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

Estimating the efficiency of primary health care services and its determinants: evidence from provincial panel data in China

Background

The efficiency of primary health care services is drawing increased attention worldwide, especially in developing countries. Health care reform in China has moved into the 'deep water zone' phase and is facing the dilemma of inefficiency in primary health care services, which is a critical challenge for universal health coverage.

Methods

In this study, we estimate the efficiency of primary health care services in China and its determinants. A combination of a super-SBM (Slack-Based Measure) model, a Malmquist productivity index model and a Tobit model is used to study provincial panel data, and the results demonstrate the inefficiency of primary health care services in China and the variations in efficiency values between regions.

Results

Over time, the productivity of primary health care services shows a decreasing trend, mainly due to slowing technology change. Financial support is needed to improve the efficiency of primary health care services, but it is worth noting that existing social health insurance coverage decreases efficiency, while economic development, urbanization and education also have a significant impact.

Conclusion

The findings suggest that increasing financial support should remain a priority in developing countries but that reasonable reimbursement design, appropriate payment methods and comprehensive supporting social health insurance policies are key to the next step of reform.

Strengthening national public health institutes: a systematic review on institution building in the public sector

Introduction

Strong and efficient institutions are vital to the development of well-functioning governments and strong societies. The term "institution building" encompasses the creation, support, development, and strengthening of organizations and institutions. Still, there is little aggregated evidence on "institution building" considering a wider system-thinking approach, best practices, or development cooperation specifically in the field of public health. In 2007, the International Association of National Public Health Institutes (IANPHI) created a guiding Framework that countries may use for developing National Public Health Institutes (NPHIs). This Framework is currently being revised.

Methods

In this context, we conducted a systematic review to facilitate this revision with recent evidence on institution building and its potential contribution to NPHI. We followed the PRISMA guidelines for systematic reviews, searching for relevant publications in seven scientific databases (Pubmed, VHL/LILACS, EconLit, Google Scholar, Web of Science, World Affairs Online, ECONBIZ) and four libraries (World Bank; European Health for All database of the World Health Organization European Region, WHO; Organization for Economic Cooperation and Development, OECD; and the African Union Common Repository). The search was carried out in October 2021. We used the "framework analysis" tool for systematically processing documents according to key themes.

Results

As a result, we identified 3,015 records, of which we included 62 documents in the final review. This systematic review fills a major gap of aggregated information on institution building in the field of public health and National Public Health Institutes. It is to our knowledge the first systematic review of this kind. The overriding result is the identification and definition of six domains of institution building in the health sector: "governance," "knowledge and innovation," "inter-institutional cooperation," "monitoring and control," "participation," and "sustainability and context-specific adaptability."

Discussion

Our results show that the described domains are highly relevant to the public health sector, and that managers and the scientific community recognize their importance. Still, they are often not applied consistently when creating or developing NPHIs. We conclude that organizations engaged in institution building of NPHIs, including IANPHI, may greatly benefit from state-of-the-art research on institution building as presented in this study.

Fiscal autonomy of subnational governments and equity in healthcare resource allocation: Evidence from China

Objectives

Promoting equity in healthcare resource allocation (EHRA) has become a critical political agenda of governments at all levels since the ambitious Universal Health Coverage was launched in China in 2009, while the role of an important institutional variable-fiscal autonomy of subnational governments-is often overlooked. The present study was designed to determine the effect of FASG on EHRA and its potential mechanism of action and heterogeneity characteristics to provide empirical support for the research field expansion and relative policies making of EHRA.

Methods

From the start, we utilized the Theil index and the entropy method to calculate the EHRA index of 22 provinces (2011-2020) based on the medical resource data of 287 prefecture-level cities. Furthermore, we used the two-way fixed effects model (FE) to identify and analyze the impact of FASG on EHRA and then used three robustness test strategies and two-stage least squares (2SLS) regression to verify the reliability of the conclusions and deal with potential endogeneity problems, respectively. At last, we extend the baseline regression model and obtain the two-way FE threshold model for conducting heterogeneity analysis, which makes us verify whether the baseline model has nonlinear characteristics.

Results

The static value and the trend of interannual changes in the EHRA values in different provinces are both very different. The regression results of the two-way FE model show that FASG has a significant positive impact on EHRA, and the corresponding estimated coefficient is - 0.0849 (P < 0.01). Moreover, this promotion effect can be reflected through two channels: enhancing the intensity of government health expenditure (IGHE) and optimizing the allocation of human resources for health (AHRH). At last, under the different economic and demographic constraints, the impact of FASG on EHRA has nonlinear characteristics, i.e., after crossing a specific threshold of per capita DGP (PGDP) and population density (PD), the promotion effect is reduced until it is not statistically significant, while after crossing a particular threshold of dependency ratio (DR), the promotion effect is further strengthened and still statistically significant.

