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Levy M, Buckell J, Clarke R, Wu N, Pei P, Sun D, Avery D, Zhang H, Lv J, Yu C, Li L, Chen Z, Yip W, Chen Y, Mihaylova B. Association between health insurance cost-sharing and choice of hospital tier for cardiovascular diseases in China: a prospective cohort study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 45:101020. [PMID: 38380231 PMCID: PMC10876671 DOI: 10.1016/j.lanwpc.2024.101020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 12/13/2023] [Accepted: 01/16/2024] [Indexed: 02/22/2024]
Abstract
Background Hospitals in China are classified into tiers (1, 2 or 3), with the largest (tier 3) having more equipment and specialist staff. Differential health insurance cost-sharing by hospital tier (lower deductibles and higher reimbursement rates in lower tiers) was introduced to reduce overcrowding in higher tier hospitals, promote use of lower tier hospitals, and limit escalating healthcare costs. However, little is known about the effects of differential cost-sharing in health insurance schemes on choice of hospital tiers. Methods In a 9-year follow-up of a prospective study of 0.5 M adults from 10 areas in China, we examined the associations between differential health insurance cost-sharing and choice of hospital tiers for patients with a first hospitalisation for stroke or ischaemic heart disease (IHD) in 2009-2017. Analyses were performed separately in urban areas (stroke: n = 20,302; IHD: n = 19,283) and rural areas (stroke: n = 21,130; IHD: n = 17,890), using conditional logit models and adjusting for individual socioeconomic and health characteristics. Findings About 64-68% of stroke and IHD cases in urban areas and 27-29% in rural areas chose tier 3 hospitals. In urban areas, higher reimbursement rates in each tier and lower tier 3 deductibles were associated with a greater likelihood of choosing their respective hospital tiers. In rural areas, the effects of cost-sharing were modest, suggesting a greater contribution of other factors. Higher socioeconomic status and greater disease severity were associated with a greater likelihood of seeking care in higher tier hospitals in urban and rural areas. Interpretation Patient choice of hospital tiers for treatment of stroke and IHD in China was influenced by differential cost-sharing in urban areas, but not in rural areas. Further strategies are required to incentivise appropriate health seeking behaviour and promote more efficient hospital use. Funding Wellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, China Ministry of Science and Technology, and National Natural Science Foundation of China.
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Affiliation(s)
- Muriel Levy
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, UK
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - John Buckell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, UK
- Medical Research Council Population Health Research Unit (MRC PHRU), Nuffield Department of Population Health, University of Oxford, UK
| | - Nina Wu
- School of Public Health, Capital Medical University, Beijing, China
| | - Pei Pei
- Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, China
| | - Dianjianyi Sun
- Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Daniel Avery
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, UK
| | - Hua Zhang
- NCDs Prevention and Control Department, Qingdao Centre for Disease Control and Prevention, Qingdao, China
| | - Jun Lv
- Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Canqing Yu
- Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Liming Li
- Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Centre, Beijing, China
| | - Zhengming Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, UK
| | - Winnie Yip
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Yiping Chen
- Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, UK
- Medical Research Council Population Health Research Unit (MRC PHRU), Nuffield Department of Population Health, University of Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, UK
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Aryal A, Clarke-Deelder E, Phommalangsy S, Kounnavong S, Fink G. Health system utilization and perceived quality among adults in Lao PDR: evidence from a nationally representative phone survey. BMC Public Health 2024; 24:565. [PMID: 38388912 PMCID: PMC10882776 DOI: 10.1186/s12889-024-18039-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND The World Health Organization (WHO) defines quality health services as being effective, safe, people-centered, timely, equitable, integrated and efficient. It is critical to understand people's perspectives and care experiences to measure progress against these goals. However, many low- and middle-income governments do not routinely collect such information. In this study, we aim to measure health systems performance from the perspective of the adult population of users and non-users in Lao PDR. METHODS Using the People's Voice Survey (PVS), a novel phone-based survey designed to integrate people's voices into primary care performance measurement, we conducted a cross-sectional survey of the general adult (18+) population in Lao PDR in 2022. We analyzed health care utilization patterns, user-reported quality of care, and coverage of key preventive health services. Data from the most recent MICS survey was used to create sampling weights generating nationally representative estimates. RESULTS A total of 2007 adults completed interviews in approximately 3.5 months. About two thirds (65%) of respondents reported visiting a health facility in the past year and, of these, the majority (61%) visited a hospital as opposed to a health center or clinic. Among those that recently visited health facilities, 28% rated their experience as "poor" or "fair". 16% had unmet need for care and 12% reported discrimination during treatment in the past year. 12% of women over 50 years old reported receiving a mammogram and 59% of adults reported receiving blood pressure screening in the previous year. CONCLUSIONS The study presents data from the first nationally representative survey in Lao PDR to measure health system performance. The results indicate that, despite progress towards universal coverage of health insurance in Lao PDR, significant gaps remain, particularly with respect to bypassing of primary care facilities, significant unmet need for care, experiences of discrimination, and overall low perceptions of quality of care.
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Affiliation(s)
- Amit Aryal
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
- University of Basel, Basel, Switzerland.
| | - Emma Clarke-Deelder
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | | | | | - Günther Fink
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
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Zhang J, Sun X, Yao A. Use of Primary Healthcare Among Chinese Older Adults With Functional Limitations. J Appl Gerontol 2024; 43:149-159. [PMID: 37947378 DOI: 10.1177/07334648231205404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
The aim of this study was to assess the factors associated with primary healthcare (PHC) utilization among older adults with functional limitations, providing insights for improving the effectiveness of PHC for this population. We used the China Health and Retirement Longitudinal Study (CHARLS) dataset, which encompasses 28 provinces in China. Logistic regression was used to analyze the people-related, care context-related, and linkage-related factors associated with PHC utilization. Approximately 55.61% of older adults with functional limitations utilized PHC in the past month, regardless of visit frequency or extent. Participants with lower educational attainment, those reporting more pain, and those living in rural areas had a higher likelihood of PHC utilization. Participants who received inpatient care in the past year had a lower likelihood of PHC utilization. We recommend that policymakers complement existing PHC health programs with increased health and social welfare support for this population.
