Health service delivery in China: a literature review

Effects of the National Essential Medicine System in reducing drug prices: an empirical study in four Chinese provinces

OBJECTIVES

The rapid increase in drug expenditure has become a major source of public criticism in China. In 2009, the National Essential Medicine System (NEMS) was launched in China to control drug prices and improve access to medicines. This study investigated whether and to what extent the prices of essential medicines were reduced after the introduction of NEMS.

METHODS

Data were obtained from 149 public primary healthcare centers (PHCs) in four Chinese provinces (Shandong, Zhejiang, Anhui and Ningxia) using a facility-based survey. In total, 10,988 essential medicines were investigated. Individual price differences and a price index were used to measure price changes for three different lists: 2009-2010, 2010-2011, and 2009-2011.

RESULTS

In the comparison between 2009 and 2010, a median decrease of 34.4% [95% confidence interval: 30.4%-39.1%] was observed in drug prices and the number of drug sales increased by 1.5%. The higher the retail price in 2010, the more the drug sales increased compared with 2009 (χ (2) = 75.9, p < 0.01). The drug revenues in 100 of the 149 surveyed PHCs decreased by an average of 39%. Where the available data allowed price changes for 2009-2011 to be assessed, drug prices were reduced significantly in 2010, but a modest decrease was seen in 2011. The Laspeyres index was less than 100 and the Paasche index was larger than the Laspeyres index in 2010 and 2011, which indicated that the frequently prescribed drugs usually had higher prices and any price reduction was milder.

CONCLUSIONS

The introduction of NEMS in PHCs in China led to price reductions in essential medicines. However, more-expensive drugs were preferred in the postreform period. Most PHCs had less drug revenue and could encounter financing dilemmas after the implementation of NEMS. Policy options such as improving the compensation mechanism and rational use of drugs should be further promoted in PHCs.

Network Relations and Boundary Spanning: Understanding the Evolution of E-Ordering in the Chinese Drug Distribution Industry

The application of e-ordering systems has brought significant changes to the drug distribution industry in China, but the effects of these changes have remained unclear. Adopting a practice perspective and based on longitudinal data collection using multiple methods, we reveal that the Chinese drug distribution practice has passed through the following three stages: the stage before e-ordering, the transitional stage in which the government attempted to impose a centralised platform, and the current fragmented systems stage. We draw upon the theoretical foundations of the network relations model and the boundary spanning theory developed by Schultze and Orlikowski and Levina and Vaast, respectively, to formulate a taxonomic framework for understanding inter-firm network practices. Applying the framework to explain long-term changes in drug distribution in China, we discover that the practice in the field has evolved from traditional, socially embedded relations to information systems-based, socially embedded relations, while the centralised platform deployed by the government was unable to establish a practice with arm's length relations. Our theoretical work contributes an integrated framework for studying inter-firm practices that explicitly incorporates the presence of inter-organisational information systems. Our empirical findings offer helpful practical insights for facilitating collective efforts toward the innovative use of novel IT in the drug distribution industry in China and in other contexts that are similar.

Addressing Antibiotic Abuse in China: An Experimental Audit Study

China has high rates of antibiotic abuse and antibiotic resistance but the causes are still a matter for debate. Strong physician financial incentives to prescribe are likely to be an important cause. However, patient demand (or physician beliefs about patient demand) is often cited and may also play a role. We use an audit study to examine the effect of removing financial incentives, and to try to separate out the effects of patient demand. We implement a number of different experimental treatments designed to try to rule out other possible explanations for our findings. Together, our results suggest that financial incentives are the main driver of antibiotic abuse in China, at least in the young and healthy population we draw on in our study.

China's distinctive engagement in global health

China has made rapid progress in four key domains of global health. China's health aid deploys medical teams, constructs facilities, donates drugs and equipment, trains personnel, and supports malaria control mainly in Africa and Asia. Prompted by the severe acute respiratory syndrome (SARS) outbreak in 2003, China has prioritised the control of cross-border transmission of infectious diseases and other health-related risks. In governance, China has joined UN and related international bodies and has begun to contribute to pooled multilateral funds. China is both a knowledge producer and sharer, offering lessons based on its health accomplishments, traditional Chinese medicine, and research and development investment in drug discovery. Global health capacity is being developed in medical universities in China, which also train foreign medical students. China's approach to global health is distinctive; different from other countries; and based on its unique history, comparative strength, and policies driven by several governmental ministries. The scope and depth of China's global engagement are likely to grow and reshape the contours of global health.

Cesarean section in Shanghai: women's or healthcare provider's preferences?

BACKGROUND

Cesarean section (CS) rate has increased rapidly over the past two decades in China mainly driven by non-medical factors. This study was to compare recalled preferences for CS among first-time mothers in early and late pregnancy with actual delivery mode; to explore factors related to CS preference and CS performed without medical indications; and to consider the role of healthcare providers in delivery mode preferences.

METHODS

An anonymous questionnaire survey, combined with data on CS indications taken from the patient record, was conducted among 272 first-time mothers having their first postnatal check-up in one university affiliated obstetrics and gynecology hospital in Shanghai, China, between September 2006 and January 2007. Logistic regression was used to study factors related to the recalled preference for CS and CS performed without medical indication, adjusting for maternal age, education and income.

RESULTS

The CS rate was 57% (151/263) among all women, 17% with medical indications and 40% without medical indications. For women without medical indications for CS (n = 215), there was no significant difference between women's preference for CS in early (25%) and late pregnancy (28%); 48% of women actually had CS. Women recalled preferring a vaginal delivery but who had CS were more likely to have had a CS suggested by a prenatal care doctor [OR (95% CI): 20 (3.88-107.1)] or by a delivery obstetrician [OR (95% CI): 26 (6.26-105.8)]. Among women recalled preferring and having CS, a suggestion from the prenatal care doctor to have CS was very common.

CONCLUSIONS

In the primiparous women without a medical indication for CS, women recall of a provider suggestion for CS was a strong predictor of CS both among women who recalled a preference for CS and among women who recalled a preference for vaginal delivery. Public health education needs strengthening, including discussion of the risks associated with CS and psychological and social support given to women to help them prepare for and cope with childbirth.

A tale of two cities: understanding the differences in medical professionalism between two Chinese cultural contexts

PURPOSE

To compare stakeholders' constructs of medical professionalism in two Chinese cultural contexts.

