Réformes économiques et activités des hôpitaux municipaux en zone rurale : une analyse dans la province de Shandong

Les vastes réformes entreprises en Chine dans le cadre de ce qu’il est convenu d’appeler le « socialisme de marché » ont eu d’importantes répercussions sur le fonctionnement du système de santé. Cette communication se propose d’en analyser certains effets sur l’activité et la performance d’un échantillon d’hôpitaux municipaux situés dans une zone rurale de la province de Shandong. Les données de base ont été recueillies lors d’une enquête en 2002 et complétées par des informations émanant des différents départements de l’administration concernés. Les déterminants de l’activité des hôpitaux ont été analysés à partir d’une analyse de panel sur la période 1986-2000. L’étude de leur performance a été faite en utilisant une analyse non paramétrique (DEA et indice de Malmquist). Les résultats obtenus suggèrent notamment que la contrainte de revenu de la population est un frein à l’augmentation de la fréquentation des hôpitaux municipaux et que les mécanismes d’assurance ne paraissent pas jouer en l’état de rôle significatif. L’activité s’avère influencée par des facteurs représentatifs de l’attractivité des hôpitaux. L’introduction d’un système de « gestion intégrée » a permis d’améliorer la qualité des soins des structures de santé de village placés sous la tutelle des hôpitaux municipaux tout en améliorant dans l’ensemble la situation financière de ces derniers. Dans l’ensemble, les hôpitaux municipaux de notre échantillon ont amélioré leur efficience durant la période d’étude sous l’influence de facteurs très variés selon les hôpitaux. Mais il apparaît que les hôpitaux financièrement contraints ont tendance à être comparativement plus efficients que les autres.activité et performance des hopitaux – efficience technique, Réformes économiques – décentralisation

Health Insurance Reform and Efficiency of Township Hospitals in Rural China: An Analysis from Survey Data

In the rural health-care organization of China, township hospitals ensure the delivery of basic medical services. Particularly damaged by the economic reforms implemented from 1975 to the end of the 1990s, township hospitals efficiency is questioned, mainly with the implementation since 2003 of the reform of health insurance in rural areas. From a database of 24 randomly selected township hospitals observed over the period 2000-2008 in Weifang prefecture (Shandong), the study examines the efficiency of township hospitals through a two-stage approach. As curative and preventive medical services delivered at township hospital level use different production processes, two data envelopment analysis models are estimated with different orientation chosen to compute scores. Results show that technical efficiency declines over time. Factors explaining the technical efficiency are mainly environmental characteristics rather than internal factors, but our results suggest also that in the context of China, the efficiency of township hospitals is influenced by unobservable factors.China, New Rural Cooperative Medical Scheme, Technical efficiency, data envelopment analysis, Township Hospitals.

The Impact of the New Rural Cooperative Medical Scheme on Activities and Financing of Township Hospitals in Weifang, China

Since 2003, the New Rural Cooperative Medical Scheme, a community-based health insurance, is gradually implemented in China, in order to increase the access of the poor to healthcare services, reduce out-of-pocket expenditures and avoid catastrophic health expenditures. The paper estimates the impact of the New Rural Cooperative Medical Scheme on a sample of 24 randomly selected township hospitals of Weifang prefecture (Shandong province, China), using a generalized form of differences-in-differences model on longitudinal data over the period 2000-2008. Estimations highlight three main results. First, the New Rural Cooperative Medical Scheme has a positive impact on the utilization of township hospitals, mainly on inpatient services, but none effect on their financial structure. In addition, the positive impact on the volume of discharged patients is higher in poor areas rather than the non-poor, reflecting a decrease of the burden of hospitalization costs. Lastly, the marginal impact of the reform is decreasing over time.China, New Rural Cooperative Medical Scheme, Impact analysis, Township Hospitals.

Evolution de l’activité et de la performance d’un échantillon d'hôpitaux municipaux en Chine

La décentralisation en Chine a placé les hôpitaux municipaux (HM) au cœur du système sanitaire en zone rurale. Nous avons utilisé les informations collectées dans un échantillon de 21 HM de la province de Shandong et dans les administrations concernées pour analyser par des méthodes quantitatives les déterminants de leur activité, mesurer leur efficience et en rechercher les facteurs explicatifs pour la période 1986-2000. Nos résultats suggèrent entre autres que le revenu per capita de la zone de desserte des HM ainsi que leur attractivité perçue ont un effet positif sur leur activité, que les tarifs pratiqués en sont un frein et que les dispositifs de couverture maladie n’ont pas d’impact significatif sur leur fréquentation. L’intégration verticale partielle des HM avec les centres de santé villageois a freiné l’activité de ces hôpitaux. Leur efficience s’est globalement améliorée durant la période étudiée, mais selon une dynamique relativement hétérogène,. Cette évolution s’est faite en partie sous l’influence de facteurs institutionnels qui tiennent à des modalités de régulation sectorielle et à des questions de gouvernance liées aux relations entre les HM et la tutelle.

