Universal health coverage in China part 1: progress and gaps

Inequalities in disease burden and care quality of chronic obstructive pulmonary disease, 1990-2021: Findings from the Global Burden of Disease Study 2021

Background

Chronic obstructive pulmonary disease (COPD) is one of the primary causes of significant morbidity and mortality worldwide. This study aimed to explore the cross-country inequalities by age, sex, and region in COPD's burden and care quality from 1990 to 2021.

Methods

We obtained data from the Global Burden of Disease 2021. Using age-standardised disability-adjusted life years rate (ASDR) per 100 000 population and quality of care index (QCI), we quantified the COPD burden and care quality, respectively. Applying the principal component analysis method, we calculated QCI scores, ranging from 0 to 100, where higher values indicate better care quality. We quantified temporal trends from 1990 to 2021 for ASDR and QCI by estimated annual percentage change (EAPC). Finally, we assessed the absolute and relative disparities in ASDR and QCI across countries using the slope index of inequality (SII) and concentration index.

Results

Between 1990 and 2021, there was a notable decline in ASDR of COPD globally (1990 = 1492.64; 2021 = 940.66; EAPC = -1.71), accompanied by an increase in QCI (1990 = 58.42; 2021 = 73.86; EAPC = 0.89). Regions with middle sociodemographic index (SDI) consistently demonstrated the highest ASDR and the lowest QCI in 1990 (ASDR = 2332.91; QCI = 31.70), whereas by 2021, low-middle SDI regions exhibited similar trends (ASDR = 1707.90; QCI = 57.50). In 2021, the highest ASDR was among individuals aged 95 years and above (16251.22), while the lowest QCI was among people aged 70-74 years (72.18). Papua New Guinea recorded the highest ASDR and the lowest QCI in 2021 (ASDR = 3004.36; QCI = 19.18). Compared to 1990, where the SII for ASDR was -612.44 and for QCI was 21.78, with concentration indices of -0.14 for ASDR and 0.11 for QCI, the absolute values of both SII and concentration index were smaller in 2021, with ASDR's SII at -555.90, QCI's at 16.72, ASDR's concentration index at -0.13, and QCI's at 0.04.

Conclusions

The global burden of COPD decreases and care quality increases over time, with notable variations across ages, sexes and SDI regions. Countries with lower SDI had disproportionately higher burden and poorer care quality for COPD.

Cancer survival statistics in China 2019-2021: a multicenter, population-based study

Background

A milestone goal of the Healthy China Program (2019-2030) is to achieve 5-year cancer survival at 43.3% for all cancers combined by 2022. To assess the progress towards this target, we analyzed the updated survival for all cancers combined and 25 specific cancer types in China from 2019 to 2021.

Methods

We conducted standardized data collection and quality control for cancer registries across 32 provincial-level regions in China, and included 6,410,940 newly diagnosed cancer patients from 281 cancer registries during 2008-2019, with follow-up data on vital status available until December 2021. We estimated the age-standardized 5-year relative survival overall and by site, age group, and period of diagnosis using the International Cancer Survival Standard Weights, and quantified the survival changes to assess the progress in cancer control.

Results

In 2019-2021, the age-standardized 5-year relative survival for all cancers combined was 43.7% (95% confidence interval [CI], 43.6-43.7). The 5-year relative survival varied by cancer type, ranging from 8.5% (95% CI, 8.2-8.7) for pancreatic cancer to 92.9% (95% CI, 92.4-93.3) for thyroid cancer. Eight cancers had 5-year survival of over 60%, including cancers of the thyroid, breast, testis, bladder, prostate, kidney, uterus, and cervix. The 5-year relative survival was generally lower in males than in females. From 2008 to 2021, we observed significant survival improvements for cancers of the lung, prostate, bone, uterus, breast, cervix, nasopharynx, larynx, and bladder. The most significant improvement was in lung cancer.

Conclusions

Progress in cancer control was evident in China. This highlights the importance of a comprehensive approach to control and prevent cancer.

Evaluating the effect of health insurance reform on health equity and financial protection for elderly in low- and middle-income countries: evidences from China

BACKGROUND

To achieve Universal Health Coverage (UHC), China have implemented health system reform to expend health coverage and improve health equity. Scholars have explored the implementing effect of this health reform, but gaps remained in health care received by elderly. This study aims to assess the effect of implementing health insurance payment reform on health care received by elderly, as well as to evaluate its effect on cost sharing to identify whether improve financial protection of elderly under this reform.

