Evolution of China's health-care system

Small money, big change: The distributional impact of differentiated doctor's visit fee on healthcare utilization

A prominent issue in China's healthcare sector is the overcrowding of high-tier hospitals, whereas low-tier hospitals and community health centers are severely underutilized. This study aims to examine whether doctor's visit fee and copay differentiated by the level of healthcare providers can change the distribution of outpatient visits across different levels of healthcare providers. By leveraging the exogeneity of the policy change implemented in a megacity in China in 2017, we apply a parametric discontinuity regression model to study the causal impact of differentiated pricing on patients' health-seeking behavior, using a large-scale insurance claim database. We find that the reform of differentiated doctor's visit fee schedule effectively increases the proportion of visits to primary care facilities among all outpatient visits. This effect is driven by a decline in visits to the highest-tier hospitals and an increase in visits to community healthcare centers. Furthermore, the policy effects are more pronounced among the elderly and people with chronic diseases. Our results suggest that shifting the focus of pricing policies from coinsurance to copays while continuing to improve the capacity of primary care facilities is an effective way to facilitate triaging patients into different levels of care without triggering moral hazard.

Spatial effects of public health laboratory emergency testing institutions under COVID-19 in China

BACKGROUND

The transmission of 2019 novel coronavirus (COVID-19) has caused global panic in the past three years. Countries have learned an important lesson in the practice of responding to COVID-19 pandemic: timely and accurate diagnosis is critical. As an important technology of virus diagnosis, nucleic acid testing (NAT) is also widely used in the identification of other infectious diseases. However, geographic factors often constrain the provision of public health services such as NAT services, and the spatial nature of their resource allocation is a significant problem.

METHODS

We used OLS, OLS-SAR, GWR, GWR-SAR, MGWR, and MGWR-SAR models to identify the determinants of spatial difference and spatial heterogeneity affecting NAT institutions in China.

RESULTS

Firstly, we identify that the distribution of NAT institutions in China shows a clear spatial agglomeration, with an overall trend of increasing distribution from west to east. There is significant spatial heterogeneity in Chinese NAT institutions. Secondly, the MGWR-SAR model results show that city level, population density, number of tertiary hospitals and number of public health emergency outbreaks are important factors influencing the spatial heterogeneity of NAT institutions in China.

CONCLUSIONS

Therefore, the government should allocate health resources rationally, optimise the spatial layout of testing facilities, and improve the ability to respond to public health emergencies. Meanwhile, third-party testing facilities need to focus on their role in the public health emergency response system as a market force to alleviate the inequitable allocation of health resources between regions. By taking these measures to prepare adequately for possible future public health emergencies.

Evaluation of Unified Healthcare Efficiency in China: A Meta-Frontier Non-radial Directional Distance Function Analysis During 2009–2019

In this study, we analyze the unified healthcare efficiency in China at the regional level from 2009 to 2019. To accurately evaluate the evolution of unified efficiency from both static and dynamic perspectives, we combine the non-radial directional distance function and the meta-frontier method to evaluate the unified healthcare efficiency and its dynamic changes. This new approach allows for regional heterogeneity and non-radial slack simultaneously. The decomposition of the meta-frontier non-radial Malmquist unified healthcare efficiency index (MNMHEI) can be used to identify the driving factors of dynamic changes. The results show that the unified healthcare efficiency in eastern China is generally higher than that in non-eastern China from the static perspective, implying significant regional differences. Moreover, the unified efficiency in both eastern and non-eastern regions shows similar time trends and reaches the maximum in 2012. From the dynamic perspective, the unified healthcare efficiency increases annually by 2.68% during the study period. This increase in eastern China as a technology leader is mainly driven by technological progress, whereas the increase in non-eastern China is mainly driven by a better catch-up effect. In addition, the impact of the reform on the non-eastern region is more significant for the decreasing technology gap, the stronger growth momentum of technological progress, and global innovative provinces.

Risk and Protective Factors for the Mental Wellbeing of Deployed Healthcare Workers During the COVID-19 Pandemic in China: A Qualitative Study

Background: Though many literatures documented burnout and occupational hazard among healthcare workers and frontliners during pandemic, not many adopted a systemic approach to look at the resilience among this population. Another under-studied population was the large numbers of global healthcare workers who have been deployed to tackle the crisis of COVID-19 pandemic in the less resourceful regions. We investigated both the mental wellbeing risk and protective factors of a deployed healthcare workers (DHWs) team in Wuhan, the epicenter of the virus outbreak during 2020. Method: A consensual qualitative research approach was adopted with 25 DHWs from H province through semi-structured interviews after 3 months of deployment period. Results: Inductive-Deductive thematic coding with self-reflexivity revealed multi-layered risk and protective factors for DHWs at the COVID-19 frontline. Intensive working schedule and high-risk environment, compounded by unfamiliar work setting and colleagues; local culture adaptation; isolation from usual social circle, strained the DHWs. Meanwhile, reciprocal relationships and "familial relatedness" with patients and colleagues; organizational support to the DHWs and their immediate families back home, formed crucial wellbeing resources in sustaining the DHWs. The dynamic and dialectical relationships between risk and protective factors embedded in multiple layers of relational contexts could be mapped into a socio-ecological framework. Conclusion: Our multidisciplinary study highlights the unique social connectedness between patient-DHWs; within DHWs team; between deploying hospital and DHWs; and between DHWs and the local partners. We recommend five organizational strategies as mental health promotion and capacity building for DHWs to build a resilient network and prevent burnout at the disaster frontline.