The Impact of the New Rural Cooperative Medical Scheme on Activities and Financing of Township Hospitals in Weifang, China

Since 2003, the New Rural Cooperative Medical Scheme is gradually implemented in China, in order first, to increase access of the poor to health services, reduce out-of-pocket expenditures and avoid catastrophic health expenditures and second to re-oriented patient to township hospitals. The paper estimates the impact of the New Rural Cooperative Medical Scheme on a sample of 24 township hospitals of Weifang prefecture (Shandong province), using a generalized form of differences-in-differences model on longitudinal data over the period 2000-2008. The estimations conclude to the significant and positive impact of the New Rural Cooperative Medical Scheme on inpatient activities and on the bed occupancy rate, and to the significant and negative impact on the average length of stay. As expected, the impact on inpatient activities is higher in poor areas than in non poor ones and the marginal impact is decreasing over time.China;New Rural Cooperative Medical Scheme;Impact analysis;Township Hospitals.

Curative Activities of Township Hospitals in Weifang Prefecture, China: An Analysis of Environmental and Supply-Side Determinants

Township hospitals, which are an important link of the Chinese rural healthcare system, were affected by the successive socio-economic reforms since the 1980s. As a consequence, their utilization declined. From longitudinal data covering nine years (2000-2008) and 24 township hospitals randomly selected in Weifang prefecture (Shandong province, China), this article analyses the environmental and supply-side determinants of the volume of township hospitals curative activities, measured by the number of outpatient visits and that of discharged patients. The Hausman-Taylor and the Fixed-Effect Vector Decomposition estimators are used in order to cope with time-invariant variables. Results of the estimations are confronted and highlight similar outcomes. Findings show that the New Rural Cooperative Medical Scheme, introduced in 2003, has contributed to increase the activity of township hospitals, although financial barriers remain to the access to expensive medical services. The analyses underline also that referral practices between health facilities levels should be reinforced and that the size of the township hospitals needs to be adequate with environmental factors as they appear to be over-sized.Health insurance, China, Healthcare services, Hausman-Taylor, Fixed-effects vector decomposition

The Impact of the New Rural Cooperative Medical Scheme on Activities and Financing of Township Hospitals in Weifang, China

Since 2003, the New Rural Cooperative Medical Scheme is gradually implemented in China, in order first, to increase access of the poor to health services, reduce out-of-pocket expenditures and avoid catastrophic health expenditures and second to re-oriented patient to township hospitals. The paper estimates the impact of the New Rural Cooperative Medical Scheme on a sample of 24 township hospitals of Weifang prefecture (Shandong province), using a generalized form of differences-in-differences model on longitudinal data over the period 2000-2008. The estimations conclude to the significant and positive impact of the New Rural Cooperative Medical Scheme on inpatient activities and on the bed occupancy rate, and to the significant and negative impact on the average length of stay. As expected, the impact on inpatient activities is higher in poor areas than in non poor ones and the marginal impact is decreasing over time.China;New Rural Cooperative Medical Scheme;Impact analysis;Township Hospitals.

Curative Activities of Township Hospitals in Weifang Prefecture, China: An Analysis of Environmental and Supply-Side Determinants

