Health service delivery in China: a literature review

Building institutions for an effective health system: lessons from China's experience with rural health reform

This paper is concerned with the management of health system changes aimed at substantially increasing the access to safe and effective health services. It argues that an effective health sector relies on trust-based relationships between users, providers and funders of health services, and that one of the major challenges governments face is to construct institutional arrangements within which these relationships can be embedded. It presents the case of China, which is implementing an ambitious health reform, drawing on a series of visits to rural counties by the author over a 10-year period. It illustrates how the development of reform strategies has been a response both to the challenges arising from the transition to a market economy and the result of actions by different actors, which have led to the gradual creation of increasingly complex institutions. The overall direction of change has been strongly influenced by the efforts made by the political leadership to manage a transition to a modern economy which provides at least some basic benefits to all. The paper concludes that the key lessons for other countries from China's experience with health system reform are less about the detailed design of specific interventions than about its approach to the management of institution-building in a context of complexity and rapid change.

Drug prescribing indicators in village health clinics across 10 provinces of Western China

BACKGROUND

The irrational use of drugs was a global problem, especially in developing countries. However, there are no studies available on irrational use of drugs in rural Western China.

OBJECTIVE

To assess the drug prescribing patterns using World Health Organization Drug Use Indicators at village health clinics in rural areas of Western China.

METHODS

A total of 20 125 prescriptions were collected from 680 primary health clinics in villages from 40 counties in 10 provinces of Western China. Five measurements were used to assess the irrational drug use: percentage of encounters with an antibiotic prescribed, average number of drugs per encounter, percentage of encounters with an injection prescribed, percentage of drugs prescribed by generic name and percentage of drugs prescribed from National Essential Medicines List or Formulary. Index of Rational Drug Prescribing (IRDP) was used as an indicator of rational drug use.

RESULTS

The percentage of prescriptions containing antibiotics was 48.43%, while the average number of drugs per prescription was 2.36, and the percentage of injection prescriptions was 22.93%. The percentage of drugs prescribed by generic name was 64.12%, and the percentage of drugs prescribed from the National Essential Drug List was 67.70%. The IRDP of the present study was 3.32 with the optimal level of 5. There are also some regional variations in these measurements.

CONCLUSIONS

The study provides some evidence of irrational use of drugs to a great extent in rural areas of Western China. Overuse of injection and overuse of antibiotics were the most prominent manifestations of such irrational drug prescribing.

The Chinese healthcare system: structure, problems and challenges

We describe the structure and present situation of the Chinese healthcare system and discuss its primary problems and challenges. We discuss problems with inefficient burden sharing, adverse provider incentives and huge inequities, and seek explanations in the structural features of the Chinese healthcare system. The current situation will be further challenged in the future by an aging population, an increasing need for privatization and growing expectations about quality of healthcare.

Giving birth at a health-care facility in rural China: is it affordable for the poor?

OBJECTIVE

To investigate changes in the expenditure of giving birth in health-care facilities in rural China during 1998-2007, to examine the financial burden on households, particularly poor ones, and to identify factors associated with out-of-pocket expenditure.

METHODS

Cross-sectional data on births between 1998 and 2007 were obtained from national household surveys conducted in 2003 and 2008. Descriptive statistics and log-linear models were used to identify factors associated with out-of-pocket expenditure on delivery.

FINDINGS

During 1998-2007, the proportion of facility-based deliveries increased from 55% to 90%. In 2007, 60% of births occurred at county-level or higher-level facilities. The Caesarean delivery rate increased from 6% to 26%. Total expenditure on a facility-based delivery increased by 152%, with a marked rise from 2002 onwards with the introduction of the New Cooperative Medical Scheme. In 2007, out-of-pocket expenditure on a facility-based delivery equalled 13% of the mean annual household income for low-income households. This proportion had decreased from 18% in 2002 and differences between income groups had narrowed. Regression models showed that Caesarean delivery and delivery at a higher-level facility were associated with higher expenditure in 2007. The New Cooperative Medical Scheme was associated with lower out-of-pocket expenditure on Caesarean delivery but not on vaginal delivery.

