Public perceptions of private health care in socialist China

Comparative Analysis of the Healthcare Delivery System in China and Nigeria: A Review

OBJECTIVES

Equitable distribution of quality healthcare services among different subpopulations in China and Nigeria is inconsistent. This necessitates an examination of potential avenues for improving healthcare provision in both countries. A comparative analysis of both health systems was carried out to provide insights into the progress each nation has made, the obstacles they face, and areas both countries can learn from each other.

METHODS

We assessed 3 key dimensions of these systems using the Hsiao analytical framework. First, we scrutinized the policy levers of the health systems. Next, we evaluated intermediate outcomes, such as access to healthcare and the quality of care. Lastly, we assessed the extent to which the health systems achieve their ultimate goals, including improving citizen health status and enhancing overall patient satisfaction with the healthcare services.

RESULTS

China surpasses Nigeria in terms of better birth outcomes, life expectancy, and management of communicable diseases. Both countries offer minimal protection against out-of-pocket spending on medical bills, which consequently exacerbates the poverty rate.

CONCLUSIONS

China surpasses Nigeria in every health metrics. However, Nigeria's healthcare system offers services to a larger proportion of its populace because of the involvement of the private sector in healthcare delivery. Both countries continue to experience significant challenges, such as limited access to healthcare services in rural areas and overall patient dissatisfaction with the quality of care provided.

Comparison of Health Care Utilization in Different Usual Sources of Care Among Older People With Cardiovascular Disease in China: Evidence From the Study on Global Ageing and Adult Health

Objectives: To compare the health care utilization in different usual sources of care (USCs) among the elderly population with cardiovascular disease in China. Methods: Cross-sectional data for 3,340 participants aged ≥50 years with cardiovascular disease from Global AGEing and Adult Health (2010)-China were used. Using the inverse probability of treatment weighting on the propensity score with survey weighting, combined with negative binomial regression and logistic regression models, the correlation between USCs and health care utilization was assessed. Results: Patients using primary care facilities as their USC had fewer hospital admissions (IRR = 0.507, 95% CI = 0.413, 0.623) but more unmet health needs (OR = 1.657, 95% CI = 1.108, 2.478) than those using public hospitals. Patients using public clinics as their USC had higher outpatient visits (IRR = 2.188, 95% CI = 1.630, 2.939) than the private clinics' group. Conclusion: The difference in inpatient care utilization and unmet health care needs between public hospitals and primary care facilities, and the difference in outpatient care utilization between public and private clinics were significant. Using primary care facilities as USCs, particularly public ones, appeared to increase care accessibility, but it still should be strengthened to better address patients' health care needs.

Functions, advantages and challenges facing private healthcare organisations in China's healthcare system: a qualitative analysis through open-ended questionnaires

OBJECTIVES

The medical reform in 2009 stimulated the growth of private healthcare organisations in China, but there is still room for their further development in the healthcare market. The objectives of the study were to provide more information about the healthcare market in China and to explore the challenges private healthcare organisations faced.

DESIGN

Qualitative descriptive study using a web-based open-ended questionnaire and thematic content analysis. Data were collected between 12 February and 20 February 2020.

SETTING

This study was conducted in China.

PARTICIPANTS

124 respondents from private healthcare organisations across 20 provinces in China.

RESULTS

Our content analysis identified three themes: (1) functioning and positioning of the healthcare institutions: current private healthcare organisations generally serve as a supplement to public hospitals and focus more on specialised medical and high-end services; (2) institutions' advantages: private healthcare organisations can flexibly respond to market demands, formulate effective strategies, introduce advanced management concepts and methods, provide personalised and diversified services, and introduce new technologies which can stimulate market vitality and promote healthy competition; and (3) institutions' challenges: private healthcare organisations face difficulties in professional development and talent cultivation, branding and establishing a reputation, and the policies for institution establishment, tax and medical insurance pose drawbacks to their development.

CONCLUSION

This study illustrates that private healthcare organisations need more government support for further development, such as providing a fairer insurance strategy and taxation policy, affording ground for a more equitable scientific research environment and promotion opportunities, and evaluating reputation score for healthcare institutions.

Determinants of choice of usual source of care among older people with cardiovascular diseases in China: evidence from the Study on Global Ageing and Adult Health

BACKGROUND

Cardiovascular diseases (CVD) are emerging as the leading contributor to death globally. The usual source of care (USC) has been proven to generate significant benefits for the elderly with CVD. Understanding the choice of USC would generate important knowledge to guide the ongoing primary care-based integrated health system building in China. This study aimed to analyze the individual-level determinants of USC choices among the Chinese elderly with CVD and to generate two exemplary patient profiles: one who is most likely to choose a public hospital as the USC, the other one who is most likely to choose a public primary care facility as the USC.

METHODS

This study was a secondary analysis using data from the World Health Organization's Study on Global AGEing and Adult Health (SAGE) Wave 1 in China. 3,309 individuals aged 50 years old and over living with CVD were included in our final analysis. Multivariable logistic regression was built to analyze the determinants of USC choice. Nomogram was used to predict the probability of patients' choice of USC.

RESULTS

Most of the elderly suffering from CVD had a preference for public hospitals as their USC compared with primary care facilities. The elderly with CVD aged 50 years old, being illiterate, residing in rural areas, within the poorest income quintile, having functional deficiencies in instrumental activities of daily living and suffering one chronic condition were found to be more likely to choose primary care facilities as their USC with the probability of 0.85. Among those choosing primary care facilities as their USC, older CVD patients with the following characteristics had the highest probability of choosing public primary care facilities as their USC, with the probability of 0.77: aged 95 years old, being married, residing in urban areas, being in the richest income quintile, being insured, having a high school or above level of education, and being able to manage activities living.