Conclusions

FASG plays an essential role in promoting EHRA, which shows that subnational governments need to attach great importance to the construction of fiscal capability in the allocation of health care resources, effectively improve the equity of medical and health fiscal expenditures, and promote the sustainable improvement of the level of EHRA.

Changes of inequality in functional disability of older populations in China from 2008 to 2018: a decomposition analysis

BACKGROUND

This study aims to determine the change of inequality in functional disability of older populations in China over the period from 2008 to 2018 and decompose the contribution of the personal and environmental predictors to the change.

METHODS

Data were drawn from two waves (2008 and 2018) of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Functional disability was assessed by the basic activities of daily living (ADL) and the instrumental activities of daily living (IADL). Concentration index (CI) was calculated to measure the socioeconomic inequality in ADL and IADL. A two-level linear regression model was established to identify the individual and care environmental predictors and their contribution to the inequality of ADL and IADL, respectively. The Oaxaca-type decomposition technique was adopted to estimate the contribution of these predictors to changes of the inequality in ADL and IADL over the period from 2008 to 2018.

RESULTS

Socioeconomic inequality in functional disability of older adults increased over the period from 2008 to 2018, with the CI for ADL changing from - 0.0085 to - 0.0137 and the CI for IADL changing from - 0.0164 to - 0.0276, respectively. Self-rated economic status was the single most powerful predictor of changes in the inequality, although the growing and dominant rating of older persons with fare economic status could offset the detrimental effects of other (rich or poor) ratings on the changes. The enlarged inequality was also attributable to the increasing importance of regular exercise and its distributional changes, as well as the accumulative long-term effect of farming in earlier life. They outweighed the counteracting effects of rural residency, living with chronic conditions and in an institution.

CONCLUSIONS

Socioeconomic inequality in functional disability of older populations in China increased over the period from 2008 to 2018. Re-distribution of wealth remains to be a powerful instrument for addressing the inequality issue, but alone it is not enough. The detrimental accumulative effect of farming will not disappear any time soon. While rural residents are catching up with their urban counterparts, new challenges such as physical inactivity are emerging.

Urban-Rural Disparity in Cognitive Performance Among Older Chinese Adults: Explaining the Changes From 2008 to 2018

Objectives

This study aims to identify the dynamic changes in cognitive performance differentials between urban and rural older adults in China from 2008 to 2018 and decomposes determinants affecting such changes.

Methods

Two waves (2008 and 2018) of data were extracted from the Chinese Longitudinal Healthy Longevity Survey. The cognitive function was tested using the Chinese Mini-Mental State Examination (MMSE). The effects of the explanatory variables (demographic, economic, neighborhood, environmental events and social and cultural domains) on the changes in the urban-rural inequality of cognitive performance were divided into two components using the Juhn–Murphy–Pierce (JMP) decomposition: quantity effect and price effect.

Results

A total of 14,628 (urban respondents: 5,675, rural respondents: 8,953) and 10,311 older adults (urban respondents: 5,879, rural respondents: 4,432) for 2008 and 2018, respectively, were included in our study. A narrowing of 0.071 in the urban-rural disparity in cognitive function score of the older adults from 2008 to 2018 was identified. Quantity and price effects of explanatory variables contributed 65.21 and 46.84%, respectively, to the observed components in explaining the narrowed disparity. Quantity effects of age (35.71%), exercise (56.72%), self-rated economic status (33.19%) and price effect of homeownership (54.97%) contributed significantly to the reduced urban-rural gap. Contrastingly, inequality in pension (−27.31%) and social security (−23.11%) between urban and rural widened cognitive performance differentials. Furthermore, effects of hunger in childhood (−10.53%) and less years of schooling (−77.20%) on the increase in urban-rural inequality seemed to be stronger over time.

Conclusion

Economic development and reform of the rural health system are responsible for the decline in the urban-rural disparity in the cognitive performance of older adults. Equalizing the distribution of social security and welfare between urban and rural must be highlighted for eliminating cognitive ability disparity. Additionally, rural older adults who endured hunger and poor education in childhood also deserve further policy interventions.

Unpacking the red packets: institution and informal payments in healthcare in China

Informal cash payments from patient to healthcare providers for services provided by the healthcare system have attracted increasing scholarly interest. However, the root and mechanism of informal payments are not well understood. This paper contributes to the literature by positing informal payments as informal institutions. We use a nationally representative longitudinal survey in 28 provinces in China to explore the root of informal payments. Our empirical findings suggest that patients' informal payments for healthcare services may originate from information acquisition and processing, failure of government and market in allocating healthcare resources, and disparities in utilization. Further, this informal institution could be changed by the self-reinforcement of individual patients. These findings suggest that policies to facilitate transparency and to remove institutional barriers, such as the introduction of market competition, may reduce the incidence of informal payments.