Successful Aging in East Asia: Comparison Among China, Korea, and Japan

OBJECTIVES

Heterogeneity in successful aging has been found across countries. Yet, comparable evidence is sparse except in North America and Europe. Extending prior research, this study examined the prevalence and correlates of successful aging in East Asia: China, Korea, and Japan.

METHOD

We used harmonized data sets from national surveys. A total of 6,479 participants (aged between 65 and 75) were analyzed. Using Rowe and Kahn's (1987, 1997) model, successful aging was defined as having no major diseases, no difficulty performing activities of daily living, obtaining a median or higher score on tests of cognitive function, and being actively engaged.

RESULTS

The average prevalence of successful agers was 17.6%. There were variations in the global and specific measures of successful aging within and across countries, even after controlling for individual sociodemographic factors (age, gender, and education). The odds of aging successfully were highest in Japan and lowest in China, especially in the rural areas. Being younger and males were associated with a higher likelihood of successful agers in both global and specific measures.

DISCUSSION

This study observed heterogeneity in successful aging in East Asia. To identify policy implications, future research should explore potential societal factors influencing individuals' opportunities for successful aging.

Is low cost really conducive to primary care utilisation: An empirical analysis of community health centers in China

Despite community health centers (CHCs) having many potential benefits, their utilisation rate is still low in urban China. Using the health belief model, the study conducted cross-sectional survey to examine factors that affected individuals' intentions to use primary care services in China. This study on 942 participants from Shanghai revealed that low cost had insignificant effect on the choice of CHCs once other key factors were accounted for. Older age, greater perceived susceptibility to contracting common diseases and more benefits of individualised care greatly increased the likelihood of using primary care services. Perceived low competencies of medical personnel along with outdated medical facilities had significant negative relationships with the intention of choosing CHCs. Based on these findings, some policy recommendations are proposed such as promoting education on prevalence of common diseases, recruiting qualified medical personnel, increasing professional training and cooperation, updating medical facilities, and offering high-quality individualised care in order to improve efficiency of primary care utilisation.

Assessing the quality of primary healthcare for diabetes in China: multivariate analysis using the China Health and Retirement Longitudinal Study (CHARLS) Database

OBJECTIVE

To assess the quality of primary healthcare (PHC) for patients with diabetes in China from 2011 to 2015.

SETTING

This study analysed data on 1006, 1472 and 1771 participants with diabetes who were surveyed in 2011, 2013 and 2015, respectively, in the China Health and Retirement Longitudinal Study, a nationally representative survey conducted in 29 provinces of China.

OUTCOME MEASURES

The study measured the proportions of patients with diabetes who received diabetes-related health education, examinations and treatments, as well as the hospital admission rate due to diabetes of these patients. Multilevel logistic regression was used to adjust sociodemographic variables.

RESULTS

According to the multivariate analysis, the proportion of patients who received diabetes-related health education decreased significantly (OR=0.74, 95% CI 0.61 to 0.90), and the proportion of those receiving examinations and treatments remained unchanged from 2011 to 2015. Diabetes-related hospitalisation increased from 4.01% in 2011 to 6.08% in 2013 (OR=1.47, 95% CI 0.97 to 2.22), and recurrent hospitalisations increased from 18.87% in 2011 to 28.45% in 2015 (OR=1.78, 95% CI 1.44 to 2.20). The proportions of patients with diabetes-related and recurrent hospitalisations in western China were higher than those in the east (OR=1.80, 95% CI 1.13 to 2.87; OR=1.92, 95% CI 1.50 to 2.45).

CONCLUSIONS

Nationally, the analysis of patient-reported process and outcome indicators cannot confirm that the quality of PHC has improved in China during 2011-2015. Regional disparities in primary diabetes care require urgent resource allocation to western China. Establishing a national quality registry for PHC, which transparently reports outcomes by region and social-economic position, is essential for countries sharing the challenge of improving both quality and equity of PHC.

Towards universal health coverage: lessons from 10 years of healthcare reform in China

Universal health coverage (UHC) is driving the global health agenda. Many countries have embarked on national policy reforms towards this goal, including China. In 2009, the Chinese government launched a new round of healthcare reform towards UHC, aiming to provide universal coverage of basic healthcare by the end of 2020. The year of 2019 marks the 10th anniversary of China’s most recent healthcare reform. Sharing China’s experience is especially timely for other countries pursuing reforms to achieve UHC. This study describes the social, economic and health context in China, and then reviews the overall progress of healthcare reform (1949 to present), with a focus on the most recent (2009) round of healthcare reform. The study comprehensively analyses key reform initiatives and major achievements according to four aspects: health insurance system, drug supply and security system, medical service system and public health service system. Lessons learnt from China may have important implications for other nations, including continued political support, increased health financing and a strong primary healthcare system as basis.

