Perceived challenges to achieving universal health coverage: a cross-sectional survey of social health insurance managers/administrators in China

Incidence of Inflammatory Bowel Disease in Urban China: A Nationwide Population-based Study

BACKGROUND & AIMS

Limited studies have evaluated the burden of inflammatory bowel disease (IBD) in China. We aimed to estimate the incidence of IBD including ulcerative colitis (UC) and Crohn's disease (CD) in urban China.

METHODS

The national urban incidence in 2016 was calculated based on urban basic medical insurance from 2012 to 2016 in China by using a 4-year washout period. The incidence in Yinzhou District estimated from the Yinzhou electronic health care record database was used to test the accuracy of the results from insurance data.

RESULTS

A total of 95,555 patients with IBD were identified. The incidence in 2016 was 10.04 (95% confidence interval, 6.95-13.71) per 100,000 person-years. The incidence rates of both UC and CD were higher among males than among females. There was a sharp increase in UC incidence before the age of 30 years and stabilization in later years (50-79 years old), whereas CD incidence peaked at 30 to 34 years old and experienced decline subsequently. The incidence of UC was much greater than that of CD, with a UC-to-CD incidence ratio of 12.61. The results from the Yinzhou database confirmed these results.

CONCLUSIONS

This study is the first to draw a portrait of the distribution of IBD in urban China. The difference in IBD incidence between urban China and other countries suggests an association between the IBD burden and industrialization process. The accelerating urbanization and industrialization process in China, a country with a population of 1.4 billion people, will likely increase the burden of IBD.

Incidence and cost of vertebral fracture in urban China: a 5-year population-based cohort study

BACKGROUND

Osteoporotic vertebral fractures cause pain and disability, which result in a heavy socioeconomic burden. However, the incidence and cost of vertebral fractures in China are unknown. We aimed to assess the incidence and cost of clinically recognized vertebral fractures among people aged 50 years and older in China from 2013 to 2017.

MATERIALS AND METHODS

This population-based cohort study was conducted by using Urban Employee Basic Medical Insurance (UEBMI) and Urban Resident Basic Medical Insurance (URBMI) data in China from 2013 to 2017, which covered more than 95% of the Chinese population in urban areas. Vertebral fractures were identified by the primary diagnosis (i.e. International Classification of Diseases code or text of diagnosis) in UEBMI and URBMI. The incidence and medical cost of these clinically recognized vertebral fractures in urban China were calculated.

RESULTS

A total of 271 981 vertebral fractures (186 428, 68.5% females and 85 553, 31.5% males) were identified, with a mean age of 70.26 years. The incidence of vertebral fractures among patients aged 50 years and over in China increased ~1.79-fold during the 5 years, from 85.21 per 100 000 person-years in 2013 to 152.13 per 100 000 person-years in 2017. Medical costs for vertebral fractures increased from US$92.74 million in 2013 to US$505.3 million in 2017. Annual costs per vertebral fracture case increased from US$3.54 thousand in 2013 to US$5.35 thousand in 2017.

CONCLUSION

The dramatic increase in the incidence and cost of clinically recognized vertebral fractures among patients aged 50 and over in urban China implies that more attention should be given to the management of osteoporosis to prevent osteoporotic fractures.

Factors and key problems influencing insured's poor perceptions of convenience of basic medical insurance: a mixed methods research of a northern city in China

BACKGROUND

This study aimed to explore the factors that affect insured's perceptions of convenience of the basic medical insurance (PCBMI) in Harbin, China and to diagnose the key problems to further propose corresponding measures. The findings provide evidence-based support for the reform of convenience of the basic medical insurance system (BMIS) and the cultivation of public literacy.

METHODS

We adopted a mixed methods design composing a multivariate regression model using the data from a cross-sectional questionnaire survey (n = 1045) of residents who were enrolled for BMIS in Harbin to identify the factors influencing the PCBMI. A quota sampling method was further adopted. Semi-structured interviews were then conducted with 30 important information providers selected by convenience sampling. Interpretative phenomenological analysis was employed to summarize and analyze the key problems.

RESULTS

Overall, approximately 51% of respondents reported poor PCBMI. The logistic regression model showed that insured without outpatient experience within two weeks (OR = 2.522, 95% CI = 1.267-5.024), had poorer levels of understanding of basic medical insurance information (OR = 2.336, 95% CI = 1.612-3.386), lived in rural areas (OR = 1.819, 95% CI = 1.036-3.195), had low levels of annual out-of-pocket medical expenses (OR = 1.488, 95% CI = 1.129-1.961), and were more likely to give the PCBMI a worse evaluation than their counterparts. The results of the qualitative analysis showed that the key problem areas of the PCBMI were the design of the BMIS, the cognitive biases of the insured, publicity information about the BMIS, and the health system environment.

CONCLUSIONS

This study found that in addition to the design of BMIS, the cognition of the insured, the BMIS information publicity and the health system environment are also the key problems hindering PCBMI. While optimizing system design and implementation, Chinese policymakers need to focus on the insured with low PCBMI characteristics. Moreover, it is necessary to focus on exploring effective BMIS information publicity methods, supporting public policy literacy and improving the health system environment.

Perceptions of the benefits of the basic medical insurance system among the insured: a mixed methods research of a northern city in China

Background

The perceptions of the benefits of the basic medical insurance system among the insured not only reflect the system's performance but also the public's basic medical insurance policy literacy, valuable information for countries that have entered the stage of deepening reform. This study aims to examine the factors that affect the perceptions of the benefits of the basic medical insurance system in China, diagnose the key problems, and propose corresponding measures for improvement.