Understanding China's growing involvement in global health and managing processes of change

Background

Recent years have seen a rapid change in China’s global engagement and a recognition that solving global challenges will need to take the changing role of China into account. The paper discusses China’s growing involvement in global health. Health is an area where there is broad agreement over global priorities and, potentially, a fertile space to build new forms of collaboration that point the way towards the adaptation of global governance to a rapidly changing context.

Results

Drawing on previous analyses of China’s management of change in its domestic health reforms and interviews with a range of stakeholders in China, the UK and Switzerland, the paper argues that China’s engagement in global health is developing and diversifying rapidly in response to the central government’s desire to see a greater role for China in global health. This diversification is part of a pattern of change management familiar from China’s domestic reform experience. Explorations underway by a range of Chinese agencies form part of a process of rapid experimentation and experiential learning that are informing China’s search for (a) new global role(s).

Conclusions

China is undergoing rapid institutional innovation and developing capacity for greater global engagement, including in health; however, substantial, recent leadership commitments make clear Chinese agencies’ need for continued exploration, innovation and rapid learning. How China engages globally is of significance to the world, not just China. The challenge for China, other global actors and multilateral organisations is to incorporate new approaches into existing global governance arrangements, including for the management of global health. This will require a willingness on all sides to learn from each other and invest the effort needed to build governance arrangements appropriate for the coming decades. This is not only important as a means of protecting global public health, but also as a demonstration of how governance arrangements can be adapted to the needs of a pluralistic global order in a context of rapid change.

"Unworthy of Care and Treatment": Cultural Devaluation and Structural Constraints to Healthcare-Seeking for Older People in Rural China

This paper examines the experiences of seeking healthcare for rural Chinese older people, a population who experiences the multiple threats of socio-economic deprivation, marginalization, and lack of access to medical care, yet have been relatively overlooked within the existing scholarly literature. Based on ethnographical data collected from six-month fieldwork conducted in a rural primary hospital in Southern China, this paper identifies a widespread discouraging, dispiriting attitude regarding healthcare-seeking for rural older members despite the ongoing efforts of institutional reforms with a particular focus on addressing access to health services amongst rural populations. Such an attitude was expressed by older people's families as well as the public in their narratives by devaluing older members' health care demands as "unworthy of care and treatment" ("buzhide zhi" in Chinese). It was also internalized by older people, based on which they deployed a family-oriented health-seeking model and strategically downgraded their expectation on receiving medical care. Moreover, underpinning this discouragement and devaluation, as well as making them culturally legitimate, is the social expectation of rural older people to be enduring and restrained with health-seeking. Simultaneously, this paper highlights the sourc2e of institutional and structural impediments, as they intersect with unfavorable socio-cultural values that normalize discouragement and devaluation.

Access to Care by Older Rural People in a Post-Reform Chinese Hospital: an Ethical Evaluation of Anthropological Findings

This paper examines older people's access to care experiences in rural China by integrating anthropological investigation with ethical inquiry. Six months of fieldwork in a post-reform primary hospital show how rural residents struggle to access gerontological and nursing care under socially disadvantageous conditions. This anthropological investigation highlights the unmet needs in medical and nursing care for older people, as well as some social, institutional and structural elements that impede access to care. Centring on protecting the vulnerable as informed by feminist ethics scholarship, this paper argues that the failure to meet older people's dependency needs is unjust, on the premise that it suggests a denial of the inherent value, rights and dignity of older people. This paper appeals for the provision of greater care and support by the state through putting in place social arrangements that better advance older people's access to care. Some policy recommendations concerning health and social care reform for older people in rural China are also proposed.

Health System in China

The health of China’s population improved dramatically during the first 30 years of the People’s Republic, established in 1949. By the mid-1970s, China was already undergoing the epidemiologic transition, years ahead of other nations of similar economic status, and by 1980, life expectancy (67 years) exceeded that of most similarly low-income nations by 7 years. Almost 30 years later, China’s 2009 health reforms were a response to deep inequity in access to affordable, quality healthcare resulting from three decades of marketization, including de facto privatization of the health sector, along with decentralized accountability and, to a large degree, financing of public health services. The reforms are built on earlier, equity-enhancing initiatives, particularly the reintroduction of social health insurance since 2003, and are planned to continue until 2020, with gradual achievement of overarching objectives on universal and equitable access to health services. The second phase of reform commenced in early 2012. China’s health reforms remain encouragingly specific but not prescriptive on strategy; set in the decentralized governance structure, they avoid the issue of reliance on local government support for the national equity objective, leaving the detailed design of health service financing, human resource distribution and accountability, essential drug lists and application of clinical care pathways, etc. to local health authorities answerable to local government, not the Ministry of Health. Community engagement in government processes, including in provision of healthcare, remains limited. This chapter uses the documentation and literature on health reform in China to provide a comprehensive overview of the current situation of the health sector and its reform in the People’s Republic.

