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Ferreira MRL, Bonfim RO, Bossonario PA, Maurin VP, Valença ABM, Abreu PDD, Andrade RLDP, Fronteira I, Monroe AA. Social protection as a right of people affected by tuberculosis: a scoping review and conceptual framework. Infect Dis Poverty 2023; 12:103. [PMID: 37993962 PMCID: PMC10664497 DOI: 10.1186/s40249-023-01157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Tuberculosis is an infectious disease strongly influenced by social determinants closely associated with cycles of poverty and social exclusion. Within this context, providing social protection for people affected by the disease constitutes a powerful instrument for reducing inequalities and enhancing inclusion and social justice. This study aimed to identify and synthesize strategies and measures aimed at ensuring social protection as a right of people affected by tuberculosis. METHODS This is a scoping review, with searches conducted in six databases in February 2023. We included publications from 2015 onwards that elucidate strategies and measures of social protection aimed at safeguarding the rights to health, nutrition, employment, income, housing, social assistance, and social security for people affected by tuberculosis. These strategies could be implemented through policies, programs, and/or governmental agreements in any given context. The data extracted from the articles underwent descriptive analysis and a narrative synthesis of findings based on the dimensions of social protection. Additionally, we developed a conceptual framework illustrating the organizational and operational aspects of measures and strategies related to each dimension of social protection identified in this review. RESULTS A total of 9317 publications were retrieved from the databases, of which sixty-three publications were included. The study's results highlighted measures and strategies concerning the social protection of people affected by tuberculosis. These measures and strategies revolved around the rights to proper nutrition and nourishment, income, housing, and health insurance, as well as expanded rights encompassing social assistance and social welfare. It was reported that ensuring these rights contributes to improving nutritional status and the quality of life for individuals with tuberculosis, along with reducing catastrophic costs, expanding access to healthcare interventions and services, and fostering TB treatment adherence, thereby leading to higher rates of TB cure. CONCLUSIONS Our findings identify social protection measures as a right for people affected by tuberculosis and have the potential to guide the development of evidence-based social and health policies through collaboration between tuberculosis control programs and governmental entities.
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Affiliation(s)
| | - Rafaele Oliveira Bonfim
- University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
| | | | | | | | - Paula Daniella de Abreu
- University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
| | | | - Inês Fronteira
- Global Health and Tropical Medicine, Institute of Hygiene and Tropical Medicine, NOVA University Lisbon, Lisbon, Portugal
- National School of Public Health, Public Health Research Center, Comprehensive Health Research Center, NOVA University Lisbon, Lisbon, Portugal
| | - Aline Aparecida Monroe
- University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
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Yan Y, Tu Y. The impact of China's urban and rural economic revitalization on the utilization of mental health inpatient services. Front Public Health 2023; 10:1043666. [PMID: 36711421 PMCID: PMC9877533 DOI: 10.3389/fpubh.2022.1043666] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/09/2022] [Indexed: 01/13/2023] Open
Abstract
Background Rural locations have a lower preference for mental healthcare than urban areas. Medical and pharmacy expenses incurred as a result of serious mental illness are covered by public health insurance, according to the People's Republic of China's Mental Health Law. This study aimed to acknowledge the disparities in the use of mental health services provided by the government health schemes among the rural and urban populations of China and to assess the real reimbursement rates for health insurance coverage. It also sheds light on China's ongoing healthcare reforms for mental health treatments. Materials and methods A retrospective cohort study of patients was conducted that were hospitalized with mental illnesses to assess rural-urban disparities in the utilization of mental health services and the role of health insurance. We used electronic health data from the major psychiatric institutes for 15 years (2005-2020) to assess the influence of health insurance systems on Chinese public preferences for mental health treatments. These psychiatric hospitals serve almost 10% of all mental health patients every year in Shandong and accept patients from all over the country. In addition, health insurance policy regulations in Shandong Province are consistent with national health insurance policy regulations. Models 1 and 2 assess disparities in the utilization of mental health treatments. Our study population was identified using patients' primary diagnosis, as recorded in the two hospitals' EHRs, which routinely record information on patients' sociodemographic characteristics, clinical characteristics of the disease, cost of the treatment, and type of the health insurance plan. The record of EHR data is considered efficient because they document all inpatient expenses incurred during hospitalization in a detailed, itemized, and reliable way. Results Urban patients had longer hospital stays (p = 0.0001), more hospitalizations (p = 0.006), and greater hospitalization expenses (p = 0.001) than rural patients. Patients who had insurance had a longer hospital stay (p = 0.0001), more hospitalizations (p = 0.0001), and greater hospitalization costs (p = 0.0001) than those who did not have insurance. Urban residents used mental health services more than rural residents. People preferred mental healthcare when the reimbursement ratio variable was larger, especially in rural areas. Conclusion Rural people of China experience mental health services are an economic burden. Uniform measures are required to be taken for the development of health insurance policies for people in rural areas.
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Affiliation(s)
- Yu Yan
- School of Law, Guangdong University of Technology, Guangzhou, Guangdong, China,*Correspondence: Yu Yan
| | - Yongqian Tu
- National Academy of Development and Strategies, Renmin University of China, Beijing, China,Yongqian Tu
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Liu X, Lin KH, Li YH, Jiang JN, Zhong ZD, Xiong YB, Zhou J, Xiang L. Impacts of Medical Security Level on Treatment Outcomes of Drug-Resistant Tuberculosis: Evidence from Wuhan City, China. Patient Prefer Adherence 2022; 16:3341-3355. [PMID: 36573226 PMCID: PMC9789709 DOI: 10.2147/ppa.s389231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Drug-resistant tuberculosis (DR-TB) is an increasingly serious global issue. DR-TB has a lower success rate and more severe interruption of treatment than ordinary tuberculosis. Incomplete treatment not only reduces recovery rate in DR-TB patients but also increases the spread of DR-TB. Optimizing medical security policies for DR-TB can reduce the economic burden of patients and can thereby improve treatment success rate. METHODS Patients with DR-TB who were registered in Wuhan Center for Tuberculosis Control and Prevention from January 2016 to December 2019 were selected as research subjects. General descriptive statistical analysis methods were used in analyzing patients' treatment outcomes and medical security compensation rate. The binary logistic regression was used in analyzing the impacts of medical security level on treatment outcomes of DR-TB. RESULTS A total of 409 DR-TB patients were included in the study, and the refusal rate was 12.47%. The treatment success rate was only 37.09% for patients who started treatment and had treatment outcomes. The total out-of-pocket expenses (OOPs) per capita for DR-TB patients were 13,005.61 Chinese yuan. The outpatient effective compensation ratio (ECR) of DR-TB patients was only 51.04%. The outpatient ECR of DR-TB with subsidies of public health projects (SPHPs) were nearly 80% higher than those without SPHP. high outpatient ECR helped optimize treatment outcomes (P < 0.001, OR = 1.038). The inpatient ECR had no effect on patients' treatment outcomes (P = 0.158, OR = 0.986). CONCLUSION Many DR-TB patients did not receive complete treatment. The key breakthrough point in improving DR-TB treatment outcomes is to optimize the outpatient medical insurance compensation policy. Including the costs of DR-TB in expenses for severe diseases in outpatient care is recommended, and financial investment should be appropriately increased to ensure the high coverage ratio of subsidies for public health projects.