METHODS

We identified hospitalization of 46,714 elderly with cerebral infarction from 2013 to 2023. To examine the determinant role played by DRGs payment reform in healthcare for elderly and their financial protection, this study employs the OLS linear regression model for analysis. In the robustness checks, we validated the baseline results through several methods, including excluding the data from the initial implementation of the reform (2021), reducing the impact of the pandemic, and exploring the group effects of different demographic characteristics.

RESULTS

The findings proposed that implementing DRGs payment reduces drug expenses but increases treatment expense of chronic disease for elderly in China. This exacerbates healthcare costs for elderly patients and seems to be contrary to the original purpose of health care reform. Additionally, the implementation of DRGs payment reduced the spending of medical insurance fund, while increased the out-of-pocket of patients, revealing a shift in health care expenses from health insurance fund to out-of-pocket.

CONCLUSIONS

This study shares the lessons from China's health reform and provides enlightenment on how to effective implement health reform to improve health equity and achieve UHC in such low- and middle-income countries facing challenges in health financing.

Quality of primary health care for chronic diseases in low-resource settings: Evidence from a comprehensive study in rural China

BACKGROUND

There is a paucity of evidence regarding the definition of the quality of primary health care (PHC) in China. This study aims to evaluate the PHC quality for chronic diseases in rural areas based on a modified conceptual framework tailored to the context of rural China.

METHODS

This comprehensive study, involving a patient survey, a provider survey and chart abstraction, and second-hand registered data, was set in three low-resource counties in rural China from 2021 to 2022. Rural patients with hypertension or type 2 diabetes, and health care workers providing care on hypertension or diabetes were involved. The modified PHC quality framework encompasses three core domains: a competent PHC system (comprehensiveness, accessibility, continuity, and coordination), effective clinical care (assessment, diagnosis, treatment, disease management, and provider competence), and positive user experience (information sharing, shared decision-making, respect for patient's preferences, and family-centeredness). Standardized PHC quality score was generated by arithmetic means or Rasch models of Item Response Theory.

RESULTS

This study included 1355 patients, 333 health care providers and 2203 medical records. Ranging from 0 (the worst) to 1 (the best), the average quality score for the PHC system was 0.718, with 0.887 for comprehensiveness, 0.781 for accessibility, 0.489 for continuity, and 0.714 for coordination. For clinical care, average quality was 0.773 for disease assessment, 0.768 for diagnosis, 0.677 for treatment, 0.777 for disease management, and 0.314 for provider competence. The average quality for user experience was 0.727, with 0.933 for information sharing, 0.657 for shared decision-making, 0.936 for respect for patients' preferences, and 0.382 for family-centeredness. The differences in quality among population subgroups, although statistically significant, were small.

CONCLUSION

The PHC quality in rural China has shown strengths and limitations. We identified large gaps in continuity of care, treatment, provider competence, family-centeredness, and shared decision-making. Policymakers should invest more effort in addressing these gaps to improve PHC quality.

Efficiency evaluation and promoter identification of primary health care system in China: an enhanced DEA-Tobit approach

BACKGROUND

With Primary Health Care (PHC) being a cornerstone of accessible, affordable, and effective healthcare worldwide, its efficiency, especially in developing countries like China, is crucial for achieving Universal Health Coverage (UHC). This study evaluates the efficiency of PHC systems in a southwest China municipality post-healthcare reform, identifying factors influencing efficiency and proposing strategies for improvement.

METHODS

Utilising a 10-year provincial panel dataset, this study employs an enhanced Data Envelopment Analysis (DEA) model integrating Slack-Based Measure (SBM) and Directional Distance Function (DDF) with the Global Malmquist-Luenberger (GML) index for efficiency evaluation. Tobit regression analysis identifies efficiency determinants within the context of China's healthcare reforms, focusing on horizontal integration, fiscal spending, urbanisation rates, and workforce optimisation.

RESULTS

The study reveals a slight decline in PHC system efficiency across the municipality from 2009 to 2018. However, the highest-performing county achieved a 2.36% increase in Total Factor Productivity (TFP), demonstrating the potential of horizontal integration reforms and strategic fiscal investments in enhancing PHC efficiency. However, an increase in nurse density per 1,000 population negatively correlated with efficiency, indicating the need for a balanced approach to workforce expansion.

CONCLUSIONS

Horizontal integration reforms, along with targeted fiscal inputs and urbanisation, are key to improving PHC efficiency in underdeveloped regions. The study underscores the importance of optimising workforce allocation and skillsets over mere expansion, providing valuable insights for policymakers aiming to strengthen PHC systems toward achieving UHC in China and similar contexts.