Methods

A mixed method design was used. Data for the quantitative study were obtained from a cross-sectional questionnaire survey (n = 1,045) of residents of Harbin who had enrolled for basic medical insurance system. A quota sampling method was further adopted. A multivariate logistic regression model was then employed to identify the factors influencing the perceptions of the benefits of the basic medical insurance system, followed by semi-structured interviews with 30 conveniently selected key informants. Interpretative phenomenological analysis was used to analyze the interview data.

Results

Approximately 44% of insured persons reported low perceptions of benefits. The logistic regression model showed that low perceptions of the benefits of the basic medical insurance system was positively correlated with the experience of daily drug purchases (OR = 1.967), perceptions of recognition with basic medical insurance system (OR = 1.948), perceptions of the financial burden of participation costs (OR = 1.887), perceptions of the convenience of using basic medical insurance for medical treatment (OR = 1.770), perceptions of the financial burden of daily drug purchases costs (OR = 1.721), perceptions of the financial burden of hospitalization costs (OR = 1.570), and type of basic medical insurance system (OR = 1.456). The results of the qualitative analysis showed that the key problem areas of perceptions of the benefits of the basic medical insurance system were: (I) system design of basic medical insurance; (II) intuitive cognition of the insured; (III) rational cognition of the insured; and (IV) the system environment.

Conclusions

Improving the perceptions of the benefits of the basic medical insurance system of the insured requires joint efforts in improving system design and implementation, exploring effective publicity methods of basic medical insurance system information, supporting public policy literacy, and promoting the health system environment.

Universal health coverage evolution, ongoing trend, and future challenge: A conceptual and historical policy review

The goal of universal health coverage (UHC) from the United Nations (UN) has metamorphized from its early phase of primary health care (PHC) to the recent sustainable development goal (SDG). In this context, we aimed to document theoretical and philosophical efforts, historical analysis, financial and political aspects in various eras, and an assessment of coverage during those eras in relation to UHC in a global scenario. Searching with broad keywords circumadjacent to UHC with scope and inter-disciplinary linkages in conceptual analysis, we further narrated the review with the historical development of UHC in different time periods. We proposed, chronologically, these frames as eras of PHC, the millennium development goal (MDG), and the ongoing sustainable development goal (SDG). Literature showed that modern healthcare access and coverage were in extension stages during the PHC era flagshipped with "health for all (HFA)", prolifically achieving vaccination, communicable disease control, and the use of modern contraceptive methods. Following the PHC era, the MDG era markedly reduced maternal, neonatal, and child mortalities mainly in developing countries. Importantly, UHC has shifted its philosophic stand of HFA to a strategic health insurance and its extension. After 2015, the concept of SDG has evolved. The strategy was further reframed as service and financial assurance. Strategies for further resource allocation, integration of health service with social health protection, human resources for health, strategic community participation, and the challenges of financial securities in some global public health concerns like the public health emergency and travelers' and migrants' health are further discussed. Some policy departures such as global partnership, research collaboration, and experience sharing are broadly discussed for recommendation.

The Contributions of Population Distribution, Healthcare Resourcing, and Transportation Infrastructure to Spatial Accessibility of Health Care

Population demand, healthcare resourcing, and transportation linkage are considered as major determinants of spatial access to health care. Temporal changes of the 3 determinants would result in gain or loss of spatial access to health care. As a remarkable milestone achieved by Targeted Poverty Reduction Project launched in China, the significant improvements in spatial access to health care served as an ideal context for investigating the relative contributions of these 3 determinants to the changes in spatial access to health care in a rural county. A national level poverty-stricken county, Chishui county from Guizhou province, China, was chosen as our study area. The enhanced two-step floating catchment area model and the chain substitution method were employed for analysis. The relative contributions of the 3 determinants demonstrated variations with villages. The relative contributions of healthcare resourcing were positive in all villages as indicated by sharp increases in healthcare resources. Population changes and transportation infrastructure expansion had both negative and positive effects on spatial access to health care for different villages. Decisionmakers should take into account the duration of travel time spent between where people live, where transport hubs are located, and where healthcare services are delivered in the process of formulating policies toward rural healthcare planning. For villages with poorly-established infrastructure, the optimization of population distribution and healthcare resourcing should be considered as the priority. A stronger marginal effect would be induced by transportation infrastructure expansion with increased spatial accessibility. This study provides empirical evidences to inform healthcare planning in low- and middle-income countries.

Successes and obstacles in implementing social health insurance in developing and middle-income countries: A scoping review of 5-year recent literatures

Social health insurance (SHI) is a form of health finance mechanism that had been implemented in many countries to achieve universal health care (UHC). To emulate the successes of SHI in many developed countries, many developing and middle-income countries (MICs) have attempted to follow suit. However, the SHI implementation has problems and obstacles. Many more obstacles were observed despite some successes. This scoping review aimed to study the various developments of SHI globally in its uses, implementation, successes, and obstacles within the last 5 years from 2017 to 2021. Using three databases (i.e., PubMed, EBSCO, and Google Scholar), we reviewed all forms of articles on SHI, including gray literature. The PRISMA-ScR protocol was adapted as the guideline. We used the following search terms: social health insurance, national health insurance, and community health insurance. A total of 57,686 articles were screened, and subsequently, 46 articles were included in the final review. Results showed that the majority of SHI studies were in China and African countries, both of which were actively pursuing SHI programs to achieve UHC. China was still regarded as a developing country. There were also recent experiences from other Asian countries, but only a few from South America. Implementing SHI to achieve UHC was desirable but will need to consider several factors and issues. This was especially the case in developing and MICs. Eventually, full UHC would only be possible with a combination of general taxation and SHI.

