Advancing the application of systems thinking in health: managing rural China health system development in complex and dynamic contexts

Background: This paper explores the evolution of schemes for rural finance in China as a case study of the long and complex process of health system development. It argues that the evolution of these schemes has been the outcome of the response of a large number of agents to a rapidly changing context and of efforts by the government to influence this adaptation process and achieve public health goals. Methods:The study draws on several sources of data including a review of official policy documents and academic papers and in-depth interviews with key policy actors at national level and at a sample of localities. Results: The study identifies three major transition points associated with changes in broad development strategy and demonstrates how the adaptation of large numbers of actors to these contextual changes had a major impact on the performance of the health system. Further, it documents how the Ministry of Health viewed its role as both an advocate for the interests of health facilities and health workers and as the agency responsible for ensuring that government health system objectives were met. It is argued that a major reason for the resilience of the health system and its ability to adapt to rapid economic and institutional change was the ability of the Ministry to provide overall strategy leadership. Additionally, it postulates that a number of interest groups have emerged, which now also seek to influence the pathway of health system development. Conclusions: This history illustrates the complex and political nature of the management of health system development and reform. The paper concludes that governments will need to increase their capacity to analyze the health sector as a complex system and to manage change processes.UKaid: DFI

Comparing the effects of China’s three basic health insurance schemes on the equity of health-related quality of life: using the method of coarsened exact matching

Abstract Background China has three basic health insurance schemes: Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS). This study aimed to compare the equity of health-related quality of life (HRQoL) of residents under any two of the schemes. Methods Using data from the 5th National Health Services Survey of Shaanxi Province, China, coarsened exact matching method was employed to control confounding factors. We included a matched sample of 6802 respondents between UEBMI and URBMI, 34,169 respondents between UEBMI and NRCMS, and 36,928 respondents between URBMI and NRCMS. HRQoL was measured by EQ-5D-3L based on the Chinese-specific value set. Concentration index was adopted to assess health inequality and was decomposed into its contributing factors to explain health inequality. Results After matching, the horizontal inequity indexes were 0.0036 and 0.0045 in UEBMI and URBMI, 0.0035 and 0.0058 in UEBMI and NRCMS, and 0.0053 and 0.0052 in URBMI and NRCMS respectively, which were mainly explained by age, educational and economic statuses. The findings demonstrated the pro-rich health inequity was much higher for the rural scheme than that for the urban ones. Conclusion This study highlights the need to consolidate all three schemes by administrating uniformly, merging funds pooling and benefit packages. Based on the contributing factors, strategies aim to facilitate health conditions of the elderly, narrow economic gap, and reduce educational inequity, are essential. This study will provide evidence-based strategies on consolidating the fragmented health schemes towards reducing health inequity in both China and other developing countries