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Abstract Globally, poverty and illness are linked, attracting widespread attention. In China, illness contributes to about 40% of rural poverty. This study sought to investigate how healthcare-seeking behavior differs between impoverished and non-impoverished populations within the same Chinese healthcare delivery system. It also sought to understand how differences should be considered when assessing spatial accessibility to provide more accurate recommendations for healthcare resource optimization and promote village revitalization and health equity in China. Methodologically, a survey conducted in May 2019 in Enshi Prefecture (a national impoverished region in Hubei Province, China) collected data on healthcare resource utilization regarding the inpatient and outpatient needs of both impoverished and non-impoverished populations. A Chi-square test compared their respective healthcare-seeking behaviors in three respects (e.g., preference for healthcare institution type, transportation mode, and travel time). Baidu Map data with healthcare institution locations and real-life travel times were then incorporated to assess spatial access to different types of healthcare institutions. Results showed that in Enshi, the most widespread village clinics (low-level) were generally the most utilized healthcare institutions for outpatient visits, with patients usually walking for about 30 min. The middle-level Township Health Centers (THCs) and high-level public hospitals were the most used for inpatient visits, with patients willing to drive up to 30 min to THCs and 60 min to hospitals. Comparatively, the impoverished have more frequent service demands but tend to choose lower-level healthcare institutions, with longer travel times and limited transportation modes. Although 75% of Enshi’s area was covered within 30 min by village clinics and 51% of the villages were within 60 min’ drive to hospitals, considerable areas remain under-served compared with the shortest travel time targets in China. In conclusion, spatial access to healthcare resources in Enshi must be further improved, especially by strengthening the service capacity of primary healthcare institutions to address the healthcare needs of Enshi’s impoverished population. The disparity in healthcare-seeking behavior between different population groups should be fully considered to effectively allocate limited healthcare resources to promote health equity for vulnerable populations as proposed in international and domestic policies.

Summary: This review comprehensively evaluates China’s progress in care of end-stage kidney disease (ESKD) by identifying achievements and gaps, reviewing ESKD-related policy initiatives, and proposing policy recommendations. In the past decade, China has made laudable progress in access to ESKD care with narrowed difference between the number of patients needing and receiving kidney replacement therapies (KRT). China has also experienced significant improvements in clinical quality and outcomes of ESKD care. These achievements stem from concerted efforts in advocating effective policies, increasing fiscal subsidies, re-designing health insurance schemes, encouraging healthcare delivery from both public and private sectors, and improving quality regulation. However, challenges remain, including inequitable access to care across regions and groups, and suboptimal quality and outcomes in some underdeveloped areas. To address these gaps, we recommend reforming the financing policy, adopting quality-based payment methods, strengthening quality monitoring system, improving chronic kidney disease prevention and management, and developing alternative KRT modalities.

Around the world, the adoption of digital technologies in health care has accelerated considerably in the wake of the COVID-19 pandemic. Prior to the emergence of the pandemic, China had already embarked on a private sector, technology enterprise-led creation of an innovative internet health care ecosystem, which has dramatically transformed China’s health care landscape. In this article, we describe the evolution of China’s internet health market, focusing on internet telemedicine. We trace its early origins with the establishment of information networks in the 1980s, to the emergence of a fast-growing internet health market in the 2010s that leveraged the capabilities of technology enterprises in e-commerce, logistics, and payment systems. Private health care platforms have played a central role throughout this transformative process. The supplyside of the market has a unique public-private mix structure, with the coexistence of public and private internet hospitals, and with the majority of telemedicine services provided by public hospital doctors working on private platforms in a dual practice capacity. We conclude with a discussion of the prospects of internet telemedicine, including how it should be optimized and harnessed to improve China’s health system. Finally, we set out areas where more research is needed.