CONCLUSIONS

Whilst public primary care facilities are the optimal USC for the elderly with CVD in China, most of them preferred to receive health care in public hospitals. This study suggests that the choice of USC for the elderly living with CVD was determined by different individual characteristics. It provides evidence regarding the choice of USC among older Chinese patients living with CVD.

Tackling the global impact of substandard and falsified and unregistered/unlicensed anti-tuberculosis medicines

Substandard and falsified (SF) medicines are a global health challenge with the World Health Organization (WHO) estimating that 1 in 10 of medicines in low- and middle-income countries (LMICs) are SF. Antimicrobials (i.e. antimalarials, antibiotics) are the most commonly reported SF medicines. SF medicines contribute significantly to the global burden of infectious diseases and antimicrobial resistance (AMR). This article discusses the challenges associated with the global impact of SF and unregistered/unlicensed antimicrobials with a focus on anti-TB medicines. Tuberculosis (TB) is the 13th leading cause of death worldwide, and is currently the second leading cause of death from a single infectious agent, ranking after COVID-19 and above HIV/AIDS. Specifically in the case of TB, poor quality of anti-TB medicines is among the drivers of the emergence of drug-resistant TB pathogens. In this article, we highlight and discuss challenges including the emergence of SF associated AMR, patient mistrust and lack of relevant data. We also present study reports to inform meaningful change. Recommended solutions involve the adaptation of interventions from high-income countries (HICs) to LMICS, the need for improvement in the uptake of medication authentication tools in LMICs, increased stewardship, and the need for global and regional multidisciplinary legal and policy cooperation, resulting in improved legal sanctions.

Primary care physicians' views on the factors for enhancing patients' trust in rural areas of Zhejiang province, China: a cross-sectional study

OBJECTIVES

To examine primary care physicians' (PCPs) perception of patients' trust and associated factors for enhancing perceived trust in rural China.

DESIGN

A cross-sectional questionnaire study.

SETTING

All township health centres (primary care facilities in rural areas of China) in both developed and less developed counties of Zhejiang province, China, were chosen as the study sites.

PARTICIPANTS

A total of 849 questionnaires were distributed from December 2019 to January 2020, and 673 PCPs working in township health centres completed the questionnaires. The response rate was 79.3%.

OUTCOME MEASURES

PCPs' perceived patients' trust in them, PCPs' practices to meet patients' expectations and PCPs' perceived conflicting patient and employer interests were measured by a self-designed and verified questionnaire. Confirmatory factor analysis was applied to verify the measurement model of PCPs' practices. Multivariable logistic regression analyses were performed to explore the association between clinical practice characteristics, discordant patient and employer interests and perceived patient trust after controlling for social-demographic characteristics.

RESULTS

Among all participants, 572 (85.0%) PCPs often/always perceived patients' trust in their clinical competence, and over two-thirds of PCPs reported ever perceived patient worries about overprescriptions. After adjustment for social-demographic characteristics, regression model results indicated that, among PCPs' clinical practices characteristics, emotional support (OR=1.23, 95% CI=1.06 to 1.42) and accurate diagnosis and treatment (OR=1.35, 95% CI=1.17 to 1.55) were positively associated with PCPs' perceived patients' trust in their clinical competence. A strong association was found between accurate diagnosis and treatment (OR=1.20, 95% CI=1.08 to 1.34, p<0.001; OR=1.22, 95% CI=1.10 to 1.35, p<0.001), conflicting patient and employer interests (OR=1.35, 95% CI=1.12 to 1.63, p<0.01; OR=1.29, 95% CI=1.07 to 1.54, p<0.01) and PCPs' perceived patient worries about unnecessary medicine or tests, respectively.

CONCLUSIONS

PCPs' emotional support to patients as well as their abilities to make accurate diagnosis and provide appropriate treatment is positively associated with PCPs' self-reported patients' trust. It is recommended that reforms to realign patient and employer's interests be investigated.

The Association of Market Mix of Hospital Ownership With Medical Disputes: Evidence From China

The prevalence and severity of medical disputes in China have attracted the attention of society and academia, and how to alleviate medical disputes has become a major concern. Following the implementation of a series of policies, the private sector in China’s hospital market has expanded rapidly over the past decade. It remains unknown whether the market mix of hospital ownership could alleviate medical disputes, this study aims to bridge the gap. Data are collected from all hospitals (2171) in Sichuan province, China, from 2012 to 2015. Using a negative binomial hurdle model, the results show that for hospitals with disputes, the private hospital market share has an inverted U-shaped relationship with the number of disputes. However, no significant relationship is found between the private hospital market share and the probability of dispute occurrence. For hospitals with disputes, competition plays a protective role in the effect of the private hospital market share on the number of disputes, hindering the increase in the number of disputes and facilitating a more rapid drop. However, medical quality is found to play an insignificant role in that effect. The findings also support encouraging new private hospitals in China rather than privatizing existing public hospitals.

Perceived social support and presenteeism among healthcare workers in China: the mediating role of organizational commitment

Objectives

We assessed the role of social support in presenteeism by examining organizational commitment among Chinese healthcare workers.

Methods

One thousand four hundred thirty-four healthcare workers from 6 hospitals in 4 Chinese cities completed a questionnaire measuring presenteeism, social support, and organizational commitment. With organizational commitment as the mediator, regression analyses and structural equation modeling were used to test the model.

