Reforming China's 50,000 township hospitals--effectiveness, challenges and opportunities

Development trend of primary healthcare after health reform in China: a longitudinal observational study

OBJECTIVES

Reconstructing the primary healthcare system is the focus of the new round of Chinese health reform. Nevertheless, there have been few studies focusing on the strengthening of primary healthcare in Chinese health system.

DESIGN

This study was a longitudinal observational study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The data of this study came from China Health Statistical Yearbook (2009-2018). We evaluated the development of primary healthcare based on the absolute values of health resources allocation and health service provision and evaluated the status of primary healthcare throughout the health system based on the composition ratios of the indicators across the health system. The Cochran-Armitage trend test and linear trend test were used to identify the indicators' trends over time.

RESULTS

From 2009 to 2018, the amounts of health resources allocation and health service provision of Chinese primary healthcare institutions showed a significant upward trend (p<0.001). However, compared with the indicators in 2009, excepting that the proportion of grants from the government in the whole health system has an upward trend, the proportions of other indicators had an escalating trend in 2018 by 3.66% for practicing (assistant) physicians, by 2.69% for nurses, by 3.99% for total revenues, by 5.87% for beds, by 8.39% for outpatient visits.

CONCLUSION

The primary healthcare system has developed rapidly, but its development speed lagged behind the entire health system, resulting in the weakening of its actual functions, which is not in line with the goal of health reform. The government should be more aware of the importance of primary healthcare at all levels of local governments and ensure adequate financial input.

Does Having a Usual Primary Care Provider Reduce Polypharmacy Behaviors of Patients With Chronic Disease? A Retrospective Study in Hubei Province, China

Background: Within China's hierarchical medical system, many patients seek medical care in different hospitals independently without integrated management. As a result, multi-hospital visiting is associated with fragmented service utilization and increased incidence of polypharmacy behaviors, especially for patients with chronic disease. It has been confirmed that factors from the perspective of patients may cause polypharmacy behaviors in Chinese community patients; whether having a usual primary care provider for chronic disease patients could reduce the polypharmacy behaviors and the effect size remains unanswered, and that is what our study aimed to answer.

Methods: Our study adopted a cluster sampling method to select 1,196 patients with hypertension or diabetes and measured some information about them. The propensity score weighting method was adopted to eliminate the influence of confounding bias, and then a multivariate logistic regression model was conducted to test the relationship between having a usual primary care provider and polypharmacy behaviors.

Results: Patients without usual primary care providers were significantly correlated with polypharmacy behaviors (OR = 2.40, 95%CI: 1.74–3.32, p < 0.001), and the corresponding marginal effect is 0.09 (95%CI: 0.06–0.12). Patients who suffer from two kinds of diseases (OR = 3.05, 95%CI: 1.87–5.10, p < 0.001), with more than three kinds of diseases (OR = 21.03, 95%CI: 12.83–35.65, p < 0.001), with disease history of 20 years and above (OR = 1.66, 95%CI: 1.14–2.42, p = 0.008), who communicate frequently with doctors (OR = 3.14, 95%CI: 1.62–6.19, p < 0.001), alcoholic patients (OR = 2.14, 95%CI: 1.08–4.19, p = 0.027), who used to have meat-based food (OR = 1.42, 95%CI: 1.00–2.00, p = 0.049), and have vegetarian-based diet (OR = 1.42, 95%CI: 1.00–2.00, p = 0.049) are more likely to have polypharmacy behaviors, while patients aged between 65 and 75 years (OR = 0.50, 95%CI: 0.33–0.77, p = 0.020), used to be brain workers (OR = 0.67, 95%CI: 0.45–0.99, p = 0.048), with disease history between 10 and 20 years (OR = 0.56, 95%CI: 0.37–0.83, p = 0.005), have had adverse drug reactions (OR = 0.64, 95%CI: 0.45–0.93, p = 0.019), and participated in medical insurance for urban and rural residents (OR = 0.35, 95%CI: 0.21–0.58, p < 0.001) were less likely to have polypharmacy behaviors.

Conclusion: The results suggest that having a usual primary care provider may reduce the incidence of having polypharmacy behaviors; we can take intervention measures to promote establishing a long-term relationship between patients and primary care providers.