Abstract Primary health care (PHC) is the most effective way to improve people's health and well-being, and primary care services should act as the cornerstone of a resilient health system and the foundation of universal health coverage. To promote high quality development of PHC, an International Symposium on Quality Primary Health Care Development was held on December 4–5, 2023 in Beijing, China, and the participants have proposed and advocated the Beijing Initiative on Quality Primary Health Care Development. The Beijing Initiative calls on all countries to carry out and strengthen 11 actions: fulfill political commitment and accountability; achieve “health in all policies” through multisectoral coordination; establish sustainable financing; empower communities and individuals; provide community-based integrated care; promote the connection and integration of health services and social services through good governance; enhance training, allocation and motivation of health workforce, and medical education; expand application of traditional and alternative medicine for disease prevention and illness healing; empower PHC with digital technology; ensure access to medicinal products and appropriate technologies; and last, strengthen global partnership and international health cooperation. The Initiative will enrich the content of quality development of PHC, build consensus, and put forward policies for quality development of PHC in China in the new era, which are expected to make contributions in accelerating global actions.

Summary: Background: Hospitals in China are classified into tiers (1, 2 or 3), with the largest (tier 3) having more equipment and specialist staff. Differential health insurance cost-sharing by hospital tier (lower deductibles and higher reimbursement rates in lower tiers) was introduced to reduce overcrowding in higher tier hospitals, promote use of lower tier hospitals, and limit escalating healthcare costs. However, little is known about the effects of differential cost-sharing in health insurance schemes on choice of hospital tiers. Methods: In a 9-year follow-up of a prospective study of 0.5 M adults from 10 areas in China, we examined the associations between differential health insurance cost-sharing and choice of hospital tiers for patients with a first hospitalisation for stroke or ischaemic heart disease (IHD) in 2009–2017. Analyses were performed separately in urban areas (stroke: n = 20,302; IHD: n = 19,283) and rural areas (stroke: n = 21,130; IHD: n = 17,890), using conditional logit models and adjusting for individual socioeconomic and health characteristics. Findings: About 64–68% of stroke and IHD cases in urban areas and 27–29% in rural areas chose tier 3 hospitals. In urban areas, higher reimbursement rates in each tier and lower tier 3 deductibles were associated with a greater likelihood of choosing their respective hospital tiers. In rural areas, the effects of cost-sharing were modest, suggesting a greater contribution of other factors. Higher socioeconomic status and greater disease severity were associated with a greater likelihood of seeking care in higher tier hospitals in urban and rural areas. Interpretation: Patient choice of hospital tiers for treatment of stroke and IHD in China was influenced by differential cost-sharing in urban areas, but not in rural areas. Further strategies are required to incentivise appropriate health seeking behaviour and promote more efficient hospital use. Funding: Wellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, China Ministry of Science and Technology, and National Natural Science Foundation of China.

The outbreak of the COVID-19 pandemic has boosted the global development of online healthcare platforms. An increasing number of public hospital doctors are providing online services on private third-party healthcare platforms, creating a new form of dual practice—online dual practice. To explore the impacts of online dual practice on health system performance as well as potential policy responses, we undertook a qualitative approach that uses in-depth interviews and thematic analysis. Following a purposive sampling, we interviewed 57 Chinese respondents involved in online dual practice. We asked respondents for their opinions on the effects of online dual practice on access, efficiency, quality of care, and advice on regulatory policy. The results suggest that online dual practice can generate mixed impacts on health system performance. The benefits include improved accessibility due to increased labor supply of public hospital doctors, better remote access to high-quality services, and lower privacy concerns. It can improve efficiency and quality by optimizing patient flows, reducing repetitive tasks, and improving the continuity of care. However, the potential distraction from designated work at public hospitals, inappropriate use of virtual care, and opportunistic physician behaviors may undermine overall accessibility, efficiency, and quality. Countries should mitigate these adverse consequences via regulations that are appropriate to their healthcare system context, policy priority, and governance capacity.

