Health system productivity in China: a comparison of pre- and post-2009 healthcare reform

Quantifying Health Policy Uncertainty in China Using Newspapers: Text Mining Study

BACKGROUND

From the severe acute respiratory syndrome (SARS) outbreak in 2003 to the COVID-19 pandemic in 2019, a series of health measures and policies have been introduced from the central to the local level in China. However, no study has constructed an uncertainty index that can reflect the volatility, risk, and policy characteristics of the health environment.

OBJECTIVE

We used text mining analysis on mainstream newspapers to quantify the volume of reports about health policy and the total number of news articles and to construct a series of indexes that could reflect the uncertainty of health policy in China.

METHODS

Using the Wisenews database, 11 of the most influential newspapers in mainland China were selected to obtain the sample articles. The health policy uncertainty (HPU) index for each month from 2003 to 2022 was constructed by searching articles containing the specified keywords and calculating their frequency. Robustness tests were conducted through correlation analysis. The HPU index was plotted using STATA (version 16.0), and a comparative analysis of the China and US HPU indexes was then performed.

RESULTS

We retrieved 6482 sample articles from 7.49 million news articles in 11 newspapers. The China HPU index was constructed, and the robustness test showed a correlation coefficient greater than 0.74, which indicates good robustness. Key health events can cause index fluctuations. At the beginning of COVID-19 (May 2020), the HPU index climbed to 502.0. In December 2022, China's HPU index reached its highest value of 613.8 after the release of the "New Ten Rules" pandemic prevention and control policy. There were significant differences in HPU index fluctuations between China and the United States during SARS and COVID-19, as well as during the Affordable Care Act period.

CONCLUSIONS

National health policy is a guide for health development, and uncertainty in health policy can affect not only the implementation of policy by managers but also the health-seeking behavior of the people. Here, we conclude that changes in critical health policies, major national or international events, and infectious diseases with widespread impact can create significant uncertainty in China's health policies. The uncertainty of health policies in China and the United States is quite different due to different political systems and news environments. What is the same is that COVID-19 has brought great policy volatility to both countries. To the best of our knowledge, our work is the first systematic text mining study of HPU in China.

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.

Estimating the Distribution and Convergence of County-level Healthcare Resources Allocative Efficiency in China Based on DEA and Spatial Panel Model

Although China's 2009 New Healthcare Reform aimed to correct the imbalance in the spatial allocation of healthcare resources with a focus on the county level, its impact on county-level allocative efficiency evolution and convergence remains unclear. This paper for the first time performs a spatial analysis to explore the distribution, evolution, and convergence of the allocative efficiency of healthcare resources with county-level data. This paper uses the sample data of 158 countries in Henan Province, China, to evaluate the evolution and convergence of the allocative efficiency of healthcare resources. Based on the estimated Data Envelopment Analysis (DEA) allocative efficiency, analysis of variance (ANOVA), and spatial descriptive analysis, we explore the county heterogeneity and efficiency evolution; a spatial panel model is then utilized to test the county-level convergence of the allocative efficiency of healthcare resources. Although the number of efficient counties has not increased, the number of inefficient individuals keeps decreasing, and the allocative efficiency of municipal districts is lower than that of nonmunicipal counties. There exists a positive spatial correlation of allocative efficiency in Henan Province, and significant and robust convergence results can be found at the county level after China's 2009 reform. This study reveals a diversified picture of China's county-level spatial evolution of allocative efficiency in healthcare resources, showing a more balanced spatial distribution of allocative efficiency since the triggering of China's 2009 reform. However, long-term investment incentives and a targeted allocation of healthcare resources are still needed to promote further efficiency convergence and increase the number of counties with efficiency.

Levels, trends, and determinants of effectiveness on the hierarchical medical system in China: Data envelopment analysis and bootstrapping truncated regression analysis

Background

The hierarchical medical system (HMS) refers to the classification of treatment according to disease priorities based on severity and difficulty to promote the fairness of medical services for residents, which is regarded as the key to the success of medical reform in China.

Methods

In the past decade of "New Medical Reform," the efficiency of HMS, including secondary and tertiary hospitals and primary healthcare centers (PHCs), was measured horizontally and vertically by employing the combination of an output-oriented superefficiency slack-based model-data envelopment analysis (SE-SBM-DEA) model with the Malmquist total factor productivity index (MTFP). In the second stage, the overall technical efficiency (OTE) scores were regressed against a set of environmental characteristics and several managerial factors through bootstrapping truncated regression.