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Affiliation(s)
- Jinxin Zhang
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
- National Health Commission Key Lab of Health Economics and Policy Research (Shandong University), Jinan, China
| | - Xiaojie Sun
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
- National Health Commission Key Lab of Health Economics and Policy Research (Shandong University), Jinan, China
| | - Aaron Yao
- Home Centered Care Institute, Schaumburg, IL, USA
- University of Virginia, Charlottesville, VA, USA
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Miao C, Fang X, Sun H, Yin Y, Li B, Shen W, Chen J, Huang X. The relationship between individual-level socioeconomic status and preference for medical service in primary health institutions: a cross-sectional study in Jiangsu, China. Front Public Health 2024; 11:1302523. [PMID: 38274517 PMCID: PMC10809986 DOI: 10.3389/fpubh.2023.1302523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/11/2023] [Indexed: 01/27/2024] Open
Abstract
Background While China's primary health care (PHC) system covers all citizens, the use of medical services supplied by primary health institutions (PHIs) is not at ideal levels. This study explored the impact of socioeconomic status (SES) on residents' first choice of medical services provided by PHIs. Methods This community-based, cross-sectional study was conducted in Jiangsu Province, China, from October 2021 to March 2022. A custom-designed questionnaire was used to evaluate 4,257 adults, of whom 1,417 chose to visit a doctor when they were sick. Logistic regression was used to test the relationships among SES, other variables and the choice of medical services, and interaction effects were explored. Results A total of 1,417 subjects were included in this study (48.7% female; mean age 44.41 ± 17.1 years). The results showed that older age (p < 0.01), rural residence (p < 0.01), a preference for part-time medical experts in PHIs (p < 0.01), and lack of coverage by basic medical insurance (p < 0.05) were associated with the first choice to use PHIs. In the multiple logistic regression model, SES was not associated with the first choice of medical services supplied by PHIs (p > 0.05), but it interacted with three variables from the Commission on Social Determinants of Health Framework (material circumstances, behaviors and biological factors, and psychosocial factors). Conclusion Vulnerable individuals who are the target visitors to PHIs are older, live in rural areas, and suffer from chronic diseases. SES, as a single factor, did not impact whether medical services at PHIs were preferred, but it mediated relationships with other factors.
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Affiliation(s)
- Chunxia Miao
- School of Management, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Xin Fang
- School of Management, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Hong Sun
- School of Economics and Management, Nanjing Forestry University, Nanjing, Jiangsu, China
| | - Yani Yin
- Personnel Department, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Bo Li
- School of Management, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Wenxing Shen
- School of Economics and Management, Nanjing Forestry University, Nanjing, Jiangsu, China
| | - Jie Chen
- Nursing Department, Children's Hospital of Fudan University, Shanghai, China
| | - Xiaojing Huang
- School of Management, Xuzhou Medical University, Xuzhou, Jiangsu, China
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Rao KD, Mehta A, Noonan C, Peters MA, Perry H. Voting with their feet: Primary care provider choice and its implications for public sector primary care services in India. Soc Sci Med 2024; 340:116414. [PMID: 38039764 PMCID: PMC10828545 DOI: 10.1016/j.socscimed.2023.116414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/26/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023]
Abstract
Expanding networks of government primary health centers (PHCs) to bring health services closer to communities is a longstanding policy objective in LMICs. In pluralistic health systems, where public and private providers compete for patients, PHCs are often not the preferred source for care. This study analyzes the market for primary care services in the Indian state of Bihar to understand how choice of primary care provider is influenced by distance, cost and quality of care. This study is based on linked surveys of rural households, PHCs, and private primary care providers conducted in 2019 and 2020. Most rural residents lived in proximity to a primary care provider, though not a qualified one. Within a 5-km distance, 60% of villages had a PHC, 90% had an informal provider, 35% an Indian systems of medicine practitioner, and 10% a private MBBS doctor. Most patients sought care from informal providers irrespective of PHC distance; only 25% of patients living in the PHC's vicinity sought care there. Reducing distance to the PHC by 1 km marginally increased the likehood of the PHC being selected, and reduced the likelihood of private clinics being selected. Reducing patient's costs at PHCs increased the likelihood of the PHC being selected and reduced the likelihood of private clinics and private hospitals being selected. Improved clinical quality at PHCs had no effect on patient selection of PHCs, private clinics, or hospitals. Illness severity reduced the likelihood of PHCs or private clinics being selected, and increased the likelihood of private hospitals selected. Wealthier patients were marginally more likely to use PHCs, substantially more likely to use private hospitals, and less likely to use private clinics. Expanding PHC network coverage or improving their quality of care is not sufficient to make PHCs more relevant to local health needs. An orientation towards essential public health functions, as well as, a community-centered approach to the organization of primary health care system is necessary.
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Affiliation(s)
- Krishna D Rao
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Akriti Mehta
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Caitlin Noonan
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Michael A Peters
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Henry Perry
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA.
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Kang L, Zhang T, Xian B, Li C, Khan MM. Public satisfaction with health system after healthcare reform in China. Health Res Policy Syst 2023; 21:128. [PMID: 38049859 PMCID: PMC10694918 DOI: 10.1186/s12961-023-01067-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 10/30/2023] [Indexed: 12/06/2023] Open
Abstract
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.
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Affiliation(s)
- Lili Kang
- School of Health Management, Fujian Medical University, Fuzhou, 350122, Fujian, China
| | - Tianyi Zhang
- School of Basic Medical Sciences, Shandong University, Jinan, China
| | - Bensong Xian
- School of Health Management, Inner Mongolia Medical University, Hohhot, China
| | - Changle Li
- School of Health Management, Fujian Medical University, Fuzhou, 350122, Fujian, China.
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, United States of America.
| | - M Mahmud Khan
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, United States of America
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Kang L, Li C, Du H. Predictors of Medical Care Delay or Avoidance Among Chinese Adults During the COVID-19 Pandemic. Patient Prefer Adherence 2023; 17:3067-3080. [PMID: 38027085 PMCID: PMC10680038 DOI: 10.2147/ppa.s436794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/02/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Medical care delay or avoidance increases morbidity and mortality risk and is costly for the national healthcare system. The objective of this study was to identify factors associated with medical care delay or avoidance among Chinese adults during the COVID-19 pandemic. Materials and Methods A cross-sectional analysis was conducted using data from the 2020 China Family Panel Study (CFPS). The CFPS was conducted from July to December 2020 during the COVID-19 pandemic. The final sample included 4369 adults. A logistic regression model was employed to identify the factors associated with medical care delay or avoidance. Results The empirical results indicate that regardless of rural-urban residence, older adults and adults with chronic conditions were less likely to delay or avoid medical care during the pandemic. However, individuals who had completed more than three years of college showed a higher likelihood of delaying or avoiding medical care. In urban areas, larger family sizes, greater general trust in physicians, and higher provider structural quality were associated with a decreased probability of delaying or avoiding medical care during the pandemic. In contrast, employed adults were more likely to delay or avoid medical care. In rural areas, current smokers were more likely to delay or avoid medical care during the pandemic. Conclusion This study has identified several factors affecting medical care delay or avoidance, some of which are amenable to policy changes. Policymakers can help improve the utilization of health facilities and patient health outcomes by implementing a series of reforms.
