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

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.

Equity and Efficiency of Health Resource Allocation of Chinese Medicine in Mainland China: 2013-2017

Background: In this study, we aimed to estimate the equity and efficiency of traditional Chinese medicine (TCM) health resource allocation, utilization, and trend in mainland China from 2013 to 2017. Methods: The data were downloaded from the China Health Statistical Yearbook (2014-2018) and the China Statistical Yearbook (2018). The equity of TCM health resource allocation was evaluated through the Lorenz curve, Gini coefficient (G), and Theil index (T) based on population size and geographical area. The efficiency and productivity of TCM health resource utilization were assessed using the data envelopment analysis-based Malmquist productivity index. Results: TCM health resource had an increasing trend every year. The equity allocated by population (G ranging from 0.1 to 0.3) was better than that by geographic region (G > 0.5). T in the intra-groups was higher than those in the inter-groups. The equity of TCM resource allocation was the middle region > eastern region > western region. Most provinces (29 out of 31) had negative productivity changes, suggesting deterioration in productivity. Moreover, the middle region with higher scale sizes had more redundant inputs than the other two regions. However, the low technological development (all technical values <1) might hinder productive progress. Conclusion: The equity of TCM health allocated by the population was better than that by the geographic region. The intra-regional difference was the main reason for inequity sources. Productivities in more than 97% of provinces are inefficient. The frequency distribution of scale efficiency (score > 1) had increased since 2015. However, the frequency distribution of technical change (score > 1) decreased every year. The slow technological progress and low scale size might be the main reasons for low productivity.

Rebuild doctor-patient trust in medical service delivery in China

Doctor–patient trust is not strong in China, but studies examining this factor remain insufficient. The present study aimed to explore the effect of doctor–patient communication, medical service quality, and service satisfaction on patient trust in doctors. Five hundred sixty-four patients with tuberculosis participated in this cross-sectional study in Dalian, China. They completed questionnaires assessing socio-demographic characteristics, doctor–patient communication, medical service quality, service satisfaction and patient trust in medical staff. A structural equation model was applied to examine the hypotheses, and all the study hypotheses were supported: (1) doctor–patient communication, medical service quality and service satisfaction were positively associated with building doctor–patient trust; (2) service quality positively mediated the relationship between doctor–patient communication and trust; (3) medical service satisfaction positively mediated the relationship between doctor–patient communication and trust; (4) medical service satisfaction positively mediated the relationship between medical service quality and doctor–patient trust; and (5) medical service quality and service satisfaction were the positively sequential mediators between communication and doctor–patient trust. Based on these findings, improvements in doctor–patient communication, medical service quality, and service satisfaction are the important issues contributing to the rebuilding of doctor–patient trust in medical service delivery.

A Tale of Transition: Trends of Catastrophic Health Expenditure and Impoverishment in Urban China, 1986-2009

From 1986 to 2009, China's health system reform first adopted a market-oriented approach and later reemphasized the role of the government starting from 2002. China's oscillating health care financing policies present us a unique opportunity to examine the consequences of government-led financing and market-oriented financing measures. This study uses the Urban Household Survey, a diary data in China that covers the period of 1986 to 2009, to examine the long-run trends in the incidence and intensity of catastrophic health expenditure and medical impoverishment. Four major findings emerge. First, the incidence and intensity of catastrophic health expenditure in urban Chinese households increased rapidly between 1986 and 2002, whereas they stabilized after 2002. Second, the incidence of medical impoverishment and its depth in the poverty gap remained stable before 2002 and decreased rapidly after 2002. Third, income and regional inequality in measures of catastrophic health expenditure widened from 1986 to 2002. They narrowed in the 2000s but remain wide. Fourth, income and regional inequality in medical impoverishment remained unchanged between 1986 and 2002 and narrowed substantially after 2002. All these results suggest that China's two cycles of health care reform generated significantly different outcomes in financial protection, holding lessons for the ongoing health care reform in China and other countries.

