Financing changes of schistosomiasis control programmes in China 1980-1995: a case study in Songzi county

Health access livelihood framework reveals potential barriers in the control of schistosomiasis in the Dongting Lake area of Hunan Province, China

Background

Access to health care is a major requirement in improving health and fostering socioeconomic development. In the People's Republic of China (P.R. China), considerable changes have occurred in the social, economic, and health systems with a shift from a centrally planned to a socialist market economy. This brought about great benefits and new challenges, particularly for vertical disease control programs, including schistosomiasis. We explored systemic barriers in access to equitable and effective control of schistosomiasis.

Methodology

Between August 2002 and February 2003, 66 interviews with staff from anti-schistosomiasis control stations and six focus group discussions with health personnel were conducted in the Dongting Lake area, Hunan Province. Additionally, 79 patients with advanced schistosomiasis japonica were interviewed. The health access livelihood framework was utilized to examine availability, accessibility, affordability, adequacy, and acceptability of schistosomiasis-related health care.

Principal Findings

We found sufficient availability of infrastructure and human resources at most control stations. Many patients with advanced schistosomiasis resided in non-endemic or moderately endemic areas, however, with poor accessibility to disease-specific knowledge and specialized health services. Moreover, none of the patients interviewed had any form of health insurance, resulting in high out-of-pocket expenditure or unaffordable care. Reports on the adequacy and acceptability of care were mixed.

Conclusions/Significance

There is a need to strengthen health awareness and schistosomiasis surveillance in post-transmission control settings, as well as to reduce diagnostic and treatment costs. Further studies are needed to gain a multi-layered, in-depth understanding of remaining barriers, so that the ultimate goal of schistosomiasis elimination in P.R. China can be reached.

China has made great strides toward reducing the burden of schistosomiasis, facilitated by sustained political commitment and a multi-faceted, integrated control strategy. The ultimate goal is disease elimination, which might be challenging due to high rates of re-infection, clusters of re-emergence, and growing health disparities. Market-oriented reforms and system-wide policies within the health care system offer new opportunities, but also entail challenges for the national schistosomiasis control program. Few studies have examined systemic barriers to equitable and effective schistosomiasis control in China. We explored the five core dimensions of access to health care, placing emphasis on schistosomiasis in the Dongting Lake area of Hunan Province. We collected and analyzed perspectives from staff working at local anti-schistosomiasis control stations and designated schistosomiasis hospitals, and from patients with advanced schistosomiasis. Our data suggest that a lack of affordability and high out-of-pocket expenditure posed a major barrier to the health care users, as did a lack of relevant health-information, and poorly accessible diagnostic and specialized surgical services. The lessons learned from this work are important in the design and development of disease control programs and entail key policy implications for schistosomiasis elimination.

Longitudinal study of child immunization determinants in China

This paper exploits longitudinal data and methods to study the determinants of child immunization in 1990 s China. Many countries such as China are experiencing rapid economic transitions characterized by declining public health expenditures, privatizing health-care sectors, increased inequality and high income growth. It is still poorly understood how such changes affect utilization of preventive health care. Data from three waves of the China Health and Nutrition Survey were used to examine the immunization effects of child, household, and community health facility characteristics, as well as changes of such effects over time. Results indicate that gender and wealth differentials in immunization increased during China's transition, though these effects were small. The most important determinants were service price and maternal education. Wealth effects were minimal, indicating that the long-run effect of economic transition on immunization rates may depend crucially on the extent to which more rapid economic growth leads to increased educational investments. Methodologically, the paper finds substantial bias from standard cross-sectional models in contrast to panel data approaches, adding to the case for expanded collection of longitudinal health data in developing countries.

Market reform: a challenge to public health?the case of schistosomiasis control in China

This study examines how the provision of schistosomiasis control has adapted to increased exposure to market forces which has occurred in China over the past decades with the main emphasis on contemporary performance of the services. Financial and service data were collected and analysed from ten schistosomiasis stations in the Hunan province. A document and literature review, key informant interviews, as well as two focus group discussions were conducted to establish their context. The study found that the schistosomiasis control stations had shifted their emphasis from prevention to clinical services and that 62% of the stations' total income now comes from charging for individual clinical services, while 90% of the total costs was related to providing these services. The study found that revenue generation had become the primary motive, and that over-treatment and prescription had become an accepted practice for all the stations. The study concludes that a combination of lax supervision and accountability, and a greater reliance on user-payment and market mechanisms has severely compromised the provision of the public goods elements of the schistosomiasis control programme.

Financing reforms of public health services in China: lessons for other nations

Financing reforms of China's public health services are characterised by a reduction in government budgetary support and the introduction of charges. These reforms have changed the financing structure of public health institutions. Before the financing reforms, in 1980, government budgetary support covered the full costs of public health institutions, while after the reforms by the middle of the 1990s, the government's contribution to the institutions' revenue had fallen to 30-50%, barely covering the salaries of health workers, and the share of revenue generated from charges had increased to 50-70%. These market-oriented financing reforms improved the productivity of public health institutions, but several unintended consequences became evident. The economic incentives that were built into the financing system led to over-provision of unnecessary services, and under-provision of socially desirable services. User fees reduced the take-up of preventive services with positive externalities. The lack of government funds resulted in under-provision of services with public goods' characteristics. The Chinese experience has generated important lessons for other nations. Firstly, a decline in the role of government in financing public health services is likely to result in decreased overall efficiency of the health sector. Secondly, levying charges for public health services can reduce demand for these services and increase the risk of disease transmission. Thirdly, market-oriented financing reforms of public health services should not be considered as a policy option. Once this step is made, the unintended consequences may outweigh the intended ones. Chinese experience strongly suggests that the government should take a very active role in financing public health services.