Universality of universal health coverage: A scoping review

BACKGROUND

The progress of Universal health coverage (UHC) is measured using tracer indicators of key interventions, which have been implemented in healthcare system. UHC is about population, comprehensive health services and financial coverage for equitable quality services and health outcome. There is dearth of evidence about the extent of the universality of UHC in terms of types of health services, its integrated definition (dimensions) and tracer indicators utilized in the measurement of UHC. Therefore, we mapped the existing literature to assess universality of UHC and summarize the challenges towards UHC.

METHODS

The checklist Preferred Reporting Items for Systematic reviews and Meta-analysis extension for Scoping Reviews was used. A systematic search was carried out in the Web of Science and PubMed databases. Hand searches were also conducted to find articles from Google Scholar, the World Bank Library, the World Health Organization Library, the United Nations Digital Library Collections, and Google. Article search date was between 20 October 2021 and 12 November 2021 and the most recent update was done on 03 March 2022. Articles on UHC coverage, financial risk protection, quality of care, and inequity were included. The Population, Concept, and Context framework was used to determine the eligibility of research questions. A stepwise approach was used to identify and select relevant studies, conduct data charting, collation and summarization, as well as report results. Simple descriptive statistics and narrative synthesis were used to present the findings.

RESULTS

Forty-seven papers were included in the final review. One-fourth of the articles (25.5%) were from the African region and 29.8% were from lower-middle-income countries. More than half of the articles (54.1%) followed a quantitative research approach. Of included articles, coverage was assessed by 53.2% of articles; financial risk protection by 27.7%, inequity by 25.5% and quality by 6.4% of the articles as the main research objectives or mentioned in result section. Most (42.5%) of articles investigated health promotion and 2.1% palliation and rehabilitation services. Policy and healthcare level and cross-cutting barriers of UHC were identified. Financing, leadership/governance, inequity, weak regulation and supervision mechanism, and poverty were most repeated policy level barriers. Poor quality health services and inadequate health workforce were the common barriers from health sector challenges. Lack of common understanding on UHC was frequently mentioned as a cross-cutting barrier.

CONCLUSIONS

The review showed that majority of the articles were from the African region. Methodologically, quantitative research design was more frequently used to investigate UHC. Palliation and rehabilitation health care services need attention in the monitoring and evaluation of UHC progress. It is also noteworthy to focus on quality and inequity of health services. The study implies that urgent action on the identified policy, health system and cross-cutting barriers is required to achieve UHC.

Experiences and Challenges of Implementing Universal Health Coverage With China's National Basic Public Health Service Program: Literature Review, Regression Analysis, and Insider Interviews

BACKGROUND

Public health service is an important component and pathway to achieve universal health coverage (UHC), a major direction goal of many countries. China's National Basic Public Health Service Program (the Program) is highly consistent with this direction.

OBJECTIVE

The aim of this study was to analyze the key experience and challenges of the Program so as to present China's approach to UHC, help other countries understand and learn from China's experience, and promote UHC across the world.

METHODS

A literature review was performed across five main electronic databases and other sources. Some data were obtained from the Department of Primary Health, National Health Commission, China. Data obtained included the financing share of the national/provincial/prefectural government among the total investment of the program in 32 provinces in 2016, their respective per capita funding levels, and some indicators related to program implementation from 2009 to 2016. The Joinpoint regression model was adopted to test the time trend of changes in program implementation indicators. Face-to-face individual interviews and group discussions were conducted with 48 key insiders.

RESULTS

The program provided full life cycle service to the whole population with an equitable and affordable financing system, enhanced the capability and quality of the health workforce, and facilitated integration of the public health service delivery system. Meanwhile, there were also some shortcomings, including lack of selection and an exit mechanism of service items, inadequate system integration, shortage of qualified professionals, limited role played by actors outside the health sector, and a large gap between the subsidy standard and the actual service cost. The Joinpoint regression analysis demonstrated that 13 indicators related to program implementation showed a significant upward trend (P<.05) from 2009 to 2016, with average annual percent change values above 10% for 6 indicators and below 6% for 7 indicators. Three indicators (coverage of health records, electronic health records, and health management among the elderly) rose rapidly with annual percent change values above 30% between 2009 and 2011, but rose slowly or remained stable between 2011 and 2016. In 2016, the subsidy standard per capita in the eastern, central, and western regions was equivalent to US $7.43, $7.15, and $6.57, respectively, of which the national-level subsidy accounted for 25.50%, 60.57%, and 79.52%, respectively.

CONCLUSIONS

The Program has made a significant contribution to China's efforts in achieving UHC. The Program focuses on a key population and provides full life cycle services for the whole population. The financing system completely supported by the government makes the services more equitable and affordable. However, there are a few challenges to implementing the Program in China, especially to increase the public investment, optimize service items, enhance quality of the services, and evaluate the health outcomes.

Healthy Community-Life Circle Planning Combining Objective Measurement and Subjective Evaluation: Theoretical and Empirical Research

BACKGROUND

The world faces vast health challenges, and urban residents living in high-density areas have even greater demand for healthy lifestyles.

METHODS

Based on the data of points of interest, a field survey, and an interview, we explored the healthy community-life circle in the downtown area of Chengdu, China from two perspectives: objective measurement and subjective perception of residents. We evaluated the coverage rate and convenience in accessing eight types of health service facilities within a 15-min walk using linear and logistics regression models to explore the degree of resident satisfaction with facilities and influencing factors.