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Affiliation(s)
- Lili Kang
- School of Health Management, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Changle Li
- School of Health Management, Fujian Medical University, Fuzhou, People’s Republic of China
| | - Huifeng Du
- School of Health Management, Inner Mongolia Medical University, Hohhot, People’s Republic of China
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Ohta R, Sano C. Rural health dialogue for the sustainability of help-seeking behaviors among older patients: grounded theory approach. BMC Geriatr 2023; 23:674. [PMID: 37853372 PMCID: PMC10585832 DOI: 10.1186/s12877-023-04401-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Help-seeking behaviors (HSBs) are essential for disease prevention and health promotion. Dialogues with peers and medical professionals can improve HSBs, both qualitatively and quantitatively. Rural communities lacking healthcare resources require effective HSBs for healthcare sustainability. The current study aimed to investigate the effect of health dialogues between medical professionals and rural citizens on their HSBs. METHODS All procedures complied with the Declaration of Helsinki and its subsequent amendments. The Unnan City Hospital Clinical Ethics Committee approved the study protocol (No. 20,220,002). A grounded theory approach was employed for the health dialogue participants in rural communities. Health dialogues with family physicians were conducted once a month at rural community centers. The dialogues and focus group interviews were recorded and coded to investigate changes in participants' perceptions and behaviors regarding HSBs. RESULTS Twenty-one dialogues were conducted in two rural community centers, with a total of 112 participants. The average age of the participants was 70.2 years (standard deviation = 5.4), with 24% being males. Analysis of the grounded theory approach revealed four themes, namely joy-driven dialogue driving the realization of HSBs, reflection on personal HSBs through learning from others, revising HSBs based on rural social resources, and familiarity with physicians, hence motivating safe and secure HSBs. CONCLUSIONS Mitigation of barriers between citizens and medical professionals and improvement of psychological safety in communities can drive effective HSBs in rural communities.
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Affiliation(s)
- Ryuichi Ohta
- Community Care, Unnan City Hospital, 96-1 Iida, Daito-cho, Unnan, 699-1221, Japan.
| | - Chiaki Sano
- Department of Community Medicine Management, Faculty of Medicine, Shimane University, 89-1 Enya cho, Izumo, Shimane Prefecture, 693-8501, Japan
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Lyu S, Qian C, McIntyre A, Lee CH. One Pandemic, Two Solutions: Comparing the U.S.-China Response and Health Priorities to COVID-19 from the Perspective of "Two Types of Control". Healthcare (Basel) 2023; 11:1848. [PMID: 37444682 DOI: 10.3390/healthcare11131848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
After three years of global rampage, the COVID-19 epidemic, the most serious infectious disease to occur worldwide since the 1918 influenza pandemic, is nearing its end. From the global experience, medical control and social control are the two main dimensions in the prevention and control of COVID-19. From the perspective of "two types of control", namely medical control and social control, this paper finds that the political system, economic structure, and cultural values of the United States greatly limit the government's ability to impose social control, forcing it to adopt medical control to fight the virus in a single dimension. In contrast, China's political system, economic structure, and cultural values allow its government to adopt stringent, extensive, and frequent social control, as well as medical control to fight the virus. This approach departs from the traditional pathway of fighting the epidemic, i.e., "infection-treatment-immunization", thereby outpacing the evolution of the virus and controlling its spread more rapidly. This finding helps explain why the Chinese government adopted a strict "zeroing" and "dynamic zeroing" policy during the first three years, at the cost of enormous economic, social, and even political legitimacy. It was not until late 2022, when the Omicron variant with the waning virulence became prevalent, that China chose to "coexist" with the virus, thus avoiding a massive epidemic-related death. While the United States adopted a pulsed-style strategy at the beginning of the epidemic, i.e., "relaxation-suppression-relaxation-suppression", and began to "coexist" with the virus in just one year, resulting in a large number of excess deaths associated with the epidemic. The study contributes to explaining the difference in the interplay between public health priorities and COVID-19 response strategies in China and the United States, based on the specific public health context and the perspective of "medical control" and "social control".
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Affiliation(s)
- Shupeng Lyu
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an 710049, China
| | - Chen Qian
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an 710049, China
| | - Aaron McIntyre
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an 710049, China
| | - Ching-Hung Lee
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an 710049, China
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Wu S, Du S, Feng R, Liu W, Ye W. Behavioral deviations: healthcare-seeking behavior of chronic disease patients with intention to visit primary health care institutions. BMC Health Serv Res 2023; 23:490. [PMID: 37189156 DOI: 10.1186/s12913-023-09528-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/10/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Although primary health care (PHC) has been proven to be effective in preventing and treating chronic diseases, the visits rate of PHC institutions is still not ideal. Some patients initially express a willingness to visit PHC institutions but end up seeking health services at non-PHC institutions, and the reasons for this behavior remain unclear. Therefore, the objective of this study is to analyze the factors that contribute to behavioral deviations among chronic disease patients who originally intended to visit PHC institutions. METHODS Data were collected from a cross-sectional survey among chronic disease patients with original intention to visit PHC institutions in Fuqing City, China. The analysis framework was guided by Andersen's behavioral model. Logistic regression models were employed to analyze the factors affecting the behavioral deviations among chronic disease patients with a willingness to visit PHC institutions. RESULTS A total of 1,048 individuals were finally included and about 40% of the participants with the original willingness to seek care from PHC institutions finally chose non-PHC institutions in their subsequent visits. The results of logistic regression analyses indicated that at the predisposition factor level, older participants (aOR60-69 = 0.602, P < 0.01; aOR70-75 = 0.475, P < 0.01) were less likely to have behavioral deviations. At the enabling factor level, compared to those covered by Urban Employee Basic Medical Insurance (UEBMI) and not reimbursed, those covered by Urban-Rural Resident Basic Medical Insurance (URRBMI) (aOR = 0.297, P < 0.01), and those answering that reimbursement from medical institutions was convenient (aOR = 0.501, P < 0.01) or very convenient (aOR = 0.358, P < 0.001) were less likely to have behavioral deviations. At the need factor level, participants who visited PHC institutions due to illness last year (aOR = 0.348, P < 0.001) and with polypharmacy (aOR = 0.546, P < 0.01) were less likely to have behavioral deviations compared to those without the visit of PHC institutions and not taking polypharmacy, respectively. CONCLUSIONS The deviations between the original willingness of PHC institution visits and subsequent behavior among chronic disease patients were associated with a number of predisposing, enabling, and need factors. Developing the health insurance system, strengthening the technical capacity of PHC institutions, and steadily developing a new concept of orderly healthcare-seeking behavior among chronic disease patients, will help promote their access to PHC institutions as well as improve the effectiveness of the tiered medical system for chronic disease care.