Whether high government subsidies reduce the healthcare provision of township healthcare centers in rural China

Background

China’s government launched a large-scale healthcare reform from 2009. One of the main targets of this round reform was to improve the primary health care system. Major reforms for primary healthcare institutions include increasing government investment. However, there are insufficient empirical studies based on large sample to catch long-term effect of increased government subsidy and lack of sufficient incentives on township healthcare centers (THCs), therefore, this study aims to provide additional empirical evidence on the concern by conducting an empirical analysis of THCs in Shaanxi province in China.

Methods

We collected nine years (2009 to 2017) data of THCs from the Health Finance Annual Report System (HFARS) that was acquired from the Health Commission of Shaanxi Province. We applied two-way fixed effect model and continue difference-in-difference (DID) model to estimate the effect of percentage of government subsidy on medical provision.

Results

A clear jump of the average percentage of government subsidy to total revenue of THCs can be found in Shaanxi province in 2011, and the average percentage has been more than 60% after 2011. Continue DID models indicate every 1% percentage of government subsidy to total revenue increase after 2011 resulted in a decrease of 1.1 to 3.5% in THCs healthcare provision (1.9% in medical revenue, 1.2% in outpatient visit, 3.5% in total occupy beds of inpatient, 1.1% in surgery revenue, 2.1% in sickbed utilization rate). The results show that the THCs with high government subsidy reduce the number of medical services after 2011.

Conclusions

We think that it is no doubt that the government should take more responsibility for the financing of primary healthcare institutions, the problem is when government plays a central role in the financing and delivery of primary health care services, more effective incentives should be developed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07201-w.

A path dependence analysis of hospital dominance in China (1949-2018): lessons for primary care strengthening

Although China's community health system helped inspire the 1978 Alma Ata Declaration on Health for All, it currently faces the challenge of strengthening primary care in response to hospital sector dominance. As the world reaffirms its commitment towards primary health services, China's recent history provides a salient case study of the issues at stake in optimizing the balance of care. In this study, we have used path dependence analysis to explain China's coevolution of hospital and primary care facilities between 1949 and 2018. We have identified two cycles of path-dependent development (1949-78 and 1978-2018) involving four sets of institutions related to medical professionalization, financing, organization and governance of health facilities. Both cycles started with a critical juncture amid a radically changing societal context, when institutions favouring hospitals were initiated or renewed, leading to a process of self-reinforcement empowering the hospitals. Later in each cycle, events occurred that modified this hospital dominance. However, pro-primary care policies during these conjunctures encountered resilience from the existing institutional environment. The result was continued consolidation of hospital dominance over the long term. These recurrent constraints suggest that primary care strengthening is unlikely to be successful without a comprehensive set of policy reforms driven by a primary care coalition with strong professional, bureaucratic and community stakes, co-ordinated and sustained over a prolonged period. Our findings imply that it is important to understand the history of health systems in China, where the challenges of health systems strengthening go beyond limited resources and include different developmental paths as compared with Western countries.

Determinants and Differences of Township Hospital Efficiency among Chinese Provinces

This study aimed to measure the efficiency and change in efficiency over time of township hospitals among Chinese provinces, to decompose the difference in efficiency between districts, and to study the correlations between the difference in efficiency and its determinants. Based on Chinese provincial panel data, the empirical analysis was established using data envelopment analysis (DEA), Malmquist index, Theil index decomposition method and Grey correlation analysis method. First, it was found that the township hospitals in most provinces were operating in an inefficient state, and the township hospitals in most provinces achieved gains in efficiency. Second, from 2003 to 2016 the shrinkage of the difference in provincial efficiency of township hospitals progressed slowly. Intra-regional difference is the main cause of the overall provincial efficiency difference of Chinese township hospitals, while inter-regional difference is the minor cause of the overall difference. Third, the correlation between the difference of overall provincial efficiency and the difference of economic development level is the highest among all the correlations, while other determinants rank second to seventh place in their degree of correlation with respect to the overall difference in provincial efficiency. Furthermore, the correlations between the intra-regional difference of provincial efficiency of Chinese township hospitals and its determinants vary tremendously across regions. Based on our findings, we can conclude, first, that efforts should be made to improve the overall provincial difference in efficiency of Chinese township hospitals, and enhance the utilization level of input resources, and to reduce resource waste. Second, in order to shrink the overall provincial efficiency of Chinese township hospitals, the most important measure that should be taken is to improve the economic development level in relatively backward provinces in order to lay a solid economic foundation for the improvement of efficiency and shrink the differences in efficiency between provinces. Third, more attention should be paid to the shrinkage of intra-regional efficiency differences in Chinese township hospitals, while the narrowing of inter-regional efficiency difference should not be ignored. For each region, it is necessary to recognize the difference in the relative importance of determinants, and to make development strategies according to local conditions so as to make full use of local characteristics and advantages.