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Affiliation(s)
- Xiao Liu
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Kun-He Lin
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Yue-Hua Li
- Wuhan Center for Tuberculosis Control and Prevention, Wuhan Pulmonary Hospital, Wuhan, People’s Republic of China
| | - Jun-Nan Jiang
- School of Public Administration, Zhongnan University of Economics and Law, Wuhan, People’s Republic of China
| | - Zheng-Dong Zhong
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Ying-Bei Xiong
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Jin Zhou
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Li Xiang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- HUST Base of National Institute of Healthcare Security, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
- Correspondence: Li Xiang, Huazhong University of Science and Technology, Wuhan, People’s Republic of China, Email
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Haldane V, Zhang Z, Ma Q, Yin T, Zhang B, Li Y, Pan Q, Dainty KN, Rea E, Pasang P, Wei X, Hu J. A qualitative study of perspectives on access to tuberculosis health services in Xigaze, China. Infect Dis Poverty 2021; 10:120. [PMID: 34544492 PMCID: PMC8451167 DOI: 10.1186/s40249-021-00906-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background Tuberculosis (TB) is a major global health threat and the leading infectious disease cause of death worldwide. Access to and retention in TB care remains a challenge for patients, particularly those living in rural and remote settings. This qualitative study explored barriers and facilitators to accessing and maintaining contact with TB care services in communities in Xigaze (Shigatse) prefecture, Xizang Autonomous Region (Tibet Autonomous Region), China from the perspective of persons impacted by TB. Methods We conduced in-depth interviews with 23 participants impacted by TB in four rural districts in Xigaze prefecture, Xizang Autonomous Region, China between April 2019 and November 2020. Interviews were conducted in Tibetan and Mandarin, transcribed in Mandarin and translated into English. Transcripts were checked against recordings by native Tibetan and Mandarin speakers. QSR NVivo12 software was used for framework analysis guided by an access to care conceptual framework by Levesque et al. Results Overall patients reported low awareness of and an indifferent attitude towards TB, although all reported understanding the need to adhere to treatment. Participants reported complex pathways to care, often requiring visits to multiple healthcare facilities. Some participants reported visiting traditional Tibetan medicine (TTM) providers. Participants reported various barriers to accessing care including challenges physically reaching care, out-of-pocket payments for tests, diagnostics and transport. Barriers to maintaining care included medication side effects and worry about treatment effectiveness. Enablers to accessing care identified included knowledge or past experience with TB, integrated models of TTM and western care, supportive village doctors who conducted home visits, free TB treatment and other subsidies, as well as having family support with care and social support as barriers and facilitators to maintaining treatment. Conclusions We identified barriers and facilitators to accessing services in rural communities in Xigaze from the perspective of persons impacted by TB. Challenges include complex pathways to care, travel distances, wait times and low awareness. Tuberculosis care in the region could be strengthened by ongoing culturally tailored educational campaigns to increase awareness, partnerships with TTM providers, providing comprehensive treatment subsidies and strengthening the role of family members in comprehensive TB care. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40249-021-00906-4.
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Affiliation(s)
- Victoria Haldane
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Zhitong Zhang
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Qi Ma
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Tingting Yin
- Weifang Medical College, Weifang, Shandong, China
| | - Bei Zhang
- Weifang Medical College, Weifang, Shandong, China
| | - Yinlong Li
- Jining Medical University, Jining, Shandong, China
| | - Qiuyu Pan
- North Sichuan Medical College, Nanchong, Sichuan, China
| | - Katie N Dainty
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St., Toronto, ON, M5T 3M6, Canada
| | - Elizabeth Rea
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Pande Pasang
- Xigaze Centre for Disease Control and Prevention, 7 Keji Road, Sangzhuzi District, Xigaze, Xizang, China
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada.
| | - Jun Hu
- Shandong University of Traditional Chinese Medicine, Jinan, 250355, China.