METHOD

Between November and December 2011, the authors adopted the nominal group technique (NGT) to elicit professional competencies valued by 97 medical education stakeholders at Peking Union Medical College (PUMC) in Beijing, China. Participants categorized the professional competencies according to an existing framework developed at National Taiwan University College of Medicine (NTUCM) in Taipei, Taiwan; they also modified and developed new categories for the framework. The authors analyzed NGT transcripts to construct a visual medical professionalism framework for PUMC and compared it with that of NTUCM.

RESULTS

The Chinese stakeholders endorsed seven of the eight competencies identified in the Taiwanese framework: clinical competence, communication, ethics, humanism, excellence, accountability, and altruism. For the eighth competency, integrity, the Chinese participants preferred the term "morality." They also added the competencies of teamwork, self-management, health promotion, and economic considerations. Both frameworks differed from typical Western professionalism frameworks in emphasizing morality and the integration of social and personal roles.

CONCLUSIONS

The resemblance between the Chinese and Taiwanese frameworks in the prominence of morality and integrity suggests the influence of Confucianism. The exclusively Chinese articulations of teamwork, health promotion, and economic considerations appear to derive from social, political, and economic factors unique to Mainland China. This study demonstrates the dynamic influence of cultural values, social history, and health care systems on the construction of medical professionalism frameworks and calls for further research to adapt global frameworks to fit specific local contexts.

Doctors' compliance with national guidelines and clinical pathway on the treatment of tuberculosis inpatients in Hubei, China

RATIONALE, AIMS AND OBJECTIVES

The Ministry of Health in China has enacted a revised National Tuberculosis Control Program (NTP) guidelines and clinical pathway (CP) on new smear-positive pulmonary tuberculosis (TB) inpatients to improve the quality of TB care and asked doctors' compliance to them on the treatment of TB inpatients. However, it remains unknown whether doctors adhere to them well. So this study focuses on evaluating the doctors' compliance with them in one representative TB hospital for medical quality improvement.

METHODS

A hospital-based retrospective study involving all medical records of newly diagnosed smear-positive pulmonary TB inpatients from July 2011 to July 2013. Analysis indicators including adequate drug regimens rate, adequate drug dosages rate and adequate length of hospital stay rate were chosen to assess doctors' compliance with NTP guidelines and CP on the treatment of new smear-positive pulmonary TB inpatients. The optimal value of these indicators is 100%.

RESULTS

Of the 334 inpatients selected, the rate of adequate drug regimens prescribed is 26.95% (90/334), and the rate of adequate drug dosages is 0% (0/90). For the dosage of single drug, the rates of adequate dosage of isoniazid, rifampicin, pyrazinamide and ethambutol are 24.44% (22/90), 85.56% (77/90), 70% (63/90) and 13.33% (12/90). Moreover, 75.56% (68/90) of isoniazid was prescribed too high and 83.34% (75/90) of ethambutol was prescribed too low. The rate of adequate length of hospital stay provided is 28.44% (95/334).

CONCLUSION

Doctors' compliance with NTP guidelines and CP on new smear-positive pulmonary TB inpatients is depressed and needs improvement.

Social determinants of community health services utilization among the users in China: a 4-year cross-sectional study

BACKGROUND

To identify social factors determining the frequency of community health service (CHS) utilization among CHS users in China.

METHODS

Nationwide cross-sectional surveys were conducted in 2008, 2009, 2010, and 2011. A total of 86,116 CHS visitors selected from 35 cities were interviewed. Descriptive analysis and multinomial logistic regression analysis were employed to analyze characteristics of CHS users, frequency of CHS utilization, and the socio-demographic and socio-economic factors influencing frequency of CHS utilization.

RESULTS

Female and senior CHS clients were more likely to make 3-5 and ≥6 CHS visits (as opposed to 1-2 visits) than male and young clients, respectively. CHS clients with higher education were less frequent users than individuals with primary education or less in 2008 and 2009; in later surveys, CHS clients with higher education were the more frequent users. The association between frequent CHS visits and family income has changed significantly between 2008 and 2011. In 2011, income status did not have a discernible effect on the likelihood of making ≥6 CHS visits, and it only had a slight effect on making 3-5 CHS visits.

CONCLUSION

CHS may play an important role in providing primary health care to meet the demands of vulnerable populations in China. Over time, individuals with higher education are increasingly likely to make frequent CHS visits than individuals with primary school education or below. The gap in frequency of CHS utilization among different economic income groups decreased from 2008 to 2011.

Population impact of a high cardiovascular risk management program delivered by village doctors in rural China: design and rationale of a large, cluster-randomized controlled trial

Background

The high-risk strategy has been proven effective in preventing cardiovascular disease; however, the population benefits from these interventions remain unknown. This study aims to assess, at the population level, the effects of an evidence-based high cardiovascular risk management program delivered by village doctors in rural China.

Methods

The study will employ a cluster-randomized controlled trial in which a total of 120 villages in five northern provinces of China, will be assigned to either intervention (60 villages) or control (60 villages). Village doctors in intervention villages will be trained to implement a simple evidence-based management program designed to identify, treat and follow-up as many as possible individuals at high-risk of cardiovascular disease in the village. The intervention will also include performance feedback as well as a performance-based incentive payment scheme and will last for 2 years. We will draw two different (independent) random samples, before and after the intervention, 20 men aged ≥ 50 years and 20 women aged ≥60 years from each village in each sample and a total of 9,600 participants from 2 samples to measure the study outcomes at the population level. The primary outcome will be the pre-post difference in mean systolic blood pressure, analyzed with a generalized estimating equations extension of linear regression model to account for cluster effect. Secondary outcomes will include monthly clinic visits, provision of lifestyle advice, use of antihypertensive medications and use of aspirin. Process and economic evaluations will also be conducted.

Discussion

This trial will be the first implementation trial in the world to evaluate the population impact of the high-risk strategy in prevention and control of cardiovascular disease. The results are expected to provide important information (effectiveness, cost-effectiveness, feasibility and acceptability) to guide policy making for rural China as well as other resource-limited countries.

Trial registration

The trial is registered at ClinicalTrials.gov (NCT01259700). Date of initial registration is December 13, 2010.

