The Changing Role of Township Health Centres

This article summarises the major changes in the role of township health centres since the initiation of socioeconomic reforms. It begins by describing the officially defined functions of health centres. Using a case study of Donglan, a poor county in southwestern China, it then shows that a wide gulf exists between the ideal model and reality in poor areas

Unintended pregnancy and induced abortion among unmarried women in China: a systematic review

BACKGROUND: Until recently, premarital examination for both men and women was a legal requirement before marriage in China. Researchers have carried out surveys of attendees' sexual activity, pregnancy and abortion before their marriages, trying to map out reproductive health needs in China, according to this unique population-based data. To systematically identify, appraise and summarise all available studies documenting pregnancy and induced abortion among unmarried Chinese women attending premarital examinations. METHODS: We searched the Chinese Biomedical Literature Index from 1978 to 2002; PUBMED; and EMBASE. Trials were assessed and data extracted by two people independently. RESULTS: Nine studies, of which seven were conducted in the urban areas, one in the rural areas, and one in both urban and rural areas, met the inclusion criteria. In the seven studies in urban areas, the majority of unmarried women had experienced sexual intercourse, with estimates ranging from 54% to 82% in five studies. Estimates of a previous pregnancy ranged from 12% to 32%. Abortion rates were high, ranging between 11 to 55% in 8 studies reporting this, which exclude the one rural study. In the three studies reporting both pregnancy and abortion, most women who had become pregnant had an induced abortion (range 86% to 96%). One large rural study documented a lower low pregnancy rate (20%) and induced abortion rate (0.8%). CONCLUSIONS: There is a large unmet need for temporary methods of contraception in urban areas of China

Introduction to the Three- County Study

A number of the articles in this volume are based on case studies in three counties: Donglan in Guangxi province,' Shibing in Guizhou province and Xunyi in Shaanxi province. Fieldwork and data analysis were carried out in collaboration with a research institution in each province: Guangxi Health Management College, Guiyang Medical College and Xi'an Medical University The health bureaux of each province have also participated in the programme. Routine reports were collected from the county statistical bureaux, and the county governments provided routine financial data. The county health bureaux provided financial and health service utilisation data for county-level health facilities and township health centres. Structured interviews were held with key members of the county governments, and county and township health facilities. Focus group discussions were held with health workers and users of health services

Achieving SDG related sexual and reproductive health targets in China: what are appropriate indicators and how we interpret them?

Background: Sexual and Reproductive Health (SRH) targets have been included as part of the United Nations Sustainable Development Goals and thus indictors are important to monitor the progress towards these targets. SRH indicators are recommended for setting norms and measuring progress at global level. However, given the diverse political, socioeconomic and cultural contexts in different countries, and lack of global agreement on broad indicators, it is important to select appropriate indicators for specific countries. Based on internationally recommended indicators and data availability in China, this paper selected four indictors to reflect SRH in China and interpreted these indictors by analyzing the underlying factors. Methods: we employed secondary data analysis and key informant interview. The major secondary data were obtained from the China Health Statistical Year Book (2005-2017), China Statistical Year Book (2005-2017), and the sub-national estimates of the Global Burden Diseases Study 2016. We also interviewed 36 key informants at national and sub-national levels. Results: the four selected SRH indicators are contraceptive prevalence rate (CPR), adolescent birth rate, abortion rate, and availability of school sex education. CPR of married women has remained above 75% over the last three decades, indicating a high level of access to family planning (FP) services; however, unmarried but sexually active women have significant unmet needs for FP services. Although adolescent birth rates in China remain low, the abortion rate, abortion numbers, and the ratio of abortions to births increased from 2014-2016 while FP policy was relaxed in China. This suggests that abortion among unmarried women is a significant contributor to the overall figures. Qualitative analysis of the availability of school sex education reveals a situation of policy absence and the conservative attitude of key stakeholders. Conclusion: Since SRH challenges vary significantly between socio-economic, political and cultural contexts, indicators for measuring progress towards SRH targets of SDGs should be selected based on country context. The CPR and abortion rate are currently available and important indicators to monitor the most basic part of SRH in China, but require modification to ensure they can reflect universal access to quality reproductive healthcare by all reproductive age women, regardless their marriage status. Indicators on sex education need to be carefully developed to fit the context in China

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

Barriers to accessing TB diagnosis for rural-to-urban migrants with chronic cough in Chongqing, China: A mixed methods study

