalties; regulatory departments should reduce regulatory costs and introduce third-party forces to strengthen health insurance supervision further.

Conclusion

The research findings of this paper will provide valuable insights into some countries' medical and health reform.

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.

Exploring Older Adults' Perceived Affordability and Accessibility of the Healthcare System: Empirical Evidence from the Chinese Social Survey 2021

The difficulties in accessibility and affordability of healthcare services have posed persistent challenges to the Chinese government ever since the 1990s. This research aimed to explore the perceived accessibility and affordability of the healthcare system, which is also referred to as the social problem of Kan Bing Nan, Kan Bing Gui among older Chinese adults. The research, based on 2169 sample data points from the Chinese Social Survey (CSS) 2021 database, explored the objective and subjective factors in constructing the public perceptions of accessibility and affordability of the healthcare system among both older adult users and older adult non-users of healthcare services, including healthcare expenditure variables, patient experience variables, financial protection variables, and social evaluation variables. The study utilized binary logistic regression analysis to investigate how four different sets of independent variables impact the perceived affordability and accessibility of the healthcare system by older adults. The research found that Kan Bing Nan, Kan Bing Gui was considered the most pressing issue among the older adults in China. Self-reported medical burdens, the cost of healthcare services, and the perceived fairness of public healthcare services were significantly associated with older adults' perceived affordability and accessibility of the healthcare system.

Spatio-temporal pattern, matching level and prediction of ageing and medical resources in China

OBJECTIVE

Population ageing, as a hot issue in global development, increases the burden of medical resources in society. This study aims to assess the current spatiotemporal evolution and interaction between population ageing and medical resources in mainland China; evaluate the matching level of medical resources to population ageing; and forecast future trends of ageing, medical resources, and the indicator of ageing-resources (IAR).

METHODS

Data on ageing (EPR) and medical resources (NHI, NBHI, and NHTP) were obtained from China Health Statistics Yearbook and China Statistical Yearbook (2011-2020). We employed spatial autocorrelation to examine the spatial-temporal distribution trends and analyzed the spatio-temporal interaction using a Bayesian spatio-temporal effect model. The IAR, an improved evaluation indicator, was used to measure the matching level of medical resources to population ageing with kernel density analysis for visualization. Finally, an ETS-DNN model was used to forecast the trends in population ageing, medical resources, and their matching level over the next decade.

RESULTS

The study found that China's ageing population and medical resources are growing annually, yet distribution is uneven across districts. There is a spatio-temporal interaction effect between ageing and medical resources, with higher levels of both in Eastern China and lower levels in Western China. The IAR is relatively high in Northwest, North China, and the Yangtze River Delta, but showed a declining trend in North China and the Yangtze River Delta. The hybrid model (ETS-DNN) gained an R2 of 0.9719, and the predicted median IAR for 2030 (0.99) across 31 regions was higher than the median IAR for 2020 (0.93).

CONCLUSION

This study analyzes the relationship between population ageing and medical resources, revealing a spatio-temporal interaction between them. The IAR evaluation indicator highlights the need to address ageing population challenges and cultivate a competent health workforce. The ETS-DNN forecasts indicate higher concentrations of both medical resources and ageing populations in eastern China, emphasizing the need for region-specific ageing security systems and health service industries. The findings provide valuable policy insights for addressing a hyper-aged society in the future.

Changes of equality of medical service utilization in China between 1993 and 2018: findings from six waves of nationwide household interview survey

BACKGROUND

Changes in China's health care system in the last three decades was remarkable. The current study aims on examine the change of equality of health care utilization in mainland China based on a nationwide household interview survey.

METHODS

We used household interview data extracted from six waves of National Health Service Survey between 1993 and 2018. Changes of health care utilization were descripted. Equality of the utilization were examined with univariate meta-regression across urban and rural areas, socioeconomic development regions and income groups.

RESULTS

The proportion of outpatient visits within last two weeks experienced a decrease from 17.0% in 1993 to 13.0% in 2013 and bounced back to 24.0% in 2018. The age-standardized trend remained unchanged. Hospitalization in the last 12 month increased from 2.6% in 1998 to 13.8% in 2018. The perceived unmet need of hospital admission fell from 35.9% in 1998 to 21.5% in 2018. The gaps in health care utilization between urban and rural areas, across regions and by income groups have been narrowed, implying improved equality of using medical services in the last two and a half decades.

CONCLUSION

China has experienced significant increases in health care utilization over the past 25 years. Meanwhile, the unmet needs for health care decreased remarkably and the equality of health care utilization improved significantly. These results imply significant achievements in health service accessibility in China.

Has South Korea achieved the goals of national health insurance? Trends in financial protection of households between 2011 and 2018

This study aims to investigate the evolution of financial protection of households against OOP in South Korea, where subsequent policies of expanding benefit coverage have been implemented primarily focusing on several severe diseases, by measuring catastrophic healthcare expenditure (CHE) and the characteristics of households vulnerable to CHE. Using the Korea Health Panel 2011-2018, this study analyzed CHE trends by the targeted severe diseases and other health problems and household income and examined the determinants of CHE using binary logistic regression. Our findings showed that CHE decreased in households with the targeted severe diseases but increased in households experiencing hospitalization that were not related to the targeted diseases, which appeared to have a significantly higher likelihood of CHE in 2018 than households with the targeted severe diseases. In addition, CHE was more prevalent and increased or remained stagnant among households whose heads had health problems than others. Inequalities in CHE also increased, showing increased Concentration Index (CI) and increased incidences of CHE in the lower income quartile during the study period. These results suggest that the current policies are insufficient to achieve its financial protection goals against healthcare expenditure in South Korea. In particular, benefit expansions targeting a specific disease may cause inequitable distribution of resources and may not enhance protection against households' financial burden.

Provincial variations in catastrophic health expenditure and medical impoverishment in China: a nationwide population-based study

Background

Financial protection, as a key dimension of Universal Health Coverage (UHC), has been under increasing attention in recent years. A series of studies have examined the nationwide extent of catastrophic health expenditure (CHE) and medical impoverishment (MI) in China. However, disparities in financial protection at the province level have rarely been studied. The aim of this study was to investigate provincial variations in financial protection as well as its inequality across provinces.

Methods

Using data from the 2017 China Household Finance Survey (CHFS), this study estimated the incidence and intensity of CHE and MI for 28 Chinese provinces. Ordinary least square (OLS) estimation, using robust standard errors, was used to explore the factors associated with financial protection at the province level. Moreover, this study examined the urban-rural differences in financial protection within each province, and calculated the concentration index of CHE and MI indicators for each province using household income per capita.