Payment reform and changes in health care in China

This paper is intended to assess the primary effects on cost, utilization and quality of care from payment reform of capitation and open enrollment in Changde city, Hunan Province of China. Open enrollment policy was introduced to deal with possible cream skimming associated with capitation. Based on the longitudinal Urban Resident Basic Medical Insurance (URBMI) Household Survey, this study analyses the URBMI data through a set of regression models. The original data included over five thousand inpatient admissions during the study period between 2008 and 2010. The study finds the payment reform to reduce its inpatient out-of-pocket cost by 19.7%, out-of-pocket ratio by 9.5%, and length of stay by 17.7%. However, the total inpatient cost, drug cost ratio, treatment effect, and patient satisfaction showed little difference between Fee-For-Service and capitation models. We conclude that the payment reform in Changde did not reduce overall inpatient expenditure, but it decreased the financial risk and length of stay of inpatient patients without compromising quality of care. The findings would contribute to the health care payment literatures from developing countries and open further research tracks on the ability of open enrollment to compensate for capitation drawbacks.

Integration of rural and urban healthcare insurance schemes in China: an empirical research

BACKGROUND

Despite the broad coverage of the healthcare insurance system in China, the imbalances in fairness, accessibility and affordability of healthcare services have hindered the universal healthcare progress. To provide better financial protection for the Chinese population, China's new medical reform was proposed to link up urban employee basic medical insurance scheme (UEBMI), urban resident basic medical insurance scheme (URBMI), new rural cooperative medical system (NRCMS) and urban and rural medical assistance programs. In this paper, we focused on people's expected healthcare insurance model and their willingness towards healthcare insurance integration, and we made a couple of relative policy suggestions.

METHODS

A questionnaire survey was conducted in four cities in China. A total of 1178 effective questionnaires were retrieved. Statistical analysis was conducted with SPSS and Excel. Chi-square test and logistic regression model were applied.

RESULTS AND DISCUSSION

The payment intention and reimbursement expectation of the three groups varied with NRCMS participants the lowest and UEBMI participants the highest. In economic developed areas, rural residents had equal or even stronger payment ability than urban residents, and the overall payment intention showed a scattered trend; while in less developed areas, urban residents had a stronger payment ability than rural residents and a more concentrated payment intention was observed. The majority of participants favored the integration, with NRCMS enrollees up to 80.5%. In the logistic regression model, we found that participants from less developed areas were more likely to oppose the integration, which we conceived was mainly due to their dissatisfaction with their local healthcare insurance schemes. Also the participants with better education background tended to oppose the integration, which might be due to their fear of benefit impairment and their concern about the challenges ahead.

CONCLUSION

Even though there are many challenges for healthcare insurance integration, it has received strong support from the mass population. However, more emphasis shall be put on equal financing and equal benefit when making further policies. As the current healthcare policies share the same design concept, principle and method, the ultimate goal of establishing a universal healthcare system is promising.

Survey using incognito standardized patients shows poor quality care in China's rural clinics

Over the past decade, China has implemented reforms designed to expand access to health care in rural areas. Little objective evidence exists, however, on the quality of that care. This study reports results from a standardized patient study designed to assess the quality of care delivered by village clinicians in rural China. To measure quality, we recruited individuals from the local community to serve as undercover patients and trained them to present consistent symptoms of two common illnesses (dysentery and angina). Based on 82 covert interactions between the standardized patients and local clinicians, we find that the quality of care is low as measured by adherence to clinical checklists and the rates of correct diagnoses and treatments. Further analysis suggests that quality is most strongly correlated with provider qualifications. Our results highlight the need for policy action to address the low quality of care delivered by grassroots providers.

Does economic incentive matter for rational use of medicine? China's experience from the essential medicines program

BACKGROUND

Before the new round of healthcare reform in China, primary healthcare providers could obtain a fixed 15 % or greater mark-up of profits by prescribing and selling medicines. There were concerns that this perverse incentive was a key cause of irrational medicine use. China's new Essential Medicines Program (EMP) was launched in 2009 as part of the national health sector reform initiatives. One of its core policies was to eliminate primary care providers' economic incentives to overprescribe or prescribe unnecessarily expensive drugs, which were regarded as consequences of China's traditional financing system for health institutions.

OBJECTIVES

The objective of the study was to measure changes in prescribing patterns in primary healthcare facilities after the removal of the economic incentives for physicians to overprescribe as a result of the implementation of the EMP.

METHODS

A comparison design was applied to 8,258 prescriptions in 2007 and 8,278 prescriptions in 2010, from 83 primary healthcare facilities nationwide. Indicators were adopted to evaluate medicine utilization, which included overall number of medicines, average number of Western and traditional Chinese medicines, pharmaceutical expenditure per outpatient prescription, and proportion of prescriptions that contained two or more antibiotics. We further assessed the use of medicines (antibiotics, infusion, hormones, and intravenous injection) per disease-specific prescription for hypertension, diabetes, coronary artery heart disease, bronchitis, upper respiratory tract infection, and gastritis. A difference-in-difference analysis was employed to evaluate the net policy effect.

RESULTS

Overall changes in indicators were not found to be statistically significant between the 2 years. The results varied for different diseases. The number of Western drugs per outpatient prescription decreased while that of traditional Chinese medicines increased. Overuse of antibiotics remained an extensive problem in the treatment of many diseases, though there was some significant improvement in certain diseases, like diabetes in rural areas. Medicine expenditure per prescription also decreased.

CONCLUSIONS

It seems that the removal of a perverse economic incentive alone would not lead to improvement of healthcare providers' prescribing patterns. The rationality of the Essential Medicines List and the lack of payers' and providers' meaningful involvement in the development of the policy possibly contribute to the lack of significant changes in prescribing behaviors. It is suggested that China should adopt more comprehensive policies for healthcare facilities, physicians, patients, and payers, rather than just relying on economic incentives to improve rational use of medicines.

Social Networks and Externalities from Gift Exchange: Evidence from A Field Experiment

This paper asks whether gift exchange generates externalities for people outside of the bilateral relationship between the gift giver and recipient, and whether the nature of this relationship is affected by social networks. We examine this question in the context of a field experiment in urban Chinese hospital outpatient clinics. We first show that when patients give a small gift, doctors reciprocate with better service and a fewer unnecessary prescriptions of antibiotics. We then show that gift giving creates externalities for third parties. If two patients, A and B are perceived as unrelated, B receives worse care when A gives a gift. However, if A identifies B as a friend, then both A and B benefit from A's gift giving. Hence, we show that gift giving can create positive or negative externalities, depending on the giver's social distance to the third party.