How Can One Strengthen a Tiered Healthcare System through Health System Reform? Lessons Learnt from Beijing, China

How one can reshape the current healthcare sector into a tiered healthcare system with clarified division of functions between primary care facilities and hospitals, and improve the utilization of primary care, is a worldwide problem, especially for the low and middle-income countries (LMICs). This paper aimed to evaluate the impact of the Beijing Reform on healthcare-seeking behavior and tried to explain the mechanism of the change of patient flow. In this before and after study, we evaluated the changes of outpatient visits and inpatient visits among different levels of health facilities. Using the monitored and statistical data of 373 healthcare institutions 1-year before and 1-year after the Beijing Reform, interrupted time series analysis was applied to evaluate the impact of the reform on healthcare-seeking behavior. Semi-structured interviews were used to further explore the mechanisms of the changes. One year after the reform, the flow of outpatients changed from tertiary hospitals to community health centers with an 11.90% decrease of outpatients in tertiary hospitals compared to a 15.01% increase in primary healthcare facilities. The number of ambulatory care visits in primary healthcare (PHC) showed a significant upward trend (P < 0.10), and the reform had a significant impact on the average number of ambulatory care visits per institution in Beijing's tertiary hospitals (p < 0.10). We concluded that the Beijing Reform has attracted a substantial number of ambulatory care visits from hospitals to primary healthcare facilities in the short-term. Comprehensive reform policies were necessary to align incentives among relative stakeholders, which was a critical lesson for other provinces in China and other LMICs.

Impact of the Family Environment on the Emotional State of Medical Staff During the COVID-19 Outbreak: The Mediating Effect of Self-Efficacy

During the outbreak of the coronavirus disease 2019 (COVID-19), the medical staff was facing severe work pressure, which led to a negative emotional state. The purpose of this study was to explore the relationship between the family environment and the emotional state of the medical staff members during the COVID-19 outbreak. Due to the importance of self-efficacy in regulating mental health, the mediating role of self-efficacy in the association between family environment and emotional state was also explored. A cross-sectional survey was performed, using an online questionnaire, on 645 medical staff who participated in the epidemic prevention and control tasks during the COVID-19 outbreak in Beijing. Family environment, self-efficacy, anxiety, and depressive symptoms were measured by the Family Environment Scale-Chinese Version (FES-CV), the General Self-Efficacy Scale (GSES), the Generalized Anxiety Disorder Scale-7 (GAD-7), and the Patient Health Questionnaire-9 (PHQ-9), respectively. Correlation analysis and mediating effect analysis were used to explore the relationships between them. First, a higher prevalence of anxiety (39%) and depressive (33%) symptoms were confirmed among the medical staff. Second, the symptoms of anxiety and depression were negatively correlated with the dimensions of cohesion and expressiveness and positively correlated with the dimensions of conflict in the FES-CV scale. Third, self-efficacy significantly mediated the association between the family environment and anxiety symptoms (P < 0.001) as well as the family environment and depressive symptoms (P < 0.001). These findings show that a negative family environment was the main predictor of symptoms of anxiety and depression in the medical staff during the COVID-19 outbreak. Furthermore, we found that self-efficacy played a critical mediating role between the family environment and the symptoms of anxiety and depression. Our study also indicates that improvements in the family environment benefit the mental health care of the medical staff, and high self-efficacy enhances this effect.

Realigning the provider payment system for primary health care: a pilot study in a rural county of Zhejiang Province, China

Aim:

This work aimed to evaluate a pre/post-reform pilot study from 2015 to 2018 in a rural county of Zhejiang Province, China to realign the provider payment system for primary health care (PHC).

Methods:

Data were extracted from the National Health Financial Annual Reports for the 21 township health centers (THCs) in Shengzhou County. An information system was designed for the reform. Differences among independent groups were assessed using Kruskal–Wallis H-test. Dunn’s post hoc test was used for multiple comparisons. Differences between paired groups were tested by Wilcoxon signed-rank test. Two-tailed P < 0.05 indicated statistical significance. Data were processed and analyzed using R 3.6.1 for Windows.