Findings

The study revealed large provincial variations in financial protection within the nation. The nationwide CHE incidence was 11.0% (95% CI: 10.7%, 11.3%), ranging from 6.3% (95% CI: 5.0%, 7.6%) in Beijing to 16.0% (95% CI: 14.0%, 18.0%) in Heilongjiang; the national MI incidence was 2.0% (95% CI: 1.8%, 2.1%), ranging from 0.03% (95% CI: 0.00%, 0.06%) in Shanghai to 4.6% (95% CI: 3.3%, 5.9%) in Anhui province. We also found similar patterns for provincial variations in intensity of CHE and MI. Moreover, substantial provincial variations in income-related inequality and urban-rural gap existed across provinces. Eastern developed provinces in general had much lower inequality within them, compared with central and western provinces.

Interpretation

Despite the great advances towards UHC in China, substantial provincial variations exist in financial protection across provinces. Policymakers should pay special attention to low-income households in central and western provinces. Provision of better financial protection for these vulnerable groups will be key to achieving UHC in China.

Funding

This research was supported by the National Natural Science Foundation of China (Grant Number: 72074049) and the Shanghai Pujiang Program (2020PJC013).

Challenges in moving toward universal health coverage: rising cost of outpatient care among Vietnam's insured rural residents, 2006-2018

OBJECTIVES

The aim of this study was to assess temporal trends in out-of-pocket (OOP) expenditures per outpatient contact by the insured residents in rural Vietnam.

STUDY DESIGN

This was a repeated cross-sectional study.

METHODS

Seven biennial waves from the Vietnam's Household Living Standard Survey covering the period 2006-2018 and a two-part model were used to assess temporal trends in OOP expenditures and its variations across various health facilities while controlling for a wide array of individual- and household-specific characteristics.

RESULTS

The pattern of health facility utilization shifted steadily from commune health centers toward higher level government hospitals and private health facilities between 2006 and 2018. The regression results indicated an upward trend in the amount of OOP expenditures, with the amount of OOP expenditures incurred per outpatient contact being 40.3% higher in 2010-2012 than in 2006-2008 and by as much as 155.5% higher in 2018. These high-cost pressures were attenuated by 63%-65% when accounting for the types of health facility contacted. The cost inflation was more pronounced for care sought at higher level government hospitals and private hospitals than at other health facilities.

CONCLUSION

The cost of accessing outpatient care rose sharply between 2006 and 2018, particularly for visits involving higher level government hospitals and private hospitals. These findings suggest that beside expanding the coverage over the transition path to universal coverage, efforts should be directed at reforming Vietnam's hospital-centric and fragmented delivery system as a way of containing costs and ensuring financial sustainability of social health insurance system.

Does self-medication reduce medical expenditure among the middle-aged and elderly population? A four-wave longitudinal study in China

Introduction

Self-medication has a high prevalence in the middle-aged and elderly population in China. Despite the published evidence demonstrating the economic benefits of self-medication, limited research has addressed the relationship between self-medication and individual medical expenditures, especially within the Chinese population. This study examined the effect of self-medication on individual medical expenditures in China and analyzed the heterogeneity between outpatient and inpatient cases.

Methods

We conducted a panel data analysis using data from four waves of the China Health and Retirement Longitudinal Study (CHARLS). Two-part mixed-effect models were implemented to estimate the effect of self-medication on total outpatient and inpatient expenses and out-of-pocket (OOP) costs, where mixed-effects logit regression was used as the first part, and generalized linear mixed models with log link and gamma distribution was used as the second part.

Results

We identified 72,041 responses representing 24,641 individuals, of which 13,185 responses incurred outpatient expenses and 9,003 responses incurred inpatient costs. Controlling for all covariates, we found that self-medication behaviors were significantly associated with a higher probability of outpatient service utilization (OR = 1.250, 95% CI = 0.179 to 0.269; P < 0.001), but displayed no significant association with outpatient expenses. Respondents who had taken self-medication were less likely to use inpatient services (OR = 0.865, 95% CI = -0.201 to -0.089; P < 0.001), and their inpatient expenses were significantly reduced by 9.4% (P < 0.001). Inpatient OOP costs were significantly reduced by 10.7% (P < 0.001), and outpatient OOP costs were significantly increased by 11.3% (P < 0.001) among respondents who had self-medicated.

Conclusions

This study allowed us to identify the economic value of self-medication among the middle-aged and elderly population in China. Future work should guide the middle-aged and elderly to take responsible self-medication to reduce their economic burden.

Trends in the Prevalence of Chronic Non-Communicable Diseases and Multimorbidity across Socioeconomic Gradients in Rural Southwest China

OBJECTIVES

This study aimed to determine the changing prevalence of five chronic non-communicable diseases (NCDs)- hypertension, coronary heart disease (CHD), stroke, chronic obstructive pulmonary disease (COPD), and asthma-- and its multimorbidity (refers to the co-existence of two or more chronic diseases in an individual) across socioeconomic spectra in rural southwest China.

MEASUREMENTS

Two cross-sectional health interviews and examination surveys were conducted among individuals aged ≥35 years in rural China. An individual socioeconomic position (SEP) index was constructed using principal component analysis. Anthropometric measurements, blood pressure, and post-bronchodilator spirometry tests were recorded for each participant.

RESULTS

The mean age and proportion of men was 56.1 years and 48.4% in 2011, while was 56.6 years and 49.4% in 2021. From 2011 to 2021, the overall prevalence of hypertension, stroke and COPD increased from 26.1%, 1.1%, and 8.7% to 40.4%, 2.4%, and 12.8%, respectively (P < 0.01), while prevalence of CHD (2.1% vs. 2.2%) and asthma (1.4% vs. 1.5%) did not differ between the two study years (P > 0.05). The prevalence of NCDs multimorbidity increased from 2.3% to 9.7%, and was also observed among subgroups categorized by sex, age, ethnicity, level of education, income, and SEP (P < 0.01). In addition, the relative increases in the prevalence of multimorbidity were greater among men, old individuals, ethnic minorities, and those with low level of education and low SEP. Both in 2011 and 2021, ethnic minorities and individuals with lower level of education and low SEP had a higher prevalence of multimorbidity of the five studied chronic NCDs than their counterparts (P <0.01).

CONCLUSIONS

The prevalence of NCDs multimorbidity increased substantially across all socioeconomic gradients in rural southwest China. Future interventions to further manage NCDs and their multimorbidity must be tailored to address socioeconomic factors.