Results

Organizational commitment was directly inversely associated with presenteeism (β = − 0.42, p < 0.001). Coworker support was moderately but significantly inversely associated with presenteeism (β = − 0.15, p < 0.001), but the path from supervisor support to presenteeism was not significant (β = 0.05, p > 0.05). The correlation between supervisor support and coworker support was significant (β = 0.71, p <0.001). Supervisor support and coworker support were significantly positively associated with organizational commitment (β = 0.41, p < 0.001, and β = 0.14, p < 0.001, respectively).

Conclusions

Supervisor support was more important in promoting organizational commitment, while coworker support was more effective in reducing presenteeism. The mediating effect of organizational commitment was significant.

Influence of family income and medical insurance coverage on health-related quality of life and optimism in cancer patients at a Hong Kong private hospital: A cross-sectional study

OBJECTIVE

Health-related quality of life (HRQL) and optimism are important health domains that express the physical, emotional, and psychological well-being of cancer patients. Previous studies have explored income and medical insurance coverage as predictors of their well-being with the aim to better understand their financial needs. The primary objective of this study was to examine the associations in the private health sector in Hong Kong.

METHODS

The study was conducted cross-sectionally with a structured questionnaire in traditional Chinese. HRQL was assessed with the RAND 12-item Health Survey, and optimism was assessed with the Life Orientation Test. The two primary predictors were family income and medical insurance coverage. The associations were tested using logistic regression, controlling for other sociodemographic and clinical covariates.

RESULTS

A total of 428 questionnaires were used in the regression model. After adjusting for other covariates, no significant association was observed with family income as the predictor. Medical insurance coverage was a significant and positive predictor of optimism with odds ratio of 2.30 and 95% confidence interval of 1.30 to 4.05 for the group with the most coverage with little to no coverage as the reference group.

CONCLUSIONS

The significant association between medical insurance coverage and optimism might be an indication that the medical cost was a financial burden to many cancer patients in Hong Kong. In addition to their medical needs, cancer support organization and health care practitioners must be able to recognize and assist with the financial needs of the cancer patients.

Current needs for the improved management of depressive disorder in community healthcare centres, Shenzhen, China: a view from primary care medical leaders

Background

The prevalence of depressive disorder in Shenzhen is higher than for any other city in China. Despite national health system reform to integrate mental health into primary care, the majority of depression cases continue to go unrecognized and untreated. Qualitative research was conducted with primary care medical leaders to describe the current clinical practice of depressive disorder in community healthcare centres (CHC) in Shenzhen and to explore the participants' perceptions of psychological, organizational and societal barriers and enablers to current practice with a view to identifying current needs for the improved care of depressive disorder in the community.

Methods

Seventeen semi-structured, audio-recorded interviews (approx. 1 h long) were conducted in Melbourne (n = 7) and Shenzhen (n = 10) with a convenience sample of primary care medical leaders who currently work in community healthcare centres (CHC) in Shenzhen and completed any one of the 3-month long, Melbourne-based, "Monash-Shenzhen Primary Healthcare Leaders Programs" conducted between 2015 and 2017. The interview guide was developed using the Theoretical Domain's Framework (TDF) and a directed content analysis (using Nvivo 11 software) was performed using English translations.

Results

Despite primary care medical leaders being aware of a mental health treatment gap and the benefits of early depression care for community wellbeing, depressive disorder was not perceived as a treatment priority in CHCs. Instead, hospital specialists were identified as holding primary responsibility for formal diagnosis and treatment initiation with primary care doctors providing early assessment and basic health education. Current needs for improved depression care included: (i) Improved professional development for primary care doctors with better access to diagnostic guidelines and tools, case-sharing and improved connection with mentors to overcome current low levels of treatment confidence. (ii) An improved consulting environment (e.g. allocated mental health resource; longer and private consultations; developed medical referral system; better access to antidepressants) which embraces mental health initiatives (e.g. development of mental health departments in local hospitals; future use of e-mental health; reimbursement for patients; doctors' incentives). (iii) Improved health literacy to overcome substantive mental health stigma in society and specific stigma directed towards the only public psychiatric hospital.

Conclusions

Whilst a multi-faceted approach is needed to improve depression care in community health centres in Shenzhen, this study highlights how appropriate mental health training is central to developing a robust work-force which can act as key agents in national healthcare reform. The cultural adaption of the depression component of the World Health Organisation's mental health gap intervention guide (mhGAP-IG.v2) could provide primary care doctors with a future training tool to develop their assessment skills and treatment confidence.

Examining the influence of health insurance literacy and perception on the people preference to purchase private voluntary health insurance

Most studies have associated “un-affordability” as a plausible cause for the lower take-up of private voluntary health insurance plans. However, others refuted this claim on the pretext that when people can afford “inpatient-care” from pocket then insurance premium cost is far less than those payments. Thus, economic factors remain insufficient in clearly explaining the reason for poor private voluntary health insurance take-up. An attempt is being made by shifting the focus towards non-economic factors and understanding the role of perception and health insurance literacy in transforming people preferences to invest in private voluntary health insurance plans. The study findings will conspicuously support decision-makers in developing strategy to increase the private voluntary health insurance take-up.

Comparison of patient perceived primary care quality in public clinics, public hospitals and private clinics in rural China

Background

In rural China, patients have free choice of health facilities for outpatient services. Comparison studies exploring the attributes of different health facilities can help identify optimal primary care service models. Using a representative sample of Chinese provinces, this study aimed to compare patients’ rating of three primary care service models used by rural residents (public clinics, public hospitals and private clinics) on a range of health care attributes related to responsiveness.