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Affiliation(s)
- Shiyin Wu
- Department of Health Management, School of Health Management, Fujian Medical University, Fuzhou, Fujian, China
| | - Shanshan Du
- School of Public Health, Fujian Medical University, 1 Xuefubei Road, Minhou District, Fuzhou, 350122, China
| | - Ruimei Feng
- School of Public Health, Fujian Medical University, 1 Xuefubei Road, Minhou District, Fuzhou, 350122, China
| | - Wenbin Liu
- Department of Health Management, School of Health Management, Fujian Medical University, Fuzhou, Fujian, China.
| | - Weimin Ye
- School of Public Health, Fujian Medical University, 1 Xuefubei Road, Minhou District, Fuzhou, 350122, China.
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Liu J, Zhai X, Yan W, Liu Q, Liu M, Liang W. Long-term impact of the COVID-19 pandemic on health services utilization in China: A nationwide longitudinal study. GLOBAL TRANSITIONS 2023; 5:21-28. [PMID: 36987499 PMCID: PMC10036308 DOI: 10.1016/j.glt.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Long-term impact of the COVID-19 pandemic on health services utilization is unknown. We aim to assess the long-term effect of the COVID-19 pandemic on health services utilization in China. METHODS Between Jan 2017 and Dec 2021, we conducted a nationwide longitudinal study using routinely collected data on health services utilization in the National Health Information System of China. We extracted national and provincial data of demographic characteristics, socio-economic characteristics, and health resources. Interrupted time-series segmented negative binominal regression models were used. RESULTS A total of 34.2 billion health facilities visits and 1.1 billion inpatients discharged were included. The largest negative impact of COVID-19 pandemic on the health services utilization was during containment period, that health facility visits were observed 32% reduction in hospitals (adjusted incidence risk ratios [aRRs] 0.68, 95%CI: 0.50-0.92), 27% reduction in community health centers (aRR 0.73, 95%CI: 0.57-0.93), and 22% reduction township centers (aRR 0.78, 95%CI: 0.67-0.91), respectively. The impact on health facility visits and inpatients discharged were reduced and eliminated over time (all p>0.05). However, the negative impact on utilization rate of beds, average length of stay, average inpatient costs, and average outpatient costs in different level of health facilities still existed two years later (all p<0.05). CONCLUSIONS The impact of the COVID-19 pandemic on health services utilization was largest during containment period and reduced over time, but it still existed two years later. There are disparities in the recovery of health services. Our findings highlighted the importance of maintaining primary healthcare services during the pandemic and strengthen resilient health system on the rapid recovery of medical services.
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Affiliation(s)
- Jue Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health and Development, Peking University, No. 5 Yiheyuan Road, Haidian, Beijing, 100871, China
| | - Xiaohui Zhai
- Medical Management Center, National Health Commission of the People's Republic of China, No. 1, Xizhimenwai South Road, Xicheng District, Beijing, 100044, China
| | - Wenxin Yan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Qiao Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Min Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Wannian Liang
- Vanke School of Public Health, Tsinghua University, No. 30, Shuangqing Road, Haidian District, 100084, Beijing, China
- Institute for Healthy China, Tsinghua University, No. 30, Shuangqing Road, Haidian District, 100084, Beijing, China
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Xiong S, Jiang W, Meng R, Hu C, Liao H, Wang Y, Cai C, Zhang X, Ye P, Ma Y, Liu T, Peng D, Yang J, Gong L, Wang Q, Peiris D, Mao L, Tian M. Factors associated with the uptake of national essential public health service package for hypertension and type-2 diabetes management in China's primary health care system: a mixed-methods study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 31:100664. [PMID: 36879777 PMCID: PMC9985050 DOI: 10.1016/j.lanwpc.2022.100664] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/04/2022] [Accepted: 11/27/2022] [Indexed: 12/15/2022]
Abstract
Background China launched the primary health care (PHC) system oriented National Essential Public Health Service Package (NEPHSP) in 2009, to combat health challenges including the increasing burden from hypertension and type-2 diabetes (T2DM). In this study, the PHC system was assessed to understand factors influencing the uptake of the NEPHSP for hypertension and T2DM management. Methods A mixed-methods study was conducted in seven counties/districts from five provinces across the mainland of China. Data included a PHC facility level survey and interviews with policy makers, health administrators, PHC providers, and individuals with hypertension and/or T2DM. The facility survey used the World Health Organisation (WHO) service availability and readiness assessment questionnaire. Interviews were thematically analysed using the WHO health systems building blocks. Findings A total of 518 facility surveys were collected with over 90% in rural settings (n = 474). Forty-eight in-depth individual interviews and 19 focus-group discussions were conducted across all sites. Triangulating the quantitative and qualitative data found that China's continuous political commitment to strengthening the PHC system led to improvements in workforce and infrastructure. Despite this, many barriers were identified, including insufficient and under-qualified PHC personnel, remaining gaps in medicines and equipment, fragmented health information systems, residents' low trust and utilization of PHC, challenges in coordinated and continuous care, and lack of cross-sectorial collaborations. Interpretation The study findings provided recommendation for future PHC system strengthening, including improving the quality of NEPHSP delivery, facilitating resource-sharing across health facilities, establishing integrated care systems, and exploring mechanisms for better cross-sectorial engagement in health governance. Funding The study is supported by National Health and Medical Research Council (NHMRC) Global Alliance for Chronic Disease funding (APP1169757).