Exploring Chinese Elderly's Trust in the Healthcare System: Empirical Evidence from a Population-Based Survey in China

This research aims to investigate how much the Chinese elderly trust the healthcare system and the critical factors that influence their trust. We use data from the China Social Survey (CSS) collected by the Chinese Academy of Social Sciences in the year 2019 to examine how demographic factors, social-economic status, internet access, and perceptions of the healthcare system impact the Chinese elderly's trust in the healthcare system. Our research finds male gender, high educational level, and having internet access are negatively related to the elderly's trust in the healthcare system. Our research also reveals that the elderly's trust in the healthcare system was significantly related to their subjective perception of their social-economic status, upward mobility, and perception of accessibility and affordability rather than other objective indicators such as income and financial protection. The results imply that the elderly have a pessimistic expectation of their subjective social status and future possibilities of upward mobility in their later life, which deepens their distrust of the health system. Additionally, the accessibility and affordability of the healthcare system have remained problematic among the Chinese elderly. The study provides important theoretical and practical implications to enhance the elderly's trust in the healthcare system.

Degree of protection provided by poverty alleviation policies for the middle-aged and older in China: evaluation of effectiveness of medical insurance system tools and vulnerable target recognition

Background

China’s medical insurance schemes and poverty alleviation policy at this stage have achieved population-wide coverage and the system's universal function. At the late stage of the elimination of absolute poverty task, how to further exert the poverty alleviation function of the medical insurance schemes has become an important agenda for targeted poverty alleviation. To analyse the risk of catastrophic health expenditure (CHE) occurrence in middle-aged and older adults with vulnerability characteristics from the perspectives of social, regional, disease, health service utilization and medical insurance schemes.

Methods

We used data from the 2018 China Health and Retirement Longitudinal Study (CHARLS) database and came up with 9190 samples. The method for calculating the CHE was adopted from WHO. Logistic regression was used to determine the different characteristics of middle-aged and older adults with a high probability of incurring CHE.

Results

The overall regional poverty rate and incidence of CHE were similar in the east, central and west, but with significant differences among provinces. The population insured by the urban and rural integrated medical insurance (URRMI) had the highest incidence of CHE (21.17%) and health expenditure burden (22.77%) among the insured population. Integration of Medicare as a medical insurance scheme with broader benefit coverage did not have a significant effect on the incidence of CHE in middle-aged and older people with vulnerability characteristics.

Conclusions

Based on the perspective of Medicare improvement, we conducted an in-depth exploration of the synergistic effect of medical insurance and the poverty alleviation system in reducing poverty, and we hope that through comprehensive strategic adjustments and multidimensional system cooperation, we can lift the vulnerable middle-aged and older adults out of poverty.

The Effect of the Referral System on the Accessibility of Healthcare Services: A Case Study of the Wuhan Metropolitan Development Zone

The geographical accessibility of public healthcare institutions is the key factor affecting the equity of healthcare services. Based on the hierarchical medical system and referral system in China, we analyzed the referral accessibility of hospitals in the Wuhan Metropolitan Development Zone. Before the implementation of the referral system, only 7.91% of the total communities met the accessibility standard for secondary and tertiary hospitals, which meant that there was significant inequality in high-level healthcare. Moreover, 5.4% of the total communities did not meet the accessibility standard for primary hospitals, which meant that there were insufficient primary hospitals. After the implementation of the referral system, the proportions of communities meeting the accessibility standards for the first-stage referral, second-stage referral and cross-level referral were 92.6%, 99.9% and 98.3%, respectively. The results show that the referral system has improved the accessibility of healthcare, but it has not completely solved healthcare inequality. The first-stage referral accessibility of healthcare services in the northern, western and eastern groups does not meet the accessibility standard, which is due to the inefficient layout of secondary hospitals. The Wuhan government should construct secondary hospitals in these groups and primary hospitals in the central urban area and the southeastern, southern, western and eastern groups.

Cost-consciousness among Chinese medical staff: a cross-sectional survey

BACKGROUND

Rapidly increasing health care costs are a widespread problem in the world. The cost-consciousness among Chinese medical staff is an important topic that needs further investigation. Our study aimed to focus on the cost-consciousness of Chinese medical staff and explore the factors related to their cost-consciousness. Differences regarding cost-consciousness between doctors and nurses were also reported.

METHODS

Eight hospitals in Liaoning Province, China, were surveyed using a self-reporting questionnaire. A total of 1043 respondents, including 635 doctors and 408 nurses, participated in the study. A revised Chinese Cost-consciousness Scale was used to estimate cost-consciousness.

RESULTS

The mean score of the Cost-consciousness Scale was 27.60 and 28.18 among doctors and nurses, respectively, and there were no significant differences in any personal characteristics. Most Chinese medical staff were aware of the treatment costs and considered cost control as their responsibility. Chinese doctors disliked adhering to guidelines more and preferred to remain independent in making or denying a treatment decision; thus, they like autonomously balancing the treatment and cost. Chinese nurses have similar attitudes, but nurses tended to deny costly services and interventions and were more sensitive to the health care costs by rationing decisions and uncertainty in their medical practice.

CONCLUSION

We reveal the attitudes regarding cost-consciousness among Chinese medical staff. Chinese medical staff was aware of their responsibility in health cost control. Chinese doctors and nurses had different tendencies with regard to health care cost containment. Our study highlights the importance of education and professional training on cost-consciousness.

Differences in medical costs among urban lung cancer patients with different health insurance schemes: a retrospective study

Background

Health insurance plays a significant role in reducing the financial burden for lung cancer patients. However, limited research exists regarding the differences in medical costs for lung cancer patients with different insurance schemes across different cities. We aimed to assess disparities in lung cancer patients’ costs by insurance type and city–specific insurance type.

Methods

Claim data of China Urban Employees’ Basic Medical Insurance (UEBMI) and Urban Residents’ Basic Medical Insurance (URBMI) between 2010 and 2016 were employed to investigate differences in medical costs. This study primarily applied descriptive analysis and a generalized linear model with a gamma distribution and a log link.

Results

In total, 92,856 lung cancer patients with inpatient records were identified, with Renminbi (RMB) 11,276 [6322–20,850] (median [interquartile range]) medical costs for the UEBMI group and RMB 8303 [4492–14,823] for the URBMI group. Out–of–pocket (OOP) expenses for the UEBMI group was RMB 2143 [1108–4506] and RMB 2975 [1367–6275] for the URBMI group. The UEBMI group also had significantly higher drug costs, medical service costs, and medical consumable costs, compared to the URBMI group. Regarding city-specific insurances, medical costs for the UEBMI and the URBMI lung cancer patients in Shanghai were RMB 9771 [5183–16,623] and RMB 9741 [5924–16,067], respectively. In Xianyang, the medical costs for UEBMI and URBMI patients were RMB 11,398 [6880–20,648] and RMB 9853 [5370–24,674], respectively. The regression results showed that the UEBMI group had 27.31% fewer OOP expenses than the URBMI group did, while patients in Xiangyang and Xianyang had 39.53 and 35.53% fewer OOP expenses, respectively, compared to patients in Shanghai.