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

Background

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

Methodology

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

Principal Findings

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

Conclusions/Significance

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

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

Changes in health expenditures in China in 2000s: has the health system reform improved affordability

Background

China's health system reform launched in early 2000s has achieved better coverage of health insurance and significantly increased the use of healthcare for vast majority of Chinese population. This study was to examine changes in the structure of total health expenditures in China in 2000–2011, and to investigate the financial burden of healthcare placed on its population, particularly between urban and rural areas and across different socio-economic development regions.

Methods

Health expenditures data came from the China National Health Accounts study in 1990–2011, and other data used to calculate the financial burden of healthcare were from China Statistical Yearbook and China Population Statistical Yearbook. Total health expenditures were divided into government and social expenditure, and out-of-pocket payment. The financial burden of healthcare was estimated as out-of-pocket payment per capita as a percentage of annual household living consumption expenditure per capita.

Results

Between 2000 and 2011, total health expenditures in China increased from Chinese yuan 319 to 1888 (United States dollars 51 to 305), with average annual increase of 17.4%. Government and social health expenditure increased rapidly being 22.9% and 18.8% of average annual growth rate, respectively. The share of out-of-pocket payment in total health expenditure for the urban population declined from 53% in 2005 to 36% in 2011, but had only a slight decrease for the rural population from 53% to 50%. Out-of-pocket payment, as a percentage of annual household living consumption, has continued to rise, particularly in the rural population from the less developed region (6.1% in 2000 to 8.8% in 2011).

Conclusions

The rapid increase of public funding to subsidize health insurance in China, as part of the reform strategy, did not mitigate the out-of-pocket payment for healthcare over the past decade. Financial burden of healthcare on the rural population increased. Affordability among the rural households with sick members, particularly in the less developed region, is getting worse. It needs effective measures on cost control including healthcare provider payment reform and well developed health insurance schemes to offer better financial protection for the vulnerable Chinese seeking essential healthcare.

Experiences with primary healthcare in Fuzhou, urban China, in the context of health sector reform: a mixed methods study

China has recently placed increased emphasis on the provision of primary healthcare services through health sector reform, in response to inequitably distributed health services. With increasing funding for community level facilities, now is an opportune time to assess the quality of primary care delivery and identify areas in need of further improvement. A mixed methodology approach was adopted for this study. Quantitative data were collected using the Primary Care Assessment Tool-Chinese version (C-PCAT), a questionnaire previously adapted for use in China to assess the quality of care at each health facility, based on clients' experiences. In addition, qualitative data were gathered through eight semi-structured interviews exploring perceptions of primary care with health directors and a policy maker to place this issue in the context of health sector reform. The study found that patients attending community health and sub-community health centres are more likely to report better experiences with primary care attributes than patients attending hospital facilities. Generally low scores for community orientation, family centredness and coordination in all types of health facility indicate an urgent need for improvement in these areas. Healthcare directors and policy makers perceived the need for greater coordination between levels of health providers, better financial reimbursement, more formal government contracts and recognition/higher status for staff at the community level and more appropriate undergraduate and postgraduate training.

The Chinese community patient's life satisfaction, assessment of community medical service, and trust in community health delivery system

BACKGROUND

Although the Chinese government put a lot of effort into promoting the community patient's life satisfaction, there still lacked the holistic and systematic approaches to promote the community patient's life satisfaction in various regions of China. On the basis of the literature, it was found that both the community patient's assessment of community medical service and trust in community health delivery system were important considerations when the community patient comprehensively evaluated community medical service to generate life satisfaction. So this study was set up to test whether and to what extent the community patient's assessments of various major aspects of community medical service/various major aspects of the community patient's trust in community health delivery system influenced life satisfaction in whole China/in various regions of China.

METHODS

In order to explore the situation of China's community health delivery system before 2009 and provide a reference for China's community health delivery system reform, the data that could comprehensively and accurately reflect the community patient's life satisfaction, assessment of community medical service, and trust in community health delivery system in various regions of China was needed, so this study collaborated with the National Bureau of Statistics of China to carry out a large-scale 2008 national community resident household survey (N = 3,306) for the first time in China. And the specified ordered probit models were established to analyze the dataset from this household survey.

RESULTS

Among major aspects of community medical service, the medical cost (particularly in developed regions), the doctor-patient communication (particularly in developed regions), the medical facility and hospital environment (particularly in developed regions), and the medical treatment process (particularly in underdeveloped regions) were all key considerations (p<0.05 for t statistics) in generating the community patient's life satisfaction. Among major aspects of the community patient's trust in community health delivery system, trust in doctor (particularly in underdeveloped regions), trust in prescription (particularly in underdeveloped regions), and trust in recommended medical examination (particularly in underdeveloped regions) were all important considerations (p<0.10 for t statistics) in generating the community patient's life satisfaction.

CONCLUSION

The reduction of medical cost (particularly in developed regions), the improvement of doctor-patient communication (particularly in developed regions), the promotion of medical facility and hospital environment (particularly in developed regions), the improvement of medical treatment process (particularly in underdeveloped regions), the promotion of trust in doctor (particularly in underdeveloped regions), the promotion of trust in prescription (particularly in underdeveloped regions), and the promotion of trust in recommended medical examination (particularly in underdeveloped regions) could help promote the community patient's life satisfaction.

Community health service capacity in China: a survey in three municipalities

RATIONALE

China is reforming its health care system. It aims to strengthen primary health care through building community health facilities and assigning a 'gate-keeper' role to primary care providers. However, it remains unknown whether community health facilities are able to fulfil such a mission. This study evaluated the service capacity of a selected sample of community health facilities and the competency of primary care practitioners employed by those facilities.

METHODS

Three municipalities from the east, middle and west of China were purposely selected. A questionnaire was undertaken in 45 randomly selected community health facilities in the three municipalities and 700 primary care practitioners responded to the survey. The survey investigated the capacity of the community health facilities in providing diagnostic services and the competency of the primary care providers in handling common health problems.

RESULTS

The most common reasons for doctor-patient encounters were common cold and chronic diseases. The capacity of the community health facilities in providing diagnostic services was limited. Although the majority of respondents believed that they could correctly identify common symptoms, many were unable to perform some essential physical examinations.

CONCLUSION

The community health facilities are not able to fulfil their designated mission because of the limited diagnostic capacity and poor competency of the primary care practitioners. Priorities should be given to capacity building for the development of community health services in the future.