RESULTS

Results showed significant differences in coverage rates between different districts. The overall convenience in accessing health service facilities decreased gradually from the city center to the outskirts. The social environment, the layout of health service facilities, and residents' travel habits were related to health service facility satisfaction. Results also showed significant differences in various facilities' accessibility satisfaction between objective measurement and residents' perception measurement. Compared with subjective measurement, the objective measurements of accessibility for sports venues (objectively measured average minus perceived average: -1.310), sports zones (-0.740), and specialized hospitals (-1.081) were lower; those for community hospitals (0.095), clinics (1.025), and pharmacies (0.765) were higher; and facility accessibility measured by subjective perception had a more significant impact on health facility satisfaction. Pharmacies (OR: 1.932) and community hospitals (OR: 1.751) had the largest impact among the eight types of facilities.

CONCLUSION

This study proposed to construct a healthy community-life circle with a category and hierarchy system.

The impact of medical cyber–physical systems on healthcare service delivery

Purpose

The pandemic has reinforced the need for revamping the healthcare service delivery systems around the world to meet the increased challenges of modern-day illnesses. The use of medical cyber–physical system (MCPS) in the healthcare is one of the means of transforming the landscape of the traditional healthcare service delivery system. The purpose of this study is to critically examine the impact of MCPS on the quality of healthcare service delivery.

Design/methodology/approach

This paper uses an evidence-based approach, the authors have conducted a systematic literature review to study the impact of MCPS on healthcare service delivery. Fifty-four articles were thematically examined to study the impact of MCPS on eight characteristics of the healthcare service delivery proposed by the world health organisation.

Findings

The study proposes support that MCPS will positively impact (1) comprehensiveness, (2) accessibility, (3) coverage, (4) continuity, (5) quality, (6) person-centredness, (7) coordination, (8) accountability and (9) efficiency dimension of the healthcare service delivery. The study further draws nine propositions to support the impact of MCPS on the healthcare service delivery.

Practical implications

This study can be used by stakeholders as a guide point while using MCPS in healthcare service delivery systems. Besides, healthcare managers can use this study to understand the performance of their healthcare system. This study can further be used for designing effective strategies for deploying MCPS to be effective and efficient in each of the dimensions of healthcare service delivery.

Originality/value

The previous studies have focussed on technology aspects of MCPS and none of them critically analysed the impact on healthcare service delivery. This is the first literature review carried out to understand the impact of MCPS on the nine dimensions of healthcare service delivery proposed by WHO. This study provides improved thematic awareness of the resulting body of knowledge, allowing the field of MCPS and healthcare service delivery to progress in a more informed and multidisciplinary manner.

Challenges to Achieving Universal Health Coverage Tthroughout the World: A Systematic Review

Objectives

No systematic review has explored the challenges related to worldwide universal health coverage (UHC). This study reviewed challenges on the road to UHC.

Methods

A systematic electronic search of all studies that identified the challenges of worldwide UHC was conducted, without any restrictions related to the publication date or language. A hand search and a bibliographic search were also conducted to identify which texts to include in this study. These sources and citations yielded a total of 2500 articles, only 26 of which met the inclusion criteria. Relevant data from these papers were extracted, summarized, grouped, and reported in tables.

Results

Of the 26 included studies, 7 (27%) were reviews, 6 (23%) were reports, and 13 (50%) had another type of study design. The publication dates of the included studies ranged from 2011 to 2020. Nine studies (35%) were published in 2019. Using the World Health Organization conceptual model, data on all of the challenges related to UHC in terms of the 4 functions of health systems (stewardship, creating resource, financing, and delivering services) were extracted from the included studies and reported.

Conclusions

This study provides a straightforward summary of previous studies that explored the challenges related to UHC and conducted an in-depth analysis of viable solutions.

Health-related quality of life of patients with haemophilia: a cross-sectional survey in the Northeast of China

INTRODUCTION

Haemophilia is a hereditary, chronic and haemorrhagic disorder caused by a deficiency in coagulation factors. Long-term spontaneous bleeding of joints and soft tissues can seriously affect the quality of life of patients.

OBJECTIVE

The study aimed to assess the health-related quality of life (HRQoL) of patients with haemophilia and associated factors.

METHODS

A snowball sampling strategy was adopted to select study participants. Eligible participants were those who were 18 years or older and had mild, moderate or severe haemophilia. They were asked to self-complete a questionnaire, collecting data regarding their sociodemographic characteristics, target joint status and HRQoL measured by the EQ-5D-5L(a tool developed by the European quality of life (EuroQol) Group).

RESULTS

The respondents reported a mean EQ-5D_utility(country-specific valuesets for the EQ-5D-5L) score of 0.51 (SD=0.34). Those with severe haemophilia had a lower utility score than those with mild/moderate haemophilia (0.46±0.37 vs 0.56±0.30, p=0.737). The linear regression analyses showed that older age (>25 years), two or more target joints, not working, low levels of knowledge of the disease and borrowing money to pay for medical treatments were associated with lower EQ-5D_utility scores.

CONCLUSION

Low HRQoL of patients with haemophilia is evident in China. Social support needs to be strengthened to address this issue.

Evaluating the accessibility to healthcare facilities under the Chinese hierarchical diagnosis and treatment system

An accurate assessment of current healthcare resource allocations is essential to address existing inequities in the hierarchical diagnosis and treatment system introduced in China. The data come from statistical reports of local governments and the developer platform of Amap, a Chinese mobile map. The data were analysed using the hierarchical two-step floating catchment area method. By spatial accessibility analysis, the distribution of accessibility to hierarchical healthcare facilities in Zhongshan City, Guangdong Province was found to be uneven, with clustered high accessibility in the central, north-western and southern parts of the city. To enhance the capacity of healthcare services, the government should allocate healthcare resources rationally to better associate with population densities.