Conclusions

Compared with the URBMI patients, the UEBMI lung cancer patients obtained more or even better health services and had reduced financial burden. The differences in insurances among cities were greater, compared to those among insurances within cities, and the differences in OOP expenses between cities were greater compared to those between UEBMI and URBMI. Our results called for further reform of China’s fragmented insurance schemes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07957-9.

Explaining the declining utilization of village clinics in rural China over time: A decomposition approach

With a goal of improving health system quality and efficiency, reforms of China's health system over the past decade have sought to strengthen primary healthcare in lower-level clinics and health centers. Despite these wide-ranging reforms and initiatives, population-based studies have documented dramatic declines in patients' use of primary care facilities during this period. In this paper, we explore the determinants of this trend in China's rural areas using detailed longitudinal data following a nationally-representative sample of rural households and village clinics from 2011 to 2018. We estimate that between 2011 and 2018, the probability that individuals sought care at village clinics when ill dropped by 44%. At the same time, the utilization of outpatient services in county hospitals increased by 56% and patient self-treatment increased by 20%. Detailed Kitagawa-Oaxaca-Blinder decompositions suggest four primary drivers of this trend: the shifting burden of disease in rural areas, changes in how patients choose to seek care given different disease conditions, declining drug inventory in village clinics, and the decreasing importance of remoteness as a determinant of healthcare seeking behavior. Our results highlight the deteriorating role of village clinics in the rural healthcare system and the increasing importance of self-treatment and higher-tier primary care services.

The impact of retirement on inpatient healthcare utilization in Guangzhou, China: a regression discontinuity analysis of 189,031 health insurance claims

Background

Previous studies suggest that retirement, a major life event, affects overall healthcare utilization. We examine, the effects of retirement on inpatient healthcare utilization, including effect heterogeneity by gender, disease category, and type of health service.

Methods

We used routine health insurance claims data (N = 87,087) spanning the period 2021 - September 2013 from the Urban Employee Basic Medical Insurance (UEBMI), a mandatory social health insurance for working and retired employees in urban China. We applied a non-parametric fuzzy regression discontinuity design using the statutory retirement age in urban China as an exogenous instrument to measure the causal effect of retirement on six measures of inpatient healthcare utilization.

Results

Retirement reduced total hospital costs (-84.71 Chinese Yuan (CNY), 95% confidence interval (CI) -172.03 – 2.61), shortened length of hospital stays (-44.59, 95% CI -70.50 – -18.68), and increased hospital readmissions (0.06, 95% CI 0.00 – 0.12) and primary hospital visits (0.06, 95% CI 0.02 – 0.09) among women. Retirement did not significantly change inpatient healthcare utilization among men. The retirement effects among women varied by disease category. Specifically, retirement substantially increased hospitalizations for non-communicable diseases (NCDs), yet had only modest or no effect on hospitalizations for communicable diseases or injuries. Retirement effects among women also varied by the type of services. For relatively inexpensive services, such as nonoperative treatment, there were surges in the extensive margin (hospital readmission). For relatively expensive and invasive services, such as surgeries, retirement reduced the intensive margin (out-of-pocket expenditures and length of stay).

Conclusions

Retirement decreases overall use of inpatient healthcare for women. The examination on the disease-related heterogeneous effects helps with the introduction and implementation of integrated healthcare delivery and appropriate incentive schemes to encourage better use of healthcare resources among older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02664-2.

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.

Trends in disparities in healthcare utilisation between and within health insurances in China between 2008 and 2018: a repeated cross-sectional study

Background

Fragmentation in China’s social health insurance schemes and income gap have been recognised as important factors for the inequitable use of healthcare. This study assessed trends in disparities in healthcare utilisation between and within health insurances in China between 2008 and 2018.

Methods

We used data from the 2008, 2013, and 2018 China National Health Services Survey. Outpatient visit, inpatient admission and foregone inpatient care were chosen to measure healthcare utilisation and underutilisation by health insurances. Absolute differences and rate ratios were generated to examine disparities between and within health insurances, and changes in disparities were analysed descriptively. Pearson χ2 tests were used to test for statistical significance of differences.

Results

The outpatient visit rate for respondents covered by the urban resident-based basic medical insurance scheme (URBMI) more than doubled between 2008 and 2018, increasing from 10.5% (9.7-11.2) to 23.5% (23.1-23.8). Inpatient admission rates for respondents covered by URBMI and the new rural cooperative medical scheme (NRCMS) more than doubled between 2008 and 2018, increasing by 7.2 (p < 0.0001) and 7.4 (p < 0.0001) percentage points, respectively. Gaps in outpatient visits and inpatient admissions narrowed across the urban employee-based basic medical insurance scheme (UEBMI), URBMI, and NRCMS through 2008 to 2018, and by 2018 the gaps were small. The rate ratios of foregone inpatient care between NRCMS and UEBMI fell from 0.9 (p > 0.1) in 2008 to 0.8 (p < 0.0001) in 2018. Faster increases in outpatient and inpatient utilisation and greater reductions in foregone inpatient care were observed in poor groups than in wealthy groups within URBMI and NRCMS. However, the poor groups within UEBMI, URBMI, and NRCMS were always more likely to forego inpatient care in comparison with their wealthy counterparts.

Conclusions

Remarkable increases in healthcare utilisation of URBMI and NRCMS, especially among the poorest groups, were accompanied by improvements in inequality in healthcare utilisation across UEBMI, URBMI, and NRCMS, and in income-based inequality in healthcare utilisation within URBMI and NRCMS. However, the poor groups were always more likely to forego admission to hospital, as recommended by doctors. We suggest further focus on the foregoing admission care of the poor groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01633-4.

Health insurance coverage and access to care in China

OBJECTIVE

The study examined the relationship between health insurance coverage and access to needed healthcare including preventive, primary, and tertiary care among Chinese adult population.

DATA AND METHODS

Data for this study came from the 2018 China Health and Retirement Longitudinal Study (CHARLS), a population-based probability sample survey. Key measures included insurance coverage (high-, moderate-, low- and no-insurance), access to care (physical examination, physician visit, office visit, inpatient care, and satisfaction with care), and personal sociodemographics. Multiple-factor generalized linear mixed model was applied to estimate the odds ratio (OR) and the 95% confidence interval (CI) of HI coverage for the four indicators of access to care, after controlling for individual characteristics and aggregation among different villages.

RESULTS

The majority of Chinese adults had some health insurance with only 3.15% uninsured. However, most had low-coverage insurance (64.82%), followed by moderate-coverage insurance (16.70%), and high-coverage insurance (15.33%). Health insurance was significantly and positively associated with access to needed healthcare (preventive, primary, and tertiary). There was also a significant gradient association between extent of insurance coverage and access to care.

CONCLUSION

Not only health insurance mattered in enhancing access to care but that there was a significant gradient association between extent of insurance coverage and access to care with higher coverage relating to better access.