The role of government and community in the scaling up and sustainability of mutual health organisations: An exploratory study in Ghana

Governments of many developing countries, including those in Sub-Saharan Africa have embraced the community-based health insurance schemes phenomenon under the health sector reforms with optimism. Ghana has introduced a National Health Insurance Scheme, which is amalgamated with social health insurance and community-based health insurance schemes. The aim of this study was to explore the role of the Ghana government and community in the scaling-up and sustainability of mutual health organisations. Four district mutual health insurance schemes were selected using geographical locations, among other criteria, as case studies. Data were gathered through interviews and documentary/literature review. The findings of the empirical study were analysed and interpreted using social policy and community field theories. The findings of the paper suggest that in order to ensure their effective scaling up and maintain overall sustainability, there is the need for some form of government regulation and subsidy. However, since government regulation cannot work without the acceptance of the community, there is the need to integrate these actors in policy formulation.

Health insurance reforms in Singapore and Hong Kong: How the two ageing asian tigers respond to health financing challenges?

Singapore and Hong Kong, two high-income "Tiger economies" in Asia, were ranked as the top two most efficient health systems in the world. Despite remarkable similarities in history and socioeconomic development, both economies embraced rather different paths in health care reforms in the past decades, which reflect their respective sociopolitical dynamics. Rapidly ageing populations and the anxiety about future funding of health care have prompted them to embark on major health financing reforms in the recent three years. While Singapore has transitioned to universal health coverage with the implementation of MediShield Life (MSL), Hong Kong is about to introduce the Voluntary Health Insurance Scheme (VHIS) to supplement its health care financing. Based on secondary materials including policy documents, press releases, and anecdotal reports, this essay compares these two recent reforms on their political context, drivers of reforms, and policy contents, and assesses their prospects in terms of coverage, financial protection, and major implementation challenges. The preliminary assessment suggests that while both programs are associated with certain drawbacks, those of the VHIS may be more fatal and warrant close attention. This essay concludes with a central caveat that underscores the pivotal role of the state in managing health care reforms.

Challenge or hindrance: Does job stress affect presenteeism among Chinese healthcare workers?

Background:

We examined the effects of challenge stress and hindrance stress on general health and presenteeism among Chinese healthcare workers.

Methods:

Structural equation modeling was used to evaluate data from a national hospital survey in China (n = 1392). Job stress, general health, and presenteeism were measured by the Perceived Ability to Work Scale, the 8-item Short-Form Health Survey, and the Challenge- and Hindrance-Related Self-reported Stress Scale.

Results:

Challenge stress and hindrance stress were significantly positively correlated (β = 0.62, SE = 0.021; p < 0.001). Challenge stress was directly negatively associated with presenteeism (β = -0.05, SE = 0.037; p < 0.001), while hindrance stress was positively associated with presenteeism (β = 0.25, SE = 0.040; p < 0.001). These associations with presenteeism were partially mediated by health.

Conclusions:

Hospital managers should provide healthcare workers with an appropriate level of challenge, but employee health is the most important consideration. Further efforts targeting job stress and health of junior healthcare workers are required.

Doktor Kot, Doktor Sla - book doctors, plant doctors and the segmentation of the medical market place in Meghalaya, northeast India

Despite decades of research on India's plural health care market, the practices of many local health traditions outside the allopathic and codified traditions are under-studied. Drawing on interview and observational data, this paper explores the space in which indigenous traditional Khasi healers in Meghalaya state, northeast India, practice. Khasi indigenous healers describe themselves as doktor sla, plant doctors, to distinguish themselves from doktor kot, or book doctors. This distinction operates as a rhetorical resource, utilised to carve a distinct sphere of expertise in relation to the allopathic sector, and to mark claims for the specifically local appropriateness of traditional practices within a shifting market of state-sponsored provision. Khasi healers are a heterogeneous group who treat a wide variety of conditions, including physical ailments which have no obvious correlates in biomedical systems, and musculoskeletal disorders, with which they have recognised expertise. In addition to claiming these discrete strengths, healers also present themselves as accommodating deficiencies in biomedicine, including inherent generic weaknesses of allopathic care as well as specific local gaps in rural health care provision. Thus, the expertise niches of traditional healers have evolved through their interactions with, and the needs of, the community, but also through managing a shifting boundary with biomedical practitioners, who are explicitly sceptical of their efficacy, but tacitly accepting of the ways in which they manage the gaps in biomedical provision. While codified non-biomedical traditions in India have engaged in universalising professionalising projects, in this setting at least, non-codified practitioners have instead utilised discourses of localism.