Challenges faced by community health nurses to achieve universal health coverage in Myanmar: A mixed methods study

Objective

This study aimed to identify the challenges of community health nurses (CHNs) in delivering effective community health care to achieve universal health coverage (UHC) in Myanmar.

Methods

A total of 30 CHNs from township health centers in the northeastern, southern, and western parts of Myanmar were purposefully recruited for quantitative and qualitative interviews. Quantitative data were processed using Microsoft Excel software, and qualitative data were analyzed using thematic analysis. This study is registered with researchregistry6201.

Results

Around the country, 30 CHNs uncovered their hardships in implementing primary health care to achieve UHC. Over 90% of the participants agreed to the problem of inadequate health infrastructure, while half of them felt unmotivated when they encountered role conflicts among various cadres of healthcare providers and poor opportunities for career promotion. Major problems arose from the lack of standard professional education at the entry point to community settings because most CHNs did not achieve specialized training in providing public health services. Complications are incapable of evaluating health services for policy-making and the inability to conduct health research to develop evidence-based practices. Insecure work and living conditions, unsupportive community relationships, and undereducation in professional practices were supportive major themes explored by CHNs to achieve a deeper understanding of the barriers to UHC. Not only the health system itself but also the population and other geographical factors have contributed to many challenges to CHNs.

Conclusion

Myanmar's CHNs face many challenges in achieving UHC. These challenges are not confined to the health sector. Some situations, such as geographical barriers and transportation problems, remain persistent challenges for healthcare providers. This study highlights the fact that current health systems should be strengthened by qualified healthcare providers and sufficient infrastructure. Meanwhile, public empowerment plays a critical role in promoting health development.

Benefit of China's Social Health Insurance Schemes: Trend Analysis and Associated Factors Since Health Reform

With the deepening of health insurance reform in China, the integration of social health insurance schemes was put on the agenda. This paper aims to illustrate the achievements and the gaps in integration by demonstrating the trends in benefits available from the three social health insurance schemes, as well as the influencing factors. Data were drawn from the three waves of the China Health and Nutrition Survey (2009, 2011, 2015) undertaken since health reforms commenced. χ2, Kruskal-Wallis test, and the Two-Part model were employed in the analysis. The overall reimbursement rate of the Urban Employee Basic Medical Insurance (UEBMI) is higher than that of Urban Resident Basic Medical Insurance (URBMI) or the New Rural Cooperative Medical Scheme (NRCMS) (p < 0.001), but the gap has narrowed since health reform began in 2009. Both the outpatient and inpatient reimbursement amounts have increased through the URBMI and NRCMS. Illness severity, higher institutional level, and inpatient service were associated with significant increases in the amount of reimbursement received across the three survey waves. The health reform improved benefits covered by the URBMI and NRCMS, but gaps with the UEBMI still exist. The government should consider more the release of health benefits and how to lead toward healthcare equity.

Health-tech startups in healthcare service delivery: A scoping review

BACKGROUND

An efficient and affordable healthcare service delivery to everyone is a prerogative of the national governments. Such delivery is quite exacting, and gaps remain. In this regard, startups are trying to disrupt the market with innovative solutions and reach the underserved market. Though anecdotal evidence remains, a rigorous literature review is missing. This paper attempts to understand the status of health-tech startups in healthcare service delivery.

METHODS

We scanned a total of 110 journals - Financial Times top 50, top ten information systems journals listed by the Australian Business Dean Council, and the top 50 Scopus indexed journals in health informatics and health information management. We followed a systematic process for this scoping review - reading of titles, abstracts, and then full papers for final analysis based on inclusion and exclusion criteria.

RESULTS

A total of 76 articles met the inclusion criteria. Only five studies portrayed the status of health-tech startups in healthcare service delivery. To capture the overall startup ecosystem, we continued with a scoping review of all the 76 articles.

DISCUSSIONS

The identified five themes are Technology adoption, Electronic health services, Business planning and framework, Psychographics, and Regulations. There is evidence of technology adoption in service delivery and its nature in the businesses undertaken by startups. Very few studies represented the patterns of the existing business model. The acceptance of the services is dependent on service effectiveness and affordability. The challenges are licensing, policies, data privacy and security, and inadequate technology access among healthcare seekers.

CONCLUSIONS

Albeit the feasibility potential, research concerning the impact of health tech startups in healthcare service delivery is emerging but incipient. The review indicates that research on startups is inadequate, especially related to entrepreneurship, business frameworks, and regulations. Future research should explore the same.

Urban prevalence of multiple sclerosis in China: A population-based study in six provinces

BACKGROUND AND PURPOSE

Multiple sclerosis (MS) is a rare neurological disease addressed by only few epidemiological studies in China. This population-based study aimed to estimate the prevalence of MS in China by using national medical insurance databases.

METHODS

Data from the Urban Employee Basic Medical Insurance database and the Urban Residence Basic Medical Insurance database, which were collected during 2012 to 2016 and included approximately 0.20 billion residents in six provinces, were used in this population-based study. The prevalent patients with MS were identified via diagnostic text or disease codes.