The impact of current smoking, regular drinking, and physical inactivity on health care-seeking behavior in China

Background

People with lifestyle behaviors, such as current smoking, regular drinking, and physical inactivity, may experience a lack of or delayed health care, leading to severe sickness and higher health care expenditures in the future. Hence, the current study aims to ascertain the effects of current smoking, regular drinking, and physical inactivity on health care-seeking behavior among adults who report physical discomfort in China.

Methods

The data used in this study were obtained from the China Family Panel Studies (CFPS). The final sample consisted of 44,362 individuals who participated in all five waves of data collection. Logistic regression models were used for the analysis.

Results

The results of fixed effects logistic regression showed that among those who reported physical discomfort, adults who currently smoked cigarettes were 0.65 times less likely to seek health care than those who formerly smoked. Compared to nondrinkers, adults who regularly drank alcohol had a decreased likelihood of seeking health care. Adults who never engaged in physical exercise had 24% lower odds of seeking health care than those who engaged in physical exercise.

Conclusions

Current smoking, regular drinking, and physical inactivity decreased the probability of seeking health care among adults who reported physical discomfort. Therefore, screening and brief advice programs should be delivered by primary-level care and should pay more attention to individuals who engage in lifestyle behaviors such as current smoking, regular drinking, and physical inactivity, thus avoiding missed opportunities to treat chronic conditions and detect new diseases early.

How do Chinese people perceive their healthcare system? Trends and determinants of public satisfaction and perceived fairness, 2006-2019

BACKGROUND

The public's perception of the health system provides valuable insights on health system performance and future directions of improvement. While China's health care reform was a response to people's discontent in the health care system due to the lack of accessibility and affordability, little is known on changes in public perception of China's health system. This paper examines trends in public perception of the health system between 2006 and 2019 and assesses determinants of public perception in China's health system.

METHODS

Seven waves of the China Social Survey, a nationally representative survey, were used to examine trends in public satisfaction with health care and perceived fairness in health care. Chi-square tests were used to examine differences across waves. Logistic regression models were used to explore determinants of public perception, including variables on sociodemographic characteristics, health system characteristics, and patient experience.

RESULTS

Satisfaction with health care increased from 57.76% to 77.26% between 2006 and 2019. Perceived fairness in health care increased from 49.79% to 72.03% during the same period. Both indicators showed that the major improvement occurred before 2013. Sociodemographic characteristics are weakly associated with public perception. Financial protection and perceived medical safety are strongly associated with public perception, while accessibility is weakly associated with public perception. Patient experience such as perceived affordability and quality in the last medical visit are strongly associated with public perception of the health care system, while the accessibility of the last medical visit shows no impacts.

CONCLUSION

Public satisfaction on health care and perceived fairness in health care in China improved over 2006-2019. The main improvement occurred in accordance with huge financial investments in public health insurance before 2013. Financial protection and perceived quality play significant roles in determining public perception, whereas accessibility and sociodemographic characteristics have limited influence on people's perception of China's health system. To achieve higher satisfaction and a higher sense of fairness in health care, China's health system needs to continue its reforms on hospital incentives and integrated delivery system to control health expenditure and improve health care quality.

Preferences for healthcare services among hypertension patients in China: a discrete choice experiment

OBJECTIVES

Our study aimed to support evidence-informed policy-making on patient-centred care by investigating preferences for healthcare services among hypertension patients.

DESIGN

We identified six attributes of healthcare services for a discrete choice experiment (DCE), and applied Bayesian-efficient design with blocking techniques to generate choice sets. After conducting the DCE, we used a mixed logit regression model to investigate patients' preferences for each attribute and analysed the heterogeneities in preferences. Estimates of willingness to pay were derived from regression coefficients.

SETTING

The DCE was conducted in Jiangsu province and Shanghai municipality in China.

PARTICIPANTS

Patients aged 18 years or older with a history of hypertension for at least 2 years and who took medications regularly were recruited.

RESULTS

Patients highly valued healthcare services that produced good treatment effects (β=4.502, p<0.001), followed by travel time to healthcare facilities within 1 hour (β=1.285, p<0.001), and the effective physician-patient communication (β=0.771, p<0.001). Continuity of care and minimal waiting time were also positive predictors (p<0.001). However, the out-of-pocket cost was a negative predictor of patients' choice (β=-0.168, p<0.001). Older adults, patients with good health-related quality of life, had comorbidities, and who were likely to visit secondary and tertiary hospitals cared more about favourable effects (p<0.05). Patients were willing to pay ¥2489 (95% CI ¥2013 to ¥2965) as long as the clinical benefits gained were substantial.

CONCLUSIONS

Our findings highlight the importance of effective, convenient, efficient, coordinated and patient-centred care for chronic diseases like hypertension. Policy-makers and healthcare providers are suggested to work on aligning the service provision with patients' preferences.

Disparities in unmet health service needs among people with disabilities in China

BACKGROUND

Extensive research has explored disparities in access to health care between people with and without disabilities, but much less is understood about disparities and associated factors within the disabled population.

OBJECTIVE

The aim of this study was to examine differences in the prevalence of unmet health-care needs by residential status (hukou status) and disability type among people with disabilities.

METHODS

Our data were from the National Survey on Basic Public Service Delivery of Persons with Disabilities. The analysis sample included a nationally representative sample of 9 642 112 adults (aged 16+ years) with disabilities. Associated factors were obtained at both individual level and community level. Cross-sectional multivariable logistic regression analyses were conducted to compare unmet medical, care, rehabilitation and accessibility needs among people with different residential statuses and different types of disabilities.

RESULTS

The estimated prevalence of unmet medical, care, rehabilitation and accessibility needs is 15.4%, 10.2%, 45.6% and 13.7%, respectively. Rural hukou was associated with an important 13-40% increase in unmet health-care needs for people with disabilities in China. These rural-urban disparities in unmet health service needs can be partly explained by community-level factors, including access to facilities, social participation and health professionals. Disparities across the type of disability were smaller, but on average, people with multiple disabilities appeared to have the highest rates of unmet care, medical and accessibility needs, whereas those with physical disability had the highest unmet rehabilitation need.

CONCLUSIONS

Differences by residential status and impairment type were evident in all types of unmet health service needs. Targeted policy designs that meet the needs for justice and equality of people with disabilities are advisable. Public health and policy efforts are required to improve access to health service and meet the needs of people with disabilities, especially in rural practices and for particular disability groups.