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Yang T, Chen T, Che Y, Chen Q, Bo D. Factors associated with catastrophic total costs due to tuberculosis under a designated hospital service model: a cross-sectional study in China. BMC Public Health 2020; 20:1009. [PMID: 32586305 PMCID: PMC7318445 DOI: 10.1186/s12889-020-09136-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/17/2020] [Indexed: 12/02/2022] Open
Abstract
Background Certain districts and counties in China designated local general hospital as the designated hospital for tuberculosis (TB) management after the promulgation of the Law of Practicing Physicians in 2009. To our knowledge, there is limited research on catastrophic payments of TB patients under this service model, often with inconsistent conclusions. In addition, there has been no published studies from China using the updated 2018 World Health Organization (WHO) definition of catastrophic total costs due to TB. This study used the latest criterion recommended by the WHO to analyze the incidence of catastrophic total costs for households affected by TB under the designated hospital model and explore its influencing factors. Methods A cross-sectional analysis was carried out in all ten designated hospitals in Ningbo, China. Eligible pulmonary TB cases confirmed by sputum culture of Mycobacterium tuberculosis were recruited and surveyed from September 2018 to October 2018. We evaluated catastrophic total costs using total costs for TB treatment exceeding 20% of the household’s annual pre-TB income. A sensitivity analysis was performed while varying the thresholds. The least absolute shrinkage and selection operator (LASSO) regression were applied to select variables, and multiple logistic regression analysis were used to identify the determinants of catastrophic total costs. Results A total of 672 patients were included, with a median age of 41 years old. The rate of catastrophic total costs of surveyed households was 37.1%, and that of households affected by MDR was 69.6%. Medical cost accounted for more than 60% of the total cost. 57.7% cases were hospitalized. The hospitalization rates of patients with no comorbidities, no severe adverse drug reactions, and rifampin-sensitive TB were 53.9, 54.9, and 55.3%, respectively. Patients in the poorest households had the highest hospitalization rates (Q1:54.8%, Q2:61.4%, Q3:52.2%, Q4:49.5%, Q5:69.7%, P = 0.011) and the highest incidence of severe adverse drug reactions (Q1:29.6%, Q2:19.6%, Q3:28.0%, Q4:33.7%, Q5:35.3%, P = 0.034). Factors such as elderly, minimum living security, unemployed before or after illness, poor economic status, seeking medical care outside the city, hospitalization, absence of local basic medical insurance coverage and MDR were positively associated with catastrophic costs. Conclusion Substantial proportions of patients and households affected by pulmonary TB faced catastrophic economic risks in Ningbo, China. The existing policies that focus on expanding the coverage of basic medical insurance and economic protection measures (such as cash transfers to compensate low-income households for direct non-medical costs and income loss) might be insufficient. Tailored program that mitigate inappropriate healthcare and address equity of care delivery are worthy of attention.
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Affiliation(s)
- Tianchi Yang
- Institute of Tuberculosis Prevention and Control, Ningbo Municipal Center for Disease Control and Prevention, Ningbo, Zhejiang, China.
| | - Tong Chen
- Institute of Tuberculosis Prevention and Control, Ningbo Municipal Center for Disease Control and Prevention, Ningbo, Zhejiang, China
| | - Yang Che
- Institute of Tuberculosis Prevention and Control, Ningbo Municipal Center for Disease Control and Prevention, Ningbo, Zhejiang, China
| | - Qin Chen
- Division of Medical Insurance, Ningbo Huamei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Dingyi Bo
- Institute of Infectious Disease Control, Haishu District Center for Disease Control and Prevention, Ningbo, Zhejiang, China
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Process Evaluation of a Clustered Randomized Control Trial of a Comprehensive Intervention to Reduce the Risk of Cardiovascular Events in Primary Health Care in Rural China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17114156. [PMID: 32532144 PMCID: PMC7312738 DOI: 10.3390/ijerph17114156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/26/2020] [Accepted: 06/08/2020] [Indexed: 12/13/2022]
Abstract
Background: Cardiovascular disease (CVD) is a major public health challenge in China. This study aims to understand the processes of implementing a comprehensive intervention to reduce CVD events in areas of drug therapy, lifestyle changes, and adherence support in a clustered randomized controlled trial (cRCT). This trial consisted of 67 clusters spanning over 3 years in Zhejiang Province, China. Method: A qualitative process evaluation was nested within the cRCT conducted in 9 township hospitals with 27 healthcare providers, 18 semi-structured interviews, and 23 observational studies of clinical practices within the intervention arm. Results: Effective and repeated trainings using an interactive approach were crucial to improve the prescribing behaviour of family doctors and their patient communication skills. However, the awareness of patients remained limited, thus compromising their use of CVD preventive drugs and adoption of healthy lifestyles. Health system factors further constrained providers’ and patients’ responses to the intervention. Financial barrier was a major concern because of the low coverage of health insurance. Other barriers included limited doctor–patient trust and suboptimal staff motivation. Conclusion: Our study suggests the feasibility of implementing a comprehensive CVD risk reduction strategy in China’s rural primary care facilities. However, health system barriers need to be addressed to ensure the success and sustainability of the intervention.
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Mao W, Jiang W, Hamilton C, Zhang H, Huang F, Lucas H, Huan S, Tang S. Over- and under-treatment of TB patients in Eastern China: an analysis based on health insurance claims data. Trop Med Int Health 2019; 24:1078-1087. [PMID: 31299130 PMCID: PMC6851836 DOI: 10.1111/tmi.13287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective Poor compliance with existing guidelines for tuberculosis (TB) care and treatment is an issue of concern in China. We assessed health service use by TB patients over the entire treatment process and compared it to the recommended guidelines. Methods We collected insurance claims data in three counties of one province of Eastern China. Patient records with a diagnosis of ‘pulmonary TB’ in 2015 and 2016 were extracted. Treatment duration, number of outpatient (OP) visits and hospital admissions, as well as total cost, out‐of‐pocket (OOP) payments and effective reimbursement rates were analysed. Results A total of 1394 patients were included in the analysis. More than 48% received over the 8 months of treatment that TB guidelines recommend, and over 28% received less. 49% of Urban and Rural Resident Basic Medical Insurance (URRBMI) TB patients were hospitalised while 30% of those with Urban Employee Basic Medical Insurance (UEBMI) had at least one admission. Median total cost for patients with hospital admission was almost 10 times that of patients without. By comparison, the average OOP was 5 times higher. UEBMI patients had a shorter treatment period, more outpatient visits but considerably fewer hospital admissions than URRBMI patients. Conclusions We found an alarming extent of TB over‐ and under‐treatment in our study population. There is an urgent need to improve compliance with treatment guidelines in China and to better understand the drivers of divergence. Extending the coverage of health insurance schemes and increasing reimbursement rates for TB outpatient services would seem to be key factors in reducing both the overall cost and financial burden on patients.