Abstract Background Private hospitals expanded rapidly in China since 2009 following its national health reform encouraging private investment in the hospital sector. Despite long-standing debates over the performance of different types of hospitals, empirical evidence under the context of developing countries remains scant. We investigated the disparities in health care quality and medical expenses among public, private not-for-profit, and private for-profit hospitals. Methods A total of 64,171 inpatients (51,933 for pneumonia (PNA), 9,022 for heart failure (HF) and 3,216 for acute myocardial infarction (AMI)) who were admitted to 528 secondary hospitals in Sichuan province, China, during the fourth quarters of 2016, 2017, and 2018 were selected for this study. Multilevel logistic regressions and multilevel linear regressions were utilized to assess the relationship between hospital ownership types and in-hospital mortality, as well as medical expenses for PNA, HF, and AMI, after adjusting for relevant hospital and patient characteristics, respectively. Results The private not-for-profit (adjusted OR, 1.69; 95% CI, 1.08, 2.64) and for-profit (adjusted OR, 1.67; 95% CI, 1.06, 2.62) hospitals showed higher in-hospital mortality than the public ones for PNA, but not for AMI and HF. No significant differences were found in medical expenses across hospital ownership types for AMI, but the private not-for-profit was associated with 9% higher medical expenses for treating HF, while private not-for-profit and for-profit hospitals were associated with 10% and 11% higher medical expenses for treating PNA than the public hospitals. No differences were found between the private not-for-profit and private for-profit hospitals both in in-hospital mortality and medical expenses across the three conditions. Conclusion The public hospitals had at least equal or even higher healthcare quality and lower medical expenses than the private ones in China, while private not-for-profit and for-profit hospitals had similar performances in these aspects. Our results added evidences on hospitals’ performances among different ownership types under China’s context, which has great potential to inform the optimization of healthcare systems implemented among developing countries confronted with similar challenges.

CD123, the interleukin-3 receptor alpha chain, is aberrantly expressed in acute myeloid leukemia blasts and leukemia stem cells. Here the authors report the design and characterize the anti-tumor activity of allogeneic CD123-targeted CAR-T cells as a therapeutic approach for acute myeloid leukemia.

Summary: Background: Universal health coverage (UHC) is a core element of Sustainable Development Goals and has become a global healthcare priority. China has been committing to provide all citizens with affordable and equitable basic healthcare over past decades. However, progress towards UHC in China has not been comprehensively assessed. This study aims to comprehensively evaluate the progress towards UHC in China by examining trends in service coverage and financial protection from 1993 to 2018, and estimating the probability of achieving UHC targets by 2030. Methods: Following the framework proposed by World Health Organization and World Bank, we selected 12 prevention service indicators, 12 treatment service indicators, and two financial protection indicators to evaluate China's progress towards UHC. We used data from four nationally representative household surveys to assess the trends in service coverage and financial protection between 1993 and 2018, as well as their inequalities across subgroups. Meta-analysis was used to construct the composite prevention and treatment indices. The regression-based relative index of inequality was used to measure the income-related inequality of UHC indicators. Bayesian linear regression was conducted to predict progress towards UHC by 2030, and the probability of achieving UHC targets. Findings: Of the 24 service coverage indicators used in this study, most of them experienced improvements between 1993 and 2018. The composite prevention index increased from 65.6% (95% CI: 52.1%–77.9%) to 87.7% (95% CI: 81.8%–92.6%) and the composite treatment index increased from 57.1% (95% CI: 43.5%–70.1%) to 75.5% (95% CI: 66.6%–83.5%). The inequalities of service coverage experienced significant declines during this period. Based on our projections, most indicators except ones in the area of non-communicable diseases (NCD) will achieve the 80% coverage target by 2030, and the prevention and treatment indices will increase to 92.7% (95% CrI: 90.3%–94.7%) and 83.2% (95% CrI: 75.1%–88.8%) by then. However, we observed limited reductions in the incidences of catastrophic health expenditure and medical impoverishment. Inequalities in financial protection remained large in 2018. Interpretation: China had made significant progress in improving healthcare service coverage and reducing inequalities between 1993 and 2018. However, China faces great challenges in improving financial protection and controlling NCD on its path towards UHC. Establishment of a primary-healthcare-based integrated delivery system and provision of better financial protection for vulnerable population should be prioritized. Funding: None.

Abstract Background Although management is important in healthcare, low- and middle-income countries (LMICs) have little experience measuring the competence of hospital management. While improving hospital management is the main focus of hospital reform in China, few studies have empirically documented the baseline situation to inform policy design. Methods We assessed the management practices of county-level hospitals in Guizhou in southwest China during 2015. We used the Development World Management Survey (D-WMS) instrument to interview 273 managers in 139 hospitals. We scored the management practices of the sampled hospitals, overall and in four dimensions (operations, monitoring, targets, personnel management) and three processes (implementation, usage, monitoring). We then converted the scores to the WMS scale and compared these with data from two other LMICs and seven high-income countries (HICs). Results On a scale of 1 (‘worst practice’) to 5 (‘best practice’), the mean (SD) hospital D-WMS scores were 2.57 (0.46) overall; 2.71 (0.48), 2.64 (0.58), 2.40 (0.64), and 2.56 (0.40) for operation, monitoring, target, and personnel, respectively; and 2.43 (0.48), 2.62 (0.48), and 2.66 (0.47) for implementation, usage, and monitoring, respectively. After conversion to WMS scores, China ranked seventh of 10 countries, after six HICs and higher than one HIC and two other LMICs (Brazil and India). China ranked higher than the two LMICs in each of the four dimensional scores. Conclusions Chinese county-level hospitals should improve their low quality of management by prioritizing target-setting and process implementation, particularly in personnel management. Meanwhile, modern management training should be given to most clinical managers.

