How are individual-level social capital and poverty associated with health equity? A study from two Chinese cities

<p>Abstract</p> <p>Background</p> <p>A growing body of literature has demonstrated that higher social capital is associated with improved health conditions. However, some research indicated that the association between social capital and health was substantially attenuated after adjustment for material deprivation. Studies exploring the association between poverty, social capital and health still have some serious limitations. In China, health equity studies focusing on urban poor are scarce. The purpose of this study is therefore to examine how poverty and individual-level social capital in urban China are associated with health equity.</p> <p>Methods</p> <p>Our study is based on a household study sample consisting of 1605 participants in two Chinese cities. For all participants, data on personal characteristics, health status, health care utilisation and social capital were collected. Factor analysis was performed to extract social capital factors. Dichotomised social capital factors were used for logistic regression models. A synergy index (if it is above 1, we can know the existence of the co-operative effect) was computed to examine the interaction effect between lack of social capital and poverty.</p> <p>Results</p> <p>Results indicated the poor had an obviously higher probability of belonging to the low individual-level social capital group in all the five dimensions, with the adjusted odds ratios ranging from 1.42 to 2.12. When the other variables were controlled for in the total sample, neighbourhood cohesion (NC), and reciprocity and social support (RSS) were statistically associated with poor self-rated health (NC: OR = 1.40; RSS: OR = 1.34). However, for the non-poor sub-sample, no social capital variable was a statistically significant predictor. The synergy index between low individual-level NC and poverty, and between low individual-level RSS and poverty were 1.22 and 1.28, respectively, indicating an aggravating effect between them.</p> <p>Conclusion</p> <p>In this study, we have shown that the interaction effect between poverty and lack of social capital (NC and RSS) was a good predictor of poor SRH in urban China. Improving NC and RSS may be helpful in reducing health inequity; however, poverty reduction is more important and therefore should be implemented at the same time. Policies that attempt to improve health equity via social capital, but neglect poverty intervention, would be counter-productive.</p

Job Satisfaction by Chinese Primary Care Doctors Following Health Care Reform

The purpose of this study is to compare primary care doctors’ job satisfaction and factors associated with it before and after the latest health care reform in China. Data for the study were obtained from China Primary Care Workforce Surveys conducted in 2008 and 2011. Compared to results from the 2008 survey, primary care doctors (PCDs) in the 2011 survey were more satisfied with their jobs overall as well as work conditions and equipment, but less satisfied with their income. In both surveys rural CHC and village clinic doctors were less satisfied than their urban counterparts with their jobs overall, income, work condition, and equipment. Logistic regressions showed that practice setting (i.e. urban, rural, or village) and educational level were two important factors associated with job satisfaction. These findings demonstrated both significant achievements and further efforts to be made to strengthen primary care workforce and enhance their job satisfaction

Evaluating the financial protection of patients with chronic disease by health insurance in rural China

Background A growing number of developing countries are developing health insurance schemes that aim to protect households, particularly the poor, from financial catastrophe and impoverishment caused by unaffordable medical care. This paper investigates the extent to which patients suffering from chronic disease in rural China face catastrophic expenditure on healthcare, and how far the New Co-operative Medical Insurance Scheme (NCMS) offers them financial protection against this. Methods A household survey was conducted in six counties in Ningxia Autonomous Region and Shandong Province, with a total of 6,147 rural households, including 3944 individual chronic disease patients. Structured questionnaires were used with chronic disease patients to investigate: their basic social and economic characteristics, including income and expenditure levels and NCMS membership; and their health care utilization, associated healthcare costs and levels of reimbursement by NCMS. 'Catastrophic' expenditure was defined as healthcare expenditure of more than 40% of household non-food expenditure. Results Expenditure for chronic diseases accounted for an average of 27% of annual non-food per capita expenditure amongst NCMS members in Shandong and 35% in Ningxia. 14-15% of families in both provinces spent more than 40% of their non-food expenditure on chronic healthcare costs. Between 8 and 11% of non NCMS members and 13% of NCMS members did not seek any medical care for chronic illness. A greater proportion of NCMS members in the poorest quintile faced catastrophic expenditure as compared to those in the richest quintile in both study sites. A slightly higher proportion of non-NCMS members than NCMS member households faced catastrophic expenditure, but the difference was not statistically significant. Conclusion A significant proportion of patients with chronic diseases face catastrophic healthcare costs and these are especially heavy for the poor. The NCMS offers only a limited degree of financial protection. The heavy financial burden of healthcare for chronic disease poses an urgent challenge to the NCMS. There is an urgent need for a clear policy on how to offer financial protection to those with chronic disease

Measuring and evaluating progress towards Universal Health Coverage in China.

BACKGROUND: This paper aims to develop a Chinese version of Universal Health Coverage (UHC) indices and to measure China's progress towards UHC. METHODS: Nineteen indicators were selected based on expert consultations to construct indices of accessibility and affordability to measure UHC. Data were drawn from health statistics yearbooks, nationally representative surveys, and health system reform surveillance. The index of accessibility includes absolute accessibility (to essential health services), relative accessibility (to hospital care) and people's subjective perceptions. The index of affordability includes absolute affordability (the incidence of catastrophic health expenditure, CHE), relative affordability (the composition of health expenditure), and people's subjective perceptions. RESULTS: The indices of accessibility and affordability both showed steady increases over the 17 years considered. Absolute accessibility had the most significant improvement (from 23.6 in 2002 to 73.8 in 2018), while the index of relative accessibility decreased from 81.4 in 2002 to 67.3 in 2018. The index of absolute affordability decreased significantly from 46.6 in 2002 to 30.5 in 2010 and then exhibited an increasing trend afterwards, reaching 52.1 in 2018. The index of relative affordability continuously increased during the observation period, from 35.3 to 75.4. CONCLUSIONS: China has made great progress in increasing the accessibility and affordability of health services since the health system reforms in 2009. However, integrating primary health care and hospital care and containing escalating medical expenditure to further reduce patients' financial burdens are key challenges for strengthening the Chinese health system

Are overwhelmed health systems an inevitable consequence of covid-19? Experiences from China, Thailand, and New York State.