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Affiliation(s)
- Wenhui Mao
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Weixi Jiang
- Global Health Research Center, Duke Kunshan University, Kunshan, China
| | | | - Hui Zhang
- National Center for TB Control and Prevention, China CDC, Beijing, China
| | - Fei Huang
- National Center for TB Control and Prevention, China CDC, Beijing, China
| | - Henry Lucas
- Institute of Development Studies, Sussex University, Brighton, UK
| | | | - Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Global Health Research Center, Duke Kunshan University, Kunshan, China
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Duan W, Zhang W, Wu C, Wang Q, Yu Y, Lin H, Liu Y, Hu D. Extent and determinants of catastrophic health expenditure for tuberculosis care in Chongqing municipality, China: a cross-sectional study. BMJ Open 2019; 9:e026638. [PMID: 30975682 PMCID: PMC6500361 DOI: 10.1136/bmjopen-2018-026638] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To investigate the extent and associations of patient/diagnostic delay and other potential factors with catastrophic health expenditure (CHE) for tuberculosis (TB) care in Chongqing municipality, China. DESIGN A cross-sectional study. SETTING Four counties of Chongqing municipality, China. PARTICIPANTS A total of 1199 patients with active pulmonary TB beyond 16 years and without mental disorders were consecutively recruited in the four counties' designated TB medical institutions. OUTCOME MEASURES The incidence and intensity of CHE for TB care were described. The association between patients' 'sociodemographic and clinical characteristics such as patient delay, diagnostic delay, forms of TB, health insurance status and hospitalisation and CHE were analysed using univariate and multivariate logistic regression. RESULTS The incidence of CHE was 52.8% and out-of-pocket (OOP) payments were 93% of the total costs for TB care. Compared with patients without delay, the incidence and intensity of CHE were higher in patients who had patient delay or diagnostic delay. Patients who experienced patient delay or diagnostic delay, who was a male, elderly (≥60 years), an inhabitant, a peasant, divorced/widow, the New Cooperative Medical Scheme membership had greater risks of incurring CHE for TB care. Having a higher educational level appeared to be a protective factor. However, hospitalisation was not associated with CHE after controlling for other variables. CONCLUSION The incidence and intensity of CHE for TB care are high, which provides baseline data about catastrophic costs that TB-related households faced in Chongqing of China. Variety of determinants of CHE implicate that it is essential to take effective measures to promote early seeking care and early diagnosis, improve the actual reimbursement rates of health insurance, especially for outpatients, and need more fine-tuned interventions such as precise poverty alleviation to reduce catastrophic costs of the vulnerable population.
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Affiliation(s)
- Weixia Duan
- Department of Prevention, Chongqing Institute of Tuberculosis Prevention and Treatment, Chongqing, China
- The center of Laboratory Medicine, Chongqing Occupational Diseases Prevention Hospital, Chongqing, China
| | - Wen Zhang
- Department of Prevention, Chongqing Institute of Tuberculosis Prevention and Treatment, Chongqing, China
| | - Chengguo Wu
- Department of Prevention, Chongqing Institute of Tuberculosis Prevention and Treatment, Chongqing, China
| | - Qingya Wang
- Department of Prevention, Chongqing Institute of Tuberculosis Prevention and Treatment, Chongqing, China
| | - Ya Yu
- Department of Prevention, Chongqing Institute of Tuberculosis Prevention and Treatment, Chongqing, China
| | - Hui Lin
- Department of Epidemiology, The Third Military Medical University, Chongqing, China
| | - Ying Liu
- Department of Prevention, Chongqing Institute of Tuberculosis Prevention and Treatment, Chongqing, China
| | - Daiyu Hu
- Department of Prevention, Chongqing Institute of Tuberculosis Prevention and Treatment, Chongqing, China
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Jiang WX, Long Q, Lucas H, Dong D, Chen JY, Xiang L, Li Q, Huang F, Wang H, Elbers C, Cobelens F, Tang SL. Impact of an innovative financing and payment model on tuberculosis patients' financial burden: is tuberculosis care more affordable for the poor? Infect Dis Poverty 2019; 8:21. [PMID: 30904025 PMCID: PMC6431427 DOI: 10.1186/s40249-019-0532-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 03/08/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In response to the high financial burden of health services facing tuberculosis (TB) patients in China, the China-Gates TB project, Phase II, has implemented a new financing and payment model as an important component of the overall project in three cities in eastern, central and western China. The model focuses on increasing the reimbursement rate for TB patients and reforming provider payment methods by replacing fee-for-service with a case-based payment approach. This study investigated changes in out-of-pocket (OOP) health expenditure and the financial burden on TB patients before and after the interventions, with a focus on potential differential impacts on patients from different income groups. METHODS Three sample counties in each of the three prefectures: Zhenjiang, Yichang and Hanzhong were chosen as study sites. TB patients who started and completed treatment before, and during the intervention period, were randomly sampled and surveyed at the baseline in 2013 and final evaluation in 2015 respectively. OOP health expenditure and percentage of patients incurring catastrophic health expenditure (CHE) were calculated for different income groups. OLS regression and logit regression were conducted to explore the intervention's impacts on patient OOP health expenditure and financial burden after adjusting for other covariates. Key-informant interviews and focus group discussions were conducted to understand the reasons for any observed changes. RESULTS Data from 738 (baseline) and 735 (evaluation) patients were available for analysis. Patient mean OOP health expenditure increased from RMB 3576 to RMB 5791, and the percentage of patients incurring CHE also increased after intervention. The percentage increase in OOP health expenditure and the likelihood of incurring CHE were significantly lower for patients from the highest income group as compared to the lowest. Qualitative findings indicated that increased use of health services not covered by the standard package of the model was likely to have caused the increase in financial burden. CONCLUSIONS The implementation of the new financing and payment model did not protect patients, especially those from the lowest income group, from financial difficulty, due partly to their increased use of health service. More financial resources should be mobilized to increase financial protection, particularly for poor patients, while cost containment strategies need to be developed and effectively implemented to improve the effective coverage of essential healthcare in China.
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Affiliation(s)
- Wei-Xi Jiang
- Global Health Research Center, Duke Kunshan University, Kunshan, 215316, Jiangsu, China
| | - Qian Long
- Global Health Research Center, Duke Kunshan University, Kunshan, 215316, Jiangsu, China
| | - Henry Lucas
- Institute of Development Studies, University of Sussex, Brighton, BN1 9RE, UK
| | - Di Dong
- Global Health Research Center, Duke Kunshan University, Kunshan, 215316, Jiangsu, China
| | - Jia-Ying Chen
- School of Policy & Management, Nanjing Medical University, Nanjing, 211166, Jiangsu, China
| | - Li Xiang
- Tongji Medical College of Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Qiang Li
- School of Public Health, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Fei Huang
- National Center for Tuberculosis Control and Prevention, China CDC, Beijing, 102206, China
| | - Hong Wang
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Chris Elbers
- Faculty of Economics and Business Administration, Vrije Universiteit Amsterdam, Amsterdam, 1081, HV, the Netherlands
| | - Frank Cobelens
- The Amsterdam Institute for Global Health and Development, Amsterdam, 1105, BP, the Netherlands
| | - Sheng-Lan Tang
- Duke Global Health Institute, Duke University, Durham, NC, 27710, USA.