Job Burnout Among Primary Healthcare Workers in Rural China: A Multilevel Analysis

The health workers in rural primary care systems are at the increasing risk of job burnout. To explore the prevalence and associated factors of the job burnout among the primary healthcare worker in rural China, a cross-sectional survey was conducted among 15,627 participants in 459 township hospitals from six provinces. A combination of stratified multi-stage sampling and cluster sampling method, and a self-administrated questionnaire with the Chinese version of the Maslach Burnout Inventory-General Scale (MBI-GS) were used in the investigation. Multilevel regression analyses were used to examine the potential associated factors on both individual and organisational levels. 47.6% of respondents were experiencing moderate burnout, and 3.3% were in severe burnout. Professionals working for over 40 h per week, at young age, with a college degree, and with professional titles at medium or high rank reported a higher degree of job burnout. At the institutional level, the high ratio of performance-based salary was associated with a higher level of depersonalization. Burnout has become prevalent among the primary healthcare workers in rural China, and multiple strategies are needed to reduce the work stress and some high-risk groups’ vulnerability to job burnout.

Demographic aging and biopower

The aging of the world's population is an unprecedented recent phenomenon in human history, as for millennia - at least from the Neolithic to the mid-18th century - the age structures of human populations have changed little. The question posed by this anthropological perspective seems at first sight quite simple: how did this aging come to be? We will see that from a demographic point of view, the answer seems trivial: a basic shift in population structure is at the origin. However, we will go further by exploring the historical and political conditions of this transition by mobilizing the Foucauldian notion of biopower. We argue that this notion has the heuristic advantage of linking several core processes at work in the demographic transition. Although our analysis focuses on France to illustrate the notion of biopower in Foucault's work, we also discuss several non-western societies to explain why demographic aging is inevitable across the globe due to biopower strategies and "dispositifs". This article also constitutes a reflexive analysis on our practices as gerontologists and on the widespread "successful aging" concept.

Doctors' Job Satisfaction and Its Relationships With Doctor-Patient Relationship and Work-Family Conflict in China: A Structural Equation Modeling

The objective of this study was to evaluate the relationship of doctors’ job satisfaction with doctor-patient relationship and work-family conflict in China. The data came from a cross-sectional survey in Hubei province, which was part of China’s Fifth National Health Services Survey conducted in 2013. The survey in Hubei covered 54 secondary and tertiary general hospitals distributed in 20 counties. Of the 1080 questionnaires, 908 were included into our analysis. After surviving from reliability and validity tests, structural equation modeling was applied for further analysis with SPSS 20.0 and Mplus 7.0. The results showed that the average score of job satisfaction is 19.61 out of 30 points, indicating a relatively low level of doctors’ job satisfaction in Hubei province. Work-family conflict was found to have negative impact on doctors’ job satisfaction, and good doctor-patient relationship was found to have positive impact on their job satisfaction. Therefore, hospital administrators and policy makers should make effort to design and implement strategies that focus on meliorating doctor-patient relationship and balancing doctors’ work and family life to further improve their job satisfaction.

Study On Potential Factors Of Patient Satisfaction: Based On Exploratory Factor Analysis

OBJECTIVE

To explore the potential common factors of patient satisfaction and the influencing factor of it.

METHODS

A questionnaire survey was organized and 2626 valid answers were obtained. Through correlation analysis and exploratory factor analysis, the potential factors of patient satisfaction were extracted.

RESULTS

Potential factors of patient satisfaction include "Medical service quality factor", "Medical expenditure factor", and "Medical convenience factor". Patients younger than 35 years old were more concerned about the medical expenditure, and patients aged from 36 to 50 years old were more concerned about medical service quality. Patients with high reimbursement ratio insurance payed more attention to medical quality, and patients with lower reimbursement ratio insurance were dissatisfied with medical expenses. Patients were dissatisfied with the expenditure of the high-level hospitals and the medical quality of low-level hospitals. Outpatient's satisfaction was lower than Inpatients in all aspects. Hierarchical diagnosis system was not established, and registration channels were highly centralized in the hospital.

CONCLUSION

Three potential factors can well explain patients' demands for the quality, price and convenience of medical services. According to social-demographic characteristics, people of different groups have different concerns. Medical reform departments should adjust policies according to the actual situation and promote the medical reform process.

Objective and subjective financial status and mortality among older adults in China

The association between financial status and mortality in older adults is well documented. However, it is unclear whether the association may vary by objective and subjective indicators of financial status. To examine this issue, we used the latest four waves (2005, 2008/2009, 2011/2012, and 2014) of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) of community-residing adults aged 65 and older (n = 25,954). Financial status was assessed using eight objective, subjective, and culturally-oriented measures to capture various dimensions of financial resources at older ages. Multivariate hazard models were used to examine how different indicators of financial status were associated with subsequent mortality in all older adults and by age, gender, and urban-rural residence. Results showed that higher financial status-either objective or subjective-was associated with lower risks of mortality. Subjective assessments of financial status had stronger associations with mortality than objective assessments. The patterns were generally similar between young-old (aged 65-79) and the oldest-old (aged 80+), between women and men, and between rural and urban areas. Together, the findings offer new evidence to help improve the socioeconomic gradient in mortality among older adults in China.