Drawing on international experiences, in particular lessons from China, Thailand and New York State, USA, Viroj Tangcharoensathien and colleagues argue that immediate, extensive and effective responses to contain the local transmission of corona virus at the very early stages of an epidemic can prevent health systems from disruption and from being overwhelmed

How does the New Cooperative Medical Scheme influence health service utilization? A study in two provinces in rural China

<p>Abstract</p> <p>Background</p> <p>Many countries are developing health financing mechanisms to pursue the goal of universal coverage. In China, a rural health insurance system entitled New Cooperative Medical Scheme (NCMS) is being developed since 2003. Although there is concern about whether the NCMS will influence the serious situation of inequity in health service utilization in rural China, there is only limited evidence available. This paper aims to assess the utilisation of outpatient and inpatient services among different income groups and provinces under NCMS in rural China.</p> <p>Methods</p> <p>Using multistage sampling processes, a cross-sectional household survey including 6,147 rural households and 22,636 individuals, was conducted in six counties in Shandong and Ningxia Provinces, China. Chi-square test, Poisson regression and log-linear regression were applied to analyze the association between NCMS and the utilization of outpatient and inpatient services and the length of stay for inpatients. Qualitative methods including individual interview and focus group discussion were applied to explain and complement the findings from the household survey.</p> <p>Results</p> <p>NCMS coverage was 95.9% in Shandong and 88.0% in Ningxia in 2006. NCMS membership had no significant association with outpatient service utilization regardless of income level and location.</p> <p>Inpatient service utilization has increased for the high income group under NCMS, but for the middle and low income, the change was not significant. Compared with non-members, NCMS members from Ningxia used inpatient services more frequently, while members from Shandong had a longer stay in hospital.</p> <p>High medical expenditure, low reimbursement rate and difference in NCMS policy design between regions were identified as the main reasons for the differences in health service utilization.</p> <p>Conclusions</p> <p>Outpatient service utilization has not significantly changed under NCMS. Although utilization of inpatient service in general has increased under NCMS, people with high income tend to benefit more than the low income group. While providing financial protection against catastrophic medical expenditure is the principal focus of NCMS, this study recommends that outpatient services should be incorporated in future NCMS policy development. NCMS policy should also be more equity oriented to achieve its policy goal.</p

Extending access to essential services against constraints: the three-tier health service delivery system in rural China (1949-1980).

BACKGROUND: China has made remarkable progress in scaling up essential services during the last six decades, making health care increasingly available in rural areas. This was partly achieved through the building of a three-tier health system in the 1950s, established as a linked network with health service facilities at county, township and village level, to extend services to the whole population. METHODS: We developed a Theory of Change to chart the policy context, contents and mechanisms that may have facilitated the establishment of the three-tier health service delivery system in rural China. We systematically synthesized the best available evidence on how China achieved universal access to essential services in resource-scarce rural settings, with a particular emphasis on the experiences learned before the 1980s, when the country suffered a particularly acute lack of resources. RESULTS: The search identified only three peered-reviewed articles that fit our criteria for scientific rigor. We therefore drew extensively on government policy documents, and triangulated them with other publications and key informant interviews. We found that China's three-tier health service delivery system was established in response to acute health challenges, including high fertility and mortality rates. Health system resources were extremely low in view of the needs and insufficient to extend access to even basic care. With strong political commitment to rural health and a "health-for-all" policy vision underlying implementation, a three-tier health service delivery model connecting villages, townships and counties was quickly established. We identified several factors that contributed to the success of the three-tier system in China: a realistic health human resource development strategy, use of mass campaigns as a vehicle to increase demand, an innovative financing mechanisms, public-private partnership models in the early stages of scale up, and an integrated approach to service delivery. An implementation process involving gradual adaptation and incorporation of the lessons learnt was also essential. CONCLUSIONS: China's 60 year experience in establishing a de-professionalized, community-based, health service delivery model that is economically feasible, institutionally and culturally appropriate mechanism can be useful to other low- and middle-income countries (LMICs) seeking to extend essential services. Lessons can be drawn from both reform content and from its implementation pathway, identifying the political, institutional and contextual factors shaping the three-tier delivery model over time

Effects of NCMS Coverage on Access to Care and Financial Protection in China

The introduction of the New Cooperative Medical Scheme in rural China is one of the largest health care reforms in the developing world since the millennium. The literature to date has mainly used the uneven rollout of NCMS across counties as a way of identifying its effects on access to care and financial protection. This study exploits the cross-county variation in NCMS generosity in 2006 and 2008 in Ningxia and Shandong province and adopts an instrumenting approach to estimate the effect of a continuous measure of coverage level. Our results confirm earlier findings of NCMS being effective in increasing access to care, but not increasing financial protection. In addition, we find that NCMS enrollees are sensitive to the incentives set in the NCMS design when choosing their provider, but also that providers seem to respond by increasing prices and/or providing more expensive care