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Affiliation(s)
- Shangzhi Xiong
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Global Health Research Centre, Duke Kunshan University, Kunshan, China
| | - Wei Jiang
- National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Ruilin Meng
- Guangdong Provincial Centre for Disease Control and Prevention, Guangzhou, China
| | - Chi Hu
- Yichang City Centre for Disease Control and Prevention, Yichang, China
| | - Hui Liao
- Wenchuan County Health Bureau, Wenchuan, China
| | - Yongchen Wang
- Division of General Practice, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chang Cai
- Public Health Policy Evaluation Unit, School of Public Health, Imperial College London, UK
| | - Xinyi Zhang
- School of Public Health, Harbin Medical University, Harbin, China
| | - Pengpeng Ye
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Yanqiuzi Ma
- National Centre for Non-Communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Tingzhuo Liu
- School of Public Health, Harbin Medical University, Harbin, China
| | - Dandan Peng
- Guangdong Provincial Centre for Disease Control and Prevention, Guangzhou, China
| | - Jiajuan Yang
- Yichang City Centre for Disease Control and Prevention, Yichang, China
| | - Li Gong
- Wenchuan County Health Bureau, Wenchuan, China
| | - Qiujun Wang
- Division of General Practice, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - David Peiris
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Limin Mao
- Centre for Social Research in Health, Faculty of Arts, Design and Architecture, University of New South Wales, Sydney, Australia
| | - Maoyi Tian
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- School of Public Health, Harbin Medical University, Harbin, China
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13
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Sepehri A, Minh KN, Vu PH. Challenges in moving toward universal health coverage: rising cost of outpatient care among Vietnam's insured rural residents, 2006-2018. Public Health 2023; 215:56-65. [PMID: 36642040 DOI: 10.1016/j.puhe.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- A Sepehri
- Department of Economics, University of Manitoba, Winnipeg, Canada.
| | - K N Minh
- Department of Economics and Management, Thang Long University, Hanoi, Viet Nam.
| | - P H Vu
- School of Banking & Finance, National Economics University, Hanoi, Viet Nam.
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14
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Xie W, Liu J, Huang Y, Xi X. Capturing What Matters with Patients' Bypass Behavior? Evidence from a Cross-Sectional Study in China. Patient Prefer Adherence 2023; 17:591-604. [PMID: 36919186 PMCID: PMC10008354 DOI: 10.2147/ppa.s395928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/18/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND In China, bypassing is becoming increasingly prevalent. Such behavior, as going directly to upper-level health-care facilities without a primary care provider (PCP) referral when facing non-critical diseases, contrasts to "expanding the role of PCPs as the first-contact of care", may cause unneglectable damage to the healthcare system and people's physical health. OBJECTIVE To examine the relationship between patient experience in primary health-care clinics (PHCs) and their bypass behavior. METHODS A cross-sectional study was designed for data collection. From July 2021 to August 2021, we conducted a questionnaire survey nationally. Fifty-three investigators were dispatched to 212 pre-chosen PHCs, around which 1060 interviewees were selected to gather information, using a convenience sampling. The primary independent variable was scores measured by Chinese Primary Care Assessment Tool (PCAT-C) to quantify patients' experience at PHCs. The dependent variable was a binary variable measured by a self-developed instrument to identify whether participants actually practiced bypassing. Covariates were well-screened determinants of patients' bypass behavior including socio-demographic factors, policy factors, and health-care suppliers. Binary logistic regression analysis was employed to evaluate the association of patients' experience with their bypass behavior. FINDINGS A total of 928 qualified questionnaires were obtained. The first contact dimension (OR 0.961 [95% CI 0.934 to 0.988], P = 0.005) and continuity dimension (OR 1.034 [95% CI 1.000 to 1.068], P = 0.047) of patients' experience were significantly associated with patients' bypass behavior (P < 0.05). In addition, age (OR 1.072, [95% CI 1.015-1.132], P = 0.013) and gender (OR 2.044, [95% CI 1.139-3.670], P = 0.017) also made a statistically significant difference. CONCLUSION Enhancement in patient experience at PHCs may help reduce their bypass behavior. Specifically, efforts are needed to improve primary care accessibility and utilization. The positive correlation between bypassing rates and continuity scores may require more attention on strengthening PCPs' technical quality besides the quality of interpersonal interactions.
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Affiliation(s)
- Wenwen Xie
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
| | - Jiayuan Liu
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
| | - Yuankai Huang
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
| | - Xiaoyu Xi
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
- Correspondence: Xiaoyu Xi, Email
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15
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Chen Y, Liu W. Utilization and out-of-pocket expenses of primary care among the multimorbid elderly in China: A two-part model with nationally representative data. Front Public Health 2022; 10:1057595. [PMID: 36504938 PMCID: PMC9730339 DOI: 10.3389/fpubh.2022.1057595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Multimorbidity has become an essential public health issue that threatens human health and leads to an increased disease burden. Primary care is the prevention and management of multimorbidity by providing continuous, comprehensive patient-centered services. Therefore, the study aimed to investigate the determinants of primary care utilization and out-of-pocket expenses (OOPE) among multimorbid elderly to promote rational utilization of primary care and reduce avoidable economic burdens. Methods The study used data from CHARLS 2015 and 2018, which included a total of 4,384 multimorbid elderly aged 60 and above. Guided by Grossman theory, determinants such as education, gender, marriage, household economy, and so on were included in this study. A two-part model was applied to evaluate primary care utilization and OOPE intensity in multimorbid populations. And the robustness testing was performed to verify research results. Results Primary care visits rate and OOPE indicated a decline from 2015 to 2018. Concerning primary outpatient care, the elderly who were female (OR = 1.51, P < 0.001), married (OR = 1.24, P < 0.05), living in rural areas (OR = 1.77, P < 0.001) and with poor self-rated health (OR = 2.23, P < 0.001) had a significantly higher probability of outpatient utilization, whereas those with middle school education (OR = 0.61, P < 0.001) and better household economy (OR = 0.96, P < 0.001) had a significantly less likelihood of using outpatient care. Rural patients (β = -0.72, P < 0.05) may have lower OOPE, while those with better household economy (β = 0.29, P < 0.05; β = 0.58, P < 0.05) and poor self-rated health (β = 0.62, P < 0.001) occurred higher OOPE. Regarding primary inpatient care, adults who were living in rural areas (OR = 1.48, P < 0.001), covered by Urban Employee Basic Medical Insurance (UEBMI) or Urban Rural Basic Medical Insurance (URBMI) (OR = 2.46, P < 0.001; OR = 1.81, P < 0.001) and with poor self-rated health (OR = 2.30, P < 0.001) had a significantly higher probability of using inpatient care, whereas individuals who were female (OR = 0.74, P < 0.001), with middle school education (OR = 0.40, P < 0.001) and better household economy (OR = 0.04, P < 0.001) had a significantly lower tendency to use inpatient care. Significantly, more OOPE occurred by individuals who were women (β = 0.18, P < 0.05) and with better household economy (β = 0.40, P < 0.001; β = 0.62, P < 0.001), whereas those who were covered by URBMI (β = -0.25, P < 0.05) and satisfied with their health (β = -0.21, P < 0.05) had less OOPE. Conclusion To prompt primary care visits and reduce economic burden among subgroups, more policy support is in need, such as tilting professional medical staff and funding to rural areas, enhancing awareness of disease prevention among vulnerable groups and so on.