Can single disease payment system based on clinical pathway reduce hospitalization costs in rural area? A case study of uterine leiomyoma in Anhui, China

BACKGROUND

Single disease payment program based on clinical pathway (CP-based SDP) plays an increasingly important role in reducing health expenditure in china and there is a clear need to explore the scheme from different perspectives. This study aimed at evaluating the effect of the scheme in rural county public hospitals within Anhui, a typical province of China,using uterine leiomyoma as an example.

METHODS

The study data were extracted from the data platform of the New Rural Cooperative Medical Office of Anhui Province using stratified-random sampling. Means, constituent ratios and coefficients of variations were calculated and/or compared between control versus experiment groups and between different years.

RESULTS

The total hospitalization expenditure (per-time) dropped from 919.08 ± 274.92 USD to 834.91 ± 225.29 USD and length of hospital stay reduced from 9.96 ± 2.39 days to 8.83 ± 1.95 days(P < 0.01), after CP-based SDP had implemented. The yearly total hospitalization expenditure manifested an atypical U-shaped trend. Medicine expense, nursing expense, assay cost and treatment cost reduced; while the fee of operation and examination increased (P < 0.05). The expense constituent ratios of medicine, assay and treatment decreased with the medicine expense dropped the most (by 4.4%). The expense constituent ratios of materials, ward, operation, examination and anesthetic increased,with the examination fee elevated the most (by 3.9%).The coefficient of variation(CVs) of treatment cost declined the most (- 0.360); while the CV of materials expense increased the most (0.186).

CONCLUSION

There existed huge discrepancies in inpatient care for uterine leiomyoma patients. Implementation of CP-based SDP can help not only in controlling hospitalization costs of uterine leiomyoma in county-level hospitals but also in standardizing the diagnosis and treatment procedures.

Traditional Mongolian, Traditional Chinese, and Western Medicine Hospitals: System Review and Patient Survey on Expectations and Perceptions of Quality of Healthcare in Inner Mongolia, China

BACKGROUND

In Inner Mongolia of China, traditional Mongolian medicine (TMM), traditional Chinese medicine (TCM), and western medicine (WM) are all supported by the government. This study compares the background and performance of these three types of medicines.

METHODS

The World Health Organization's Six Building Blocks framework was used for the system review. Data were collected from literature review and key informant interviews. A cross-sectional survey was conducted in three types of hospitals at the provincial, municipal (city), and prefectural (county) levels from April to August, 2016. Eight hospitals were included and, within each one, patients from four outpatient departments were selected. A total of 1,322 patients were interviewed about their expectations and perceptions of the health service.

RESULTS

Government support for TMM includes higher budget allocation and a higher reimbursement rate. TMM is preferred by Mongolian people, those living in pasturing areas, and those seeking treatment for musculoskeletal problems/injuries. Patients attending TMM hospitals had the highest expectations and perceptions of the health service in general. However, human resources and research capacity of TMM are relatively limited.

CONCLUSION

To further enhance the role of the popular TMM for local minority's health, human resources and research capacity strengthening are essential.

Functional activities and social participation after stroke in rural China: a qualitative study of barriers and facilitators

Objective:

To explore the perspectives of stroke survivors in China’s rural areas, particularly with respect to environmental barriers and facilitators related to their functional activity and social participation.

Design:

Qualitative content analysis. A cross-sectional study.

Setting:

In-depth interviewing in the participants’ homes.

Subjects:

In total, 18 community-dwelling stroke survivors in the rural areas of China.

Results:

The sub-themes to functional activity and social participation were restricted life-space mobility, reduced daily activities, and shrunken social networks. The main environmental facilitator was family support, which positively affected all facets of the participants’ lives, including assistance in daily living, assistance in gaining access to healthcare, and performing environmental modifications. The main barriers involved were physical barriers (toilet barriers, lack of assistive devices, barriers to getting out) and vague and complex regulations.

Conclusion:

Stroke survivors in rural China experienced environmental barriers mainly including physical barriers and complex regulations. The nuclear family’s support is an important environmental facilitator.

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.

Prevalence and correlates of successful ageing: a comparative study between China and South Korea

Successful ageing is often defined as a later life with less disease and disease-related disability, high level of cognitive and physical functions, and an active life style. Few studies have compared successful ageing across different societies in a non-Western social context. This study aims to compare prevalence and correlates of successful ageing between China and South Korea. The data come from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) and the Korean Longitudinal Study of Ageing (KLoSA). A total of 19,346 community-dwelling elders over 65 years were included, 15,191 from China and 4,155 from Korea. A multidimensional construct of successful ageing was used, with the criteria of no major comorbidity, being free of disability, good mental health, engaging in social or productive activity, and satisfaction on life. Correlates of successful ageing included demographics (gender, age, and rural/urban residence), socioeconomic features (financial status, education, and spouse accompany), and health behaviours (smoking, alcohol-drinking, and exercising). The results showed that 18.6 % of the older adults in China was successful agers, which was less than 25.2 % in Korea. When gender and age were adjusted, older adults were 51 % less likely to be successful agers in China than Korea (p < 0.001). The association patterns between successful ageing and its correlates are similar between China and Korea. However, before the socioeconomic variables are under control, rural residence was negatively related to successful ageing in China, whereas this is not the case in Korea. And the gender gap of successful ageing was mostly explained by socioeconomic features and health behaviours in Korea, but not in China. In both countries, good financial condition was highly associated with successful ageing. The study suggests that advancement of public health system could better control progression of non-communicable diseases among old people and thus promote successful ageing.