The role of health system governance in strengthening the rural health insurance system in China

BACKGROUND

Systems of governance play a key role in the operation and performance of health systems. In the past six decades, China has made great advances in strengthening its health system, most notably in establishing a health insurance system that enables residents of rural areas to achieve access to essential services. Although there have been several studies of rural health insurance schemes, these have focused on coverage and service utilization, while much less attention has been given to the role of governance in designing and implementing these schemes.

METHODS

Information from publications and policy documents relevant to the development of two rural health insurance policies in China was obtained, analysed, and synthesise. 92 documents on CMS (Cooperative Medical Scheme) or NCMS (New Rural Cooperative Medical Scheme) from four databases searched were included. Data extraction and synthesis of the information were guided by a framework that drew on that developed by the WHO to describe health system governance and leadership.

RESULTS

We identified a series of governance practices that were supportive of progress, including the prioritisation by the central government of health system development and certain health policies within overall national development; strong government commitment combined with a hierarchal administrative system; clear policy goals coupled with the ability for local government to adopt policy measures that take account of local conditions; and the accumulation and use of the evidence generated from local practices. However these good practices were not seen in all governance domains. For example, poor collaboration between different government departments was shown to be a considerable challenge that undermined the operation of the insurance schemes.

CONCLUSIONS

China's success in achieving scale up of CMS and NCMS has attracted considerable interest in many low and middle income countries (LMICs), especially with regard to the schemes' designs, coverage, and funding mechanisms. However, this study demonstrates that health systems governance may be critical to enable the development and operation of such schemes. Given that many LMICs are expanding health financing system to cover populations in rural areas or the informal sectors, we argue that strengthening specific practices in each governance domain could inform the adaptation of these schemes to other settings.

The impact of a bundled policy intervention on improving the performance of rural healthcare in China

BACKGROUND

The strategy of health policy has been changed for improving the performances to meeting the increasing healthcare demands. However, limited evidences were found to prove that the bundled payment was valid for service delivering in public sector. This study was designed to evaluate the effectiveness of a bundled policy on strengthening the county-village communication and improving the quality of chronic disease management.

METHODS

This is a retrospective cohort study using the data collected in 2011, 2012 and 2014 from the Rural Health Development Project in China. The policy intervention included performance-related contract with health facilities, developing technical guideline for doctors and nurses, routine monitoring of performance, and efforts to increase public awareness about the services. There were two intervention counties in Henan Province, China, while one county with similar characteristics in Henan was selected as control. Funding allocation, work load and salary for health care workers, volume of township-to-village technical assistance were reported before and after the policy was implemented. Our study also examined the policy impacts on improving treatment outcomes of diabetes and hypertension care.

RESULTS

There were substantial increases in the provision of the basic package of services including 96.6 % of patients with hypertension, 91.2 % of patients with diabetes under the health management system. After the intervention, there were 34.3 % (hypertension) and 42.0 % (diabetes) increase in regular follow-up visit rates, 24.6 and 17.2 % increase in blood pressure and blood glucose control rates, respectively. The family health records system covered 96 % of the rural families. Technical assistance between township health centres and village clinics were enhanced. Compared with baseline, the monthly training meeting and field supervision & guidance between township health centres and village clinics increased 1.0 meeting, 1.5 field visits, respectively, while the increases in the control county were only 0.3 meeting and 0.3 field visits. At the end of this study, 93.8 % of health workers achieved their performance goals. More patients were referred to appropriate levels of care.

CONCLUSION

This bundled policy intervention effectively improved rural health care delivery. The result of our study can be used for local governments to implement performance-based health system management in developing country.

Determinants of basic public health services provision by village doctors in China: using non-communicable diseases management as an example

BACKGROUND

To ensure equity and accessibility of public health care in rural areas, the Chinese central government has launched a series of policies to motivate village doctors to provide basic public health services. Using chronic disease management and prevention as an example, this study aims to identify factors associated with village doctors' basic public health services provision and to formulate targeted interventions in rural China.

METHODS

Data was obtained from a survey of village doctors in three provinces in China in 2014. Using a multistage sampling process, data was collected through the self-administered questionnaire. The data was then analyzed using multilevel logistic regression models.

RESULTS

The high-level basic public health services for chronic diseases (BPHS) provision rate was 85.2% among the 1149 village doctors whom were included in the analysis. Among individual level variables, more education, more training opportunities, receiving more public health care subsidy (OR = 3.856, 95 % CI: 1.937-7.678, and OR = 4.027, 95% CI: 1.722-9.420), being under integrated management (OR = 1.978, 95% CI: 1.132-3.458), and being a New Cooperative Medical Scheme insurance program-contracted provider (OR = 2.099, 95% CI: 1.187-3.712) were associated with the higher BPHS provision by village doctors. Among county level factors, Foreign Direct Investment Index showed a significant negative correlation with BPHS provision, while the government funding for BPHS showed no correlation (P > 0.100).