RESULTS

The crude prevalence in 2016 was 2.44 per 100,000 population (95% confidence interval (CI) 2.18-2.72), with the prevalence in females being higher than that in males. The standardized prevalence (based on 2010 Chinese census data) was 2.29 (95% CI 2.21-2.38). The prevalence in both sexes in 2016 increased up to the age range of 30-34 years. Subsequently, the female prevalence declined with increasing age, but male prevalence stabilized with increasing age. During the 5-year time period, prevalence ranged from 2.32 (95% CI 2.06-2.60) in 2015 to 2.91 (95% CI 2.39-3.47) in 2012.

CONCLUSIONS

The prevalence of MS in China was lower than that in Europe and North America. The temporal trend of prevalence in China was also observed to be stable. As the first prevalence study of MS in mainland China, this population-based study can provide useful information for worldwide healthcare services and prevention of MS.

Prevalence of mammary Paget's disease in urban China in 2016

No national data have been available on descriptive epidemiology of mammary Paget's disease (MPD) in China. This population-based study aimed to estimate the prevalence of MPD and its pattens by sex, age and area in China. We conducted a population-based study using data in 2016 from China's Urban Employee Basic Medical Insurance and Urban Resident Basic Medical Insurance, covering approximately 0.43 billion residents. MPD cases were identified based on the diagnostic names and codes in claim data. A total of 825 patients of confirmed diagnosis of MPD were found during the study period. The prevalence of MPD in 2016 was 0.42 per 100,000 population (95% CI 0.19 to 0.73), with marked female predominance. The prevalence rates peaked at 40-59 years and ≥ 80 years in females and males, respectively. The prevalence rates varied among different regions, ranging from 0.06 (95% CI 0.00 to 0.23) in Northeast China to 1.21 (95% CI 0.07 to 3.72) in Northwest China. MPD showed marked female predominance in China. Chinese female patients were much younger, with lower prevalence than that in the United States. Obvious sex difference in the age pattern of MPD prevalence was also observed in China.

Incidence of gastrointestinal stromal tumor in Chinese urban population: A national population-based study

BACKGROUND

Information on incidence of gastrointestinal stromal tumor (GIST), the most common type of mesenchymal tumor in gastrointestinal tract, was limited in China. This study aimed to estimate the incidence of GIST in urban population from mainland China in 2016.

METHODS

Urban Employee Basic Medical Insurance (UEBMI) and Urban Residence Basic Medical Insurance (URBMI) in China were used. The denominator of incidence was the total person-years of insured individuals in 2016 in the database, covering approximately 0.43 billion individuals. The numerator was the number of incident GIST cases in 2016.

RESULTS

The crude incidence in 2016 was 0.40 per 100,000 person-years (95% CI, 0.06-1.03). Male incidence was higher than female incidence (0.44 vs. 0.36, rate ratio: 1.22, p < 0.001). The mean age at diagnosis was 55.20 years (SD = 14.26) and the incidence among those aged 50 years or older was 2.63 times (0.84 vs. 0.32, p < 0.001) higher than those aged under 50. The highest incidence was observed in East China (2.29, 95% CI: 0.46-5.54).

CONCLUSIONS

The incidence of GIST in mainland China was lower than Europe, North America and Korea. The mean age at diagnosis of GIST in China was younger than that of Europe and Canada. This study provides useful information to further research, policy formulating and management of GIST.

Analyzing the Financial Sustainability of User Fee Removal Policies: A Rapid First Assessment Methodology with a Practical Application for Burkina Faso

The purpose of this paper is to briefly present a methodological framework that does not require cumbersome investigations for a first assessment of the financial sustainability of policies aiming to remove or reduce healthcare user fees (the so-called free healthcare policy [FHCP]). This paper is organized in two main sections. The first analyzes the various possibilities available to finance an FHCP. Using several scenarios, it includes a special focus devoted to the calculus of what to consider when assessing the sustainability of expanding fiscal space for financing the FHCP. The second section relies on the current FHCP being implemented in Burkina Faso to illustrate a selection of specific issues raised in the methodological framework. The results suggest that sustainable FHCP financing is not outside the range of the government but does represent a significant challenge, as it will require, both currently and in the future, complex and delicate budget trade-offs at the highest governmental levels, regardless of other policy options to be considered.

Managers in the publicly funded health services in China - characteristics and responsibilities

BACKGROUND

Health service managers are integral to supporting the effective and efficient delivery of services. Understanding their competencies is essential to support reform and improvement of healthcare provision in China. This paper examines the characteristics and educational background of senior managers working in the community health and hospital sectors in China. We also examine their levels of commitment to continued professional development and continuous education.

METHODS

A self-administered paper-based questionnaire was administered to 477 level I, II and III managers in community health services and public hospitals in China. The response rate was over 80%.

RESULTS

Findings demonstrate significant differences in terms of educational background and commitment to ongoing professional development between the managers in China across levels of management, and between the community and hospital sectors. Hospital managers tend to be older; hospital managers at higher management levels are predominantly male but predominantly female in the community health services. A greater proportion of hospital managers have postgraduate qualifications. In addition, the participants identified specific management tasks that they considered important.

CONCLUSIONS

This is the first large scale study examining the educational background and commitment to professional development of senior health service managers in China. This study determined that there are differences between the demographics of managers in China across levels of management, but more importantly between the CHC and the hospital sectors. The identification of important managerial tasks will facilitate the development of appropriate education and training for Chinese healthcare managers. All sectors and levels reported the need for informal education focussed on the core roles of developing organisation image and public relations, improving quality and safety of service provision and provision of leadership. Further research to explore the underlying reasons for the above differences is needed to design appropriate professional development for China's health services managers. In addition, the importance of managerial tasks across sectors and management levels requires further investigation.