Methods

This was a secondary analysis using the household survey data from World Health Organization (WHO) Study on global AGEing and adult health (SAGE). Using a multistage cluster sampling strategy, eight provinces were selected and finally 3435 overall respondents reporting they had visited public clinics, public hospitals or private clinics during the last year, were included in our analysis. Five items were used to measure patient perceived quality in five domains including prompt attention, communication and autonomy, dignity and confidentiality. ANOVA and Turkey’s post hoc tests were used to conduct comparative analysis of five domains. Separate multivariate linear regression models were estimated to examine the association of primary care service models with each domain after controlling for patient characteristics.

Results

The distribution of last health facilities visited was: 29.5% public clinics; 31.2% public hospitals and; 39.3% private clinics. Public clinics perform best in all five domains: prompt attention (4.15), dignity (4.17), communication (4.07), autonomy (4.05) and confidentiality (4.02). Public hospitals perform better than private clinics in dignity (4.03 vs 3.94), communication (3.97 vs 3.82), autonomy (3.92 vs 3.74) and confidentiality (3.94 vs 3.73), but equivalently in prompt attention (3.92 vs 3.93). Rural residents who are older, wealthier, and with higher self-rated health status have significantly higher patient perceived quality of care in all domains.

Conclusions

Rural public clinics, which share many characteristics with the optimal primary care delivery model, should be strongly strengthened to respond to patients’ needs. Better doctor-patient interaction training would improve respect, confidentiality, autonomy and, most importantly, health care quality for rural patients.

Health Care Payments in Vietnam: Patients' Quagmire of Caring for Health versus Economic Destitution

In the last three decades many developing and middle-income nations' health care systems have been financed via out-of-pocket payments by individuals. User fees charges, however, may not be the best approach or thenmost equitable approach to finance and/or reform health services in developing nations. This study investigates the status of Vietnam's current health system as a result of implementing user fees policies. A recent mandate by the government to increase the universal cover to 100% attempts to tackle inadequate insurance cover, one of the four major factors contributing to the high and increasing probability of destitution for Vietnamese patients (the other three being: non-residency, long stay in hospital, and high cost of treatment). Empirical results however suggest that this may be catastrophic for low-income earners: if insurance cover reimbursement decreases below 50% of actual health expenditures, the probability of Vietnamese falling into destitution will rise further. Our findings provide policy implications and directions to improve Vietnam's health care system, in particular by ensuring the utilization of health services and financial protection for the people.

Qualitative analysis of direction of public hospital reforms in China

Reforms in public hospitals are among the most important improvements in China's health care system over the last two decades. However, the reforms that should be implemented in public hospitals are unclear. Thus, a feasible direction of reforms in Chinese public hospitals is suggested and reliable policy suggestions are provided for the government to reform public hospitals. The data used in this study were mainly derived from a qualitative study. Focus group discussions and in-depth interviews were conducted in Shanghai, Guangdong, and Gansu between May and December 2014. Government funding accounted for approximately eight percent of the total annual revenue of public hospitals in China, and the insufficient government subsidy considerably affects the operation mechanism of public hospitals. However, solely increasing this subsidy cannot address the inappropriate incentives of public hospitals in China. The most crucial step in setting the direction of reforms in public hospitals in China is transforming inappropriate incentives by implementing a new evaluation index system for directors and physicians in public hospitals.

Variation in access to pediatric surgical care among coexisting public and private providers: inguinal hernia as a model

BACKGROUND

Faced with growing healthcare demand, the Saudi government is increasingly relying on privatization as a tool to improve patient access to care. Variation in children's access to surgical care between public (PB) and private providers (PV) has not been previously analyzed.

OBJECTIVES

To compare access to pediatric surgical services between two coexisting PB and PV.

DESIGN

Retrospective comparative study.

SETTINGS

A major teaching hospital and the largest PV group in Saudi Arabia.

PATIENTS AND METHODS

The outcomes for children who underwent inguinal herniotomy (IH) between May 2010 and December 2014 at both providers were with IH serving as the model. Data collected included patient demographics, insurance coverage, referral pattern and access parameters including time-to-surgery (TTS), surgery wait time (SWT) and duration of symptoms (DOS).

MAIN OUTCOME MEASURE(S)

TTS, SWT and DOS.

RESULTS

Of 574 IH cases, 56 cases of in-hospital referrals were excluded leaving 290 PB and 228 PV cases. PV patients were younger (12.0 vs 16.4 months, P=.043) and more likely to be male (81.6% vs 72.8%, P=.019), expatriates (18% vs 3.4%, P < .001) and insured (47.4% vs 0%, P < .001). The emergency department was more frequently the source for PB referrals (35.2% vs 12.7%, P < .001) while most PV patients were self-referred (72.8% vs 16.7%, P < .001). Access parameters were remarkably better at PV: TTS (21 vs 66 days, P < .001), SWT (4 vs 31 days, P < .001) and DOS (33 vs 114 days, P < .001).

CONCLUSION

When coexisting, PV offers significantly better access to pediatric surgical services compared to PB. Diverting public funds to expand children's access to PV can be a valid choice to improve access to care in case when outcomes with the two providers are similar.

LIMITATIONS

Although it is the first and largest comparison in the pediatric population, the sample may not represent the whole population since it is confined to a single selected surgical condition.

The choice and preference for public-private health care among urban residents in China: evidence from a discrete choice experiment

Background

Public health care dominated the services provision in China before 1980s. However, the number of private health care providers in China has been increasing since then. The growth of private hospitals escalated after a market-oriented reform was implemented in 2001. Through an experimental approach, this study aims to a better understanding of the dynamic change in preference of health care utilisation among the residents in urban China.