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16
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Hou Y, Tao W, Hou S, Li W. Levels, trends, and determinants of effectiveness on the hierarchical medical system in China: Data envelopment analysis and bootstrapping truncated regression analysis. Front Public Health 2022; 10:921303. [PMID: 36203685 PMCID: PMC9530448 DOI: 10.3389/fpubh.2022.921303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/19/2022] [Indexed: 01/22/2023] Open
Abstract
Background The hierarchical medical system (HMS) refers to the classification of treatment according to disease priorities based on severity and difficulty to promote the fairness of medical services for residents, which is regarded as the key to the success of medical reform in China. Methods In the past decade of "New Medical Reform," the efficiency of HMS, including secondary and tertiary hospitals and primary healthcare centers (PHCs), was measured horizontally and vertically by employing the combination of an output-oriented superefficiency slack-based model-data envelopment analysis (SE-SBM-DEA) model with the Malmquist total factor productivity index (MTFP). In the second stage, the overall technical efficiency (OTE) scores were regressed against a set of environmental characteristics and several managerial factors through bootstrapping truncated regression. Results On average, the OTE score in tertiary hospitals was 0.93, which was higher than that in secondary hospitals and PHCs (0.9 and 0.92, respectively). In terms of trend, the OTE of tertiary hospitals declined at first and then increased. The opposite was true of secondary hospitals, in which the APC of the OTE was 10.82 and -3.11% in early and late 2012, respectively. The PHCs generally showed a fluctuating downward trend. In the aspects of productivity, all institutions showed a downturn by an annual average rate of 2.73, 0.51, and 2.70%, respectively. There was a significant negative relationship between the ratio of outpatients to inpatients and tertiary hospitals. Additionally, the medical technical personnel per 1,000 population negatively affected PHCs. In contrast, the GDP per capita had a significantly positive effect on tertiary hospitals, and the number of beds per 1,000 population positively influenced PHCs. Conclusion The efficiency of medical institutions at various levels in HMS was unbalanced and took the form of an "inverted pyramid." Multilateral factors influence the efficiency of HMS, and to address it, multi-intervention packages focusing on sinking high-quality medical resources and improving healthcare capacity, and guiding hierarchical medical practice should be adopted.
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Affiliation(s)
- Yuanxin Hou
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, China
| | - Wenjuan Tao
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, China
| | - Shufen Hou
- Department of Critical Care Medicine, Chongqing University Three Gorges Hospital, Chongqing, China
| | - Weimin Li
- President's Office, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Weimin Li
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17
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Arsyad DS, Hamsyah EF, Qalby N, Qanitha A, Westerink J, Cramer MJ, Visseren FLJ, Doevendans PA, Ansariadi A. The readiness of public primary health care (PUSKESMAS) for cardiovascular services in Makasar city, Indonesia. BMC Health Serv Res 2022; 22:1112. [PMID: 36050732 PMCID: PMC9436735 DOI: 10.1186/s12913-022-08499-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/24/2022] [Indexed: 11/25/2022] Open
Abstract
Backgrounds The increasing burden of cardiovascular disease (CVD) has become a major challenge globally, including in Indonesia. Understanding the readiness of primary health care facilities is necessary to confront the challenge of providing access to quality CVD health care services. Our study aimed to provide information regarding readiness to deliver CVD health services in public primary health care namely Puskesmas. Methods The study questionnaire was adapted from the World Health Organization (WHO) Service Availability and Readiness Assessment (SARA), modified based on the package of essentials for non-communicable disease (PEN) and the Indonesian Ministry of health regulation. Data were collected from all Puskesmas facilities (N = 47) located in Makassar city. We analysed relevant data following the WHO-SARA manual to assess the readiness of Puskesmas to deliver CVD services. Human resources, diagnostic capacity, supporting equipment, essential medication, infrastructure and guidelines, and ambulatory services domain were assessed based on the availability of each tracer item in a particular domain. The mean domain score was calculated based on the availability of tracer items within each domain. Furthermore, the means of all domains’ scores are expressed as an overall readiness index. Higher scores indicate greater readiness of Puskesmas to deliver CVD-related health care. Results Puskesmas delivers health promotion, disease prevention, and prompt diagnosis for cardiovascular-related diseases, including hypertension, diabetes, coronary heart disease (CHD), and stroke. Meanwhile, basic treatments were observed in the majority of the Puskesmas. Long-term care for hypertension and diabetes patients and rehabilitation for CHD and stroke were only observed in a few Puskesmas. The readiness score of Puskesmas to deliver CVD health care ranged from 60 to 86 for. Furthermore, there were 11 Puskesmas (23.4%) with a score below 75, indicating a sub-optimal readiness for delivering CVD health services. A shortage of essential medicines and a low capacity for diagnostic testing were the most noticeable shortcomings leading to suboptimal readiness for high-quality CVD health services. Conclusion Close cooperation with the government and other related stakeholders is required to tackle the identified shortcomings, especially the continuous monitoring of adequate supplies of medicines and diagnostic tools to achieve better CVD care for patients in Indonesia. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08499-w.
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Affiliation(s)
- Dian Sidik Arsyad
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, 3584, CT, Utrecht, The Netherlands. .,Department of Epidemiology, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia.
| | - Esliana Fitrida Hamsyah
- Department of Epidemiology, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
| | - Nurul Qalby
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, 3584, CT, Utrecht, The Netherlands.,Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | | | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten J Cramer
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, 3584, CT, Utrecht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Ansariadi Ansariadi
- Department of Epidemiology, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
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Horizontal Integration and Financing Reform of Rural Primary Care in China: A Model for Low-Resource and Remote Settings. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148356. [PMID: 35886206 PMCID: PMC9323543 DOI: 10.3390/ijerph19148356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/28/2022] [Accepted: 07/07/2022] [Indexed: 02/06/2023]
Abstract
Primary health care (PHC) systems are compromised by under-resourcing and inadequate governance, and fail to provide high-quality health care services in most low- and middle-income countries (LMICs). As a response to solve the problems of underfunding and understaffing, Pengshui County, an impoverished area in rural Chongqing, China, implemented a profound reform of its PHC delivery system in 2009, focusing on horizontal integration and financing mechanisms. This paper aims to present new evidence from the Pengshui model, and to assess the relevant changes over the past 10 years (2009–2018). An inductive approach was adopted, based on analysis of national and local policy documents and administrative data. From 2009 to 2018, the proportion of outpatients who sought first-contact care in rural community or township health centers increased from 29% (522,700 of 1,817,600) in 2009, to 40% (849,900 of 2,147,800) in 2018 (the national average in 2018 was 23%). Our findings suggest that many positive results have been achieved through the reform, and that innovations in financial governance and incentive mechanisms are the main driving forces behind the improvement. Pengshui County’s experience has proven to be a successful experiment, particularly in rural and low-income areas.