CONCLUSION

Expenditure on facility-based delivery greatly increased in rural China over 1998-2007 because of greater use of higher-level facilities, more Caesarean deliveries and the introduction of the New Cooperative Medical Scheme. The financial burden on the rural poor remained high.

Utilisation, contents and costs of prenatal care under a rural health insurance (New Co-operative Medical System) in rural China: lessons from implementation

Background

In China, the New Co-operative Medical System (NCMS), a rural health insurance system, has expanded nationwide since 2003. This study aims to describe prenatal care use, content and costs of care in one county where prenatal care is included in the NCMS and two counties where it is not. It also explores the perceptions of stakeholders of the prenatal care benefit package in order to understand the strengths and weaknesses of the approach in the context of rural China and to draw lessons from early implementation.

Methods

This study is based on the data from a cross-sectional survey and a qualitative investigation conducted in 2009. A survey recruited women giving birth in 2008, including 544 women in RC County (which covered prenatal care) and 619, and 1071 in other two counties (which did not). The qualitative investigation in RC included focus group discussions with women giving birth before or after 2007, individual interviews with local policy makers and health managers, NCMS managers and obstetric doctors in township hospitals.

Results

There were no significant differences in prenatal care use between RC County (which covered prenatal care) and other two counties (which did not): over 70% of women started prenatal visits early and over 60% had five or more visits. In the three counties: a small proportion of women received the number of haemoglobin and urine tests recommended by the national guideline; 90% of women received more ultrasound tests than recommended; and the out-of-pocket expenditure for prenatal care consumed a high proportion of women's annual income in the low income group. In RC: only 20% of NCMS members claimed the reimbursement; the qualitative study found that the reimbursement for prenatal care was not well understood by women and had little influence on women's decisions to make prenatal visits; and several women indicated that doctors suggested them taking more expensive tests.

Conclusions

Whether or not prenatal care was included in the NCMS, prenatal care use was high, but the contents of care were not provided following the national guideline and more expensive tests were recommended by doctors. Costs were substantial for the poor.

Balancing the funds in the New Cooperative Medical Scheme in rural China: determinants and influencing factors in two provinces

In recent years, the central government in China has been leading the re-establishment of its rural health insurance system, but local government institutions have considerable flexibility in the specific design and management of schemes. Maintaining a reasonable balance of funds is critical to ensure that the schemes are sustainable and effective in offering financial protection to members. This paper explores the financial management of the NCMS in China through a case study of the balance of funds and the factors influencing this, in six counties in two Chinese provinces. The main data source is NCMS management data from each county from 2003 to 2005, supplemented by: a household questionnaire survey, qualitative interviews and focus group discussions with all local stakeholders and policy document analysis. The study found that five out of six counties held a large fund surplus, whilst enrolees obtained only partial financial protection. However, in one county greater risk pooling for enrolees was accompanied by relatively high utilisation levels, resulting in a fund deficit. The opportunities to sustainably increase the financial protection offered to NCMS enrolees are limited by the financial pressures on local government, specific political incentives and low technical capacities at the county level and below. Our analysis suggests that in the short term, efforts should be made to improve the management of the current NCMS design, which should be supported through capacity building for NCMS offices. However, further medium-term initiatives may be required including changes to the design of the schemes.

Availability and use of essential medicines in China: manufacturing, supply, and prescribing in Shandong and Gansu provinces

Background

The current health care reform in China launched in 2009 tackles the problem of access to appropriate medicines for its 1.3 billion people by focusing on providing essential medicines to all. To provide evidence for the reform process, we investigated the manufacturing, purchasing, and prescribing of essential medicines in two provinces.