Methods

Based on a discrete choice experiment (DCE) from a random sample of respondents in urban China, the study evaluated preference over health care attributes affecting individuals’ choice for the utilisation of hospital health care. The marginal willingness-to-pay for five health care attributes was estimated, including public/private provision of health care, by analysing mixed logit and latent class models.

Results

The results indicated a significantly negative marginal willingness-to-pay for private health care, which was interpreted as representing people’s previous interactions with the health care system. The latent class model further suggested preference heterogeneity across our sample. We found that Hukou type, a typical indicator of socioeconomic background, was significantly related to respondents’ preference for health care utilisation. Permanent urban residents (urban Hukou) valued private health care less; in contrast rural migrants (rural Hukou) were more likely to be indifferent between public/private provision.

Conclusion

Urban residents in China showed a high disposition to obtain health care from the public providers of health care. Our results have implications in the context of the Chinese government attempts to expand the private health care sector in the short term. Policy makers need to consider residents’ preference for health care in health policy development as the preference can only change in the long term.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1829-0) contains supplementary material, which is available to authorized users.

Optimizing Partner Notification Programs for Men Who Have Sex with Men: Factorial Survey Results from South China

Background

Syphilis is prevalent among men who have sex with men (MSM) in China. Syphilis partner notification (PN) programs targeting MSM has been considered as one of effective strategies to prevention and control of the infection in the population. We examined willingness and preferences for PN among MSM to measure feasibility and optimize uptake.

Methods

Participation in a syphilis PN program was measured using a factorial survey from both the perspective of the index patient and the partner. Respondents were recruited from April-July 2011 using convenience sampling at two sites—a MSM sexually transmitted disease (STD) clinic and a MSM community based organization (CBO). Respondents first evaluated three factorial survey vignettes to measure probability of participation and then an anonymous sociodemographic questionnaire. A two-level mixed linear model was fitted for the factorial survey analysis.

Results

In 372 respondents with mean age (± SD) 28.5 (± 6.0) years, most were single (82.0%) and closeted gays (66.7%). The Internet was the most frequent place to search for sex. Few (31.2%) had legal names for casual partners, but most had instant messenger (86.5%) and mobile phone numbers (77.7%). The mean probability of participation in a syphilis PN program was 64.5% (± 32.4%) for index patients and 63.7% (± 32.6%) for partners. Referral of the partner to a private clinic or MSM CBO for follow-up decreased participation compared to the local Center for Disease Control and Prevention (CDC) or public STD clinic.

Conclusions

Enhanced PN services may be feasible among MSM in South China. Internet and mobile phone PN may contact partners untraceable by traditional PN. Referral of partners to the local CDC or public STD clinic may maximize PN participation.

Cost-effectiveness analysis of hepatocellular carcinoma screening by combinations of ultrasound and alpha-fetoprotein among Alaska Native people, 1983-2012

BACKGROUND

The American Association for the Study of Liver Diseases (AASLD) recommends semi-annual hepatocellular carcinoma (HCC) screening using ultrasound (US) in persons with chronic hepatitis B (CHB) virus infection at high risk for HCC such as Asian males aged ≥40 years and Asian females aged ≥50 years.

OBJECTIVE

To analyse the cost-effectiveness of 2 HCC screening methods in the Alaska Native (AN) health system: US-alone, or screening by alpha-fetoprotein (AFP) initially and switching to US for subsequent screenings if AFP >10 ng/mL (AFP→US).

DESIGN

A spreadsheet-based model was developed for accounting the costs of 2 hypothetical HCC screening methods. We used epidemiologic data from a cohort of 839 AN persons with CHB who were offered HCC screening by AFP/US semi-annually during 1983-2012. We assumed that compared with AFP→US, US-alone identifies 33% more tumours at an early stage (defined as a single tumour ≤5 cm or ≤3 tumours ≤3 cm in diameter). Years of life gained (YLG) attributed to screening was estimated by comparing additional years of survival among persons with early- compared with late-stage tumours. Screening costs were calculated using Medicare reimbursement rates in 2012. Future screening costs and YLG were projected over a 30-year time horizon using a 3% discount rate.

RESULTS

The total cost of screening for the cohort by AFP→US would have been approximately $357,000 ($36,000/early-stage tumour detected) compared to $814,000 ($59,000/early-stage tumour detected) by US-alone. The AFP→US method would have yielded an additional 27.8 YLG ($13,000/YLG) compared with 38.9 YLG ($21,000/YLG) for US-alone. Screening by US-alone would incur an additional $114,000 per extra early-tumour detected compared with AFP→US and $41,000 per extra YLG.

CONCLUSIONS

Although US-alone HCC screening might have yielded more YLG than AFP→US, the reduced costs of the AFP→US method could expand access to HCC screening in resource constrained settings.

Health insurance and quality of care: Comparing perceptions of quality between insured and uninsured patients in Ghana's hospitals

BACKGROUND

The introduction of health insurance in Ghana in 2003 has resulted in a tremendous increase in utilization of health services. However, concerns are being raised about the quality of patient care. Some of the concerns include long waiting times, verbal abuse of patients by health care providers, inadequate physical examination by doctors and discrimination of insured patients. The study compares perceptions of quality of care between insured and uninsured out-patients in selected hospitals in Ghana to determine whether there is any unequal treatment between insured and uninsured patients in terms of quality of care, as empirical and anecdotal evidence seem to suggest.