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Clarke-Deelder E, Afriyie DO, Nseluke M, Masiye F, Fink G. Health care seeking in modern urban LMIC settings: evidence from Lusaka, Zambia. BMC Public Health 2022; 22:1205. [PMID: 35710372 PMCID: PMC9202228 DOI: 10.1186/s12889-022-13549-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/24/2022] [Indexed: 11/15/2022] Open
Abstract
Background In an effort to improve population health, many low- and middle-income countries (LMICs) have expanded access to public primary care facilities and removed user fees for services in these facilities. However, a growing literature suggests that many patients bypass nearby primary care facilities to seek care at more distant or higher-level facilities. Patients in urban areas, a growing segment of the population in LMICs, generally have more options for where to seek care than patients in rural areas. However, evidence on care-seeking trajectories and bypassing patterns in urban areas remains relatively scarce. Methods We obtained a complete list of public health facilities and interviewed randomly selected informal sector households across 31 urban areas in Lusaka District, Zambia. All households and facilities listed were geocoded, and care-seeking trajectories mapped across the entire urban area. We analyzed three types of bypassing: i) not using health centers or health posts for primary care; ii) seeking care outside of the residential neighborhood; iii) directly seeking care at teaching hospitals. Results A total of 620 households were interviewed, linked to 88 health facilities. Among 571 adults who had recently sought non-emergency care, 65% sought care at a hospital. Among 141 children who recently sought care for diarrhea, cough, fever, or fast breathing, 34% sought care at a hospital. 71% of adults bypassed primary care facilities, 26% bypassed health centers and hospitals close to them for more distant facilities, and 8% directly sought care at a teaching hospital. Bypassing was also observed for 59% of children, who were more likely to seek care outside of the formal care sector, with 21% of children treated at drug shops or pharmacies. Conclusions The results presented here strongly highlight the complexity of urban health systems. Most adult patients in Lusaka do not use public primary health facilities for non-emergency care, and heavily rely on pharmacies and drug shops for treatment of children. Major efforts will likely be needed if the government wants to instate health centers as the principal primary care access point in this setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13549-3.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Doris Osei Afriyie
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Mweene Nseluke
- Directorate of Clinical Care and Diagnostic Services, Ministry of Health, Lusaka, Zambia
| | - Felix Masiye
- Department of Economics, University of Zambia, Lusaka, Zambia
| | - Günther Fink
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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20
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Zhang JG, Wang H, Gu XF, Wang XY, Wang WJ, Du LB, Cao HL, Zhang X, Shi JH, Zhao YQ, Ma L, Liu YY, Huang JX, Cao J, Fan YP, Li L, Feng CY, Zhu Q, Du JC, Wang XH, Han BB, Qiao YL. Status and associated factors of cross-regional healthcare-seeking among patients with advanced colorectal cancer in China: a multicenter cross-sectional study. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:342. [PMID: 35433943 PMCID: PMC9011287 DOI: 10.21037/atm-22-1003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/21/2022] [Indexed: 11/06/2022]
Abstract
Background The imbalanced allocation of medical resources leads to the occurrence of cross-regional healthcare-seeking in China. Due to the low cure rate, advanced colorectal cancer (CRC) patients may seek cross-regional healthcare for high-level medical facilities. Investigating status of cross-regional healthcare-seeking and its associated factors among advanced CRC patients is important for policymakers to understand access to health services and improve the quality of oncology services. Methods From March 2020 to March 2021, a cross‑sectional, nation-wide, hospital-based, multi-center survey was conducted. Nineteen hospitals in seven regions were selected by multi-stage stratified sampling. All eligible CRC patients in the selected hospitals were invited to participate in the current study. The outcome variable, cross-regional healthcare-seeking, was defined as seeking health facilities outside the local administration policy of medical insurance. The demographics, clinical information, and medical treatment history of each eligible CRC patient in stage III or IV, were collected through the patients' self-reporting or medical records by trained interviewers. Univariate and multivariate logistic analyses were used to explore the associated factors of cross-regional healthcare-seeking. All statistical analyses were conducted using SAS 9.4. Results A total of 4,589 individuals with advanced CRC were included. The average age of the patients was 60.1±11.6 years, and 59.5% were males. About 37.5% of the patients suffered from metastatic CRC at first diagnosis. Approximately 36.5% of the patients had sought cross-regional health care previously, and among them, 31.9% had encountered problems. The most common problems included complicated procedures (95.3%), unreimbursed expenses of outpatient service (71.0%), and reimbursement delay (59.4%). Logistic regression analysis showed that patients who completed undergraduate or above [odds ratio (OR) =1.40, 95% confidence interval (CI): 1.13-1.73], had an annual household income of more than 100,000 Chinse Yuan (CNY) (OR =1.46, 95% CI: 1.21-1.78), and had metastasis at diagnosis (OR =1.33, 95% CI: 1.18-1.51) were more likely to seek cross-regional health care. Conclusions About one third of advanced CRC patients seek cross-regional health care, and 31.9% had encountered problems. There is a need to simplify procedures of reimbursement, optimize direct settlement system and referral mechanisms in order to improve the equality of health services.