Financial Affordability, Health Insurance, and Use of Health Care Services by the Elderly: Findings From the China Health and Retirement Longitudinal Study

The rapidly growing aging population has attracted global attention. This study explores the associations between 3 basic health insurances, and it identifies factors associated with health care services among the elderly populations. This study is based on multistage stratified cluster sampling method from the 2013 China Health and Retirement Longitudinal Study (CHARLS) resulting in 7589 participants. Medical Insurance for Urban Employees (MIUE) members were more likely to use inpatient health care services. Health insurance programs were associated with inpatient services usage but not outpatient services usage. There are significant disparities in medical costs and health care service usage among the 3 insurance programs. Health insurance program is only associated with inpatient care. These findings may provide some suggestions to support improvements to the Chinese health care system.

Prevalence and Incidence of Multiple Myeloma in Urban Area in China: A National Population-Based Analysis

Multiple myeloma (MM) is the second most frequent malignancy of blood, and information on disease burden of MM is limited in developing countries. We aimed to estimate the prevalence and incidence of MM in China. We used data from the national urban employee and urban resident basic medical insurance from 2012 to 2016 in China. MM cases were based on the primary diagnosis (International Classification of Diseases (ICD) code, ICD for oncology, or text of diagnosis) of patients. The crude prevalence and incidence were 6.88 per 100,000 population (95% CI, 5.75–8.00) and 1.60 per 100,000 person-years (1.28–1.92), respectively. The standardized prevalence and incidence were 5.68 (5.64–5.72) and 1.15 (1.11–1.19), respectively. Overall, the rates were higher in males compared with females for prevalence (7.89 vs. 5.79, P < 0.05) and incidence (1.84 vs. 1.30, P < 0.05). Both rates increased with age, and the mean age (SD) of MM patients was 57.9 (14.4) years. Prevalence peaked between 55 and 74 years old for both genders. The incidence in women aged 55–59 had a significantly high incidence of 5.53 (4.98–6.11). The prevalence and incidence were significantly lower than those in North America, Australia, and Western Europe but were in the same range as those in Japan or Korea. MM should be one of the cancers in the spotlight from both medical and socioeconomic perspectives in low-resource but populous countries because of the incidence of more elderly MM patients in the next decade. Further research is warranted to examine the potential pathophysiologic mechanism.

Spatiotemporal Analysis of Influenza in China, 2005-2018

Influenza is a major cause of morbidity and mortality worldwide, as well as in China. Knowledge of the spatial and temporal characteristics of influenza is important in evaluating and developing disease control programs. This study aims to describe an accurate spatiotemporal pattern of influenza at the prefecture level and explore the risk factors associated with influenza incidence risk in mainland China from 2005 to 2018. The incidence data of influenza were obtained from the Chinese Notifiable Infectious Disease Reporting System (CNIDRS). The Besag York Mollié (BYM) model was extended to include temporal and space-time interaction terms. The parameters for this extended Bayesian spatiotemporal model were estimated through integrated nested Laplace approximations (INLA) using the package R-INLA in R. A total of 702,226 influenza cases were reported in mainland China in CNIDRS from 2005–2018. The yearly reported incidence rate of influenza increased 15.6 times over the study period, from 3.51 in 2005 to 55.09 in 2008 per 100,000 populations. The temporal term in the spatiotemporal model showed that much of the increase occurred during the last 3 years of the study period. The risk factor analysis showed that the decreased number of influenza vaccines for sale, the new update of the influenza surveillance protocol, the increase in the rate of influenza A (H1N1)pdm09 among all processed specimens from influenza-like illness (ILI) patients, and the increase in the latitude and longitude of geographic location were associated with an increase in the influenza incidence risk. After the adjusting for fixed covariate effects and time random effects, the map of the spatial structured term shows that high-risk areas clustered in the central part of China and the lowest-risk areas in the east and west. Large space-time variations in influenza have been found since 2009. In conclusion, an increasing trend of influenza was observed from 2005 to 2018. The insufficient flu vaccine supplements, the newly emerging influenza A (H1N1)pdm09 and expansion of influenza surveillance efforts might be the major causes of the dramatic changes in outbreak and spatio-temporal epidemic patterns. Clusters of prefectures with high relative risks of influenza were identified in the central part of China. Future research with more risk factors at both national and local levels is necessary to explain the changing spatiotemporal patterns of influenza in China.

Antihypertensive drugs use over a 5-year period among children and adolescents in Beijing, China: An observational study

Evidence on the prescription patterns of antihypertensive drug use in children and adolescents in China is scarce. A descriptive analysis of the Beijing Medical Claim Data, which covered over 95% of the urban residents, was conducted to investigate antihypertensive prescribing patterns and trends in children and adolescents aged under 18 from 2009 to 2014 in Beijing, China. An additional meta-analysis of trends in hypertension prevalence was conducted to compare trends with antihypertensive medications.A total of 11,882 patients received at least 1 prescription for antihypertensive drugs from 2009 to 2014. The number of annual antihypertensive users increased from 2009 to 2012, then declined steadily until 2014, which was consistent with the trend of the hypertension prevalence estimated from the meta-analysis. β-receptor blockers, thiazide diuretics, and angiotensin-converting enzyme inhibitors were the 3 most commonly prescribed antihypertensive drugs. More boys took the antihypertensive drugs than girls. For users aged under 3 years, thiazide diuretics, α-receptor blockers, and angiotensin-converting enzyme inhibitors were the most prescribed drugs, while β-receptor blockers, thiazide diuretics were the most used drugs for users above 3 years.In conclusion, antihypertensive drug prescribing for children and adolescents increased from 2009 to 2014, with different characteristics in different subgroups.