Contracting with private providers for primary care services: evidence from urban China

Controversy surrounds the role of the private sector in health service delivery, including primary care and population health services. China's recent health reforms call for non-discrimination against private providers and emphasize strengthening primary care, but formal contracting-out initiatives remain few, and the associated empirical evidence is very limited. This paper presents a case study of contracting with private providers for urban primary and preventive health services in Shandong Province, China. The case study draws on three primary sources of data: administrative records; a household survey of over 1600 community residents in Weifang and City Y; and a provider survey of over 1000 staff at community health stations (CHS) in both Weifang and City Y. We supplement the quantitative data with one-on-one, in-depth interviews with key informants, including local officials in charge of public health and government finance.We find significant differences in patient mix: Residents in the communities served by private community health stations are of lower socioeconomic status (more likely to be uninsured and to report poor health), compared to residents in communities served by a government-owned CHS. Analysis of a household survey of 1013 residents shows that they are more willing to do a routine health exam at their neighborhood CHS if they are of low socioeconomic status (as measured either by education or income). Government and private community health stations in Weifang did not statistically differ in their performance on contracted dimensions, after controlling for size and other CHS characteristics. In contrast, the comparison City Y had lower performance and a large gap between public and private providers. We discuss why these patterns arose and what policymakers and residents considered to be the main issues and concerns regarding primary care services.

Consumer choice among Mutual Healthcare Purchasers: a feasible option for China?

In its 2009 blue print of healthcare reform, the Chinese government aimed to create a competitive health insurance market in order to increase efficiency in the health insurance sector. A major advantage of a competitive health insurance market is that insurers are stimulated to act as well-motivated prudent purchasers of healthcare on behalf of their enrolees, and that consumers can choose among these purchasers. To emphasize the insurers' role of purchasers of care we denote them, as well as other entities that can fulfil this role (e.g. fundholding community health centres), as 'Mutual Healthcare Purchasers' (MHPs). As feasible proposals for creating competition in China's health insurance sector have yet to be made, we suggest two potential approaches to create competition among MHPs: (1) separating finance and operation of social health insurance and allowing consumer choice among operators of social health insurance schemes; (2) allowing consumer choice among fund-holding community health centres. Although the benefits of competition are widely accepted in China, the problematic consequences of a free competitive health insurance market - especially in relation to affordability and accessibility - are generally neglected. To solve the problems of lack of affordability and inaccessibility that would occur in the case of unregulated competition among MHPs, at least the following regulations are proposed to the Chinese policy makers: a 'standard benefit package' for basic health insurance, a 'risk-equalization scheme', and 'open enrolment'. Potential obstacles for implementing a risk equalization scheme are examined based on theoretical arguments and international experiences. We conclude that allowing consumer choice among MHPs and implementing a risk equalization scheme in China is politically and technically complex. Therefore, the Chinese government should prepare carefully for a market-oriented reform in its healthcare sector and adopt a strategic approach in the implementation procedure.

Measuring attitude toward social health insurance

In order to understand the health care system a country chooses to adopt or the health care reform a country decides to undertake, one must first be able to measure a country's attitude toward social health insurance. Our primary goal was to develop a construct that allows us to measure this "attitude toward social health insurance". Using a sample of 724 students from the People's Republic of China, Germany, and the United States and an initial set of sixteen items, we extract a scale that measures the basic attitude toward social health insurance in the three countries. The scale is internally consistent in each of the three countries. A secondary factor labeled "government responsibility" is marginally consistent for the total sample and for the German sample. German respondents have the most favorable attitude toward social health insurance, followed by China, and then the United States. Chinese respondents have the most favorable attitude toward government responsibility in health insurance. The scale developed here can be used to further investigate and understand which health care system will succeed and which will fail in a given country, which is important from both a political and an economic perspective.

Use of and factors associated with self-treatment in China

Background

When an individual is ill or symptomatic, they have the options of seeking professional health care, self-treating or doing nothing. In China, some studies suggest that the number of individuals opting to self-treat has been rapidly increasing in recent years. Therefore, the aim of this study was to analyze the trends of and factors related to self-treatment in China.

Methods

Self-treatment was measured based the concept and data of the China National Health Survey (CNHS), which covers 802,454 individuals. We used CNHS data from 1993, 1998, 2003, and 2008, and a Multinomial Logit Selection Model to estimate the factors influencing the decision to self-treat.

Results

The prevalences of self-treatment with a recall period of two-weeks were significantly higher in urban compared with rural areas (31.2% vs 14.9% in 1993, 43.5% vs 21.4% in 1998, 47.2% vs 31.4% in 2003, 31.0% vs 25.3% in 2008) in China. Economic (per capita income, TV, sanitary water) and individual (education, profession, family members, exercise) factors, as well as accessibility to drugs had a positive association with the probability of self-treating. Different illness symptoms, severity, and duration show a negative association with the probability of self-treating, showing a degree of rationality in decision-making. Different insurance systems were also found to have an effect on self-treatment decision-making.

Conclusions

Self-treatment and professional medical services have shared the incremental medical needs of residents in recent years in China. Self-perceived illness status, economic circumstances, and education play important roles in health care decision-making.

Multifactor Analysis on the Income of Primary Health Care Institutions Implementing EMS in Hubei Province, China: A Cross-sectional Study

The objectives of this study are to measure the level of income of primary health care institutions during essential medicines system (EMS) implementation and to identify its main influencing factors for finding the evidence to promote the EMS in China’s deepening health care reform.

The field investigation with a stratified sampling method contained primary health institutions from Hubei province, based on the different economic levels. Government-run institutions which implemented EMS were all collected; they were a total of 402. A structured questionnaire survey was carried out at all institutions involving indicators such as income of primary health care institutions, government subsidy, institution staff salaries, institution indebtedness, number of health personnel, drug price cut (per cent) and number of drug use. The Statistical Package for the Social Sciences (SPSS) 12.0 was used for independent variables selection and to perform multiple linear regressions.

Government subsidy (X1), institution staff salaries (X2), institution indebtedness (X3) and number of health personnel (X4) are factors chosen into the regression model, the square root of the income of primary health institutions (Y). The model Y = 3.827 + 0.030X1 + 0.045X2 + 0.002X3 + 0.033X4 (F = 164.663, P < 0.001), where coefficient of determination R2 = 0.656. The biggest influence on income of primary health institutions is institution staff salaries (standardized coefficients = 0.398), followed by number of health personnel (standardized coefficients = 0.318) and government subsidy (standardized coefficients = 0.264).

To protect the income of primary health care institutions, more attention should be paid to the agency staffing reform, individual performance appraisal and government subsidies. For best outcomes of EMS, the subsequent implementation should be a more completed set of supporting measures besides the design of system itself.