An exploration of China's mortality decline under Mao: A provincial analysis, 1950-80

Between 1950 and 1980, China experienced the most rapid sustained increase in life expectancy of any population in documented global history. We know of no study that has quantitatively assessed the relative importance of the various explanations proposed for this gain in survival. We have created and analysed a new, province-level panel data set spanning the decades between 1950 and 1980 by combining historical information from China's public health archives, official provincial yearbooks, and infant and child mortality records contained in the 1988 National Survey of Fertility and Contraception. Although exploratory, our results suggest that gains in school enrolment and public health campaigns together are associated with 55-70 per cent of China's dramatic reductions in infant and under-5 mortality during our study period. These results underscore the importance of non-medical determinants of population health, and suggest that, in some circumstances, general education of the population may amplify the effectiveness of public health interventions.

Improving the doctor-patient relationship in China: the role of balint groups

OBJECTIVE

Doctor-patient relationships in China have been deteriorating for the past 10 years. Many Chinese doctors are involved in tense and conflictual doctor-patient relationships. Most patients do not trust doctors or other medical staff and physical attacks on these professionals have become a common event. The Balint group offers a better understanding of the doctor-patient relationship in a safe environment and relieves the doctors from the daily stress.

METHOD

This article (1) describes the specifics of Balint work in China, (2) reports experiences from the first International Balint Conference in China, and (3) compares these experiences with the doctor-patient relationship described by Michael and Enid Balint in the 1950s.

RESULTS

Chinese doctors have a great need to communicate, to share their own feelings of powerlessness, helplessness, frustration, and anger. The Balint method is highly appreciated in China. All participants experienced the 2 1/2-day meeting as very helpful. Also, in China, Balint work as relationship work in the analytical group process fosters the ability for introspection alongside openness, unconscious processes, "thinking outside the box," "courage of one's own stupidity," and "beginner's spirit," thus promoting the individuation, the "small but significant change in the personality of the doctor."

CONCLUSIONS

Perhaps Balint work in China is a contribution to the integration of traditional Chinese virtues: benevolence, tolerance, magnanimity, and prudence with modern medicine. Balint work could be an alternative to the outcome-oriented pressure to perform and to the machine paradigm of biomedicine.

Relative health performance in BRICS over the past 20 years: the winners and losers

OBJECTIVE

To determine whether the health performance of Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--has kept in step with their economic development.

METHODS

Reductions in age- and sex-specific mortality seen in each BRICS country between 1990 and 2011 were measured. These results were compared with those of the best-performing countries in the world and the best-performing countries with similar income levels. We estimated each country's progress in reducing mortality and compared changes in that country's mortality rates against other countries with similar mean incomes to examine changes in avoidable mortality.

FINDINGS

The relative health performance of the five study countries differed markedly over the study period. Brazil demonstrated fairly even improvement in relative health performance across the different age and sex subgroups that we assessed. India's improvement was more modest and more varied across the subgroups. South Africa and the Russian Federation exhibited large declines in health performance as well as large sex-specific inequalities in health. Although China's levels of avoidable mortality decreased in absolute terms, the level of improvement appeared low in the context of China's economic growth.

CONCLUSION

When evaluating a country's health performance in terms of avoidable mortality, it is useful to compare that performance against the performance of other countries. Such comparison allows any country-specific improvements to be distinguished from general global improvements.

Nurse employment contracts in Chinese hospitals: impact of inequitable benefit structures on nurse and patient satisfaction

PURPOSE

Ongoing economic and health system reforms in China have transformed nurse employment in Chinese hospitals. Employment of 'bianzhi' nurses, a type of position with state-guaranteed lifetime employment that has been customary since 1949, is decreasing while there is an increase in the contract-based nurse employment with limited job security and reduced benefits. The consequences of inequities between the two types of nurses in terms of wages and job-related benefits are unknown. This study examined current rates of contract-based nurse employment and the effects of the new nurse contract employment strategy on nurse and patient outcomes in Chinese hospitals.

METHODS

This cross-sectional study used geographically representative survey data collected from 2008 to 2010 from 181 hospitals in six provinces, two municipalities, and one autonomous region in China. Logistic regression models were used to estimate the association between contract-based nurse utilization, dissatisfaction among contract-based nurses, nurse intentions to leave their positions, and patient satisfaction, controlling for nurse, patient, and hospital characteristics.