CONCLUSION

Increasing public health care subsidies received by individual village doctors, availability and attendance of training opportunities, and integrated management and NCMS contracting of village clinics are important factors in increasing BPHS provision in rural areas.

Universal health insurance coverage for 1.3 billion people: What accounts for China's success?

China successfully achieved universal health insurance coverage in 2011, representing the largest expansion of insurance coverage in human history. While the achievement is widely recognized, it is still largely unexplored why China was able to attain it within a short period. This study aims to fill the gap. Through a systematic political and socio-economic analysis, it identifies seven major drivers for China's success, including (1) the SARS outbreak as a wake-up call, (2) strong public support for government intervention in health care, (3) renewed political commitment from top leaders, (4) heavy government subsidies, (5) fiscal capacity backed by China's economic power, (6) financial and political responsibilities delegated to local governments and (7) programmatic implementation strategy. Three of the factors seem to be unique to China (i.e., the SARS outbreak, the delegation, and the programmatic strategy.) while the other factors are commonly found in other countries' insurance expansion experiences. This study also discusses challenges and recommendations for China's health financing, such as reducing financial risk as an immediate task, equalizing benefit across insurance programs as a long-term goal, improving quality by tying provider payment to performance, and controlling costs through coordinated reform initiatives. Finally, it draws lessons for other developing countries.

Health policy evolution in Lao People's Democratic Republic: context, processes and agency

During the last 20 years Lao People's Democratic Republic has successfully developed and adopted some 30 health policies, strategies, decrees and laws in the field of health. Still, the implementation process remains arduous. This article aims at discussing challenges of health policy development and effective implementation by contextualizing the policy evolution over time and by focusing particularly on the National Drug Policy and the Health Care Law. Special attention is given to the role of research in policymaking. The analysis was guided by the conceptual framework of policy context, process, content and actors, combined with an institutional perspective, and showed that effective implementation of a health policy is highly dependent on both structures and agency of those involved in the policy process. The National Drug Policy was formulated and adopted in a short period of time in a resource-scarce setting, but with dedicated policy entrepreneurs and support of concerned international collaborators. Timely introduction of operational health systems research played a crucial role to support the implementation, as well as the subsequent revision of the policy. The development of the Health Care Law took several years and once adopted, the implementation was delayed by institutional legacies and issues concerning the choice of institutional design and financing, despite strong support of the law among the policymakers. Among many factors, timing of the implementation appeared to be of crucial importance, in combination with strong leadership. These two examples show that more research, that problematizes the complex policy environment in combination with improved communication between researchers and policymakers, is necessary to inform about measures for effective implementation. A way forward can be to strengthen the domestic research capacity and the international research collaboration regionally as well as globally.

Advancing the application of systems thinking in health: managing rural China health system development in complex and dynamic contexts

Background

This paper explores the evolution of schemes for rural finance in China as a case study of the long and complex process of health system development. It argues that the evolution of these schemes has been the outcome of the response of a large number of agents to a rapidly changing context and of efforts by the government to influence this adaptation process and achieve public health goals.

Methods

The study draws on several sources of data including a review of official policy documents and academic papers and in-depth interviews with key policy actors at national level and at a sample of localities.

Results

The study identifies three major transition points associated with changes in broad development strategy and demonstrates how the adaptation of large numbers of actors to these contextual changes had a major impact on the performance of the health system. Further, it documents how the Ministry of Health viewed its role as both an advocate for the interests of health facilities and health workers and as the agency responsible for ensuring that government health system objectives were met. It is argued that a major reason for the resilience of the health system and its ability to adapt to rapid economic and institutional change was the ability of the Ministry to provide overall strategy leadership. Additionally, it postulates that a number of interest groups have emerged, which now also seek to influence the pathway of health system development.

Conclusions

This history illustrates the complex and political nature of the management of health system development and reform. The paper concludes that governments will need to increase their capacity to analyze the health sector as a complex system and to manage change processes.