Results

On average, the OTE score in tertiary hospitals was 0.93, which was higher than that in secondary hospitals and PHCs (0.9 and 0.92, respectively). In terms of trend, the OTE of tertiary hospitals declined at first and then increased. The opposite was true of secondary hospitals, in which the APC of the OTE was 10.82 and -3.11% in early and late 2012, respectively. The PHCs generally showed a fluctuating downward trend. In the aspects of productivity, all institutions showed a downturn by an annual average rate of 2.73, 0.51, and 2.70%, respectively. There was a significant negative relationship between the ratio of outpatients to inpatients and tertiary hospitals. Additionally, the medical technical personnel per 1,000 population negatively affected PHCs. In contrast, the GDP per capita had a significantly positive effect on tertiary hospitals, and the number of beds per 1,000 population positively influenced PHCs.

Conclusion

The efficiency of medical institutions at various levels in HMS was unbalanced and took the form of an "inverted pyramid." Multilateral factors influence the efficiency of HMS, and to address it, multi-intervention packages focusing on sinking high-quality medical resources and improving healthcare capacity, and guiding hierarchical medical practice should be adopted.

The efficiency of health resource allocation and its influencing factors: evidence from the super efficiency slack based model-Tobit model

BACKGROUND

This study aims to analyze the health resource allocation efficiency in Sichuan Province from 2010 to 2018 and provide other countries with China's experience.

METHODS

We used the super efficiency slack based model (SBM) model and Malmquist index to analyze the super efficiency and inter-period efficiency of health resource allocation in 19 cities in Sichuan Province from 2010 to 2018 and propose the input-output optimization scheme of health resource allocation in 2018. Finally, the Tobit model was used to estimate the influencing factors of health resource allocation efficiency.

RESULTS

The total allocation of health resources in Sichuan Province was increasing in addition to the total number of visits from 2010 to 2018. The super efficiency SBM results identified that the sample's average score was between 0.651 and 3.244, with an average of 1.041, of which 15 cities had not reached data envelopment analysis effectiveness. According to the Malmquist index, the average total factor productivity index of Sichuan Province was 0.930, which showed an imbalance in resource input, and its fluctuation was mainly related to the technological progress index and scale efficiency. The efficiency score was affected by the average annual income of residents, population density and education level.

CONCLUSIONS

The amount of health resource allocation in Sichuan Province had shown an overall upward trend since 2010. However, resource allocation efficiency was not high, and there were problems such as significant regional differences, insufficient technological innovation capabilities and unscientific allocation of resource scale. To optimize the resource allocation structure, we suggest that the relevant departments pay attention to the impact of natural disasters, the average annual income of residents, population density and education level on efficiency to allocate health resources scientifically.

Working intentions of medical students in response to healthcare workplace violence and descending resources reform in China

BACKGROUND

In order to curb healthcare workplace violence (WPV) and better allocate healthcare resources, China launched the descending resources reform in 2013 and tightened the anti-violence legal environment simultaneously. Medical students are expected to reconsider their working intentions of entering the medical market (inter-market effect) and choosing high- or low-level hospitals (intra-market effect) in response to the evolving WPV. The goal of this study was to explore the link between the perceived WPV incidence and medical students' willingness to practice medicine in the context of China's descending resources reform.

METHOD

Medical students were selected with cluster sampling from 8 medical colleges in Zhejiang Province, China, and 1497 valid questionnaires were collected by using a five-point unbalanced scale, to perform cross-sectional empirical research using the ordered logit model (OLM).

RESULTS

The perceived WPV incidence negatively correlate with the willingness of medical students to practice medicine but positively correlate with their willingness to practice in low-level hospitals, indicating the existence of inter- and intra-market effects. The anti-violence legal environment has no direct link with working intention but contributes to the perceived decline in the incidence of violence. Descending resources reform has simultaneous opposite effects on medical students, with the coexistence of prudent motives driven by reform costs and optimistic expectations of sharing external benefits.

CONCLUSIONS

Safety needs and risk aversion motive play an important role in medical students' career choice when facing severe WPV. Tightening of the anti-violence legal environment and the descending resources reform could drive medical students to low-level hospitals.

The impact of healthcare reform on the dynamic changes in health service utilization and equity: a 10-year follow-up study

In the past decade, the government of China has implemented healthcare reforms to provide universal access to healthcare by 2020. We aimed to systematically analyse the dynamic changes in health services and equity during the past 10 years to understand the correlation between health services and social-economic status. We performed a longitudinal study in which we extracted aggregated data mainly from a project (2009, 2011, 2012, 2015, 2019). A multi-stage stratified cluster randomized design was used to obtain a representative sample in each county. Concentration indexes were used to analyse the equity of the changes in utilization. We built multivariate random-effects generalized least squares regression models with the panel data to test whether the rate of receiving a medical consultation in the last 2 weeks or the rate of hospital admission or the prevalence of chronic illness was associated with social-economic status including education level and rural disposable income per capita. We found declines in both the rate of not receiving a medical consultation during the last 2 weeks (P < 0.05 intervention group) and the rate of hospital avoidance (P < 0.05) from 2009 to 2019. The equity in residents' health service utilization has improved constantly. We additionally found that rural disposable income per capita is a protective factor for the rate of a receiving a medical consultation during the last 2 weeks and the rate of hospital admission. China's 2009 healthcare reform have positively influenced utilization rates and equity in health service utilization in the past decade, a range of health service-targeted strategies are needed including strengthen the prevention and treatment of chronic diseases, focus attention on the health status of elderly residents and improve social-economic status, especially the level of education.