METHODS

A cross-sectional survey of 818 out-patients was conducted in 17 general hospitals from three regions of Ghana. These are the Upper East, Brong Ahafo and Central Regions. Convenience sampling was employed to select the patients in exit interviews. Descriptive statistics, including frequency distributions, means and standard deviations, were used to describe socio-economic and demographic characteristics of respondents. Factor analysis was used to determine distinct quality of care constructs; t-test statistic was used to test for differences in quality perceptions between the insured and uninsured patients; and regression analysis was used to test the association between health insurance and quality of care.

RESULTS

Overall, there was no significant difference in perceptions of quality between insured and uninsured patients. However, there was a significant difference between insured and uninsured patients in respect of financial access to care. The major quality of care concern affecting all patients was the problem of inadequate resources, especially lack of doctors, lack of drugs and other basic supplies and equipment to work with.

CONCLUSIONS

It was concluded that generally, insured and uninsured patients are not treated unequally, contrary to prevailing anecdotal and empirical evidence. On the contrary, quality of care is a concern of both insured and uninsured patients.

A Comparison of Quality of Community Health Services Between Public and Private Community Health Centers in Urban China

BACKGROUND

This study was the first of its kind to evaluate and compare the quality of private and public community health centers (CHCs) in urban China.

METHODS

A total of 2501 CHCs in 35 cities were chosen in 2011 using a multistage sampling method, and data on human resources, medical equipment and drug inventory were collected. A subset of 422 CHCs was randomly selected and 100 prescriptions from each CHCs were reviewed to evaluate prescribing practice. In total, 12,386 patients who visited the selected 422 CHCs were interviewed to assess patient satisfaction and payments.

RESULTS

Controlling for population covered per CHC and geographic regions, private CHCs were higher than public CHCs in average building area (2310.96 vs. 2000.92 square meters), average number of medical equipment (6.42 vs. 6.14), average number of physicians and nurses per 10,000 population (4.86 vs. 3.81 and 3.38 vs. 2.62), and average number of medicines in stock (435.08 vs. 375.83), but lower in average percentage of medicines on the national essential medicines list (67.29% vs. 77.55%). Prescriptions from private CHCs had significantly higher number of drugs per prescription (2.38 vs. 2.24), higher percentage of prescriptions with injections (36.44% vs. 30.50%), and higher percentage of prescriptions with antibiotics (37.17% vs. 30.14%). Patient satisfaction was similar between the 2 groups, and patient payments per visit were lower in private CHCs after controlling for patients' sociodemographic characteristics.

CONCLUSIONS

Private CHCs are better equipped and better staffed than public CHCs but are less compliant with national policy on essential medicines and have poorer prescribing quality in China, warranting more rigorous government supervision.

Implications of dual practice for universal health coverage

Making progress towards universal health coverage (UHC) requires that health workers are adequate in numbers, prepared for their jobs and motivated to perform. In establishing the best ways to develop the health workforce, relatively little attention has been paid to the trends and implications of dual practice - concurrent employment in public and private sectors. We review recent research on dual practice for its potential to guide staffing policies in relation to UHC. Many studies describe the characteristics and correlates of dual practice and speculate about impacts, but there is very little evidence that is directly relevant to policy-makers. No studies have evaluated the impact of policies on the characteristics of dual practice or implications for UHC. We address this lack and call for case studies of policy interventions on dual practice in different contexts. Such research requires investment in better data collection and greater determination on the part of researchers, research funding bodies and national research councils to overcome the difficulties of researching sensitive topics of health systems functions.

Patient dissatisfaction in China: What matters

Patient satisfaction is a focal concern of health-care delivery and an expected outcome of medical care. Recently, the violent conflict between doctors and patients in China has intensified. Patient dissatisfaction has been recognized as an important concern and an urgent issue in the reform of China's health care. The objectives of this study are to investigate the determinants of patient dissatisfaction attributed to patient, hospital, and health-care market characteristics, as well as to explore the major determinants in the context of China. Data from 2007 to 2010 Urban Resident Basic Medical Insurance Survey (URBMIS) are used in this study. A total of 13,336 patients are selected conditional on health-care utilization. Analysis of satisfaction is based on outpatient utilization (last 2 weeks' reference, 6393 individuals) and inpatient utilization (last 1-year reference, 6943 individuals). Satisfaction was measured as ordinal variables (scales 1-5). Ordinary least squares (OLS) regression and an ordered probit model are applied to investigate the determinants. Blinder-Oaxaca decomposition is further employed to detect the proportion each predictor's contribution. The results indicate that patients' gender, education, and insurance status are significantly related to patient satisfaction. Higher-level hospitals are found to negatively correlate with patient satisfaction. Lower competition in providers' market and a higher market share of private hospitals are found to positively correlate with patient dissatisfaction. Meanwhile, the survey indicates that "medical charges too expensive" is chiefly responsible for patient dissatisfaction. Our study provides empirical evidence on the determinants of patient dissatisfaction in China. In particular, the results indicate that establishing a high competition among various providers in the health-care market will act as a "double-edged sword," with great policy implications.

National Health Systems

Health care systems ideally include universal access to comprehensive prepaid medical care along with health promotion and disease prevention. National health insurance and national health services of various models have evolved in the developed world and increasingly in developing countries as well. Some models, such as the Bismarckian social security model and the Bereidge National Health Service model, or National Health insurance such as in pioneered in Canada, are used by a number of countries. The common features are based on principles of national responsibility and solidarity for health, social solidarity for providing funding and searching for effective ways of providing care. Various universal systems of health coverage exist in all industrialized countries, except in the United States which has a mix of public and private insurance but with high percentages of uninsured and poorly insured. Health reform is a continuing process as all countries aspire to assure health care for all. Aging populations, increasing costs, advancing and increasing technology all require nations to modify and adapt organization and financing systems of health care, health protection and promotion.