Historical roots of hospital centrism in China (1835-1949): A path dependence analysis

Stronger primary care has been associated with important contributions to health system performance, yet countries struggle to resource it adequately, given competing demands from hospitals. Although historically China has originated influential models of primary health care, it has an enduring problem with hospital dominance in health service delivery. This paper is a historical analysis of the co-evolution of hospitals and primary care providers in China from 1835 (the year when the first hospital was built in mainland China) to 1949 (the year when the People's Republic of China was founded), which aims to shed light on approaches to primary care strengthening. We develop and use a path dependence analytic framework, specifying the critical juncture, conjuncture and post-juncture development of the institutions shaping the balance between hospitals and primary care providers in China. We find that China had historically formed the hospital-centric model involving four sets of regenerating and mutually reinforcing institutions: 1) financial resources were being disproportionally distributed to hospitals; 2) high-quality medical professionals were largely concentrated in hospitals; 3) large outpatient departments were incorporated in hospitals, which functioned as a first point of care for many patients; 4) hospitals answered primarily to the demand of the more privileged social group. The early institutionalization of a hospital-centric model of Western medicine in China from 1835 became resistant to change, and efforts to strengthen primary care eventually took a divergent low-cost and de-professionalized developmental path towards 1949. As China still has a hospital-centric health system seeded in the nineteenth century, these findings can inform the framing of contemporary options for primary care strengthening. Without addressing these deep regenerating causes using a whole-system approach, China is unlikely to achieve a primary care orientation for health system development.

Equity and efficiency of primary health care resource allocation in mainland China

BACKGROUND

China had proposed the unification of equity and efficiency since the launch of the new round of health system reform in 2009. And the central government gave priority to the development of primary health care (PHC) whilst ensuring its availability and improving its efficiency. This study aimed to evaluate the changes of equity and efficiency in PHC resource allocation (PHCRA) and explored ways to improve the current situation.

METHODS

The data of this study came from the China Health Statistical Yearbook (2013-2017) and China Statistical Yearbook (2017). Three and five indicators were used to measure equity and efficiency, respectively. The Lorenz curve, Gini coefficient (G), Theil index (T) and health resource density index (HRDI) were used to assess equity in demographic and geographical dimensions. Data envelopment analysis (DEA) and the Malmquist productivity index (MPI) were chosen to measure the efficiency and productivity of PHCRA.

RESULTS

From 2012 to 2016, the total amount of PHCR had increased year by year. The Gs by population size were below 0.2 and that by geographical area were between 0.6 and 0.7. T had the same trend with G, and intra-regional contribution rates were higher than inter-regional contribution rates, which were all beyond 60%. From 2012 to 2016, the numbers of provinces that achieved an effective DEA were 4, 3, 4, 5 and 5, respectively. The mean of the total factor productivity index was 0.994.

CONCLUSION

The equity of PHCRA in terms of population size is superior in the geographical area. Intra-regional differences are the main source of inequality. The eastern region has the highest density of PHCR, whereas the western region has the lowest. In addition, PHC institutions in more than 80% of the provinces are inefficient, and the productivity of the institutions decline by 0.6% from 2012 to 2016 because of technological retrogression.

Does having a usual primary care provider reduce patient self-referrals in rural China's rural multi-tiered medical system? A retrospective study in Qianjiang District, China

INTRODUCTION

Within China's multi-tiered medical system, many patients seek care in higher-tiered hospitals without a referral by a primary-care provider. This trend, generally referred to as patient self-referral behavior, may reduce the efficiency of the health care system. This study seeks to test the hypothesis that having a usual primary care provider could reduce patients' self-referral behavior.

METHODS

We obtained medical records of 832 patients who were hospitalized for common respiratory diseases from township hospitals in Qianjiang District of Chongqing City during 2012-2014. Logit regressions were performed to examine the association between having a township hospital as a usual provider and self-referring to a county hospital after being discharged from a township hospital, while controlling for patients' gender, age, income, education, severity of disease, distance to the nearest county hospital and the general quality of the township hospitals in their community. A propensity score weighting approach was applied.