The less healthy urban population: income-related health inequality in China

Background

Health inequality has been recognized as a problem all over the world. In China, the poor usually have less access to healthcare than the better-off, despite having higher levels of need. Since the proportion of the Chinese population living in urban areas increased tremendously with the urbanization movements, attention has been paid to the association between urban/rural residence and population health. It is important to understand the variation in health across income groups, and in particular to take into account the effects of urban/rural residence on the degree of income-related health inequalities.

Methods

This paper empirically assesses the magnitude of rural/urban disparities in income-related adult health status, i.e., self-assessed health (SAH) and physical activity limitation, using Concentration Indices. It then uses decomposition methods to unravel the causes of inequalities and their variations across urban and rural populations. Data from the China Health and Nutrition Survey (CHNS) 2006 are used.

Results

The study finds that the poor are less likely to report their health status as “excellent or good” and are more likely to have physical activity limitation. Such inequality is more pronounced for the urban population than for the rural population. Results from the decomposition analysis suggest that, for the urban population, 76.47 per cent to 79.07 per cent of inequalities are driven by non-demographic/socioeconomic-related factors, among which income, job status and educational level are the most important factors. For the rural population, 48.19 per cent to 77.78 per cent of inequalities are driven by non-demographic factors. Income and educational attainment appear to have a prominent influence on inequality.

Conclusion

The findings suggest that policy targeting the poor, especially the urban poor, is needed in order to reduce health inequality.

Outpatient prescription practices in rural township health centers in Sichuan Province, China

Background

Sichuan Province is an agricultural and economically developing province in western China. To understand practices of prescribing medications for outpatients in rural township health centers is important for the development of the rural medical and health services in this province and western China.

Methods

This is an observational study based on data from the 4th National Health Services Survey of China. A total of 3,059 prescriptions from 30 township health centers in Sichuan Province were collected and analyzed. Seven indicators were employed in the analyses to characterize the prescription practices. They are disease distribution, average cost per encounter, number of medications per encounter, percentage of encounters with antibiotics, percentage of encounters with glucocorticoids, percentage of encounters with combined glucocorticoids and antibiotics, and percentage of encounters with injections.

Results

The average medication cost per encounter was 16.30 Yuan ($2.59). About 60% of the prescriptions contained Chinese patent medicine (CPM), and almost all prescriptions (98.07%) contained western medicine. 85.18% of the prescriptions contained antibiotics, of which, 24.98% contained two or more types of antibiotics; the percentage of prescriptions with glucocorticoids was 19.99%; the percentage of prescriptions with both glucocorticoids and antibiotics was 16.67%; 51.40% of the prescriptions included injections, of which, 39.90% included two or more injections.

Conclusions

The findings from this study demonstrated irrational medication uses of antibiotics, glucocorticoids and injections prescribed for outpatients in the rural township health centers in Sichuan Province. The reasons for irrational medication uses are not only solely due to the pursuit of maximizing benefits in the township health centers, but also more likely attributable to the lack of medical knowledge of rational medication uses among rural doctors and the lack of medical devices for disease diagnosis in those township health centers. The policy implication from this study is to enhance professional training in rational medication uses for rural doctors, improve hardware facilities for township health centers, promote health education to rural residents and establish a public reporting system to monitor prescription practices in rural township health centers, etc.

The influences of patient's satisfaction with medical service delivery, assessment of medical service, and trust in health delivery system on patient's life satisfaction in China

BACKGROUND

Patient's satisfaction with medical service delivery/assessment of medical service/trust in health delivery system may have significant influence on patient's life satisfaction in China's health delivery system/in various kinds of hospitals.The aim of this study was to test whether and to what extent patient's satisfaction with medical service delivery/patient's assessments of various major aspects of medical service/various major aspects of patient's trust in health delivery system influenced patient's life satisfaction in China's health delivery system/in various kinds of hospitals.

METHODS

This study collaborated with National Bureau of Statistics of China to carry out a 2008 national urban resident household survey in 17 provinces, autonomous regions, and municipalities directly under the central government (N = 3,386), and specified ordered probit models were established to analyze dataset from this household survey.

RESULTS

The key considerations in generating patient's life satisfaction involved patient's overall satisfaction with medical service delivery, assessment of doctor-patient communication, assessment of medical cost, assessment of medical treatment process, assessment of medical facility and hospital environment, assessment of waiting time for medical service, trust in prescription, trust in doctor, and trust in recommended medical examination. But the major considerations in generating patient's life satisfaction were different among low level public hospital, high level public hospital, and private hospital.

CONCLUSION

The promotion of patient's overall satisfaction with medical service delivery, the improvement of doctor-patient communication, the reduction of medical cost, the improvement of medical treatment process, the promotion of medical facility and hospital environment, the reduction of waiting time for medical service, the promotion of patient's trust in prescription, the promotion of patient's trust in doctor, and the promotion of patient's trust in recommended medical examination could all help promote patient's life satisfaction. But their promotion effects were different among low level public hospital, high level public hospital, and private hospital.

Effects of China's national essential medicines policy on the use of injection in primary health facilities

The overuse of injection exists more than 20 years since economic reform in China. It is a persistent problem and seems becoming a new challenge in the new health reform period. This study was designed to assess the effect of national essential medicines policy (NEMP) on injection use at primary health facilities in China by investigating their prescription information. Questionnaires were designed and disseminated to collect empirical data on injection use at 120 primary health facilities in 6 provinces from January to September in 2010 and 2011. The injection use was measured as the indicator as the percentage of prescriptions with one or more injections. The results showed that the percentage of prescriptions with one or more injections was decreased from 38.91% to 36.82% (χ (2)=11.158, P=0.001) in the all survey areas during the NEMP reform. The difference in level of the injection use in 2011 was significant among the eastern, central and western regions (χ (2)=223.584, P=0.000); level of the injection use in western region was the lowest (27.73%), while that in the central region was the highest (43.10%). The level of the injection use in 2011 among different provinces was also of great difference (26.00%-58.25%, range: 32.25%). The level of the injection use in 2011 was still much higher than the standard suggested by WHO for developing countries (13.4%-24.1%). It was concluded that NEMP has improved injection use in China, but the injection abuse situation remains serious, indicating that one of the priorities to the next stage of NEMP is to promote the rational use of drugs, especially the injection use.