Methods

We conducted surveys in 2007 of all manufacturers (n = 253) and of 59 purposively selected retail and 63 hospital pharmacies in Shandong and Gansu provinces to assess production and supply of products on the 2004 National Essential Medicines List (NEML), as well as factors underlying decision making about production and supply. We also reviewed prescriptions (n = 5456) in health facilities to calculate standard indicators of appropriate medicines use.

Results

Overall, manufacturers in Shandong and Gansu produced only 62% and 50%, respectively, of the essential medicines they were licensed to produce. Of a randomly selected 10% of NEML products, retail pharmacies stocked up to 60% of Western products. Median availability in hospital pharmacies ranged from 19% to 69%. Manufacturer and retail pharmacy managers based decisions on medicines production and stocking on economic considerations, while hospital pharmacy managers cited clinical need. Between 64% and 86% of prescriptions contained an essential medicine. However, overprescribing of antibiotics (34%-77% of prescriptions) and injectables (22%-61%) for adult non-infectious outpatient consultations was common.

Conclusions

We found that manufacturers, retail pharmacies, and hospital pharmacies paid limited attention to China's 2004 NEML in their decisions to manufacture, purchase, and stock essential medicines. We also found that prescribing of essential medicines was frequently inappropriate. These results should inform strategies to improve affordable access to essential medicines under the current health care reform.

Synthetic evaluation of the effect of health promotion: impact of a UNICEF project in 40 poor western counties of China

OBJECTIVE

To synthetically evaluate the effects of a health promotion project launched by the Ministry of Health of China and the United Nations Children's Fund (UNICEF) in 40 poor western counties of China.

STUDY DESIGN

The two surveys were cross-sectional studies. Stratified multistage random sampling was used to recruit subjects.

METHODS

Data were collected through two surveys conducted in the 40 'UNICEF project counties' in 1999 and 2000. After categorizing the 27 evaluation indicators into four aspects, a hybrid of the Analytic Hierarchy Process, the Technique for Order Preference by Similarity to Ideal Solution, and linear weighting were used to analyse the changes. The 40 counties were classified into three different levels according to differences in the synthetic indicator derived. Comparing the synthetic evaluation indicators of these two surveys, issues for implementation of the project were identified and discussed.

RESULTS

The values of the synthetic indicators were significantly higher in 2000 than in 1999 (P=0.02); this indicated that the projects were effective. Among the 40 counties, 11 counties were at a higher level in 2000, 10 counties were at a lower level, and others were in the middle level. Comparative analysis showed that 36% of village clinics were not licensed to practice medicine, nearly 50% of village clinics had no records of medicine purchases, nearly 20% of village clinics had no pressure cooker for disinfection, and 20% of pregnant women did not receive any prenatal care.

CONCLUSIONS

The health promotion projects in the 40 counties were effective. Health management, medical treatment conditions, maternal health and child health care have improved to some extent. However, much remains to be done to improve health care in these 40 poor counties. The findings of this study can help decision makers to improve the implementation of such improvements.

Comparing public and private hospitals in China: evidence from Guangdong

BACKGROUND

The literature comparing private not-for-profit, for-profit, and government providers mostly relies on empirical evidence from high-income and established market economies. Studies from developing and transitional economies remain scarce, especially regarding patient case-mix and quality of care in public and private hospitals, even though countries such as China have expanded a mixed-ownership approach to service delivery. The purpose of this study is to compare the operations and performance of public and private hospitals in Guangdong Province, China, focusing on differences in patient case-mix and quality of care.

METHODS

We analyze survey data collected from 362 government-owned and private hospitals in Guangdong Province in 2005, combining mandatorily reported administrative data with a survey instrument designed for this study. We use univariate and multi-variate regression analyses to compare hospital characteristics and to identify factors associated with simple measures of structural quality and patient outcomes.