<p>Abstract</p> <p>Background</p> <p>China is facing a significant tuberculosis epidemic among rural-to-urban migrants, which poses a threat to TB control. This study aimed to understand the health seeking behaviour of and health systems responses to migrants and permanent urban residents suffering from chronic cough, in order to identify the factors influencing delays for both groups in receiving a TB diagnosis in urban China.</p> <p>Methods</p> <p>Combining a prospective cohort study of adult suspect TB patients and a qualitative study, the Piot model was used to analyze the health seeking behaviour of TB suspects among migrants and permanent urban residents, the factors influencing their decision and the responses by general health providers. Methods included a patient survey, focus group discussions with migrants in the general population, qualitative interviews with migrant and permanent resident TB suspects and TB patients as well as key stakeholders related to TB control and the management of migrants.</p> <p>Results</p> <p>Sixty eight percent of migrants delayed for more than two weeks before seeking care for symptoms suggestive of TB, compared to 54% of residents (p < 0.01). When they first decided to seek professional care, migrants were 1.5 times more likely than residents to use less expensive, community-level health services. Only 5% were ultimately referred to a TB dispensary. Major reasons for both patient and provider delay included lack of knowledge and mistrust of the TB control programme, lack of knowledge about TB (patients), and profit-seeking behaviour (providers). In the follow up survey, 61% of the migrants and 41% of the residents who still had symptoms gave up continuing to seek professional care, with a statistically significant difference between the two groups (p < 0.05).</p> <p>Conclusion</p> <p>Rural-to-urban migrants are more likely than permanent residents to delay in seeking care for symptoms suggestive of TB in urban Chongqing. 'Patient-' and 'provider-' related factors interact to pose barriers to TB diagnosis for migrants, including: low awareness, and poor knowledge among both the general public and TB suspects about TB as a disease and about the TB control programme; low financial capacity to pay for care and diagnostic tests; and inadequate use of diagnostic tests and referral to TB dispensaries by general health providers.</p

A framework for comparative analysis of health systems: experiences from the Asia Pacific Observatory on Health Systems and Policies

Drawing on published work from the Asia Pacific Observatory on Health Systems and Policies, this paper presents a framework for undertaking comparative studies on the health systems of countries. Organized under seven types of research approaches, such as national case-studies using a common format, this framework is illustrated using studies of low- and middle-income countries published by the Asia Pacific Observatory. Such studies are important contributions, since much of the health systems research literature comes from high-income countries. No one research approach, however, can adequately analyse a health system, let alone produce a nuanced comparison of different countries. Multiple comparative studies offer a better understanding, as a health system is a complex entity to describe and analyse. Appreciation of context and culture is crucial: what works in one country may not do so in another. Further, a single research method, such as performance indicators, or a study of a particular health system function or component, produces only a partial picture. Applying a comparative framework of several study approaches helps to inform and explain progress against health system targets, to identify differences among countries, and to assess policies and programmes. Multi-method comparative research produces policy-relevant learning that can assist countries to achieve Sustainable Development Goal 3: ensure healthy lives and promoting well-being for all at all ages by 2030

Factors associated with patient, and diagnostic delays in Chinese TB patients: a systematic review and meta-analysis

BACKGROUND: Delay in seeking care is a major impediment to effective management of tuberculosis (TB) in China. To elucidate factors that underpin patient and diagnostic delays in TB management, we conducted a systematic review and meta-analysis of factors that are associated with delays in TB care-seeking and diagnosis in the country. METHODS: This review was prepared following standard procedures of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and checklist. Relevant studies published up to November 2012 were identified from three major international and Chinese literature databases: Medline/PubMed, EMBASE and CNKI (China National Knowledge Infrastructure). RESULTS: We included 29 studies involving 38,947 patients from 17 provinces in China. Qualitative analysis showed that key individual level determinants of delays included socio-demographic and economic factors, mostly poverty, rural residence, lack of health insurance, lower educational attainment, stigma and poor knowledge of TB. Health facility determinants included limited availability of resources to perform prompt diagnosis, lack of qualified health workers and geographical barriers. Quantitative meta-analysis indicated that living in rural areas was a risk factor for patient delays (pooled odds ratio (OR) (95% confidence interval (CI)): 1.79 (1.62, 1.98)) and diagnostic delays (pooled OR (95% CI): 1.40 (1.23, 1.59)). Female patients had higher risk of patient delay (pooled OR (95% CI): 1.94 (1.13, 3.33)). Low educational attainment (primary school and below) was also a risk factor for patient delay (pooled OR (95% CI): 2.14 (1.03, 4.47)). The practice of seeking care first from Traditional Chinese Medicine (TMC) providers was also identified as a risk factor for diagnostic delay (pooled OR (95% CI): 5.75 (3.03, 10.94)). CONCLUSION: Patient and diagnostic delays in TB care are mediated by individual and health facility factors. Population-based interventions that seek to reduce TB stigma and raise awareness about the benefits of early diagnosis and prompt treatment are needed. Policies that remove patients’ financial barriers in access to TB care, and integration of the informal care sector into TB control in urban and rural settings are central factors in TB control

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