Mutual referral: a survey of GPs in Beijing

BACKGROUND

China has been engaged in the process of reforming its health care system recently. The government has attempted to rebuild the referral system to lower cost and enhance equity of the medical services.

OBJECTIVE

This study was undertaken to evaluate the current status of mutual referral pilot programme, perceived factors that affect referral behaviour and changes that would improve the current referral process in Beijing.

METHODS

Using a cross-sectional study design, we sent a postal questionnaire to 138 urban district community health service (CHS) centres in Beijing. Questions were chosen from a formal consensus process based on a nominal group technique.

RESULTS

One hundred twenty-five of 138 (90.6%) CHS centres responded to the survey. Seventy-six (61.8%) CHS centres reported that the mutual referral system was feasible. Twenty-six (21.1%) CHS centres reported that the mutual referral programme was running smoothly. Uncertainties of diagnosis/management and access to particular medical specialty interest or skills were the two most common factors that were suggested as affecting referral behaviour. The presence of a dedicated department to accept referrals in hospitals and the use of referral guidelines were the most preferred choices as likely to improve the current referral process.

CONCLUSIONS

Since a system of gatekeeper role by GPs at CHS organizations has not been established in Beijing, most CHS doctors agree that to ensure the smooth operation of referrals, a dedicated department should be assigned by hospitals to receive referred patients. Official guidelines on referral should be developed, and health authorities should strengthen their supervision of referrals.

Differences in reporting of maternal and child health indicators: A comparison between routine and survey data in Guizhou Province, China

BACKGROUND

The quality of routine data, such as the maternal mortality ratio (MMR), infant mortality rate (IMR), and under-five mortality rate (U5MR) is often questioned. The objective of this study was to compare routine and survey data on key maternal and child health indicators, including the MMR, IMR, and U5MR in the Guizhou Province of China.

METHODS

In 2008, an urban area and a rural area in the Guizhou Province were randomly selected. All households in the selected areas were included and, of the total 5466 households therein, 5459 were visited. The response rate was 99.9%. Survey data were collected from mothers (46.0%), fathers (32.5%), grandmothers (11.1%), grandfathers (9.0%), and other caregivers (1.4%). Data from routine records of the health bureaus in selected areas were reviewed for the same indicators. The Chi-square test was used to study the differences between routine data and survey data.

RESULTS

We found the differences between the routine and survey data live births in the survey data (68) was fewer than in the routine data (94) in the rural area, while live births in the survey data (106) was larger than in the routine data (96) in the urban area. The IMR was higher in the survey data (51.7 per thousand) as compared with routine data (31.6 per thousand). The U5MR was higher (69.0 per thousand) in the survey data than in the routine data (42.1 per thousand). Indicators related to the coverage of maternal and child health interventions were over-reported in routine data.

CONCLUSION

Small differences were observed between routine data and survey data in Guizhou, one of the poorest areas of China. The quality of routine data in urban areas was better than in rural areas.

The determinants of Chinese provincial government health expenditures: evidence from 2002-2006 data

There is great divergence in provincial government health expenditures in China. Real per capita provincial government health expenditures (GHE) over the period 2002-2006 are examined using panel regression analysis. Key determinants of real per capita provincial GHE are real provincial per capita general budget revenue, real provincial per capita transfers from the central government, the proportion of provincial population under age 15, urban employee basic health insurance coverage, and proportion of urban population. Roughly equal and relatively low elasticities of budget revenue and transfers imply that the GHE is a necessity rather than a luxury good, and transfers have yet to become efficient instruments for the fair allocation of health resources by policy makers. Moreover, severe acute respiratory syndrome outbreak has increased the GHE, but we find no statistical evidence that provincial GHE have fluctuated according to the public health status.

High Caesarean section rate in rural China: is it related to health insurance (New Co-operative Medical Scheme)?

The epidemic of Caesarean section (CS) is worldwide, and it has been argued that it is mainly due to non-medical factors, including healthcare financing patterns. We investigated the use of CS in rural China and the related factors, particularly health insurance in the form of the New Co-operative Medical Scheme introduced in 2003. A cross-sectional survey of women who gave birth in 2008-2009 was conducted in five rural counties in central and western China. Of the 5049 new mothers, 73% were interviewed. The association between health insurance coverage and self-reported CS (divided into emergency and non-emergency CS) were examined by cross-tabulation and logistic regression, adjusting for maternal age, education, occupation, household income, previous abortions, parity and type of birth health facility. We found that 46% of all births (3550) were CSs, with 13% having an emergency and 33% a non-emergency CS. Women reported that half of the non-emergency CSs were recommended by a doctor and half were requested by themselves. In those counties with mid-range CS rates (28%-63%), health insurance coverage was associated with having CS, and particularly with having non-emergency CS. In those counties with the highest (82%) and lowest (13%) rate, there was no statistically significant association. The findings suggest that health insurance coverage may have facilitated the overuse of CS. Further studies are needed to develop appropriate interventions to reduce non-medically indicated CS, focussing on payment mechanisms, healthcare provider practice patterns, and maternal requests.

Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study

BACKGROUND

In the past decade, the Government of China initiated health-care reforms to achieve universal access to health care by 2020. We assessed trends in health-care access and financial protection between 2003, and 2011, nationwide.

METHODS

We used data from the 2003, 2008, and 2011 National Health Services Survey (NHSS), which used multistage stratified cluster sampling to select 94 of 2859 counties from China's 31 provinces and municipalities. The 2011 survey was done with a subset of the NHSS sampling frame to monitor key indicators after the national health-care reforms were announced in 2009. Three sets of indicators were chosen to measure trends in access to coverage, health-care activities, and financial protection. Data were disaggregated by urban or rural residence and by three geographical regions: east, central, and west, and by household income. We examined change in equity across and within regions.

FINDINGS

The number of households interviewed was 57,023 in 2003, 56,456 in 2008, and 18,822 in 2011. Response rates were 98·3%, 95·0%, and 95·5%, respectively. The number of individuals interviewed was 193,689 in 2003, 177,501 in 2008, and 59,835 in 2011. Between 2003 and 2011, insurance coverage increased from 29·7% (57,526 of 193,689) to 95·7% (57,262 of 59,835, p<0·0001). The average share of inpatient costs reimbursed from insurance increased from 14·4 (13·7-15·1) in 2003 to 46·9 (44·7-49·1) in 2011 (p<0·0001). Hospital delivery rates averaged 95·8% (1219 of 1272) in 2011. Hospital admissions increased 2·5 times to 8·8% (5288 of 59,835, p<0·0001) in 2011 from 3·6% (6981 of 193,689) in 2003. 12·9% of households (2425 of 18,800) had catastrophic health expenses in 2011. Caesarean section rates increased from 19·2% (736 of 3835) to 36·3% (443 of 1221, p<0·0001) between 2003 and 2011.