RESULTS

Compared to private hospitals, government hospitals have a higher average value of total assets, more pieces of expensive medical equipment, more employees, and more physicians (controlling for hospital beds, urban location, insurance network, and university affiliation). Government and for-profit private hospitals do not statistically differ in total staffing, although for-profits have proportionally more support staff and fewer medical professionals. Mortality rates for non-government non-profit and for-profit hospitals do not statistically differ from those of government hospitals of similar size, accreditation level, and patient mix.

CONCLUSIONS

In combination with other evidence on health service delivery in China, our results suggest that changes in ownership type alone are unlikely to dramatically improve or harm overall quality. System incentives need to be designed to reward desired hospital performance and protect vulnerable patients, regardless of hospital ownership type.

Inpatient treatment of diabetic patients in Asia: evidence from India, China, Thailand and Malaysia

AIMS

The prevalence of Type 2 diabetes mellitus (DM) has grown rapidly, but little is known about the drivers of inpatient spending in low- and middle-income countries. This study aims to compare the clinical presentation and expenditure on hospital admission for inpatients with a primary diagnosis of Type 2 DM in India, China, Thailand and Malaysia.

METHODS

We analysed data on adult, Type 2 DM patients admitted between 2005 and 2008 to five tertiary hospitals in the four countries, reporting expenditures relative to income per capita in 2007.

RESULTS

Hospital admission spending for diabetic inpatients with no complications ranged from 11 to 75% of per-capita income. Spending for patients with complications ranged from 6% to over 300% more than spending for patients without complications treated at the same hospital. Glycated haemoglobin was significantly higher for the uninsured patients, compared with insured patients, in India (8.6 vs. 8.1%), Hangzhou, China (9.0 vs. 8.1%), and Shandong, China (10.9 vs. 9.9%). When the hospital admission expenditures of the insured and uninsured patients were statistically different in India and China, the uninsured always spent less than the insured patients.

CONCLUSIONS

With the rising prevalence of DM, households and health systems in these countries will face greater economic burdens. The returns to investment in preventing diabetic complications appear substantial. Countries with large out-of-pocket financing burdens such as India and China are associated with the widest gaps in resource use between insured and uninsured patients. This probably reflects both overuse by the insured and underuse by the uninsured.

Evaluating community health centers in the City of Dalian, China: how satisfied are patients with the medical services provided and their health professionals?

Around 58 community health centers (CHCs) were investigated to evaluate their performance, and 372 residents were surveyed randomly about their satisfaction towards these centers. State-owned CHCs gained the least benefits and received most patient visits. Residents' opinions about health professionals working in these centers showed marked distrust due to their insufficient work experience and low education level; however, affordability, availability and access to services and drugs among CHCs generated comparatively high satisfaction. Therefore, enhancing CHCs' service delivery is a necessity to improve the quality of community doctors and nurses, increase enrolment and training programs, and augmenting hospitals' support to CHCs.

Where did all the GPs go? Increasing supply and geographical equity in England and Scotland

OBJECTIVES

To examine the effect on geographical equity of increases in the total supply of general practitioners (GPs) and the ending of entry restrictions in 2002 and to explore the factors associated with the distribution of GPs across England.

METHODS

Calculation of Gini coefficients to measure geographical equity in GPs per 100,000 population in England and Scotland. Multiple regression of GPs per capita and change in GPs per capita on demographics, morbidity, deprivation and measures of amenity in English Primary Care Trusts (PCTs).

RESULTS

Equity in England rose between 1974 and 1994 but then decreased, and in 2006 it was below the 1974 level. After 2002, England had a greater percentage increase in GP supply than Scotland and a smaller increase in inequity. The level of GP per capita supply in 2006 was positively correlated with morbidity and PCT amenity, and negatively correlated with unemployment and poor air quality. The increase in per capita supply between 2002 and 2006 was not significantly associated with morbidity, deprivation or amenities.

CONCLUSIONS

Reducing geographical inequity in the provision of GPs requires targeted area level policies.