Abstract Background Provider payment system has a profound impact on health system performance. In 2016, a number of counties in rural Guizhou, China, implemented global budget (GB) for county hospitals with quality control measures. The aim of this study is to measure the impact of GB combined with pay-for-performance on the quality of care of inpatients in county-level hospitals in China. Methods Inpatient cases of four diseases, including pneumonia, chronic asthma, acute myocardial infarction and stroke, from 16 county-level hospitals in Guizhou province that implemented GB in 2016 were selected as the intervention group, and similar inpatient cases from 10 county-level hospitals that still implemented fee-for-services were used as the control group. Propensity matching score (PSM) was used for data matching to control for age factors, and difference-in-differences (DID) models were constructed using the matched samples to perform regression analysis on quality of care for the four diseases. Results After the implementation of GB, rate of sputum culture in patients with pneumonia, rate of aspirin at discharge, rate of discharge with β-blocker and rate of smoking cessation advice in patients with acute myocardial infarction increased. Rate of oxygenation index assessment in patient with chronic asthma decreased 20.3%. There are no significant changes in other indicators of process quality. Conclusions The inclusion of pay-for-performance in the global budget payment system will help to reduce the quality risks associated with the reform of the payment system and improve the quality of care. Future reform should also consider the inclusion of the pay-for-performance mechanism.

Background To address disparities in healthcare quality and access between rural and urban areas in China, reforms emphasize strengthening primary care and digital health utilization. Yet, evidence on digital health approaches in rural areas is lacking. Objective This study will evaluate the effectiveness of Guangdong Second Provincial General Hospital's Digital Health Kiosk program, which uses the Dingbei telemedicine platform to connect rural clinicians to physicians in upper-level health facilities and provide access to artificial intelligence-enabled diagnostic support. We hypothesize that our interventions will increase healthcare utilization and patient satisfaction, decrease out-of-pocket costs, and improve health outcomes. Methods This cluster randomized control trial will enroll clinics according to a partial factorial design. Clinics will be randomized to either a control arm with clinician medical training, a second arm additionally receiving Dingbei telemedicine training, or a third arm with monetary incentives for patient visits conducted through Dingbei plus all prior interventions. Clinics in the second and third arm will then be orthogonally randomized to a social marketing arm that targets villager awareness of the kiosk program. We will use surveys and Dingbei administrative data to evaluate clinic utilization, revenue, and clinician competency, as well as patient satisfaction and expenses. Results We have received ethical approval from Guangdong Second Provincial General Hospital (IRB approval number: GD2H-KY IRB-AF-SC.07-01.1), Peking University (IRB00001052-21007), and the University of North Carolina at Chapel Hill (323385). Study enrollment began April 2022. Conclusions This study has the potential to inform future telemedicine approaches and assess telemedicine as a method to address disparities in healthcare access. Trial registration number : ChiCTR2100053872