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Affiliation(s)
- Jian-Gong Zhang
- Department of Cancer Epidemiology, Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Henan Engineering Research Center of Cancer Prevention and Control, Henan International Joint Laboratory of Cancer Prevention, Zhengzhou, China
| | - Hong Wang
- Department of Cancer Epidemiology, Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Henan Engineering Research Center of Cancer Prevention and Control, Henan International Joint Laboratory of Cancer Prevention, Zhengzhou, China
| | - Xiao-Fen Gu
- Department of Student Affairs, Affiliated Tumor Hospital, Xinjiang Medical University, Ürümqi, China
| | - Xiao-Yang Wang
- Department of Cancer Epidemiology, Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Henan Engineering Research Center of Cancer Prevention and Control, Henan International Joint Laboratory of Cancer Prevention, Zhengzhou, China
| | - Wen-Jun Wang
- School of Nursing, Jining Medical University, Jining, China
| | - Ling-Bin Du
- Department of Cancer Prevention, The Cancer Hospital of the University of Chinese Academy of Sciences, Zhejiang Cancer Hospital, Hangzhou, China
| | - He-Lu Cao
- Department of Preventive Health, Xinxiang Central Hospital, Xinxiang, China
| | - Xi Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital & Institute, Beijing, China
| | - Ji-Hai Shi
- The Clinical Epidemiology of Research Center, Department of Dermatological, The First Affiliated Hospital of Baotou Medical College, Baotou, China
| | - Yu-Qian Zhao
- Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li Ma
- Public Health School, Dalian Medical University, Dalian, China
| | - Yun-Yong Liu
- Liaoning Office for Cancer Control and Research, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China
| | - Juan-Xiu Huang
- Department of Gastroenterology, Wuzhou Red Cross Hospital, Wuzhou, China
| | - Ji Cao
- Department of Cancer Prevention and Control Office, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yan-Ping Fan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Li Li
- Department of Clinical Research, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Chang-Yan Feng
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
| | - Qian Zhu
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Jing-Chang Du
- School of Public Health, Chengdu Medical College, Chengdu, China
| | - Xiao-Hui Wang
- Department of Public Health, Gansu Provincial Cancer Hospital, Lanzhou, China
| | - Bin-Bin Han
- Department of Cancer Epidemiology, Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Henan Engineering Research Center of Cancer Prevention and Control, Henan International Joint Laboratory of Cancer Prevention, Zhengzhou, China
| | - You-Lin Qiao
- Department of Cancer Epidemiology, Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Henan Engineering Research Center of Cancer Prevention and Control, Henan International Joint Laboratory of Cancer Prevention, Zhengzhou, China.,Center for Global Health, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Yin S, Hu M, Chen W. Quality Perceptions and Choice of Public Health Facilities: A Mediation Effect Analysis of Outpatient Experience in Rural China. Patient Prefer Adherence 2022; 16:2089-2102. [PMID: 35983546 PMCID: PMC9381010 DOI: 10.2147/ppa.s370805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 08/02/2022] [Indexed: 01/10/2023] Open
Abstract
PURPOSE Outpatients have choices of providers in the hierarchical health service delivery system of China. Understanding how quality perceptions and outpatient experience affect the choice of health facility would help inform decisions about priorities for action aimed at guiding the use of primary care. This study examines how quality perceptions of outpatient service affect the facility level choice in rural China. METHODS Household surveys were conducted in 2011, 2012 and 2015 in Ningxia Hui Autonomous Region, China. We selected 968 respondents as the study sample, who had at least two outpatient visits to the public health facilities during each survey period. Prior quality perceptions of the outpatient service at the village clinics, township centers, and county hospitals were reported on an 8-item Quality Indicator questionnaire. Experienced quality perception from the first outpatient visit was also reported. The outcome of interest was outpatients' facility level choices. We used regression and mediation analysis to explore whether and how outpatient experience at a specific health facility would mediate the relationship between prior quality perceptions and the facility level choice. RESULTS Overall, the quality perception was positively and significantly associated with outpatients' staying at the same or lower levels of care (β=0.265, P=0.007). This effect was fully mediated by experienced quality perception (z=2.985, P=0.003). The indirect effect was significant for three particular dimensions, including quality perceptions of the environment (β=0.075, P=0.025), doctor-patient communication (β=0.065, P=0.022), and physician ability (β=0.062, P=0.021). CONCLUSION Outpatient quality perceptions-especially positive perceptions regarding environment, doctor-patient communication, and physician ability-could contribute to minimizing upward referral via improvement in outpatient experience. Policymakers and health care providers may need to therefore optimize outpatient experience as they push to develop a more locally responsive primary care system.
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Affiliation(s)
- Shuying Yin
- Department of Health Economics, School of Public Health, Fudan University, Shanghai, People’s Republic of China
- Research Department I, Shenzhen Health Development Research and Data Management Center, Shenzhen, People’s Republic of China
| | - Min Hu
- Department of Health Economics, School of Public Health, Fudan University, Shanghai, People’s Republic of China
| | - Wen Chen
- Department of Health Economics, School of Public Health, Fudan University, Shanghai, People’s Republic of China
- Correspondence: Wen Chen; Min Hu, The Department of Health Economics, School of Public Health, Fudan University, No. 187 Box, 138 Yixueyuan Road, Xuhui District, Shanghai, 200032, People’s Republic of China, Tel +86 13818325486; +86 17717031079, Email ;
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Correia LL, Machado MMT, Araújo DABS, Gomes YVC, Pinheiro MSN, Rocha HAL, Nogueira DL, Sousa GDSD, Farias-Antuñez S, Castro MC. Primary Health Care during the COVID-19 pandemic in Fortaleza, Brazil: associated factors and pattern of use by mothers and children up to 18 months of age. REVISTA BRASILEIRA DE EPIDEMIOLOGIA 2022; 25:e220036. [DOI: 10.1590/1980-549720220036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022] Open
Abstract
ABSTRACT Objective: To analyze the delay or failure to seek primary health care by the mother-child dyads during the COVID-19 pandemic, a practice that has a high potential to increase maternal and child morbidity and mortality. Methods: Data from three survey rounds of the Iracema-COVID cohort study, collected 6, 12, and 18 months after birth, showed the patterns of postpartum attendance to primary health care consultation of the mother-child dyad. Crude and adjusted multinomial logistic regressions with robust variance were used to assess factors associated with nonattendance. Results: Among the 314 cohort mothers, 25% did not attend any primary health care consultation during the 18-months postpartum, while 30% of the mothers did all three. Regarding the child, 75% had regular primary health care consultations in all three survey rounds, while 4% did not attend any in their first 18 months of life. By the end of the first COVID-19 wave, the proportion of mother and child who attended the consultations had fallen by 23 and 18%, respectively. The main factors associated with nonattendance were mothers aged below 25 years, and mothers with more than one child. Conclusion: An important delay or nonattendance to primary health care consultation by the mother-child dyad was observed during the COVID-19 pandemic. Such practice, with a high potential to increase maternal and child morbidity and mortality, was particularly frequent among younger mothers and those with more than one child.
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