Temporal trends and correlates in multiple hospitalizations among older adults: findings from a nationally representative sample in China

OBJECTIVE

This study aims to examine the trends and correlates in multiple hospitalizations among older adults in China.

METHODS

The data were from the China Health and Retirement Longitudinal Study (CHARLS), and generalized ordered logit model (GOLM) was used to identify the correlates of multiple hospitalizations among older adults aged≥60 years old.

RESULTS

Between 2011 and 2018, the proportion of older adults having multiple hospitalizations in the past year showed an increasing trend in the total sample (p value for trend = 0.014). Being older, male, illiterate, living in the middle/western region, having higher annual per capita household expenditure, health insurance, multimorbidity, and being depressed were associated with increased odds of multiple hospitalizations.

CONCLUSIONS

Our findings indicated that older adults with multiple hospitalizations may expect an increasing burden on healthcare system. More efforts are needed to improve health insurance and primary healthcare to reduce avoidable hospitalizations.

Provincial inequality of China's progress towards universal health coverage: An empirical analysis in 2016-21

Background

Achieving universal health coverage (UHC) is a crucial target shared by the Sustainable Development Goals (SDGs). As UHC levels are influenced by factors such as the regional economy and resource allocation, subnational evidence in China is urgently needed. This study aimed to monitor provincial progress from 2016 to 2021, thereby informing the development of region-specific strategies.

Methods

Based on the UHC monitoring framework proposed by the World Health Organization, a UHC index was constructed comprising the service coverage dimension (16 indicators) and financial protection dimension (four indicators). In this observational study, routinely collected health data from 25 provinces (autonomous regions and municipalities) in mainland China were obtained from statistical yearbooks, relevant literature, and nationally representative surveys. The indices were calculated using geometric means. Socioeconomic inequalities among provinces were quantified using the slope index of inequality (SII) and relative index of inequality (RII).

Results

From 2016 to 2021, China made laudable progress towards achieving UHC, with the index rising from 56.94 in 2016 to 63.03 in 2021. Most provinces demonstrated better performance in service coverage. Western provinces generally presented faster rates of progress, which were attributed to more substantial increases in financial protection. Despite significant disparities, with the UHC index ranging from 77.94 in Shanghai to 54.61 in Fujian in 2021, the overall equity of UHC has improved across the 25 provinces. SII decreased from 17.78 (95% confidence interval (CI) = 11.64, 23.93) to 12.25 (95% CI = 5.86, 18.63) and RII from 1.38 (95% CI = 1.29, 1.46) to 1.22 (95% CI = 1.16, 1.29). However, the non-communicable disease (NCD) domain experienced a drop in both index score and equity, underscoring the need for prioritised attention.

Conclusions

In the context of SDGs and the 'Healthy China 2030' initiative, China has made commendable progress towards UHC, and inter-provincial equity has improved. However, substantial differences persisted. The equitable realisation of UHC necessitates prioritising the enhancement of service capacity and financial protection in less developed regions, particularly by addressing shortages in the general practitioner workforce and mitigating catastrophic payments. Developed regions should focus on preventing NCDs through effective interventions targeting key risk factors. This study provides insights for other countries to adopt comprehensive monitoring frameworks, identify subnational disparities, and introduce targeted policy initiatives.

Medical insurance, livelihood capital and public health in China

BACKGROUND

Medical insurance stands as a pivotal component within the overarching framework of public service systems. The intricate interplay between the extent of healthcare coverage and the overall well-being of the populace remains a pivotal research question within the academic sphere.

METHODS

Drawing from the comprehensive dataset of the Chinese Household Livelihood Survey, this article employs a rigorous data model to delve into the profound implications of medical coverage on population health.

RESULTS

The descriptive analysis revealed that areas with broader medical coverage tend to exhibit higher levels of overall population health. This initial observation provided a foundation for further quantitative exploration using multiple regression analysis. The regression analysis demonstrated a statistically significant positive relationship between medical coverage and population health. This finding is particularly noteworthy as it suggests that expanding access to healthcare services has tangible benefits for improving the overall health of a population.

CONCLUSION

From the lens of familial sustenance, this article delves into the intricate health implications of medical coverage, thereby introducing a novel theoretical lens to the evolving discourse surrounding medical insurance healthcare systems and their impact on public health. This approach aims to enrich the current understanding of this complex relationship and contribute to the scholarly dialogue.