Preliminary evaluation of a new initiative to centralize colorectal cancer care during the COVID-19 epidemic in Shanghai, China: a retrospective study

Background

A novel colorectal cancer center (CCC) was developed in the Shanghai Tenth People’s hospital of Tongji University during the COVID-19 epidemic. In this study, we aimed to evaluate the CCC model in terms of three aspects.

Methods

This retrospective study used data from the Shanghai Tenth People’s hospital patient databases. The research hypothesis was that the CCC reduces preoperative waiting time (PWT), length of hospital stay (LOS), and costs of hospitalization, without reducing the quality of surgery. Thus, we compared the time, cost, and quality between March 1 to December 31, 2019, and March 1 to December 31, 2020. Descriptive and inferential analyses of patient demographic characteristics, time, postoperative outcomes, and inpatient costs were conducted.

Results

A total of 965 hospitalizations for colorectal cancer (CRC) were identified—415 in 2019 and 550 in 2020. In the CCC, PWT declined by 26.2 hours (P<0.01). Patients in the CCC express group only needed to wait for 24.5 hours before undergoing surgery, with a shorter LOS than the normal group (P<0.01). None of the patients had any symptoms of COVID-19 or were high-risk COVID-19 contacts, and the incidence of immediate postoperative complications was low. The mean total inpatient cost (TIC) for all patients with CRC was 78,309.824 Chinese Yuan in 2020, which was slightly lower than that in 2019.

Conclusions

This study found that the centralized management model for CRC care could help patients save the PWT, LOS and costs of hospitalization during the COVID-19 epidemic.

The Comparison Between Different Hospital Market Definition Approaches: An Empirical Analysis of 11 Representative Diseases in Sichuan Province, China

Objective: This study aims to provide empirical evidence for the controversy about whether the inference is consistent if alternative hospital market definition methods are employed, and for which definition method is the best alternative to the predicted patient flow approach.

Data sources: Collecting data from the discharge data of inpatients and hospital administrative data of Sichuan province in China in the fourth quarter of 2018.

Study Design: We employed Herfindahl–Hirschman Index (HHI) as the proxy of market competition used as an example to measure the hospital market structure. Correlation coefficients of HHIs based on different definition methods were assessed. The corresponding coefficient of each HHI estimated in identical regression models was then compared. In addition, since the predicted patient flow method has been argued by the literature of its advantages compared with the previous approaches, we took the predicted patient flow as a reference to compare with the other approaches.

Data Extraction Methods: We selected the common diseases with a significant burden, and 11 diseases were included (902,767 hospitalizations).

Principal Findings: The correlation coefficients of HHIs based on different market definition methods are all significantly greater than 0, and the coefficients of HHIs are different in identical regression models. Taking the predicted patient flow approach as a reference, we found that the correlation coefficients between HHIs based on fixed radius and predicted patient flow approach is larger than others, and their parameter estimates are all consistent.

Conclusion: Although the HHIs based on different definition methods are significantly and positively correlated, the inferences about the effectiveness of market structure would be inconsistent when alternative market definition methods are employed. The fixed radius would be the best alternative when researchers want to use the predicted patient flow method to define the hospital market but are hindered by the data limitations and computational complexity.

The effect of Iran's health transformation plan on hospital performance: Kerman province

Iran has performed Health Transformation Plan (HTP) from 2014 to obtain its defined goals. This study assesses and compares university and non-university hospitals' efficiency and productivity in Kerman provinces, Iran. The data of 19 selected hospitals, two years before and two years after Health Transformation Plan, was collected in this cross-sectional study. These data included the variables of physician and nurse number, and active beds as inputs and bed occupancy rate and inpatient admission adjusted with the length of stay as outputs. Data Envelopment Analysis method used to measure hospital efficiency. Malmquist Productivity Index is used to measure the efficiency change model before and after the plan. The efficiency and effect of the plan on hospitals' efficiency and productivity were assessed using R software. The results indicated that all hospitals' average efficiency before the HTP was 0.843 and after the HTP was increased to 0.874. However, it was not significant (P>0.05). Productivity also had a decreasing trend. Based on the DEA method results, it was found that university and non-university hospitals' efficiency and productivity did not increase significantly after the HTP. Therefore, it is recommended that attention be paid to hospitals' performance indicators regarding how resources are allocated and decisions made.