PRINCIPAL RESULTS

Hospital-level utilization of contract-based nurses varies greatly from 0 to 91%, with an average of 51%. Contract-based nurses were significantly more dissatisfied with their remuneration and benefits than 'bianzhi' nurses who have more job security (P <0.01). Contract-based nurses who were dissatisfied with their salary and benefits were more likely to intend to leave their current positions (P <0.01). Hospitals with high levels of dissatisfaction with salary and benefits among contract-based nurses were rated lower and less likely to be recommended by patients (P < 0.05).

CONCLUSIONS

Our results suggest a high utilization of contract-based nurses in Chinese hospitals, and that the inequities in benefits between contract-based nurses and 'bianzhi' nurses may adversely affect both nurse and patient satisfaction in hospitals. Our study provides empirical support for the 'equal pay for equal work' policy emphasized by the China Ministry of Health's recent regulations, and calls for efforts in Chinese hospitals to eliminate the disparities between 'bianzhi' and contract-based nurses.

The Impacts of Unmet Needs for Long-Term Care on Mortality Among Older Adults in China

The unmet needs of persons needing long-term care have recently drawn attention in China, the nation with the world’s largest elderly population. Using national panel data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), we examined the 3-year mortality of 3,089 Chinese adults above the age of 65 years who required long-term care. Long-term care needs were measured by the inability to perform any of the following six activities of daily living for 3 months: eating, dressing, bathing, getting in/out of the bed, indoor transferring, and toileting. Exponential parametric hazard models were used to investigate the association between unmet care needs on subsequent mortality. Results showed that older adults with unmet needs had an approximately 10% increased risk of mortality compared with those whose needs were met when demographics were under control. The risks were particularly elevated among older women and among urban older adults. We conclude by discussing these findings and the importance of a national social insurance program (or additional programs) specialized for the provision of long-term care in China.

Factors associated with job satisfaction by Chinese primary care providers

OBJECTIVES

This study provides a snapshot of the current state of primary care workforce (PCW) serving China's grassroots communities and examines the factors associated with their job satisfaction.

METHODS

Data for the study were from the 2011 China Primary Care Workforce Survey, a nationally representative survey that provides the most current assessment of community-based PCW. Outcome measures included 12 items on job satisfaction. Covariates included intrinsic and extrinsic factors associated with job satisfaction. In addition, PCW type (i.e., physicians, nurses, public health, and village doctors) and practice setting (i.e., rural versus urban) were included to identify potential differences due to the type of PCW and practice settings.

RESULTS

The overall satisfaction level is rather low with only 47.6% of the Chinese PCW reporting either satisfied or very satisfied with their job. PCW are least satisfied with their income level (only 8.6% are either satisfied or very satisfied), benefits (12.8%), and professional development (19.5%). They (particularly village doctors) are also dissatisfied with their workload (37.2%). Lower income and higher workload are the two major contributing factors toward job dissatisfaction.

CONCLUSION

To improve the general satisfaction level, policymakers must provide better pay and benefits and more opportunities for career development, particularly for village doctors.

Report from China: health insurance in China--evolution, current status, and challenges

The authors review the evolution of health insurance in China and analyze how it has been shaped to its current form by political and economic dynamics. They summarize the current status of health insurance in terms of population coverage, benefit design, scope of service, and its interaction with providers; address challenges regarding future health insurance reform; and propose policy recommendations. Although the recent health insurance reform has made major breakthroughs in population coverage, it is still too early to judge whether the political willingness to appease social unrest can be translated into concrete health care protections for the population.

A qualitative study about self-medication in the community among market vendors in Fuzhou, China

Despite government efforts to increase healthcare insurance and access in China, many individuals, regardless of insurance status, continue to engage in high levels of self-medication. To understand the factors influencing common self-medication behaviour in a community of food market vendors in Fuzhou China, a total of 30 market vendors were randomly recruited from six food markets in 2007. In-depth interviews were conducted with each participant at their market stalls by trained interviewers using a semi-structured open-ended interview protocol. Participants were asked broad questions about their health-seeking behaviours as well as their past experiences with self-medication and hospital care. ATLAS. ti was used to manage and analyse the interview data. The results showed that hospital-based healthcare services were perceived as better quality. However, self-medication was viewed as more affordable in terms of money and time. Other factors prompting self-medication, included confidence in understanding the health problem, the easy accessibility of local pharmacies and the influences of friends/peers and advertising. Three broad domains, attitude, cost and effectiveness, were all seen to determine past decisions and experiences with self-medication. Interestingly, the effective management of self-medication via pharmacy resources raised particular concern because of perceived variation in quality. In conclusion, self-medication was found to be an important and common health-seeking behaviour driven by multiple factors. A sound and comprehensive public health system should systematically attend to these behaviours and the pharmacies, where much of the behaviour occurs.