Abstract Background Underutilization of health services among chronic non-communicable disease sufferers, especially for hypertension (HBP) and diabetes mellitus (DM), was considered as a significant contributing factor to substantial cases in terms of both avoidable morbidity and mortality. However, evidence on health services underutilization and its associated factors in poverty-stricken areas remain scarce based on previous literature. This study aims to describe health services underutilization for people diagnosed with chronic diseases in impoverished regions and to identify its associated factors, which are expected to provide practical implications for the implementations of interventions tailored to the specific needs of disadvantaged residents in rural China to achieve effective utilization of health services in a timely manner. Methods Data were collected from a cross-sectional survey conducted through face-to-face interviews among 2413 patients from six counties in rural central China in 2019. The Anderson behavioral model was adopted to explore the associated factors. A two-level logistic model was employed to investigate the association strengths reflected by adjusted odds ratios (AOR) and 95% confidence intervals in forest plots. Results On average, 17.58% of the respondents with HBP and 14.87% with DM had experienced health services underutilization during 1 month before the survey. Multilevel logistic regression indicated that predisposing factors (age), enabling factors (income and a regular source of care), and need factors (self-reported health score) were the common predictors of health service underutilization both for hypertensive and diabetic patients in impoverished areas, among which obtaining a regular source of care was found to be relatively determinant as a protective factor for health services underutilization after controlling for other covariates. Conclusions Our results suggested that the implementation of a series of comprehensive strategies should be addressed throughout policy-making procedures to improve the provision of regular source of care as a significant determinant for reducing health services underutilization, thus ultimately achieving equal utilization of health services in impoverished regions, especially among chronic disease patients. Our findings are expected to provide practical implications for other developing countries confronted with similar challenges resulting from underdeveloped healthcare systems and aging population structures.

ABSTRACTIndia has recently implemented several major health care reforms at national and state levels, yet the nation continues to face significant challenges in achieving better health system performance. These challenges are particularly daunting in India’s poorer states, like Odisha. The first step toward overcoming these challenges is to understand their root causes. Toward this end, the Harvard T.H. Chan School of Public Health conducted a comprehensive study in Odisha based on ten new field surveys of the system’s performance to provide a multi-perspective analysis. This article reports on the assessment of the performance of Odisha’s health system and the preliminary diagnosis of underlying causes of the strengths and challenges. This comprehensive health system assessment is aimed toward the overarching goals of informing and supporting efforts to improve the performance of health systems in Odisha and other similar contexts.

Population aging is a defining demographic reality of our era. It is associated with an increase in the societal burden of delivering care to older adults with chronic conditions or frailty. How to integrate global population aging and technology development to help address the growing demands for care facing many aging societies is both a challenge and an opportunity for innovation. We propose a social technology approach that promotes use of technologies to assist individuals, families, and communities to cope more effectively with the disabilities of older adults who can no longer live independently due to dementia, serious mental illness, and multiple chronic health problems. The main contributions of the social technology approach include: (1) fostering multidisciplinary collaboration among social scientists, engineers, and healthcare experts; (2) including ethical and humanistic standards in creating and evaluating innovations; (3) improving social systems through working with those who deliver, manage, and design older adult care services; (4) promoting social justice through social policy research and innovation, particularly for disadvantaged groups; (5) fostering social integration by creating age-friendly and intergenerational programs; and (6) seeking global benefit by identifying and generalizing best practices. As an emergent, experimental approach, social technology requires systematic evaluation in an iterative process to refine its relevance and uses in different local settings. By linking technological interventions to the social and cultural systems of older people, we aim to help technological advances become an organic part of the complex social world that supports and sustains care delivery to older adults in need.

Some of Adam Wagstsaff’s colleagues and research collaborators submitted short reflections about the different ways Adam made a difference through his amazing research output to health equity and health systems as well as a leader and mentor. The Guest Editors of this Special Issue selected a set of six essays related to dimensions of Adam’s contributions. The first contribution highlights his role early on in his career, prior to joining the World Bank, in defining and expanding an important field of research on equity in health (“Adam and Equity,” by Eddy van Doorslaer and Owen O’Donnell). The second contribution focuses on Adam’s early work on equity and health within the World Bank and his leadership on important initiatives that have had impact far beyond the World Bank (“Adam and Health Equity at the World Bank,” by Davidson Gwatkin and Abdo Yazbeck). The next contribution focuses on Adam’s deep dive into providing support, through research, for country-specific programs and reforms, with a special focus on some countries in East Asia (“Adam and Country Health System Research,” by Magnus Lindelow, Caryn Bredenkamp, Winnie Yip, and Sarah Bales). The next contribution highlights Adam’s many ways of contributing to the International Health Economics Association, from the impressive technical contributions to leadership and organizational reform (“Adam and iHEA,” by Diane McIntyre). The next to last contribution focuses on Adam’s long-term leadership in the research group at the World Bank and the long-lasting influence on integrating the research produced into World Bank operations and creating an environment that rewarded producing evidence for action (“Adam the Research Manager,” by Deon Filmer and Damien de Walque). The last contribution pulls on the thread found in many of the earlier ones, mentorship with honesty, directness, caring, commitment, and equity (“Adam the Mentor,” by Agnes Couffinhal, Caryn Bredenkamp, and Reem Hafez).