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Zhou Y, Chen C, Jiang H, Pan HQ, Zhu LM, Lu W. High admission rates and heavy inpatient service costs of urban tuberculosis patients in eastern China. BMC Health Serv Res 2019; 19:47. [PMID: 30658635 PMCID: PMC6339337 DOI: 10.1186/s12913-019-3892-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 01/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis patients often experience hospitalization. Inpatient services may result in high medical expenditures. It is important to explore the hospitalization rates of tuberculosis patients and the potential factors that are associated with admission rates and inpatient service expenditures. METHODS Data from patients diagnosed and treated at the No.3 hospital of Zhenjiang City from Apr. 2014 to Mar. 2015 were obtained. Univariate and multivariate statistical analyses were applied for the analysis of potential factors associated with admission rates, average length of stay and cost. RESULTS A total of 356 tuberculosis patients were treated at the No.3 hospital of Zhenjiang City. A total of 221 of the 356 patients were hospitalized. Sputum smear test results and type of health insurance were the potential factors associated with hospitalization rates. The average admission was (1.26 ± 0.64) per patient. The average length of stay of inpatients was 29.99 ± 25.83 days. Age, occupation, and sputum smear test were related to the average length of stay. The average total cost to inpatients was 13007.91 ± 5205.58 CNY. The sputum smear test results, type of health insurance, occupation and age were the main potential factors associated with TB inpatient expenditures. CONCLUSIONS The admission rate of tuberculosis patients was high. Despite advances in TB insurance policies, there were substantial costs associated with TB diagnosis and treatment. TB patients still face a heavy financial burden. Health care providers should revise the service package and reform the health insurance regulations to ensure that TB patients receive appropriate care.
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Affiliation(s)
- Yang Zhou
- Department of Chronic Disease Control and Prevention, Centers for Disease Control and Prevention of Jiangsu Province, 172 Jiangsu Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Cheng Chen
- Department of Chronic Disease Control and Prevention, Centers for Disease Control and Prevention of Jiangsu Province, 172 Jiangsu Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Hui Jiang
- Centers for Disease Control and Prevention of Zhenjiang City, Zhenjiang, Jiangsu Province, People's Republic of China
| | - Hong-Qiu Pan
- No.3 Hospital of Zhenjiang City, Zhenjiang, Jiangsu Province, People's Republic of China
| | - Li-Mei Zhu
- Department of Chronic Disease Control and Prevention, Centers for Disease Control and Prevention of Jiangsu Province, 172 Jiangsu Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Wei Lu
- Department of Chronic Disease Control and Prevention, Centers for Disease Control and Prevention of Jiangsu Province, 172 Jiangsu Road, Nanjing, 210009, Jiangsu Province, People's Republic of China.
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11
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Xu J, Wang J, King M, Liu R, Yu F, Xing J, Su L, Lu M. Rural-urban disparities in the utilization of mental health inpatient services in China: the role of health insurance. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2018; 18:377-393. [PMID: 29589249 PMCID: PMC6223725 DOI: 10.1007/s10754-018-9238-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 03/17/2018] [Indexed: 05/28/2023]
Abstract
Reducing rural-urban disparities in health and health care has been a key policy goal for the Chinese government. With mental health becoming an increasingly significant public health issue in China, empirical evidence of disparities in the use of mental health services can guide steps to reduce them. We conducted this study to inform China's on-going health-care reform through examining how health insurance might reduce rural-urban disparities in the utilization of mental health inpatient services in China. This retrospective study used 10 years (2005-2014) of hospital electronic health records from the Shandong Center for Mental Health and the DaiZhuang Psychiatric Hospital, two major psychiatric hospitals in Shandong Province. Health insurance was measured using types of health insurance and the actual reimbursement ratio (RR). Utilization of mental health inpatient services was measured by hospitalization cost, length of stay (LOS), and frequency of hospitalization. We examined rural-urban disparities in the use of mental health services, as well as the role of health insurance in reducing such disparities. Hospitalization costs, LOS, and frequency of hospitalization were all found to be lower among rural than among urban inpatients. Having health insurance and benefiting from a relatively high RR were found to be significantly associated with a greater utilization of inpatient services, among both urban and rural residents. In addition, an increase in the RR was found to be significantly associated with an increase in the use of mental health services among rural patients. Consistent with the existing literature, our study suggests that increasing insurance schemes' reimbursement levels could lead to substantial increases in the use of mental health inpatient services among rural patients, and a reduction in rural-urban disparities in service utilization. In order to promote mental health care and reduce rural-urban disparities in its utilization in China, improving rural health insurance coverage (e.g., reducing the coinsurance rate) would be a powerful policy instrument.
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Affiliation(s)
- Junfang Xu
- Research Center for Public Health, School of Medicine, Tsinghua University, Beijing, China
| | - Jian Wang
- Center for Health Economic Experiments and Public Policy, Department of Social Medicine and Administration, School of Public Health, Shandong University, No. 44 Wen Hua Xi Road, Jinan, Shandong, China.