A comparison between antenatal care quality in public and private sector in rural Hebei, China

Aim

To evaluate the quality of antenatal care (ANC) in Hebei Province and compare it between the public and private sector and within the public sector.

Methods

We conducted a Maternal, Newborn and Child Health Household Survey in 2010 using a two-stage sampling procedure and included 1079 mothers. The quality of ANC was assessed on the basis of the number of ANC visits, the time of the first ANC visit, 16 different ANC procedures, owning a maternal health care booklet, and the type of service provider.

Results

Almost all women (98%) received ANC services at least once, 80% at least four times, and 54% at least five times. About half of the women (46%) visited ANC facility within their first trimester. Neither public nor private sector provided all 16 standardized services, but significantly more women in public sector received ANC procedures. Most women received ANC in county or higher-level hospitals (75%) and very few in township hospitals (8%). Significantly fewer women were weighed and tested for HIV/AIDS in township than in county or higher-level hospitals.

Conclusion

The quality of ANC in Hebei was poorer than required by China’s national and World Health Organization norms. Although the public sector performed better than the private sector, the utilization and quality of care of ANC services in this sector varied and women generally visited county or higher-level health facilities.

Helping the decision maker effectively promote various experts' views into various optimal solutions to China's institutional problem of health care provider selection through the organization of a pilot health care provider research system

BACKGROUND

The main aim of China's Health Care System Reform was to help the decision maker find the optimal solution to China's institutional problem of health care provider selection. A pilot health care provider research system was recently organized in China's health care system, and it could efficiently collect the data for determining the optimal solution to China's institutional problem of health care provider selection from various experts, then the purpose of this study was to apply the optimal implementation methodology to help the decision maker effectively promote various experts' views into various optimal solutions to this problem under the support of this pilot system.

METHODS

After the general framework of China's institutional problem of health care provider selection was established, this study collaborated with the National Bureau of Statistics of China to commission a large-scale 2009 to 2010 national expert survey (n = 3,914) through the organization of a pilot health care provider research system for the first time in China, and the analytic network process (ANP) implementation methodology was adopted to analyze the dataset from this survey.

RESULTS

The market-oriented health care provider approach was the optimal solution to China's institutional problem of health care provider selection from the doctors' point of view; the traditional government's regulation-oriented health care provider approach was the optimal solution to China's institutional problem of health care provider selection from the pharmacists' point of view, the hospital administrators' point of view, and the point of view of health officials in health administration departments; the public private partnership (PPP) approach was the optimal solution to China's institutional problem of health care provider selection from the nurses' point of view, the point of view of officials in medical insurance agencies, and the health care researchers' point of view.

CONCLUSIONS

The data collected through a pilot health care provider research system in the 2009 to 2010 national expert survey could help the decision maker effectively promote various experts' views into various optimal solutions to China's institutional problem of health care provider selection.

Contracting with private providers for primary care services: evidence from urban China

Controversy surrounds the role of the private sector in health service delivery, including primary care and population health services. China's recent health reforms call for non-discrimination against private providers and emphasize strengthening primary care, but formal contracting-out initiatives remain few, and the associated empirical evidence is very limited. This paper presents a case study of contracting with private providers for urban primary and preventive health services in Shandong Province, China. The case study draws on three primary sources of data: administrative records; a household survey of over 1600 community residents in Weifang and City Y; and a provider survey of over 1000 staff at community health stations (CHS) in both Weifang and City Y. We supplement the quantitative data with one-on-one, in-depth interviews with key informants, including local officials in charge of public health and government finance.We find significant differences in patient mix: Residents in the communities served by private community health stations are of lower socioeconomic status (more likely to be uninsured and to report poor health), compared to residents in communities served by a government-owned CHS. Analysis of a household survey of 1013 residents shows that they are more willing to do a routine health exam at their neighborhood CHS if they are of low socioeconomic status (as measured either by education or income). Government and private community health stations in Weifang did not statistically differ in their performance on contracted dimensions, after controlling for size and other CHS characteristics. In contrast, the comparison City Y had lower performance and a large gap between public and private providers. We discuss why these patterns arose and what policymakers and residents considered to be the main issues and concerns regarding primary care services.

Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review

INTRODUCTION

Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.

METHODS AND FINDINGS

Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of "private sector" included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. "Competitive dynamics" for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.

CONCLUSIONS

Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.

Quality of private and public ambulatory health care in low and middle income countries: systematic review of comparative studies

BACKGROUND

In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options.

METHODS AND FINDINGS

We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred.

CONCLUSIONS

Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases.

The contemporary healthcare crisis in China and the role of medical professionalism

The healthcare crisis that has developed in the last two decades during China's economic reform has caused healthcare and hospital financing reforms to be largely experienced by patients as a crisis in the patient-healthcare professional relationship (PPR) at the bedside. The nature and magnitude of this crisis were epitomized by the "Harbin Scandal"-an incident that took place in August 2005 in a Harbin teaching hospital in which the family of an elderly patient hospitalized in the intensive care unit (ICU) for 66 days paid over RMB yen6 million. The news was publicized globally and ended in the firing of six top hospital administrators including the hospital president and the ICU director. This paper seeks to show that the Chinese healthcare crisis is ultimately linked to a conflict of interests between patients and healthcare professionals (HCPs), which is inherent in the reformed healthcare system of China. Hence the crisis is, at its core, a crisis of fidelity and confidence that must be restored to the PPR. At the "macro" level, it is simplistic to blame the crisis on the failure of the market system, and at the "micro" level, it is naïve to expect that a contractual understanding of the PPR will effectively restore the confidence of patients. This paper will show that the fiduciary relationship and medical professionalism share similar attributes, with fidelity being the core value of both. It concludes that the loss of medical fidelity implies the dissolution of the PPR and the demise of the medical profession and challenges Chinese HCPs to keep their fidelity as a means to both protect their patients' interests and to preserve their profession's survival.