From 1986 to 2009, China’s health system reform first adopted a market-oriented approach and later reemphasized the role of the government starting from 2002. China’s oscillating health care financing policies present us a unique opportunity to examine the consequences of government-led financing and market-oriented financing measures. This study uses the Urban Household Survey, a diary data in China that covers the period of 1986 to 2009, to examine the long-run trends in the incidence and intensity of catastrophic health expenditure and medical impoverishment. Four major findings emerge. First, the incidence and intensity of catastrophic health expenditure in urban Chinese households increased rapidly between 1986 and 2002, whereas they stabilized after 2002. Second, the incidence of medical impoverishment and its depth in the poverty gap remained stable before 2002 and decreased rapidly after 2002. Third, income and regional inequality in measures of catastrophic health expenditure widened from 1986 to 2002. They narrowed in the 2000s but remain wide. Fourth, income and regional inequality in medical impoverishment remained unchanged between 1986 and 2002 and narrowed substantially after 2002. All these results suggest that China’s two cycles of health care reform generated significantly different outcomes in financial protection, holding lessons for the ongoing health care reform in China and other countries.

As China’s health system is faced with challenges of overcrowded hospitals, there is a great need to better understand the recent patterns and determinants of people’s choice between primary care facilities and hospitals for outpatient care. Based on recent individual-level data from the China Health and Retirement Longitudinal Survey (CHARLS) and official province-level data from China health statistical yearbooks, we examine the patterns of outpatient visits to primary care facilities versus hospitals among middle-aged and older individuals and explore both supply- and demand-side correlates that explain these patterns. We find that 53% of outpatient visits were paid to primary care facilities as opposed to hospitals in 2015, compared to 60% in 2011. Both supply and demand factors were associated with this decline. On the supply side, we find that the density of primary care facilities did not account for this decline, but higher densities of hospitals and licensed doctors were associated with lower use of primary care facilities. On the demand side, we find that individuals with higher socioeconomic status and greater health care needs were less likely to use primary health care facilities. Our findings suggest that a high concentration of health care professionals in hospitals diverts patients away from primary care facilities. Staffing the primary care facilities with a well-trained health care workforce is the key to a well-functioning primary care system. The findings also suggest a need to address demand-side inequality issues.

Abstract Background Quality of care (QoC) attracts global concerns when unsafe and misuse of healthcare wastes resources and endangers people’s health, especially in low- and middle-income countries. However, little is known about quality of care delivered in China. This study was intended to gauge the quality of care for acute myocardial infarction (AMI) patients in Beijing and identify the quality gaps across tertiary hospitals. Methods One thousand two hundred twenty eight patients, covered by Employee Essential Health Insurance Scheme and diagnosed of AMI, was sampled from 14 large comprehensive hospitals in Beijing, China. Chart review study was conducted through the discharge data and medical records of inpatients to evaluate 6 quality outcomes of interest, including the use of aspirin, beta blocker, and statin at discharge; use of aspirin within 24 h at arrival; angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD); percutaneous transluminal coronary intervention (PCI) within 90 min at arrival. Results Of the 1228 subjects, the mean age was 60.8 (11.8 SD) years and 83.0% were male. The overall medication prescribed was highly compliant with the clinical guidelines (97.0% [95% CI 96.8–97.2] for aspirin and 96.3% [95% CI 96.0–96.5] for statin), except for beta-blocker (83.6% [95% CI 83.0–84.1]) and ACEI/ARB use (61.4% [95% CI 60.7–62.2]). More than half of eligible patients did not receive appropriate PCI therapy (44.0% [95% CI 42.5–45.4]). Great variations across hospitals was observed in aspirin within 24 h and beta-blocker at discharge (P