| | - Madeleine King
- School of Public Policy and Management, Tsinghua University, Beijing, China
| | - Ruiyun Liu
- Shandong Center for Mental Health, Jinan, Shandong, China
| | - Fenghua Yu
- Shandong Health and Family Planning Commission, Jinan, Shandong, China
| | - Jinshui Xing
- Shandong Center for Mental Health, Jinan, Shandong, China
| | - Lei Su
- Shandong Center for Mental Health, Jinan, Shandong, China
| | - Mingshan Lu
- Department of Economics, University of Calgary, Calgary, Canada
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12
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Viney K, Wingfield T, Kuksa L, Lönnroth K. Access and adherence to tuberculosis prevention and care for hard-to-reach groups. Tuberculosis (Edinb) 2018. [DOI: 10.1183/2312508x.10022117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Chimbatata NBW, Zhou C, Chimbatata CM, Mhango L, Diwan VK, Xu B. Barriers to prompt TB diagnosis-a comparative study between northern Malawi and eastern rural China. Trans R Soc Trop Med Hyg 2017; 111:504-511. [PMID: 29425379 DOI: 10.1093/trstmh/try002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 01/07/2018] [Indexed: 11/12/2022] Open
Abstract
Background Tuberculosis (TB) case detection in China has improved remarkably, partly benefiting from the reducing delay to TB care, whereas the timeliness of TB care in Malawi remains problematic. Methods This study investigates barriers hindering timely TB diagnosis in Malawi and China, and attempts to share the experience in high burden countries. A cross-sectional study on TB diagnostic delay was conducted among 254 Malawian and 146 Chinese TB patients. Results The medians of patient's delays were 22 and 20 days (p>0.05), and provider delays were 12 and 11.5 days (p>0.05) in Malawi and China, respectively. Malawian patients had a higher proportion (72.05% vs 67.12%) of patient's delay longer than 14 days (p=0.042), which was significantly associated with initial visits to lower-level health providers in the villages (aOR=1.989, 95% CI: 1.075-3.682), and patients conducting casual/piece work (aOR=3.318, 95% CI: 1.228-8.964). Initial healthcare visits at village level also led to longer provider delay in both Malawi (aOR=2.055, 1.211-3.487) and China (aOR=5.627, 2.218-14.276). Conclusion Establishing a good communication and referral mechanism between different levels of health facilities is crucial to timely TB diagnosis. China's experience on pro-poor interventions could be useful to its Malawian counterpart and other similar settings with high TB burden.
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Affiliation(s)
- Nathan B W Chimbatata
- School of Public Health, Fudan University, Shanghai.,Key Laboratory of Public Health Safety (Ministry of Education), Shanghai, China.,Mzuzu University, Mzuzu
| | - Changming Zhou
- School of Public Health, Fudan University, Shanghai.,Key Laboratory of Public Health Safety (Ministry of Education), Shanghai, China
| | | | | | - Vinod K Diwan
- Department of Public Health Sciences (Global Health/IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Biao Xu
- School of Public Health, Fudan University, Shanghai.,Key Laboratory of Public Health Safety (Ministry of Education), Shanghai, China.,Department of Public Health Sciences (Global Health/IHCAR), Karolinska Institutet, Stockholm, Sweden
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14
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Hutchison C, Khan MS, Yoong J, Lin X, Coker RJ. Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China. BMC Public Health 2017; 17:221. [PMID: 28222724 PMCID: PMC5320743 DOI: 10.1186/s12889-017-4089-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 01/30/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) and multidrug-resistance tuberculosis (MDR-TB) pose serious challenges to global health, particularly in China, which has the second highest case burden in the world. Disparities in access to care for the poorest, rural TB patients may be exacerbated for MDR-TB patients, although this has not been investigated widely. We examine whether certain patient groups experience different barriers to accessing TB services, whether there are added challenges for patients with MDR-TB, and how patients and health providers cope in Yunnan, a mountainous province in China with a largely rural population and high TB burden. METHODS Using a qualitative study design, we conducted five focus group discussions and 47 in-depth interviews with purposively sampled TB and MDR-TB patients and healthcare providers in Mandarin, between August 2014 and May 2015. Field-notes and interview transcripts were analysed via a combination of open and thematic coding. RESULTS Patients and healthcare providers consistently cited financial constraints as the most common barriers to accessing care. Rural residents, farmers and ethnic minorities were the most vulnerable to these barriers, and patients with MDR-TB reported a higher financial burden owing to the centralisation and longer duration of treatment. Support in the form of free or subsidised treatment and medical insurance, was deemed essential but inadequate for alleviating financial barriers to patients. Most patients coped by selling their assets or borrowing money from family members, which often strained relationships. Notably, some healthcare providers themselves reported making financial and other contributions to assist patients, but recognised these practices as unsustainable. CONCLUSIONS Financial constraints were identified by TB and MDR-TB patients and health care professionals as the most pervasive barrier to care. Barriers appeared to be magnified for ethnic minorities and patients coming from rural areas, especially those with MDR-TB. To reduce financial barriers and improve treatment outcomes, there is a need for further research into the total costs of seeking and accessing TB and MDR-TB care. This will enable better assessment and targeting of appropriate financial support for identified vulnerable groups and geographic development of relevant services.
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Affiliation(s)
- C Hutchison
- London School of Hygiene and Tropical Medicine, London, UK
| | - M S Khan
- London School of Hygiene and Tropical Medicine, London, UK.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - J Yoong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.,Centre for Economic and Social Research, University of Southern California, Los Angeles, USA
| | - X Lin
- Yunnan Center for Disease Control and Prevention, Kunming, China.
| | - R J Coker
- London School of Hygiene and Tropical Medicine, London, UK.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.,Faculty of Public Health, Mahidol University, Bangkok, Thailand
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15
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Xiang L, Pan Y, Hou S, Zhang H, Sato KD, Li Q, Wang J, Tang S. The impact of the new cooperative medical scheme on financial burden of tuberculosis patients: evidence from six counties in China. Infect Dis Poverty 2016; 5:8. [PMID: 26818723 PMCID: PMC4730613 DOI: 10.1186/s40249-015-0094-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 12/30/2015] [Indexed: 12/05/2022] Open
Abstract
Background Tuberculosis (TB) patients in China encounter heavy financial burdens throughout the course of their treatment and it is unclear how China’s health insurance systems affect the alleviation of this burden under the integrated approach. This study aimed to measure reimbursement for TB services under the New Cooperative Medical Scheme (NCMS) in rural China and to evaluate changes in catastrophic health expenditure (CHE) caused by the reimbursement policies. Methods Reimbursement data were obtained from routine data systems for the NCMS in Yichang (YC) and Hanzhong (HZ). 1884 TB inpatients reimbursed by NCMS from 2010 to 2012 were included. Household surveys were conducted. A total of 494 TB patients under the NCMS were selected in this paper. 12 Focus Group Discussions (FGDs) were held. We measured the impact of the NCMS by counterfactual analysis, which analyzed the financial burden alleviation. Equity was assessed by Concentration Index (CI), and disaggregated by project sites. Results TB inpatients were reimbursed with an effective reimbursement rate of 57.3 %. Average out-of-pocket (OOP) payments for outpatient and inpatient services after diagnosis were 1413 yuan and 430 yuan, and 3572 yuan and 3013 yuan in YC and HZ, respectively. The reimbursement level for TB outpatient care after diagnosis was very low due to a limited outpatient quota. TB patients in HZ incurred higher effective reimbursement rates, but the incidence of CHE remained higher. The reduction of CHE incidence after the NCMS showed no difference statistically (P > 0.05). The severity of CHE was alleviated slightly. CIs after reimbursement were all below zero and their absolute values were higher than those before reimbursement. Conclusions Low reimbursement for TB patients could lead to heavy financial burden. Poor TB patients incurred high rates of CHE. The NCMS was found to be a protective factor for CHE, but the impact was modest and the equity of CHE did not improve. The NCMS reimbursement policies should be improved in the future to include a more comprehensive coverage of care. Supplemental programs may be necessary to expand coverage for TB care. Electronic supplementary material The online version of this article (doi:10.1186/s40249-015-0094-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Li Xiang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, China.