Findings:

First, payments to THCs shifted from a “soft budget” to a mixed system of line-item input-based and categorized output-based payments, accounting for 17.54% and 82.46%, respectively, of total revenue in 2017. Second, providers were more motivated to deliver services after the reform; total volumes increased by 27.80%, 19.22%, and 30.31% for inpatient visits, outpatient visits, and the National Essential Public Health Services Package (NEPHSP), respectively. Third, NEPHSP payments were shifted from capitation to resource-based relative value scale (RBRVS) payments, resulting in a change in the NEPHSP subsidy from 36.41 to 67.35 per capita among the 21 THCs in 2017. Fourth, incentive merit pay to primary health physicians accounted for 38.40% of total salary, and the average salary increased by 32.74%, with a 32.45% increase in working intensity. A small proportion of penalties for unqualified products and pay-for-performance rewards were blended with the payments. The reform should be modified to motivate providers in remote areas.

Conclusion:

In the context of a profit-driven, hospital-centered system, add-on payments – including categorized output-based payments to THCs and incentive merit pay to primary care physicians (PCPs) – are probably worth pursuing to achieve more active and output/outcome-based PHC in China.

CAN THE “TAX THE RICH, SUBSIDISE THE POOR” POLICY IMPROVE FINANCIAL SATISFACTION AMONG MALAYSIANS?

“Tax the rich, subsidise the poor” is deemed one of the typical finance characteristics of democracy and a solution in reducing income inequality. The Malaysian government has also adopted this strategy in its income redistribution policy. Evidently, this strategy can minimise the income gaps at the country level. However, it is doubtful if it can be effectively done at the individual level. The rich have to pay more while the poor can enjoy the ‘free’ income. Would that lead to financial satisfaction? Hence, the main objective of this study was to investigate the impact of individual perceptions on the government’s democratic act in implementing "tax the rich, subsidise the poor" policy for financial satisfaction among Malaysians. For an empirical analysis, this paper discusses the study conducted which used the sixth wave of the World Value Survey (WVS) data with 1290 respondents and is regressed by the ordered logit and ordered probit modelling. The results indicated that the democratic act of ‘taxing the rich and subsidising the poor’ in reality reduces financial satisfaction among Malaysians. In contrast, these same Malaysians wish for a larger income difference as an incentive for individual efforts. In view of this, the government and policy makers should make revisions to the current progressive taxation system or look for other alternative taxation systems which may be seen as fairer and can improve financial satisfaction among Malaysians at each income level.

The Mixed Effect of China's New Health Care Reform on Health Insurance Coverage and the Efficiency of Health Service Utilisation: A Longitudinal Approach

In 2009, China launched a new health care reform as it endeavoured to develop a tiered system of disease diagnosis and treatment to promote the integration of medical resources. This was important for improving service capacity and building medical alliances that would eventually lead to improved health service utilisation efficiency. However, while the 2009 reform aimed to provide universal health insurance coverage to all citizens, its overall effect on health service utilisation efficiency remains unclear. We aimed to examine the new health care reform's mixed effect by applying a longitudinal study using China Health and Nutrition Survey (CHNS) data and the difference-in-difference (DID) method to estimate the health reform's impact on health insurance coverage rate. Then, we studied whether the increase in health insurance coverage rate affected health service utilisation efficiency in China. Our results showed that the increase in insurance coverage rate has indeed made expensive medical services available to low-income individuals. However, it also increased the likelihood of use of hospitals rather than primary care facilities, since there is more insurance cover for outpatient visits, which has led to an increased demand for quality services. This effect has generated a negative impact on health care utilisation which directly pertains to systemic inefficiency. This study thus indicates that China's latest health reform requires further policies to improve its overall efficiency.