Environmental Health Indicators for China: Data Resources for Chinese Environmental Public Health Tracking

Many developed countries use environmental public health tracking to gain a better understanding of the link between environmental hazards and public health. To respond to complicated environmental health issues, the National Institute of Environmental Health (NIEH), Chinese Center for Disease Control and Prevention (China CDC), has begun to build a Chinese Environmental Public Health Tracking (CEPHT) system. On behalf of the CEPHT, authors provide insight into the CEPHT's development, current status, and future plans. In the initial stage of CEPHT, an indicator framework linking environment and public health that included a list of publicly available data sources regarding environmental hazards, public health outcomes, and risk factors in China was developed. An analysis of data availability, along with a comparison between CEPHT's indicator system and other tracking networks, revealed the existence of barriers and gaps in data integration that affect China's ability to track environmental public health. The lack of access to data, combined with inadequate data quality, has led to difficulties linking environmental hazards to their effects on public health. Current CEPHT efforts will help integrate environmental factors and exposure data with public health outcomes. For the near future, CEPHT plans to focus on increasing collaboration among data tracking agencies, improving data quality, and expanding proper data sharing. https://doi.org/10.1289/EHP4319.

Justice and public participation in universal health coverage: when is tiered coverage unfair and who should decide?

Universal health coverage is often implemented within countries through several national insurance schemes that collectively cover their populations. Yet the extent of services and benefits available can vary substantially between different schemes. This paper argues that these variations in coverage comprise tiering and then reviews different accounts of health and social justice that consider whether and when a tiered health system is fair. Using these accounts, it shows that the fairness of tiering can be determined by assessing whether differences in coverage mean enrolees under some national insurance schemes do not achieve sufficient health or normal functioning and/or feel inferior relative to those belonging to other national insurance schemes. The paper further contends that these determinations of fairness should involve the people covered by different insurance schemes. Key universal health coverage questions to involve the public in answering are: Do the sum of differences between the schemes in your country generate feelings of unequal moral worth and/or mean enrolees struggle to achieve sufficient health or normal functioning? Which specific differences between health insurance schemes generate the greatest feelings of unequal moral worth in individuals? Which specific differences generate the greatest barriers to individuals achieving sufficient health or normal functioning? Rather than identifying which services to extend coverage to first, answering these questions will identify which disparities in services and benefits are the most morally urgent to address. Finally, some initial thoughts are offered on who from the public should be involved in making these decisions and how they might be involved as a matter of justice.

Spatial Accessibility to Healthcare Services in Metropolitan Suburbs: The Case of Qingpu, Shanghai

Spatial accessibility is an important factor for planning healthcare services to maintain a quality life for the metropolitan area. The metropolitan suburb is a special area for its location and rapidly changing population during urbanization. Taking Qingpu district, a suburb of Shanghai as a case, this study evaluated the spatial accessibility to healthcare services of 203 villages and neighborhoods based on the Two-Step Floating Catchment Area (2SFCA) method by ArcGIS software. The result shows that the spatial accessibility in the whole district is quite uneven under lower thresholds, and the spatial differences are beyond the traditional zoning of East Qingpu, New City and West Qingpu. The worst accessibility was mainly distributed at the edges of Jinze, Liantang and Zhujiajiao, while the best accessibility was mainly distributed in the New City and the region close around it. The average value of the spatial accessibility in Qingpu is 2.84, with a reach equal under 90 min threshold by bus index of 2.85, or an under 60 min threshold by self-driving index of 2.70. Secondly, the difference shows a new pattern, that is the spatial accessibility could be affected by both the New City and the Central City. Thirdly, the transportation mode, urbanization, the density of road network and bus lines, as well as the number of doctors in each healthcare service would directly affect the spatial accessibility. Lastly, in order to improve the spatial accessibility in metropolitan suburbs, greater effort is needed in increasing the numbers of bus stations and doctors, especially the areas which are farthest from the New City or the Central City, such as Jinze, and Lian Tang town in Qingpu. We acknowledge that the public transportation is vital to the accessibility to healthcare services. We also emphasize that healthcare services should be planned based on the anticipated future trends of population agglomeration. Our results for Shanghai are applicable to other big cities that are experiencing similar rapid urbanization in China, or other developing countries in Southeast Asia, South Asia, South America and Africa.

Sino-Australian University Partnership in Health Management Education

This paper outlines a successful partnership program between La Trobe University in Melbourne Australia, and Harbin Medical University in Harbin, China. These two universities have been collaborating for more than 15 years to provide a comprehensive Master of Health Administration program that adapts the Australian curriculum to meet the rapidly increasing need for qualified health services managers throughout China. This paper describes the mechanisms by which the joint programs were developed and how the two universities work together in partnership to continually improve the program components and outcomes, taking into account the significant differences in context and cultures. Since 2001, La Trobe University has enrolled about 1000 Chinese health services managers, with 721 completing a Master's degree, who are now having increasing influence on the reforms of the Chinese health care system. The partnership has enriched Australian knowledge of Chinese culture and values, as well as the Chinese health system and health policies, as evidenced by the large volume of joint publications. The profession of health management has been substantially strengthened in China, and working together, Chinese and Australian academics have had demonstrated impact on enhancing the reforms of the Chinese public health system. Further studies, with sufficient funds for data collection, are needed to evaluate the long-term impacts of transnational programs on academic and health system development in China.

Big data and medical research in China

Luxia Zhang and colleagues discuss the development of big data in Chinese healthcare and the opportunities for its use in medical research