Microelement strontium and human health: comprehensive analysis of the role in inflammation and non-communicable diseases (NCDs)

Strontium (Sr), a trace element with a long history and a significant presence in the Earth's crust, plays a critical yet often overlooked role in various biological processes affecting human health. This comprehensive review explores the multifaceted implications of Sr, especially in the context of non-communicable diseases (NCDs) such as cardiovascular diseases, osteoporosis, hypertension, and diabetes mellitus. Sr is predominantly acquired through diet and water and has shown promise as a clinical marker for calcium absorption studies. It contributes to the mitigation of several NCDs by inhibiting oxidative stress, showcasing antioxidant properties, and suppressing inflammatory cytokines. The review delves deep into the mechanisms through which Sr interacts with human physiology, emphasizing its uptake, metabolism, and potential to prevent chronic conditions. Despite its apparent benefits in managing bone fractures, hypertension, and diabetes, current research on Sr's role in human health is not exhaustive. The review underscores the need for more comprehensive studies to solidify Sr's beneficial associations and address the gaps in understanding Sr intake and its optimal levels for human health.

Influencing factors of health screening among retirees: an extended TPB approach

Background

Health screenings are promoted worldwide as they help detect and prevent overall health issues. Despite expanding coverage, the participation rate among the retired population has not significantly increased. Given the special role of health screenings in promoting health and healthy aging, understanding the behavioral intentions, and influencing factors of retirees' voluntary participation in health screenings is crucial. This study aims to explore the participation intentions in health screenings among the Chinese retired population by integrating the Theory of Planned Behavior (TPB) and Self-Efficacy (SE).

Methods

This study used a cross-sectional design to conduct an online questionnaire among 311 retirees in 2023. The questionnaire, tailored for the Chinese retired population, combines the TPB theory and Self-Efficacy theory, including demographic structure, the basic structure of TPB, and SE.

Results

A Structural Equation Modeling (SEM) approach was used to identify factors related to health screening behaviors. Of the respondents, 311 completed the survey (88.9% response rate). The most crucial determinant of health examination behavior was behavioral intention, with a correlation score of (1.524, p < 0.001). Significant correlates of behavioral intention included Subjective Norms (SN) and Self-Efficacy (SE), followed by Perceived Behavioral Control (PBC) and Attitude (AT), with correlation scores of (0.401, p < 0.001), (0.339, p < 0.001), (0.082, p < 0.001), and (0.060, p < 0.05), respectively.

Conclusion

This study provides insights for enhancing the willingness and behavior of retirees to participate in health screenings.

Impact of the Essential Public Health Service program on financial protection and health outcomes among hypertensive patients: A quasi-experimental study in China

BACKGROUND

The Chinese government launched the Essential Public Health Service (EPHS) program nationwide in 2009. However, prior studies have not provided clear and integrated evidence on whether the EPHS program improves health outcomes and prevents financial risks among individuals. Because hypertension is the chronic disease with the highest prevalence, this study evaluated the impact of the EPHS program among hypertensive patients to provide evidence for the progress of the program.

METHODS

A cohort of hypertensive patients was identified from the 2011-2018 China Health and Retirement Longitudinal Study (CHARLS). The outcomes assessed included hospitalization expenditure, outpatient expenditure and cardiovascular disease (heart attack and stroke). The key independent variable was whether an individual received EPHS-covered blood pressure measurements in 2013-2015. Based on the International Health Partnership+ (IHP+) common monitoring and evaluation (M&E) framework, a difference-in-differences (DID) method with propensity score matching (PSM) was used to examine the impact of the EPHS program on hypertensive patients.

RESULTS

The results showed that among hypertensive patients covered by the EPHS program, outpatient total costs/OOP costs were reduced by 29.8% and 30.8%, respectively, and hospitalization total costs/OOP costs were reduced by 34.9% and 35.6%, respectively. The EPHS program reduced the probability of heart attack and stroke among hypertensive patients by 3.5% and 2.7%, respectively. Mechanistic tests showed that the EPHS program improved health outcomes by reducing alcohol consumption and increasing physical activity, thereby further reducing health expenditure among hypertensive patients. The impacts of the EPHS program on hypertensive patients varied by age, educational attainment, residential region, and alcohol consumption status.

CONCLUSION

The EPHS program in China significantly improved health outcomes and prevented financial risks for hypertensive patients. This evidence provides a valuable reference for low- and middle-income countries with their essential public health service programs.