The inter-section of political history and health policy in Asia--the historical foundations for health policy analysis

One of the challenges for health reform in Asia is the diverse set of socio-economic and political structures, and the related variability in the direction and pace of health systems and policy reform. This paper aims to make comparative observations and analysis of health policy reform in the context of historical change, and considers the implications of these findings for the practice of health policy analysis. We adopt an ecological model for analysis of policy development, whereby health systems are considered as dynamic social constructs shaped by changing political and social conditions. Utilizing historical, social scientific and health literature, timelines of health and history for five countries (Cambodia, Myanmar, Mongolia, North Korea and Timor Leste) are mapped over a 30-50 year period. The case studies compare and contrast key turning points in political and health policy history, and examines the manner in which these turning points sets the scene for the acting out of longer term health policy formation, particularly with regard to the managerial domains of health policy making. Findings illustrate that the direction of health policy reform is shaped by the character of political reform, with countries in the region being at variable stages of transition from monolithic and centralized administrations, towards more complex management arrangements characterized by a diversity of health providers, constituency interest and financing sources. The pace of reform is driven by a country's institutional capability to withstand and manage transition shocks of post conflict rehabilitation and emergence of liberal economic reforms in an altered governance context. These findings demonstrate that health policy analysis needs to be informed by a deeper understanding and questioning of the historical trajectory and political stance that sets the stage for the acting out of health policy formation, in order that health systems function optimally along their own historical pathways.

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.

Time trends and determinants of pharmaceutical expenditure in China (1990-2009)

BACKGROUND

Pharmaceutical policy reform is currently one of the primary areas of health reform in China. The national pharmaceutical policy of China has multiple objectives: to develop the domestic pharmaceutical industry and encourage innovation, to control escalation of total pharmaceutical expenditures (TPE) which constitute a substantial component of total health expenditures (THE), and to ensure access to essential medicines for poor and uninsured patients. The current pharmaceutical system has been criticized for its high costs, questionable prescribing practices, and poor regulation of drug quality. This study aims to examine the time trends and influential factors of TPE in China.

METHOD

Data from the 2010 China National Health Accounts Report and the 2010 China Health Statistics Year Book were used in the analysis. Time trends of TPE as a share of THE (TPE/THE), of gross domestic product [GDP] (TPE/GDP), and the relationship between TPE/THE and GDP were examined. The growth of TPE was examined after adjusting for health care utilization and GDP. The determinants of the TPE/THE and the TPE/GDP between 1990 and 2009 were investigated by two time-series regression models including the amount of prescriptions dispensed (using proxy variables of health utilization), the price indices of medical services, and the price indices of pharmaceuticals during that time period.

RESULTS

Descriptive analyses showed that TPE and THE grew consistently during the years 1990-2009. The ratio of the THE/GDP increased more rapidly in recent years than the TPE/GDP. Furthermore, outpatient pharmaceutical expenditures (PEs) per visit and hospital PEs per admission grew throughout the study period. The amount of outpatient visits did not show a significant growth pattern during the 1990s, despite rapid GDP growth during that period. The time-series models showed that the TPE/THE was negatively associated with GDP during the same year (p = 0.039), as well as the medical consumer price index [CPI] (p = 0.021). The TPE/GDP was influenced by the price index of prescriptions (p < 0.001) and the amount of health services utilization, including inpatient admissions (p = 0.012) and outpatient visits (p = 0.003).

CONCLUSION

The cost escalations in PEs and health expenditures were concurrent with GDP growth. TPE has been the major source of financial burden for patients. Even though the rapid growth in China's economy may ameliorate the overall TPE burden, control of PEs is still a key for successful health system reform.

Adapting to social and political transitions - the influence of history on health policy formation in the Republic of the Union of Myanmar (Burma)

The Republic of the Union of Myanmar (Burma) has a long and complex history characterized by internal conflict and tense international relations. Post-independence, the health sector has gradually evolved, but with health service development and indicators lagging well behind regional expectations. In recent years, the country has initiated political reforms and a reorientation of development policy towards social sector investment. In this study, from a systems and historical perspective, we used publicly available data sources and grey literature to describe and analyze links between health policy and history from the post-independence period up until 2012. Three major periods are discernable in post war health system development and political history in Myanmar. The first post-independence period was associated with the development of the primary health care system extending up to the 1988 political events. The second period is from 1988 to 2005, when the country launched a free market economic model and was arguably experiencing its highest levels of international isolation as well as very low levels of national health investment. The third period (2005-2012) represents the first attempts at health reform and recovery, linked to emerging trends in national political reform and international politics. Based on the most recent period of macro-political reform, the central state is set to transition from a direct implementer of a command and control management system, towards stewardship of a significantly more complex and decentralized administrative order. Historical analysis demonstrates the extent to which these periodic shifts in the macro-political and economic order acts to reset the parameters for health policy making. This case demonstrates important lessons for other countries in transition by highlighting the extent to which analysis of political history can be instructive for determination of more feasible boundaries for future health policy action.

Health governance and healthcare reforms in China

This article examines the role of health governance in shaping the outcomes of healthcare reforms in China. The analysis shows that the failure of reforms during the 1980s and 1990s was in part due to inadequate attention to key aspects in health governance, such as strategic interactions among government, providers and users, as well as incentive structures shaping their preferences and behaviour. Although more recent reforms seek to correct these flaws, they are insufficiently targeted at the fundamental governance problems that beset the sector. The article suggests that the Chinese government needs to heighten its efforts to enhance health governance and change the ways providers are paid if it is to succeed in achieving its goal of providing health care to all at affordable cost.