The cycle of commodification: migrant labour, welfare, and the market in global China and Vietnam

China and Vietnam have experienced waves of labour and welfare reform since both countries shifted to market socialism, pursuing a development model that depends on the labour of millions of rural–urban migrants in global factories. Their similar development trajectories are productive for theorizing the relationship between labour and welfare. This article conceptualises the two countries’ distinctive regime of migrant labour welfare as integral to a cycle of commodification that encompasses the overlapping processes of commodification, de-commodification and re-commodification of labour. After decades of collectivized labour under state socialism, the cycle begins with the commodification of labour through market reforms that led to mass rural–urban migration and the rise of the global factory alongside the dismantling of the former socialist welfare system. It was then followed by de-commodification attempts aimed at providing forms of social protection that offset the labour precarity caused by decades of labour market liberalisation. Despite the emergence of new universal welfare programs, the market has increasingly intruded into social protection, especially through financialized products targeted at the labouring masses who must compensate for the failings of public welfare programs. As such, these welfare regimes are undergoing a process of re-commodification in which the protection of labour is re-embedded into the market as a commodity to be consumed by the migrant workers with their meagre wages. The “cycle of commodification” offers an analytical framework to understand welfare regimes as a social and political field that keeps evolving in response to the changing global valuation of labour.

Predictors and reasons for inappropriate hospitalization days for surgical patients in a tertiary hospital in Wuhan, China: a retrospective study

BACKGROUND

Inappropriate hospitalization day (IHD) is recognized as an important indication of the excessive demand for health-care services, especially for surgical patients. We aim to examine the degree of IHDs, predictors associated with higher incidences of IHDs, and reasons for each IHD in different periods of hospitalization.

METHODS

A total of 4586 hospital days from 408 cases were evaluated by a cross-sectional and retrospective audit program carried out in a tertiary hospital with 5613 beds and 9623 faculty in Wuhan, China. This study used the revised Chinese version of the Appropriateness Evaluation Protocol (C-AEP) to assess IHDs, and the Delay Tool to ascertain each reason for IHDs. A binary logistic regression model was performed to examine the predictors of higher incidences of IHDs.

RESULTS

The average frequency of IHDs was 23.24 %, and a total of 322 cases (78.92 %) were reported to have experienced at least one IHD. The multivariate analysis showed that patients at the age of 60-69 with respect to under 50, and with overlength of stay were predictors of higher incidences of preoperative IHDs, while admission from outpatient, multiple diagnosis, higher surgical incision level, and overlength of stay were predictors of higher incidence of postoperative IHDs. The most frequent reasons related to health providers for IHDs were doctor's conservative views of patient management and delays in inspection, prescription, appointment, or result report. Patient factors gave rise to nearly a quarter of postoperative IHDs.

CONCLUSIONS

Findings from this study indicate that measures including paying more attention to the construction of MDT for diagnosis and treatment in general surgery, reducing laboratory turnaround time, dispelling distrust among health-care providers and patients, setting stricter discharge standards and, providing integrated out-of-hospital services could be adopted accordingly to improve the inappropriateness of hospital stays.

Minimizing the Risk of Catastrophic Health Expenditure in China: A Multi-Dimensional Analysis of Vulnerable Groups

Background: In moving toward universal health coverage in China, it is crucial to identify which populations should be prioritized for which interventions rather than blindly increasing welfare packages or capital investments. We identify the characteristics of vulnerable groups from multiple perspectives through estimating catastrophic health expenditure (CHE) and recommend intervention priorities. Methods: Data were from National Health Service Survey conducted in 2003, 2008, and 2013. According to the recommendation of WHO, this study adopted 40% as the CHE threshold. A binary regression was used to identify the determinants of CHE occurrence; a probit model was used to obtain CHE standardized incidence under the characteristics of single and two dimensions in 2013. Results: The total incidence of CHE in 2013 was 13.9%, which shows a general trend of growth from 2003 to 2013. Families in western and central regions and rural areas were more at risk. Factors related to social demography show that households with a female or an unmarried head of household or with a low socioeconomic status were more likely to experience CHE. Households with older adults aged 60 and above had 1,524 times higher likelihood of experiencing CHE. Among the health insurance schemes, the participants covered by the New Rural Cooperative Medical Scheme had the highest risk compared with the participants of all basic health insurance schemes. Households with several members seeking outpatient, inpatient care or with non-communicable diseases were more likely to experience CHE. Households with members not seeing a doctor or hospitalized despite the need for it were more likely to experience CHE. Characteristics such as a household head with characteristics related to low socioeconomic status, having more than two hospitalized family members, ranked high. Meanwhile, the combination of having illiterate household heads and with being covered by other health insurance plans or by none ranked the first place. Cancer notably caused a relatively high medical expenditure among households with CHE. Conclusion: In China, considering the vulnerability of the population across different dimensions is conducive to the alleviation of high CHE. Furthermore, people with multiple vulnerabilities should be prioritized for intervention. Identifying and targeting them to offer help and support will be an effective approach.

Primary care physicians' views on the factors for enhancing patients' trust in rural areas of Zhejiang province, China: a cross-sectional study

OBJECTIVES

To examine primary care physicians' (PCPs) perception of patients' trust and associated factors for enhancing perceived trust in rural China.

DESIGN

A cross-sectional questionnaire study.

SETTING

All township health centres (primary care facilities in rural areas of China) in both developed and less developed counties of Zhejiang province, China, were chosen as the study sites.

PARTICIPANTS

A total of 849 questionnaires were distributed from December 2019 to January 2020, and 673 PCPs working in township health centres completed the questionnaires. The response rate was 79.3%.

OUTCOME MEASURES

PCPs' perceived patients' trust in them, PCPs' practices to meet patients' expectations and PCPs' perceived conflicting patient and employer interests were measured by a self-designed and verified questionnaire. Confirmatory factor analysis was applied to verify the measurement model of PCPs' practices. Multivariable logistic regression analyses were performed to explore the association between clinical practice characteristics, discordant patient and employer interests and perceived patient trust after controlling for social-demographic characteristics.

RESULTS

Among all participants, 572 (85.0%) PCPs often/always perceived patients' trust in their clinical competence, and over two-thirds of PCPs reported ever perceived patient worries about overprescriptions. After adjustment for social-demographic characteristics, regression model results indicated that, among PCPs' clinical practices characteristics, emotional support (OR=1.23, 95% CI=1.06 to 1.42) and accurate diagnosis and treatment (OR=1.35, 95% CI=1.17 to 1.55) were positively associated with PCPs' perceived patients' trust in their clinical competence. A strong association was found between accurate diagnosis and treatment (OR=1.20, 95% CI=1.08 to 1.34, p<0.001; OR=1.22, 95% CI=1.10 to 1.35, p<0.001), conflicting patient and employer interests (OR=1.35, 95% CI=1.12 to 1.63, p<0.01; OR=1.29, 95% CI=1.07 to 1.54, p<0.01) and PCPs' perceived patient worries about unnecessary medicine or tests, respectively.