Summary: Background: China initiated major health-care reforms in 2009 aiming to provide universal health care for all by 2020. However, little is known about trends in health-care use and health outcomes across different socioeconomic groups in the past decade. Methods: We used data from the China Kadoorie Biobank (CKB), a nationwide prospective cohort study of adults aged 30–79 years in 2004–08, in ten regions (five urban, five rural) in China. Individuals who were alive in 2009 were included in the present study. Data for all admissions were obtained by linkage to electronic hospital records from the health insurance system, and to region-specific disease and death registers. Generalised linear models were used to estimate trends in annual hospital admission rates, 28-day case fatality rates, and mean length of stay for stroke, ischaemic heart disease, and any cause in all relevant individuals. Findings: 512 715 participants were recruited to the CKB between June 25, 2004, and July 15, 2008, 505 995 of whom were still alive on Jan 1, 2009, and contributed to the present study. Among them, we recorded 794 824 hospital admissions (74 313 for stroke, 69 446 for ischaemic heart disease) between 2009 and 2016. After adjustment for demographic, socioeconomic, lifestyle, and morbidity factors, hospitalisation rates increased annually by 3·6% for stroke, 5·4% for ischaemic heart disease, and 4·2% for any cause, between 2009 and 2016. Higher socioeconomic groups had higher hospitalisation rates, but the annual proportional increases were higher in those with lower education or income levels, those enrolled in the urban or rural resident health insurance scheme, and for those in rural areas. Lower socioeconomic groups had higher case fatality rates for stroke and ischaemic heart disease, but greater reductions in case fatality rates than higher socioeconomic groups. By contrast, mean length of stay decreased by around 2% annually for stroke, ischaemic heart disease, and any cause, but decreased to a greater extent in higher than lower socioeconomic groups for stroke and ischaemic heart disease. Interpretation: Between 2009 and 2016, lower socioeconomic groups in China had greater increases in hospital admission rates and greater reductions in case fatality rates for stroke and ischaemic heart disease. Additional strategies are needed to further reduce socioeconomic differences in health-care use and disease outcomes. Funding: Wellcome Trust, Medical Research Council, British Heart Foundation, Cancer Research UK, Kadoorie Charitable Foundation, China Ministry of Science and Technology, and Chinese National Natural Science Foundation.

Background Stroke is the leading cause of mortality in China, with limited evidence of in-hospital burden obtained from nationwide surveys. We aimed to monitor and track the temporal trends and rural–urban disparities in cerebrovascular risk factors, management and outcomes from 2005 to 2015.Methods We used a two-stage random sampling survey to create a nationally representative sample of patients admitted for ischaemic stroke in 2005, 2010 and 2015. We sampled participating hospitals with an economic-geographical region-stratified random-sampling approach first and then obtained patients with a systematic sampling approach. We weighed our survey data to estimate the national-level results and assess changes from 2005 to 2015.Results We analysed 28 277 ischaemic stroke admissions from 189 participating hospitals. From 2005 to 2015, the estimated national hospital admission rate for ischaemic stroke per 100 000 people increased (from 75.9 to 402.7, Ptrend

The redistributive effects of a social insurance programme are determined by how the programme is paid for—who pays and how much do they pay?—and how the benefits are distributed. As a result, the redistributive effects of a social health insurance programme should be evaluated on the basis of its net benefit—the difference between benefits and payment. Among the rich body of empirical analysis on equity in health care financing, however, most studies have relied on partial analysis, assessing equity by source of financing while ignoring the benefit side, or looking at equity in benefits but ignoring the funding side. Either approach risks misleading findings. In this study, therefore, the primary objective was to assess the distribution of net benefits across income groups under Taiwan''s National Health Insurance (NHI) programme.This study observed a nationally representative sample of 74 012 NHI enrolees from 1996 to 2000. The unique NHI databases in Taiwan provide comprehensive enrolment and utilization information, and allowed linkage to each enrolee''s income tax files. In addition to crude estimates, two-part models and ordinary least-square models were used to adjust inpatient and outpatient benefits for health care needs (age, sex, major disease status and physical disability).After adjusting for health care needs, the distribution of net benefits showed an apparent pro-poor pattern, with the lowest income group receiving the highest net benefits (NT$3353) and the top income group receiving the lowest net benefits (−NT$3072) in 1996. Although a clear pro-poor pattern was observed among those enrolees who paid wage-based premiums, this vertically equitable pattern was less evident among the enrolees who paid fixed premiums. Overall, a trend of increasing net benefits was observed in all income groups between 1996 and 2000, and all the NHI enrolees can be considered better off over time.In addition to contributing to the limited literature on equity in net benefits, the study provides an important policy reference to developing countries with large underground economies and relatively small populations of regular wage-earners as it indicates that using fixed premiums as a major financing scheme may pose a serious equity concern and policy challenge. [ABSTRACT FROM AUTHOR]