Building institutions for health and health systems in contexts of rapid change

Many Asian countries are in the midst of multiple interconnected social, economic, demographic, technological, institutional and environmental transitions. These changes are having important impacts on health and well-being and on the capacity of health systems to respond to health-related problems. This paper focuses on the creation of institutions to overcome information asymmetry and encourage the provision of safe, effective and affordable health services in this context of complexity and rapid change. It presents a review of literature on different approaches to the analysis of the management of system development and institution-building. There is a general agreement that the outcome of an intervention depends a great deal on the way that a large number of agents respond. Their response is influenced by the institutional arrangements that mediate relationships between health sector actors and also by their understandings and expectations of how other actors will respond. The impact of a policy or specific intervention is difficult to predict and there is a substantial risk of unintended outcomes. This creates the need for an iterative learning approach in which widespread experimentation is encouraged, good and bad experiences are evaluated and policies are formulated on the basis of the lessons learned. This enables actors to learn their roles and responsibilities and the appropriate responses to new incentive structures. The paper concludes with an outline of the information needs of managers of health system change in societies in the midst of rapid development.

Engaging sub-national governments in addressing health equities: challenges and opportunities in China's health system reform

China's current health system reform (HSR) is striving to resolve deep inequities in health outcomes. Achieving this goal is difficult not only because of continuously increasing income disparities in China but also because of weaknesses in healthcare financing and delivery at the local level. We explore to what extent sub-national governments, which are largely responsible for health financing in China, are addressing health inequities. We describe the recent trend in health inequalities in China, and analyse government expenditure on health in the context of China's decentralization and intergovernmental model to assess whether national, provincial and sub-provincial public resource allocations and local government accountability relationships are aligned with this goal. Our analysis reveals that government expenditure on health at sub-national levels, which accounts for ∼90% of total government expenditure on health, is increasingly regressive across provinces, and across prefectures within provinces. Increasing inequity in public expenditure at sub-national levels indicates that resources and responsibilities at sub-national levels in China are not well aligned with national priorities. China's HSR would benefit from complementary measures to improve the governance and financing of public service delivery. We discuss the existing weaknesses in local governance and suggest possible approaches to better align the responsibilities and capacity of sub-national governments with national policies, standards, laws and regulations, therefore ensuring local-level implementation and enforcement. Drawing on China's institutional framework and ongoing reform pilots, we present possible approaches to: (1) consolidate key health financing responsibilities at the provincial level and strengthen the accountability of provincial governments, (2) define targets for expenditure on primary health care, outputs and outcomes for each province and (3) use independent sources to monitor and evaluate policy implementation and service delivery and to strengthen sub-national government performance management.

Chinese-style decentralization and health system reform

David Hipgrave and colleagues discuss health system reform in China and argue that parallel reforms in governance, financing, and accountability are also needed to ensure health equity.

The effect of new cooperative medical scheme on health outcomes and alleviating catastrophic health expenditure in China: a systematic review

BACKGROUND

In 2002, the Chinese government launched a new rural health financing policy to provide health insurance (New Cooperative Medical Scheme, NCMS) for its rural population. NCMS, jointly financed by governments and individual households, aims to protect households from impoverishment due to catastrophic health expenditure. In 2011, NCMS covered more than 96% of the rural population. We have systematically searched and reviewed available evidence to estimate the effects of NCMS on health outcomes and on alleviating catastrophic health expenditure.

METHODS

PubMed, Web of Science with Conference Proceedings, ProQuest Digital Dissertations, CMCI, CNKI, and VIP were searched. We also obtained literature from colleague communications. Quasi-experimental studies regarding the effect of NCMS on health outcomes and catastrophic health expenditure were included. Two independent reviewers screened the literature, extracted the data, and assessed the study quality.

RESULTS

Fifteen studies out of the 6123 studies in the literature fulfilled criteria and were included in this review. Twelve studies identified the relationship between NCMS and health outcomes, among which six studies measured sickness or injury in the past four weeks, four measured sickness or injury in the past two weeks, and five measured self-reported health status. Four studies focused on the relationship between NCMS and alleviating catastrophic health expenditure. However, the results from these studies were in conflict: individual studies indicated that NCMS had positive, negative, or no effect on health outcomes and/or the incidence of catastrophic health payments, respectively.

CONCLUSIONS

We still have no clear evidence that NCMS improves the health outcomes and decreases the alleviating catastrophic health expenditure of the China's rural population. In addition, the heterogeneity among individual studies reminds us that provider payment method reforms, benefit package and information systems around NCMS should be improved in the future.