Translating genomic research into care for people with schizophrenia in China

The implications of increased understanding of the genetic contribution to schizophrenia for patients and their families remain unclear. We carried out a study of Chinese patients'(n=118) and relatives' (n=78) views of illness severity, attribution of cause, concern about developing illness, and effect of schizophrenia on family planning. A comparison sample of English-survey respondents was also obtained, using the same series of questions (n=42 patients, n=127 relatives). Fewer Chinese patients and family members rated schizophrenia as very severe (33%) than did the predominantly North American respondents (67%, p<0.0001). The pattern of attribution of cause differed between samples (p<0.0001), favoring environmental alone in the Chinese sample (52%), with a low frequency of genetics alone (9%). Although comparatively fewer Chinese respondents were very concerned about developing schizophrenia themselves or about the risk of illness in their families (21%), this high level of concern was more common in family members (28%). Finally, Chinese respondents were somewhat less likely to indicate that schizophrenia impacted on family planning decisions (31%) than were English-survey respondents (45%, p=0.02). The descriptive findings contribute to understanding schizophrenia in China. The comparative findings must be regarded as preliminary, since differences in demographics could influence results. The present findings suggest that understanding patients' and families' attributions of cause of schizophrenia may be important for developing a shared model of illness in order to decrease stigmatization, and improve therapeutic alliances.

Barriers to increasing hospital birth rates in rural Shanxi Province, China

This study investigated the reasons for continued high rates of home births in rural Shanxi Province, northern China, despite a national programme designed to encourage hospital deliveries. We conducted semi-structured interviews with 30 home-birthing women in five rural counties and drew on hospital audit data, observations and interviews with local health workers from a larger study. Multiple barriers were identified, including economic and geographic factors and poor quality of maternity care. Women's main reasons for not having institutional births were financial difficulties (n=26); poor quality of antenatal care (n=13); transport problems (n=11); dissatisfaction with hospital care expressed as fear of being in hospital (n=10); convenience of being at home and continuity of care provided by traditional birth attendants (TBAs) (n=10); and belief that the birth would be normal (n=6). These barriers must all be overcome to improve access to and acceptability of hospital birth. To ensure that the national policy of improving the hospital birth rate is implemented effectively, the government needs to improve the quality of antenatal and delivery care, increase financial subsidies to reduce out-of-pocket payments, remove transport barriers, and where hospital birth is not available in remote areas, consider allowing skilled attendance at home on an outreach basis and integrate TBAs into the health system.

Recapturing public health sciences for HIV/AIDS in China

In recent years, human immunodeficiency virus (HIV) has spread from high-risk groups to the general population in China. Scientific interpretation of HIV figures, prevalence and proportion vs. incidence is displayed to correctly guide politicians and lay people in understanding the situation. Although behaviour-focused studies have been conducted in China, many have focused on 'scientific' issues, with limited attention given to human dimensions or contexts. An evidence-based public health approach, with strict evaluation in terms of cost-effectiveness and behavioural outcomes, needs to be developed, together with activity to encourage decentralization and community engagement of programmes. Policies and strategies on HIV prevention and control need to be mindful of Chinese culture and reality, including the expansion of screening and surveillance.

The status of glycemic control: A cross-sectional study of outpatients with type 2 diabetes mellitus across primary, secondary, and tertiary hospitals in the Jiangsu province of China

OBJECTIVES

The aims of the study were to determine the following: the status of glycemic control in patients with type 2 diabetes mellitus (DM) at primary, secondary, and tertiary hospitals in the Jiangsu province of China; and the factors associated with achieving glycemic targets.

METHODS

This study, in which patients were enrolled from July 20 to 31, 2009, at 56 diabetes centers, used a multiple-stage, stratified sampling method to select a representative sample of the population with DM in Jiangsu. The sampling process was stratified by geographic and demographic regions, and by the outpatient numbers in the hospitals. A primary hospital was defined as a community medical institution that provided primary health services; a secondary hospital was a local medical institution that provided comprehensive health services; and a tertiary hospital was a regional medical institution that provided comprehensive and specialist health services. In primary hospitals, patients with DM were treated by general physicians; at secondary and tertiary hospitals, they were seen by specialists. Also, primary and tertiary hospitals treated patients in cities, whereas secondary hospitals treated patients from towns or rural areas. Patients with a medical history of type 2 DM for >6 months and registration at each diabetes center for > or = 6 months, and who were residents of Jiangsu province, were recruited. During the patient enrollment visit, information about DM complications and comorbidities, as well as DM management, was obtained by retrospectively reviewing medical records; basic patient data (eg, date of birth, sex, weight, height) were obtained by patient interview. Blood samples were collected for assessment of glycosylated hemoglobin (HbA1c) at a central laboratory.

RESULTS

Of 3046 sampled subjects, the analysis was performed in 2966 subjects with complete data. The mean (SD) HbA1c value for analyzed patients was 7.2% (1.6%). The proportion of patients with tight glycemic control was 40.2% (1193/2966) when a threshold of HbA1c <6.5% was used, and 56.1% (1665/2966) when a threshold of HbA1c <7.0% was used. Compared with patients who had inadequate glycemic control, those with tight control were younger (P < 0.001), had shorter duration of DM (P < 0.001), had lower body mass index (BMI) (P = 0.005 for HbA1c <6.5% and P = 0.01 for HbA1c <7.0%), had more education (P < 0.001) and income (P = 0.003 for HbA1c <6.5% and P = 0.008 for HbA1c <7.0%), were more likely to monitor their glucose (P = NS for HbA1c <6.5% and P = 0.043 for HbA1c <7.0%) and attend DM education (P = 0.027 for HbA1c <6.5% and P = 0.002 for HbA1c <7.0%) at least once a month, and were more likely to receive oral antidiabetic drugs (OADs) (P < 0.001). Age, BMI, and DM duration did not differ significantly between hospital types. Compared with primary (36.2%) and secondary hospitals (36.5%), tertiary hospitals (42.2%) had more patients with HbA1c <6.5% (P = 0.043); tertiary hospitals also had more patients with once-monthly glucose self-monitoring (P = 0.001), patients with higher income (P < 0.001) and education (P < 0.001), and those who were more likely to use > or = 2 OADs or insulin with OADs (P < 0.001).