International audienceTownship hospitals, which are an important link of the Chinese rural healthcare system, were affected by the successive socio-economic reforms since the 1980s. As a consequence, their utilization declined. From longitudinal data covering nine years (2000-2008) and 24 township hospitals randomly selected in Weifang prefecture (Shandong province, China), this article analyses the environmental and supply-side determinants of the volume of township hospitals curative activities, measured by the number of outpatient visits and that of discharged patients. The Hausman-Taylor and the Fixed-Effect Vector Decomposition estimators are used in order to cope with time-invariant variables. Results of the estimations are confronted and highlight similar outcomes. Findings show that the New Rural Cooperative Medical Scheme, introduced in 2003, has contributed to increase the activity of township hospitals, although financial barriers remain to the access to expensive medical services. The analyses underline also that referral practices between health facilities levels should be reinforced and that the size of the township hospitals needs to be adequate with environmental factors as they appear to be over-sized.Les hôpitaux municipaux, qui sont un maillon essentiel du système de santé rural Chinois, ont été affectés par les réformes économiques successives depuis les années 1980 et ont ainsi vu leur fréquentation s’affaiblir. À partir d’observations longitudinales sur neuf années (2000-2008) et 24 hôpitaux municipaux sélectionnés de façon aléatoire dans la préfecture de Weifang (Province du Shandong, Chine), cet article analyse les facteurs d’environnement et d’offre qui influencent le volume des activités curatives des hôpitaux municipaux, mesurépar le volume de consultations externes et d’hospitalisations. Afin d’estimer l’effet de variables invariantes dans le temps, deux estimateurs sont utilisés : Hausman-Taylor et Fixed-Effect Vector Decomposition. Les résultats des estimations des deux estimateurs sont similaires. Ils montrent que le système d’assurance mutualiste graduellement introduit à partir de 2003 influence positivement l’activité des hôpitaux municipaux, même s’il subsiste des barrières financières à l’accès aux soins de santé coûteux. L’analyse souligne aussi queles liens de référencement entre les différents niveaux de structures de santé devraient être renforcés et que la taille des hôpitaux municipaux, qui semble surestimée, doit être adaptée en fonction des facteurs environnementaux

Health Insurance Reform and Efficiency of Township Hospitals in Rural China: An Analysis from Survey Data

In the rural health-care organization of China, township hospitals ensure the delivery of basic medical services. Particularly damaged by the economic reforms implemented from 1975 to the end of the 1990s, township hospitals efficiency is questioned, mainly with the implementation since 2003 of the reform of health insurance in rural areas. From a database of 24 randomly selected township hospitals observed over the period 2000-2008 in Weifang prefecture (Shandong), the study examines the efficiency of township hospitals through a two-stage approach. As curative and preventive medical services delivered at township hospital level use different production processes, two data envelopment analysis models are estimated with different orientation chosen to compute scores. Results show that technical efficiency declines over time. Factors explaining the technical efficiency are mainly environmental characteristics rather than internal factors, but our results suggest also that in the context of China, the efficiency of township hospitals is influenced by unobservable factors.China;New Rural Cooperative Medical Scheme;Technical efficiency;data envelopment analysis;Township Hospitals.

Effect of low-dose rituximab treatment on autoimmune nodopathy with anti-contactin 1 antibody

BackgroundAutoimmune nodopathy with anti-contactin-1 (CNTN1) responds well to rituximab instead of traditional therapies. Although a low-dose rituximab regimen was administered to patients with other autoimmune diseases, such as myasthenia gravis and neuromyelitis optica spectrum disorders, and satisfactory outcomes were obtained, this low-dose rituximab regimen has not been trialed in anti-CNTN1-positive patients.MethodsAnti–CNTN1 nodopathy patients were enrolled in this prospective, open-label, self-controlled pilot study. A cell-based assay was used to detect anti-CNTN1 antibodies and their subclasses in both serum and cerebrospinal fluid. Clinical features were evaluated at baseline, 2 days, 14 days, and 6 months after single low-dose rituximab treatment (600 mg). The titers of the subclasses of anti-CNTN1 antibody and peripheral B cells were also evaluated at baseline, 2 days, and 6 months after the rituximab regimen.ResultsTwo patients with anti–CNTN1 antibodies were enrolled. Both patients had neurological symptoms including muscle weakness, tremor, sensory ataxia, numbness and mild nephrotic symptoms. In the field of neurological symptoms, sensory ataxia markedly improved, and the titer of anti-CNTN1 antibody as well as CD19+ B cells decreased only two days following low-dose rituximab treatment. Other neurological symptoms improved within two weeks of rituximab treatment. At the 6-month follow-up, all neurological symptoms steadily improved with steroid reduction, and both the anti-CNTN1 antibody titer and CD19+ B cells steadily decreased. No adverse events were observed after this single low-dose rituximab treatment.ConclusionsWe confirmed the clinical efficacy of low-dose rituximab by B cell depletion in autoimmune nodopathy with anti-CNTN1 antibody. This rapid and long-lasting response suggests that low-dose rituximab is a promising option for anti-CNTN1 nodopathy