| | - Yao Pan
- The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Shuangyi Hou
- Hubei Provincial Center for Disease Control and Prevention, Wuhan, China.
| | - Hongwei Zhang
- Shaanxi Provincial Institute for TB Control and Prevention, Xi'an, China.
| | - Kaori D Sato
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Qiang Li
- School of Public Health, Xi'an Jiaotong University, Xi'an, China.
| | - Jing Wang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, China.
| | - Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, NC, USA. .,Global Health Research Center, Duke Kunshan University, Kunshan, China.
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16
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Hu H, Chen J, Sato KD, Zhou Y, Jiang H, Wu P, Wang H. Factors that associated with TB patient admission rate and TB inpatient service cost: a cross-sectional study in China. Infect Dis Poverty 2016; 5:4. [PMID: 26786599 PMCID: PMC4719743 DOI: 10.1186/s40249-016-0097-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 01/04/2016] [Indexed: 11/10/2022] Open
Abstract
Background China has recently adopted the “TB designated hospital model” to improve the quality of tuberculosis (TB) treatment and patient management. Considering that inpatient service often results in high patient financial burden, and therefore influences patient adherence to treatment, it is critical to better understand the TB patient admission rate and TB inpatient service cost, as well as their influential factors in this new model. Methods Quantitative and qualitative studies were conducted in two cities, Hanzhong in Shaanxi Province and Zhenjiang in Jiangsu Province, in China. Quantitative data were obtained from a sample survey of 533 TB patients and TB inpatient records from 2010–2012 in six county designated hospitals. Qualitative information was obtained through interviews with key stakeholders (40 key informant interviews, 14 focus group discussions) and reviews of health policy documents in study areas. Both univariate and multivariate statistical analyses were applied for the quantitative analysis, and the thematic framework approach was applied for the qualitative analysis. Results The TB patient admission rates in Zhenjiang and Hanzhong were 54.8 and 55.9 %, respectively. Qualitative analyses revealed that financial incentives, misunderstanding of infectious disease control and failure of health insurance regulations were the key factors associated with the admission rates and medical costs. Quantitative analyses found differences in hospitalization rate existed among patients with different health insurance and patients from different counties. Average medical costs for TB inpatients in Jurong and Zhenba were 7,215 CNY and 4,644 CNY, which was higher than the 5,500 CNY and 3,800 CNY limits set by the New Rural Cooperative Medical System. No differences in medical cost or length of stay were found between patients with and without comorbidities in county-level hospitals. Conclusions TB patient admission rates and inpatient service costs were relatively high. Studies of related factors indicated that a package of interventions, including health education programs, reform of health insurance regulations and improvement of TB treatment guidelines, are urgently required to ensure that TB patients receive appropriate care. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0097-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hongyan Hu
- Center for Health Policy Studies, Nanjing Medical University, Hanzhong Road 140, 210029, Nanjing, P. R. China.
| | - Jiaying Chen
- Center for Health Policy Studies, Nanjing Medical University, Hanzhong Road 140, 210029, Nanjing, P. R. China.
| | - Kaori D Sato
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Yang Zhou
- Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu Province, China.
| | - Hui Jiang
- Zhenjiang Center for Disease Control and Prevention, Zhenjiang, Jiangsu Province, China.
| | - Pingbo Wu
- Hanzhong Center for Disease Control and Prevention, Hanzhong, Shaanxi Province, China.
| | - Hong Wang
- Bill & Melinda Gates Foundation, Seattle, WA, USA.
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17
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Chen S, Zhang H, Pan Y, Long Q, Xiang L, Yao L, Lucas H. Are free anti-tuberculosis drugs enough? An empirical study from three cities in China. Infect Dis Poverty 2015; 4:47. [PMID: 26510711 PMCID: PMC4625923 DOI: 10.1186/s40249-015-0080-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 10/10/2015] [Indexed: 11/26/2022] Open
Abstract
Background Tuberculosis (TB) patients in China still face a number of barriers in seeking diagnosis and treatment. There is evidence that the economic burden on TB patients and their households discourages treatment compliance. Methods A cross-sectional study was conducted in three cities of China. Patients were selected using probability proportional to size (PPS) cluster sampling of rural townships or urban streets, followed by list sampling from a patient register. Data were collected using a questionnaire survey, key informant interviews and focus group discussions with TB patients to gain an understanding of the economic burden of TB and implications of this burden for treatment compliance. Results A total of 797 TB patients were surveyed, of which 60 were interviewed in-depth following the survey. More than half had catastrophic health expenditure. TB patients with higher household incomes were less likely to report non-compliance (OR 0.355, 95 % CI 0.140–0.830) and patients who felt that the economic burden relating to TB treatment was high more likely to report non-compliance (OR 3.650, 95 % CI 1.278–12.346). Those who had high costs for transportation, lodging and food were also more likely to report non-compliance (OR 4.150, 95 % CI 1.804–21.999). The findings from the qualitative studies supported those from the survey. Conclusion The economic burden associated with seeking diagnosis and treatment remains a barrier for TB patients in China. Reducing the cost of treatment and giving patients subsidies for transportation, lodging and food is likely to improve treatment compliance. Improving doctors’ salary system to cut off the revenue-oriented incentive, and expanding current insurance’s coverage can be helpful to reduce patients’ actual burden or anticipated burden. Future research on this issue is needed. Electronic supplementary material The online version of this article (doi:10.1186/s40249-015-0080-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shanquan Chen
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.