RESULTS

We found that having a usual primary care provider was associated with a lower likelihood of self-referral (odds ratio = 0.58, 95% confidence interval [CI] =0.41-0.82), and a 9% (95% CI: -14%, - 3%) reduction in the probability of patients' self-referral behavior.

DISCUSSION/CONCLUSION

The results suggest that establishing a long-term relationship between patients and primary care providers may enhance the patient-physician relationship and reduce patients' tendency for unnecessary use of medical resources.

Efficiency and productivity measurement of rural township hospitals in China: a bootstrapping data envelopment analysis

OBJECTIVE

Township hospitals (THs) are important components of the three-tier rural healthcare system of China. However, the efficiency and productivity of THs have been questioned since the healthcare reform was implemented in 2009. The objective of this study is to analyse the efficiency and productivity changes in THs before and after the reform process.

SETTING AND PARTICIPANTS

A total of 48 sample THs were selected from the Xiaogan Prefecture in Hubei Province from 2008 to 2014.

OUTCOME MEASURES

First, bootstrapping data envelopment analysis (DEA) was performed to estimate the technical efficiency (TE), pure technical efficiency (PTE) and scale efficiency (SE) of the sample THs during the period. Second, the bootstrapping Malmquist productivity index was used to calculate the productivity changes over time.

RESULTS

The average TE, PTE and SE of the sample THs over the 7-year period were 0.5147, 0.6373 and 0.7080, respectively. The average TE and PTE increased from 2008 to 2012 but declined considerably after 2012. In general, the sample THs experienced a negative shift in productivity from 2008 to 2014. The negative change was 2.14%, which was attributed to a 23.89% decrease in technological changes (TC). The sample THs experienced a positive productivity shift from 2008 to 2012 but experienced deterioration from 2012 to 2014.

CONCLUSIONS

There was considerable space for TE improvement in the sample THs since the average TE was relatively low. From 2008 to 2014, the sample THs experienced a decrease in productivity, and the adverse alteration in TC should be emphasised. In the context of healthcare reform, the factors that influence TE and productivity of THs are complex. Results suggest that numerous quantitative and qualitative studies are necessary to explore the reasons for the changes in TE and productivity.

Factors Associated With Place of Death Among the Chinese Oldest Old

Based on 6,444 deceased respondents ages 80 to 105 years from the first three waves of the Chinese Longitudinal Healthy Longevity Survey, the authors use multilevel modeling to examine how community development, individual sociodemographic characteristics, health conditions, and health resources affect place of death. Results show that 92% of Chinese oldest old die at home, with 7% dying in hospitals and 1% at institutions. Analyses indicate that residents from relatively developed communities in China tend to have a higher chance of hospital and/or institutional deaths; individuals with higher socioeconomic status (SES) and worsening health are more likely to experience hospital deaths; those who have pension and/or public and/or collective free medical services are more likely to die in hospitals and/or institutions. The authors also propose a theory about place of death consisting of three evolutionary stages, which might explain the disparity in patterns of place of death in different societies.

Organizational barriers associated with the implementation of national essential medicines policy: A cross-sectional study of township hospitals in China

This study identifies potential organizational barriers associated with the implementation of the Chinese National Essential Medicines Policy (NEMP) in rural primary health care institutions. We used a multistage sampling strategy to select 90 township hospitals from six provinces, two from each of eastern, middle, and western China. Data relating to eight core NEMP indicators and institutional characteristics were collected from January to September 2011, using a questionnaire. Prescription-associated indicators were calculated from 9000 outpatient prescriptions selected at random. We categorized the eight NEMP indicators using an exploratory factor analysis, and performed linear regressions to determine the association between the factor scores and institution-level characteristics. The results identified three main factors. Overall, low levels of expenditure of medicines (F1) and poor performance in rational use of medicines (F2) were evident. The availability of medicines (F3) varied significantly across both hospitals and regions. Factor scores had no significant relationship with hospital size (in terms of number of beds and health workers); however, they were associated with revenue and structure of the hospital, patient service load, and support for health workers. Regression analyses showed that public finance per health worker was negatively associated with the availability of medicines (p < 0.05), remuneration of prescribers was positively associated with higher performance in the rational use of medicines (p < 0.05), and drug sales were negatively associated with higher levels of drug expenditure (p < 0.01). In conclusion, irrational use of medicines remains a serious issue, although the financial barriers for gaining access to essential medicines may be less for prescribers and consumers. Limited public finance from local governments may reduce medicine stock lines of township hospitals and lead them to seek alternative sources of income, jeopardizing their capacity to meet the needs of local consumers.