INTERPRETATION

Remarkable increases in insurance coverage and inpatient reimbursement were accompanied by increased use and coverage of health care. Important advances have been made in achieving equal access to services and insurance coverage across and within regions. However, these increases have not been accompanied by reductions in catastrophic health expenses. With the achievement of basic health-services coverage, future challenges include stronger risk protection, and greater efficiency and quality of care.

FUNDING

None.

Unintended Consequences of Policy Decisions to Reduce Maternal Mortality in the Asia Pacific

OBJECTIVES:To describe the role of midwives and maternity care in three low resource settings and to challenge some policy options introduced to reduce maternal mortality for women residing in rural and remote areas.

APPROACH:A series of retrospective analyses were undertaken drawing on work the authors have conducted in rural and remote China, Timor-Leste, and Samoa over the past 5–20 years. Sources include our own empirical research, grey literature, as well as published secondary sources.

FINDINGS:In China, hospital birthing is promoted as a major strategy in reducing maternal mortality. This has greatly increased financial burdens for women and their families. In Samoa, traditional birth attendants (TBAs) are integrated into Samoa’s health system alongside midwives and other health professionals, and they play a critical role in providing support for pregnant and birthing women. In Timor-Leste, the government has moved away from training TBAs and has shifted the focus from skilled attendance to facility-based delivery. Evaluation of a national maternity waiting home strategy, designed to improve access to facility-based delivery, did not improve access for women in remote areas.

CONCLUSIONS:Low-income countries need to be cautious when adopting global solutions, such as facility-based delivery, to tackle maternal deaths. Women-centered and cost-effective care should be provided locally. Culturally compatible maternity care can be achieved in concert with safety and emergency obstetric care. Midwives can create the bridges between social and professional systems that allow this to happen.

Patient knowledge and antibiotic abuse: Evidence from an audit study in China

We conduct an audit study in which a pair of simulated patients with identical flu-like complaints visits the same physician. Simulated patient A is instructed to ask a question that showcases his/her knowledge of appropriate antibiotic use, whereas patient B is instructed to say nothing beyond describing his/her symptoms. We find that a patient who displays knowledge of appropriate antibiotics use reduces both antibiotic prescription rates and drug expenditures. Such knowledge also increases physicians' information provision about possible side effects, but has a negative impact on the quality of the physician-patient interactions. Our results suggest that antibiotics abuse in China is not driven by patients actively demanding antibiotics, but is largely a supply-side phenomenon.

The influences of patient's trust in medical service and attitude towards health policy on patient's overall satisfaction with medical service and sub satisfaction in China

BACKGROUND

It is widely accepted that patient generates overall satisfaction with medical service and sub satisfaction on the basis of response to patient's trust in medical service and response to patient's attitude towards health policy in China. This study aimed to investigate the correlations between patient's trust in medical service/patient's attitude towards health policy and patient's overall satisfaction with medical service/sub satisfaction in current medical experience and find inspiration for future reform of China's health delivery system on improving patient's overall satisfaction with medical service and sub satisfaction in considering patient's trust in medical service and patient's attitude towards health policy.

METHODS

This study collaborated with the National Bureau of Statistics to collect a sample of 3,424 residents from 17 provinces and municipalities in a 2008 China household survey on patient's trust in medical service, patient's attitude towards health policy, patient's overall satisfaction and sub satisfaction in current medical experience.

RESULTS

Patient's overall satisfaction with medical service and most kinds of sub satisfaction in current medical experience were significantly influenced by both patient's trust in medical service and patient's attitude towards health policy; among all kinds of sub satisfaction in current medical experience, patient's trust in medical service/patient's attitude towards health policy had the largest influence on patient's satisfaction with medical costs, the influences of patient's trust in medical service/patient's attitude towards health policy on patient's satisfaction with doctor-patient interaction and satisfaction with treatment process were at medium-level, patient's trust in medical service/patient's attitude towards health policy had the smallest influence on patient's satisfaction with medical facilities and hospital environment, while patient's satisfaction with waiting time in hospital was not influenced by patient's trust in medical service/patient's attitude towards health policy.

CONCLUSION

In order to improve patient's overall satisfaction with medical service and sub satisfaction in considering patient's trust in medical service and patient's attitude towards health policy, both improving patient's interpersonal trust in medical service from individual's own medical experience/public trust in medical service and improving patient's attitude towards health policy were indirect but effective ways.

An analysis of China's national essential medicines policy

Although China embraced the concept of essential medicines in 1979 and issued its first National Essential Medicines List in 1982, until recently China has lacked a comprehensive national essential drug policy. In its most recent health-care reform (2009-2012), the Chinese government explicitly proposed the establishment of a national essential medicines system, and made it one of five top priorities in the coming years. We review the evolution of China's essential medicines policies, explain the importance of fully implementing the essential medicines policy, and analyze recent policy developments surrounding essential medicines.

Can the New Cooperative Medical Scheme promote rural elders' access to health-care services?

The aim of the present study was to examine the impact of the New Cooperative Medical Scheme (NCMS) on rural elders' access to health-care services. Articles were identified from PubMed, Elsevier, Wiley, EBSCO, EMBASE, SCI Expanded, ProQuest, Google, and CNKI which is the most informative database in Chinese, with the search terms "rural", "China", "old", "older", or "elder", "elderly", or "aged", "aging", "medical insurance", or "community-based medical insurance", or "cooperative medical scheme". Related websites and yearbooks were searched as well. The NCMS has improved the health-care utilization of rural elders, and they have the highest satisfaction with it among all age groups. However, affordability difficulty remained the common barrier for the rural elderly to access quality health care, in spite of the special considerations given to the rural elderly, such as premium remission and free check-ups. Faced with ever-growing health challenges, some impoverished rural elders with poor physical health and functional limitations may lack sufficient access to basic health-care services. Followed by the provider payment reform initiated by the NCMS, a stricter regulation for doctors' prescriptions, clinical practice and disease management is needed to promote rural elders' access to health-care services. Health management for rural elders can be expected for the NCMS to promote rural elders' health-care access once a better coordination between the NCMS and health-care system can be achieved.