Transformational Process of Health Care Choice of Poor in Kerala

Choice of poor people towards the type of health care services (public or private) has not been much discussed. This is mainly because of the underlying assumption that their choice has always been restricted to public health care services. The inefficiency of the public health care system in India has created a vacuum among the poor people regarding their preference for health care. Their tendency to transform from accessing public to private health care services is discussed in this context.

The study was conducted among the low-income urban households of Kerala. It was noted that there is a strong willingness among these categories to access private health care services. Efficiency of the health care services was pointed out as a major reason for this. However, issues such as the high cost of private health care services remain unresolved. An option to revamp the public health care system cannot materialise especially when the budget allocation for public health service has reduced considerably. In this context, a proposal for an integrated system, which would work on distributive and redistributive mechanisms is suggested.

Comparing public and private hospitals in China: evidence from Guangdong

BACKGROUND

The literature comparing private not-for-profit, for-profit, and government providers mostly relies on empirical evidence from high-income and established market economies. Studies from developing and transitional economies remain scarce, especially regarding patient case-mix and quality of care in public and private hospitals, even though countries such as China have expanded a mixed-ownership approach to service delivery. The purpose of this study is to compare the operations and performance of public and private hospitals in Guangdong Province, China, focusing on differences in patient case-mix and quality of care.

METHODS

We analyze survey data collected from 362 government-owned and private hospitals in Guangdong Province in 2005, combining mandatorily reported administrative data with a survey instrument designed for this study. We use univariate and multi-variate regression analyses to compare hospital characteristics and to identify factors associated with simple measures of structural quality and patient outcomes.

RESULTS

Compared to private hospitals, government hospitals have a higher average value of total assets, more pieces of expensive medical equipment, more employees, and more physicians (controlling for hospital beds, urban location, insurance network, and university affiliation). Government and for-profit private hospitals do not statistically differ in total staffing, although for-profits have proportionally more support staff and fewer medical professionals. Mortality rates for non-government non-profit and for-profit hospitals do not statistically differ from those of government hospitals of similar size, accreditation level, and patient mix.

CONCLUSIONS

In combination with other evidence on health service delivery in China, our results suggest that changes in ownership type alone are unlikely to dramatically improve or harm overall quality. System incentives need to be designed to reward desired hospital performance and protect vulnerable patients, regardless of hospital ownership type.

From plan to market in the health sector?: China's experience

Countries worldwide confront the challenge of defining and achieving appropriate roles for government and market forces in the health sector. China-as both a developing and a transitional economy-represents an important case. This paper uses an international comparative perspective to examine how the health of China's population and other aspects of health system performance changed during the reform era. We draw on standard public finance and health economics theory, as well as the more recent incomplete-contracting theory of property rights, to summarize the comparative advantages of government and market for financing and delivery of health services, particularly in developing and transitional economies. We then describe and analyze against this theoretical background the transformation of China's health sector and recent commitment of government funds to move toward universal coverage.

Syphilis in China: results of a national surveillance programme

BACKGROUND

After a massive syphilis epidemic in the first half of the 20th century, China was able to eliminate this infection for 20 years (1960-80). However, substantial changes in Chinese society have been followed by a resurgent epidemic of sexually transmitted diseases. Sporadic reports have provided clues to the magnitude of the spread of syphilis, but a national surveillance effort is needed to provide data for planning and intervention.

METHODS

We collected and assessed case report data from China's national sexually transmitted disease surveillance system and sentinel site network.

FINDINGS

In 1993, the reported total rate of cases of syphilis in China was 0.2 cases per 100,000, whereas primary and secondary syphilis alone represented 5.7 cases per 100,000 persons in 2005. The rate of congenital syphilis increased greatly with an average yearly rise of 71.9%, from 0.01 cases per 100,000 livebirths in 1991 to 19.68 cases per 100 000 livebirths in 2005.

INTERPRETATION

The results suggest that a range of unique biological and social forces are driving the spread of syphilis in China. A national campaign for detection and treatment of syphilis, and a credible prevention strategy, are urgently needed.

Black or white cat? Ideology meets reality in healthcare finance and provision

Despite the intense debates over state or private sector dominance in healthcare finance and provision, there are no clear winners. Failed models exist on either end of the ideological spectrum and no country in the world has one that is purely public or purely private. Neither does a perfect public-private mix exist; all solutions are, at best, partial. The important questions are whether or not the political choices made are affordable, sustainable and equitable. When ideology meets reality, it boils down to what trade-offs different societies at different stages of economic development are willing to make.

Medical malpractice in the People's Republic of China: the 2002 Regulation on the Handling of Medical Accidents

In China, there have been numerous reports that doctors or other health care workers have been attacked by patients or members of patient’s families. From 2000 to 2003, there were 502 reports of violence against health care workers in the city of Beijing, in which 90 health care workers were wounded or disabled. From January 1991 to July 2001, in Hubei Province, 568 attacks on health care facilities and workers were reported, and some health care workers were even killed. In Jiangsu Province, from 2000 to 2002, violent events against health care facilities and workers increased by 35% every year, with an average of 177 such events occurring each year. Those acts of violence have been attributed, in part, to the inadequacy of the legal system for handling medical disputes that was in effect prior to 2002.