CONCLUSION

The overall status of glycemic control was unsatisfactory during the study period, although patients at tertiary hospitals appeared to have better control than those at primary or secondary hospitals.

Socio-economic disparities in maternal mortality in China between 1996 and 2006

OBJECTIVE

China's economic reforms have raised concerns over rising inequalities in maternal mortality, but it is not known whether the gap across socio-economic regions has increased over time.

DESIGN

A population-based, longitudinal, ecological correlation study.

SETTING

China.

SAMPLE

Records from the National Maternal and Child Mortality Surveillance System between 1996 and 2006.

METHODS

We report levels, causes and timing of maternal deaths, and examine crude and adjusted time trends in the overall and cause-specific maternal mortality ratio in five socio-economic regions (using Poisson regression). We examine whether socio-economic disparities have widened over time using concentration curves.

MAIN OUTCOME MEASURES

All-causes and cause-specific maternal mortality ratios.

RESULTS

Maternal mortality (MMR) declined by 6% per year (yearly rate ratio, RR, 0.94; 95% CI 0.93-0.96). The decline was most pronounced in the wealthiest rural type-I counties (RR 0.89; 95% CI 0.85-0.93), and in the poorest rural type-IV counties (RR 0.90; 95% CI 0.82-1.00). There were declines in almost all causes of maternal death. Postpartum haemorrhage (PPH) was by far the leading cause of maternal death (32%, 997/3164). The decline in MMR was largely explained by the increased uptake of institutional births. Concentration curves suggest that wealth-related regional inequalities did not increase over time.

CONCLUSIONS

China's extraordinary economic growth has not adversely affected disparities in MMR across socio-economic regions over time, but poor rural women remain at disproportionate risk. Other emerging economies can learn from China's focus on the supply and quality of maternity services along with more general health systems strengthening.

Nursing shortage in China: State, causes, and strategy

This article describes the nursing shortage situation in China and the causes for it. China is a major donor of nurses to other parts of the world and this article discusses the solutions China has implemented to address its nursing shortage, and the challenges that it is currently facing. The strategies that have been employed include: improving the health care system, improving work cultures for increased retention through policy and regulation, making greater investments in nursing education to build sustainable nursing education infrastructures, and enhancing the image of the nursing profession. These solutions may serve as a reference to other countries to deal with the crisis of a nursing shortage.

Age, chronic non-communicable disease and choice of traditional Chinese and western medicine outpatient services in a Chinese population

Background

In 1997 Hong Kong reunified with China and the development of traditional Chinese medicine (TCM) started with this change in national identity. However, the two latest discussion papers on Hong Kong's healthcare reform have failed to mention the role of TCM in primary healthcare, despite TCM's public popularity and its potential in tackling the chronic non-communicable disease (NCD) challenge in the ageing population. This study aims to describe the interrelationship between age, non-communicable disease (NCD) status, and the choice of TCM and western medicine (WM) services in the Hong Kong population.

Methods

This study is a secondary analysis of the Thematic Household Survey (THS) 2005 dataset. The THS is a Hong Kong population representative face to face survey was conducted by the Hong Kong Administrative Region Government of China. A random sample of respondents aged >15 years were invited to report their use of TCM and WM in the past year, together with other health and demographic information. A total of 33,263 persons were interviewed (response rate 79.2%).

Results

Amongst those who received outpatient services in the past year (n = 18,087), 80.23% only visited WM doctors, 3.17% consulted TCM practitioners solely, and 16.60% used both type of services (double consulters). Compared to those who only consulted WM doctor, multinomial logistic regression showed that double consulters were more likely to be older, female, NCD patients, and have higher socioeconomic backgrounds. Further analysis showed that the association between age and double consulting was curvilinear (inverted U shaped) regardless of NCD status. Middle aged (45-60 years) NCD patients, and the NCD free "young old" group (60-75 years) were most likely to double consult. On the other hand, the relationship between age and use of TCM as an alternative to WM was linear regardless of NCD status. The NCD free segment of the population was more inclined to use TCM alone as they become older.

Conclusion

In Hong Kong, most patients have chosen WM provided in the public sector as their sole outpatient service provider for NCD. Amongst TCM service users, middle aged NCD patients are more likely to choose both TCM and WM outpatient services. Meanwhile, older people without NCD are more likely to use TCM as their main form of care, but the size of this population group is small. These utilization patterns show that patients choose both modalities to manage their NCD and TCM should be considered within policies for supporting patients with NCD under the wider primary health and social care system that supports patient choice.