| | - Hui Zhang
- National Center for TB Control and Prevention, China CDC, Beijing, PR China. .,Chinese Center for Disease Control and Prevention, Beijing, PR China.
| | - Yao Pan
- The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Qian Long
- Duke Global Health Institute, Duke University, Durham, NC, USA. .,Global Health Research Center, Duke Kunshan University, Kunshan, China.
| | - Li Xiang
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, China.
| | - Lan Yao
- School of Medicine and Health Management, Huazhong University of Science and Technology, Wuhan, China.
| | - Henry Lucas
- Institute of Development Studies, Sussex University, Brighton, UK.
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18
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Zou G, Zeng Z, Chen W, Ling L. Self-reported illnesses and service utilisation among migrants working in small-to medium sized enterprises in Guangdong, China. Public Health 2015; 129:970-8. [PMID: 26077388 DOI: 10.1016/j.puhe.2015.04.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 04/06/2015] [Accepted: 04/22/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES As one of the most vulnerable populations in China, many migrants work in the small-to-medium-sized enterprises (SMEs). This study aims to describe the self-reported illnesses and service utilization of the migrants working in the SMEs in Pearl River Delta Areas (PRDA) of Guangdong province, China. STUDY DESIGN Cross-sectional survey. METHODS We interviewed 856 migrants working in the SMEs of different manufacturing industries in 2012. Descriptive analysis was employed to report self-reported illnesses and service utilisation among migrants in the last two weeks and in the last year. Statistical tests such as χ2 test were used to explore factors influencing their service utilisation. RESULTS In the last two weeks, 91(11%) of the respondents reported having any illness. The most reported illness was respiratory problem (69%), while 9.9%, 7.7% and 13% reported having digestive, skin and other problems respectively. The most important symptom was cough (39%). Thirty-seven percent of the respondents who reported any illness had visited health facilities. The lower income group were more likely to visit health facilities than the higher income group (P = 0.006). The most reported reason for not visiting health facilities was 'feeling not serious' (65%). In the last year, 13% reported having respiratory problems and 7.8% reported accidental injuries. Less than 3% received hospitalization care. The proportion of those without hospitalization to those who should have been hospitalized was 31%. CONCLUSION Underuse of the health service among migrants working in the SMEs could be associated with the 'healthy migrant' effect. However, when assessed among the ill migrants in the SMEs, the utilisation rate was still low mainly due to their poor health awareness. Improving their risk perception and integration of occupational and general health service is crucial to improve the health conditions and utilisation of service among migrants in the SMES.
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Affiliation(s)
- G Zou
- Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, China; Institute for International Health and Development, Queen Margaret University, Edinburgh, UK
| | - Z Zeng
- Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, China; Hunan Provincial Women and Children's Hospital, Changsha, Hunan, China
| | - W Chen
- Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, China; Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - L Ling
- Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, China; Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China.
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19
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Qiu S, Pan H, Zhang S, Peng X, Zheng X, Xu G, Wang M, Wang J, Lu H. Is tuberculosis treatment really free in China? A study comparing two areas with different management models. PLoS One 2015; 10:e0126770. [PMID: 25993411 PMCID: PMC4439067 DOI: 10.1371/journal.pone.0126770] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 04/07/2015] [Indexed: 11/25/2022] Open
Abstract
Objective China has implemented a free-service policy for tuberculosis. However, patients still have to pay a substantial proportion of their annual income for treatment of this disease. This study describes the economic burden on patients with tuberculosis; identifies related factors by comparing two areas with different management models; and provides policy recommendation for tuberculosis control reform in China. Methods There are three tuberculosis management models in China: the tuberculosis dispensary model, specialist model and integrated model. We selected Zhangjiagang (ZJG) and Taixing (TX) as the study sites, which correspond to areas implementing the integrated model and dispensary model, respectively. Patients diagnosed and treated for tuberculosis since January 2010 were recruited as study subjects. A total of 590 patients (316 patients from ZJG and 274 patients from TX) were interviewed with a response rate of 81%. The economic burden attributed to tuberculosis, including direct costs and indirect costs, was estimated and compared between the two study sites. The Mann-Whitney U Test was used to compare the cost differences between the two groups. Potential factors related to the total out-of-pocket costs were analyzed based on a step-by-step multivariate linear regression model after the logarithmic transformation of the costs. Results The average (median, interquartile range) total cost was 18793.33 (9965, 3200-24400) CNY for patients in ZJG, which was significantly higher than for patients in TX (mean: 6598.33, median: 2263, interquartile range: 983–6688) (Z = 10.42, P < 0.001). After excluding expenses covered by health insurance, the average out-of-pocket costs were 14304.4 CNY in ZJG and 5639.2 CNY in TX. Based on the multivariable linear regression analysis, factors related to the total out-of-pocket costs were study site, age, number of clinical visits, residence, diagnosis delay, hospitalization, intake of liver protective drugs and use of the second-line drugs. Conclusion Under the current “free of diagnosis and treatment” policy, the financial burden remains heavy on tuberculosis patients. Policy makers need to consider appropriate steps to lessen the burden of out-of-pocket costs for tuberculosis patients in China and how best to improve service delivery for poor patients.
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Affiliation(s)
- Sangsang Qiu
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hongqiu Pan
- Department of Tuberculosis, Third Hospital of Zhenjiang City, Zhenjiang, China
| | - Simin Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Xianzhen Peng
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Xianzhi Zheng
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Guisheng Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Min Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Jianming Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
- Department of Social Medicine and Health Education, School of Public Health, Nanjing Medical University, Nanjing, China
- The Innovation Center for Social Risk Governance in Health, Nanjing, China
- * E-mail: (JW); (HL)
| | - Hui Lu
- Department of Social Medicine and Health Education, School of Public Health, Nanjing Medical University, Nanjing, China
- * E-mail: (JW); (HL)
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