Absence of appropriate hospitalization cost control for patients with medical insurance: a comparative analysis study

OBJECTIVE

Expose the weak loops in the Chinese medical insurance coverage and uncover hospitals' role of over-pricing hospitalized insured patients compared with those non-insured.

METHODS

A multi-linear regression method was used to analyze hospitalization expense for insured and uninsured patients with uncomplicated acute appendicitis, cholecystitis, benign uterine tumors, and normal delivery.

RESULTS

Hospitalization cost is higher among insured than uninsured patients due to longer hospitalization lengths of stay, type of disease (highest among cholecystitis patients), type of gender - females, old-aged people, and type of marital status - singles, as well as drugs expenses, surgical expenses, and other medical acts.

CONCLUSION

Require a better government's supervision system over medical insurance expenses such as reforming methods of payments, building up new cost compensation mechanism, and unifying and stabilizing prices for each category of medicines.

China's health system and its reform: a review of recent studies

This paper provides a survey of the recent empirical research on China's 'old' health system (i.e. prior to the spate of reforms beginning in 2003). It argues that this research has enhanced our understanding of the system prior to 2003, in some cases reinforcing conclusions (e.g. the demand-inducement associated with perverse incentives) while in other cases suggesting a slightly less clear storyline (e.g. the link between insurance and out-of-pocket spending). It also concludes that the research to date points to the importance of careful evaluation of the current reforms, and its potential to modify policies as the rollout proceeds. Finally, it argues that the research on the pre-2003 system suggests that while the recently announced further reforms are a step in the right direction, the hoped-for improvements in China's health system will far more likely occur if the reforms become less timid in certain key areas, namely provider payments and intergovernmental fiscal relations.

Purchasing health care in China: competing or non-competing third-party purchasers?

OBJECTIVES

China's government has decided to increase government funding by 1-1.5% of the Gross Domestic Products in the health care sector. However, it is still a question how to turn the new funding into efficient health care.

METHODS

To help to answer this question we analyze three prototype models of organizing the health care system that may be relevant for China, namely the "Government provision model", the "regulated market with non-competing third-party purchasers", and the "regulated market with competing third-party purchasers". The pre- and post-reform English health care system and the present Dutch health care system are used as examples of the three models. During the last 20 years these countries had, just as China, major health care reforms from a national centrally planned system to a market-based system. Based on the experiences in these countries we analyze the advantages and disadvantages of these three prototype models and discuss their relevance for China.

RESULTS AND CONCLUSIONS

We conclude that the creation of prudent third-party purchasers, who have the incentive and ability to act on behalf of individual consumers, is a critical success factor, whatever model China chooses to implement.

Health policy reform in China: lessons from Asia

Declining access to health care and rapidly rising health expenditures are a matter of grave public concern in China. After decades of efforts to reduce its involvement, the Chinese government is currently in the process of reforming the sector through increase in public expenditures and expansion of health insurance. The objective of this paper is to assess the potential of the reform direction in light of international experiences with similar reforms. It argues--on the basis of examination of reform experiences in Korea, Singapore and Thailand--that financing reforms without parallel measures to improve the provision system, especially how providers are paid, are unlikely to address the problems and may actually aggravate them. If the financing reforms are to succeed, it is vital for China to reform the incentives that guide the providers' behaviour.

From plan to market in the health sector?: China's experience

Countries worldwide confront the challenge of defining and achieving appropriate roles for government and market forces in the health sector. China-as both a developing and a transitional economy-represents an important case. This paper uses an international comparative perspective to examine how the health of China's population and other aspects of health system performance changed during the reform era. We draw on standard public finance and health economics theory, as well as the more recent incomplete-contracting theory of property rights, to summarize the comparative advantages of government and market for financing and delivery of health services, particularly in developing and transitional economies. We then describe and analyze against this theoretical background the transformation of China's health sector and recent commitment of government funds to move toward universal coverage.