Health service delivery in China: a literature review

We report the results of a review of the Chinese- and English-language literatures on service delivery in China, asking how well China's health-care providers perform and what determines their performance. Although data and methodological limitations suggest caution in drawing conclusions, a critical reading of the available evidence suggests that current health service delivery in China leaves room for improvement, in terms of quality, responsiveness to patients, efficiency, cost escalation, and equity. The literature suggests that these problems will not be solved by simply shifting ownership to the private sector or by simply encouraging providers -- public and private -- to compete with one another for individual patients. By contrast, substantial improvements could be (and in some places have already been) made by changing the way providers are paid -- shifting away from fee-for-service and the distorted price schedule. Other elements of 'active purchasing' by insurers could further improve outcomes. Rigorous evaluations, based on richer micro-level data, could considerably strengthen the evidence base for service delivery policy in China.

Public perceptions of private health care in socialist China

We present the findings of a United Nations Development Programme-World Health Organization study commissioned by China's Ministry of Health on use of public and private ambulatory care services in three Chinese provinces. We found much unmet medical need (16 percent), attributed mainly to the perceived high cost of care. Seventy-one percent had no health insurance (90 percent in rural and 51 percent in urban areas). For 33 percent, the last consultation was with a private practitioner. Widespread dissatisfaction with public providers (mainly high user fees and poor staff attitudes) is driving patients to seek cheaper but lower-quality care from poorly regulated private providers.

Utilization of maternal care in rural HeBei Province, the People's Republic of China: individual and structural characteristics

PURPOSE

To study the effect of individual's socio-economic characteristics and the structure of the health services in the village on utilization of maternal care in rural HeBei, the People's Republic of China (PRC).

DATA

Data were collected from 4273 women who gave birth to one child at least, living in a stratified sample of 288 villages in HeBei Province.

FINDINGS

54.8% of the women had at least one pre-natal care visit, 27.5% gave birth in a health care facility, and 18.1% had post-natal check-up. Utilization was inversely related to age and parity and positively to education. Occupation was related to use of pre- and post-natal services, but not to home birth. Per-capita income and living arrangement are not related to utilization. MCH worker in the village promote pre- and post-natal care, but also home delivery. Village doctors promote pre-natal care and hospital delivery but do not promote post-natal check-up. Women tend to avoid the maternal services in the township health centers but some are ready to travel to city hospitals for delivery and post-natal care.

CONCLUSIONS

Health education programs regarding the importance of all three maternal care services are clearly needed. These programs should address not only women of child bearing age but also care providers, MCH workers in particular. Township health center should reach-out and motivate women to use their accessible services.

Comparative research and analysis methods for shared learning from health system reforms

The pace and breadth of health reforms point to the need for a comparative methodology to support shared learning from country experiences. A common understanding of health reforms is a first prerequisite for comparative research. Dimensions characterising content, sequence, process, purpose and scope of policy change are identified on the basis of a literature review. Reforms can have a gradual build up, starting with piecemeal policy changes that can be eventually integrated to enhance their benefits. Comprehensive reforms can be defined as policy formulation and implementation that comprises the systemic, programmatic, organisational and instrumental policy levels through explicit strategies sustained in well-documented experiences and theories and implemented with the support of a specialised agency with consensus-building capacity. A minimum-data set is proposed on the basis of an extensive literature review to support the comparability of health reform case studies and descriptions. Its components are: the current health system, its background and context, the reform rationale, the specific proposals, political actors and processes, achievements and limitations, and lastly the reform's wider impact. Case studies can be compared historically, through particularistic comparisons, using ideal types and by means of exemplars. The advantages and limitation of each method are analysed as well as how they can be combined to frame the research questions and minimise resources. Finally, the International Clearinghouse for Health System Reform Initiatives is described as an instrument to disseminate comparative research and analysis in support of shared learning.

China's health care sector in transition: resources, demand and reforms

Economic development and reforms have had profound impacts on China's health care sector. As a result, the health care sector in China is in transition. This report reviews the major changes, and the possible policy response to these changes in China's health care sector. It discusses resource availability in the Chinese health sector, and analyses the trend of household demand for health care goods and services. This study also examines the trade and investment situations in China's health sector and investigates the major forces that are driving the transition in health care and comments on the potential policy responses.