CONCLUSIONS

PCPs' emotional support to patients as well as their abilities to make accurate diagnosis and provide appropriate treatment is positively associated with PCPs' self-reported patients' trust. It is recommended that reforms to realign patient and employer's interests be investigated.

Health service underutilization and its associated factors for chronic diseases patients in poverty-stricken areas in China: a multilevel analysis

Background

Underutilization of health services among chronic non-communicable disease sufferers, especially for hypertension (HBP) and diabetes mellitus (DM), was considered as a significant contributing factor to substantial cases in terms of both avoidable morbidity and mortality. However, evidence on health services underutilization and its associated factors in poverty-stricken areas remain scarce based on previous literature. This study aims to describe health services underutilization for people diagnosed with chronic diseases in impoverished regions and to identify its associated factors, which are expected to provide practical implications for the implementations of interventions tailored to the specific needs of disadvantaged residents in rural China to achieve effective utilization of health services in a timely manner.

Methods

Data were collected from a cross-sectional survey conducted through face-to-face interviews among 2413 patients from six counties in rural central China in 2019. The Anderson behavioral model was adopted to explore the associated factors. A two-level logistic model was employed to investigate the association strengths reflected by adjusted odds ratios (AOR) and 95% confidence intervals in forest plots.

Results

On average, 17.58% of the respondents with HBP and 14.87% with DM had experienced health services underutilization during 1 month before the survey. Multilevel logistic regression indicated that predisposing factors (age), enabling factors (income and a regular source of care), and need factors (self-reported health score) were the common predictors of health service underutilization both for hypertensive and diabetic patients in impoverished areas, among which obtaining a regular source of care was found to be relatively determinant as a protective factor for health services underutilization after controlling for other covariates.

Conclusions

Our results suggested that the implementation of a series of comprehensive strategies should be addressed throughout policy-making procedures to improve the provision of regular source of care as a significant determinant for reducing health services underutilization, thus ultimately achieving equal utilization of health services in impoverished regions, especially among chronic disease patients. Our findings are expected to provide practical implications for other developing countries confronted with similar challenges resulting from underdeveloped healthcare systems and aging population structures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06725-5.

Temporal trends and variation in out-of-pocket expenditures and patient cost sharing: evidence from a Chinese national survey 2011-2015

OBJECTIVES

This study aims to examine: (1) temporal trends in the percentage of cost-sharing and amount of out-of-pocket expenditure (OOPE) from 2011 to 2015; (2) factors associated with cost-sharing and OOPE; and (3) the relationships between province-level economic development and cost-sharing and OOPE in China.

SETTING

A total of 10,316 adults aged ≥45 years from China followed-up from 2011 to 2015 were included in the analysis. We measured two main outcome variables: (1) patient cost sharing, measured by the percentage of OOPE as total healthcare expenditure, and (2) absolute amount of OOPE.

RESULTS

Based on self-reported data, we did not find substantial differences in the percentage of cost sharing, but a significant increase in the absolute amount of OOPE among the middle-aged and older Chinese between 2011 and 2015. The percentage of cost-sharing was considerably higher for outpatient than inpatient care, and the majority paid more than 80% of the total cost for prescription drugs. Provinces with higher GDP per capita tend to have lower cost-sharing and a higher OOPE than their counterparts, but the relationship for OOPE became insignificant after adjusting for individual factors.

CONCLUSION

Reducing out-of-pocket expenditure and patient cost sharing is required to improve financial protection from illness, especially for those with those with chronic conditions and reside in less developed regions in China. Ongoing monitoring of financial protection using data from various sources is warranted.

Benefit of China's Social Health Insurance Schemes: Trend Analysis and Associated Factors Since Health Reform

With the deepening of health insurance reform in China, the integration of social health insurance schemes was put on the agenda. This paper aims to illustrate the achievements and the gaps in integration by demonstrating the trends in benefits available from the three social health insurance schemes, as well as the influencing factors. Data were drawn from the three waves of the China Health and Nutrition Survey (2009, 2011, 2015) undertaken since health reforms commenced. χ2, Kruskal-Wallis test, and the Two-Part model were employed in the analysis. The overall reimbursement rate of the Urban Employee Basic Medical Insurance (UEBMI) is higher than that of Urban Resident Basic Medical Insurance (URBMI) or the New Rural Cooperative Medical Scheme (NRCMS) (p < 0.001), but the gap has narrowed since health reform began in 2009. Both the outpatient and inpatient reimbursement amounts have increased through the URBMI and NRCMS. Illness severity, higher institutional level, and inpatient service were associated with significant increases in the amount of reimbursement received across the three survey waves. The health reform improved benefits covered by the URBMI and NRCMS, but gaps with the UEBMI still exist. The government should consider more the release of health benefits and how to lead toward healthcare equity.

The benefits of an integrated social medical insurance for health services utilization in rural China: evidence from the China health and retirement longitudinal study

Background

Improving health equity is a fundamental goal for establishing social health insurance. This article evaluated the benefits of the Integration of Social Medical Insurance (ISMI) policy for health services utilization in rural China.

Methods

Using the China Health and Retirement Longitudinal study (2011‒2018), we estimated the changes in rates and equity in health services utilization by a generalized linear mixed model, concentration curves, concentration indices, and a horizontal inequity index before and after the introduction of the ISMI policy.

Results

For the changes in rates, the generalized linear mixed model showed that the rate of inpatient health services utilization (IHSU) nearly doubled after the introduction of the ISMI policy (8.78 % vs. 16.58 %), while the rate of outpatient health services utilization (OHSU) decreased (20.25 % vs. 16.35 %) after the implementation of the policy. For the changes in inequity, the concentration index of OHSU decreased significantly from − 0.0636 (95 % CL: −0.0846, − 0.0430) before the policy to − 0.0457 (95 % CL: −0.0684, − 0.0229) after it. In addition, the horizontal inequity index decreased from − 0.0284 before the implementation of the policy to − 0.0171 after it, indicating that the inequity of OHSU was further reduced. The concentration index of IHSU increased significantly from − 0.0532 (95 % CL: −0.0868, − 0.0196) before the policy was implemented to − 0.1105 (95 % CL: −0.1333, − 0.0876) afterwards; the horizontal inequity index of IHSU increased from − 0.0066 before policy implementation to − 0.0595 afterwards, indicating that more low-income participants utilized inpatient services after the policy came into effect.

Conclusions

The ISMI policy had a positive effect on improving the rate of IHSU but not on the rate of OHSU. This is in line with this policy’s original intention of focusing on inpatient service rather than outpatients to achieve its principal goal of preventing catastrophic health expenditure. The ISMI policy had a positive effect on reducing the inequity in OHSU but a negative effect on the decrease in inequity in IHSU. Further research is needed to verify this change. This research on the effects of integration policy implementation may be useful to policy makers and has important policy implications for other developing countries facing similar challenges on the road to universal health coverage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01457-8.

Measuring and evaluating progress towards Universal Health Coverage in China

Background

This paper aims to develop a Chinese version of Universal Health Coverage (UHC) indices and to measure China's progress towards UHC.

Methods

Nineteen indicators were selected based on expert consultations to construct indices of accessibility and affordability to measure UHC. Data were drawn from health statistics yearbooks, nationally representative surveys, and health system reform surveillance. The index of accessibility includes absolute accessibility (to essential health services), relative accessibility (to hospital care) and people's subjective perceptions. The index of affordability includes absolute affordability (the incidence of catastrophic health expenditure, CHE), relative affordability (the composition of health expenditure), and people's subjective perceptions.

Results

The indices of accessibility and affordability both showed steady increases over the 17 years considered. Absolute accessibility had the most significant improvement (from 23.6 in 2002 to 73.8 in 2018), while the index of relative accessibility decreased from 81.4 in 2002 to 67.3 in 2018. The index of absolute affordability decreased significantly from 46.6 in 2002 to 30.5 in 2010 and then exhibited an increasing trend afterwards, reaching 52.1 in 2018. The index of relative affordability continuously increased during the observation period, from 35.3 to 75.4.

Conclusions

China has made great progress in increasing the accessibility and affordability of health services since the health system reforms in 2009. However, integrating primary health care and hospital care and containing escalating medical expenditure to further reduce patients' financial burdens are key challenges for strengthening the Chinese health system.

Efficiency Comparison of Public Hospitals under Different Administrative Affiliations in China: A Pilot City Case

This study seeks to measure the efficiency disparity and productivity change of tertiary general public hospitals in Wuhan city, central China from the perspective of administrative affiliations by using panel data from 2013 to 2017. Sample hospitals were divided into three categories, namely provincial hospitals, municipal hospitals, and other levels of hospitals. Data envelopment analysis with bootstrapping technique was used to estimate efficiency scores, and a sensitive analysis was performed by varying the specification of model by considering undesirable outputs to test robustness of estimation, and efficiency evolution analysis was carried out by using the Malmquist index. The results indicated that the average values of provincial hospitals and municipal hospitals have experienced efficiency improvement over the period, especially after the initiation of Pilot Public Hospital Reform, but hospitals under other affiliations showed an opposite trend. Meanwhile, differences of administrative subordination in technical efficiency of public hospitals emerged, and the disparity was likely to grow over time. The higher efficiency of hospitals affiliated with municipality, as compared with those governed by province and under other administrative affiliations, may be attributed to better governance and organization structure.

Does smoking impact trust in physicians and satisfaction with the health system in China?

INTRODUCTION

Trust and satisfaction play vital roles in how smokers react to smoking cessation treatment delivered by physicians. This paper aims to ascertain whether smoking status and pack-years of smoking affect trust in physicians and satisfaction with the health system in China.

METHODS

The current study used the ordered probit model to evaluate how smoking status affects trust in physicians and satisfaction with the health system in China. Data from the China Family Panel Studies (CFPS) 2018 were used for the analysis, and the final sample consisted of 29500 adults. The CFPS is a nationally representative, comprehensive, high-quality, biennial longitudinal survey of Chinese communities, families, and individuals. The survey was conducted in 25 provinces and their administrative equivalents. The population of 25 provinces represents 95% of the total population in Mainland China.

RESULTS

According to the ordered probit model, the results showed that current smokers were significantly negatively associated with trust in physicians, and more cigarette smoking was associated with decreased trust in physicians. Moreover, current smokers were also significantly negatively related to satisfaction with the health system.

CONCLUSIONS

The present study found that current smokers would be more likely to rate trust in physicians lower, and less likely to rate greater satisfaction with the health system, than never smokers. These results may have important implications for regaining trust in physicians from smokers and supporting health-system reform for tobacco treatment.

Incidence of catastrophic healthcare expenditure and its main determinants in Mexican households caring for a person with a mental disorder

BACKGROUND

There are few studies on the impact of out-of-pocket mental health care expenditures and sociodemographic factors on the probability of Mexican households to incur catastrophic healthcare expenditures (CHE).

OBJECTIVE

The goal of the present study was to estimate the incidence of CHE and its main determinants among the households of persons with mental disorders (MD) in Mexico.

METHODS

A cross-sectional survey was conducted, including 387 households of persons with MD. The estimation of the CHE was obtained by the health expenditure distribution method. A Logistic Regression (LR) was used to identify the determinants of probability variation of CHE occurrence. Since we expected a proportion of CHE between 20% and 80%, we assume linearity in the probability function, therefore we additionally used an Ordinary Least Squares (OLS) model.

RESULTS

In our sample, the incidence of CHE was 34.8%. The two mental illnesses most frequently associated with CHE were schizophrenia and hyperactive disorder (35.5% and 32.6% of CHE cases, respectively). The regression coefficients showed that for each unit (US$53.77) increase in income, the probability of CHE was reduced by 8.6%, while for each unit increase in hospitalization or medication expenditures, the probability of CHE increased by 12.9% or 19%, respectively. For each additional household member, the probability of CHE increased by 3%, and households with a male patient had a 7% greater probability of CHE.

CONCLUSION

Household income, household size, hospitalization and medication expenses, and sex of the patient were significant predictors of CHE for households caring for a person with MD.

Inpatients' Perception of Patient-Centered Care in Guangdong Province, China: A Cross-Sectional Study

This study aimed to investigate the perceptions of patient-centered care (PCC) among inpatients in Guangdong Province (GD), China. Based on these perspectives, we sought to understand existing PCC practices in medical institutions and identify the impacts of inpatients’ sociodemographic status on their perceived PCC. A self-developed PCC questionnaire was used to investigate inpatients’ perceptions of PCC. A cross-sectional survey was conducted in nine tertiary-level hospitals across five cities in GD. Descriptive statistics was used to describe the levels of PCC in GD. The differences in PCC levels across different sociodemographic groups were assessed using analysis of variance and multivariate linear regression. Valid responses were provided by 1863 inpatients. The mean overall PCC score was 8.58 (standard deviation [SD] = 1.36); inpatients from the Pearl River Delta and eastern GD area reported significantly higher scores than those from western and northern GD area (P<.01). Inpatients from rural areas tended to report lower PCC scores than their urban counterparts. Among the PCC questionnaire sub-domains, inpatients scored highest and lowest in “patient experience” (mean = 8.96, SD = 1.34) and “medical insurance” (mean = 7.93, SD = 2.05), respectively. This study provided a comprehensive overview of inpatients’ perceptions of PCC in the public healthcare system in GD, China. Our findings highlighted that a majority of inpatients were satisfied with the PCC in public healthcare system; however, a significant discrepancy between inpatients with different sociodemographic status remained.