Background: Responsiveness is an indicator used to measure how well a health system performs relative to non-health aspects. This study assessed whether seven dimensions proposed by the World Health Organization (WHO) to measure responsiveness (dignity, autonomy, confidentiality, prompt attention, social support, basic amenities, and choices of providers) are applicable in evaluating the health system of Taiwan. Methods: A key informant survey and focus group research were used in this study. The translated WHO proposed questionnaire was sent to 205 nominated key informants by mail, and 132 (64.4%) were returned. We used principal component analysis to extract factors. Linear regression analysis was used to assess the relationship between the total score and the extracted factors. A qualitative content analysis was also carried out in focus group research. Results: Principal component analysis produced five factors (respect, access, confidentiality, basic amenities, and social support) that explained 63.5% of the total variances. These five factors demonstrated acceptable internal consistency and four of them (except social support) were significantly correlated with the total responsiveness score. The focus group interviews revealed health providers' communication ability and medical ethics were also highly appraised by Taiwanese. Conclusion: When the performance of a health system is to be evaluated, elements of responsiveness proposed by WHO may have to be tailored to fit different cultural backgrounds. Four key features illustrate the uniqueness of Taiwanese perspectives: the idea of autonomy may not be conceptualized, prompt attention and choice of providers are on the same track, social support during care is trivially correlated to the total responsiveness score, and accountability of health providers is deemed essential to a health system. [ABSTRACT FROM AUTHOR]

The collapse of China's Cooperative Medical System (CMS) in 1978 resulted in the lack of an organized financing scheme for health care, adversely affecting rural farmers access to health care, especially among the poor. The Chinese government recently announced a policy to re-establish some forms of community-based insurance (CBI). Many existing schemes involve low premiums but high co-payments. We hypothesized that such benefit design leads to unequal distribution of the net benefits (NB) benefits net of payment because even though low premiums are more affordable to poor farmers, high co-payments may have a significant deterrent effect on the poor in the use of services in CBI. To test this hypothesis empirically, we estimated the probability of farmers joining a re-established CBI using logistic regression, and the utilization of health care services for those who joined the scheme using the two-part model. Based on the estimations, we predicted the distribution of NB among those who joined the CBI and for the entire population in the community. Our data came from a household survey of 4160 members of 1173 households conducted in six villages in Fengshan Township, Guizhou Province, China. Three principal findings emerged from this study. First, income is an important factor influencing farmers decision to join a CBI despite the premium representing a very small fraction of household income. Secondly, both income and health status influence enrolees utilization of health services: richer/sicker participants obtain greater NB from the CBI than poorer/healthier members, meaning that the poorer/healthier participants subsidize the rich/sick. Thirdly, wealthy farmers benefit the most from the CBI with low premium and high co-payment features at every level of health status. In conclusion, policy recommendations related to the improvement of the benefit distribution of CBI schemes are made based on the results from this study. [ABSTRACT FROM AUTHOR]

Background : Comprehensive aphasia treatment includes interventions aimed at assisting family and friends in learning about and adjusting to aphasia. These interventions include education-oriented information, counselling and support, and communication skill training. While the need for family training and support is recognised, there is very little empirical evidence about the content or value of such assistance at different stages of aphasia. Aims : The primary objective of this study was to identify information needed by family members at the onset of aphasia (hospitalisation), initial rehabilitation, and chronic phases of aphasia. Methods and Procedures : A qualitative approach was used for this study. Focus groups of four to six participants were interviewed. Transcripts from the focus groups were analysed using a five-stage framework approach: familiarisation, identifying a thematic framework, indexing, charting, and mapping with interpretation. A total of 16 adult family members participated in the study. Results : Three thematic recommendations were identified across the three time periods. Based on number of times cited, family members rated information about aphasia most important, followed by psychosocial support and hopefulness. The specific type of information needed by families varied depending on the time post-onset of aphasia. Conclusions : Results from this study support research and educational materials that address the needs of family members of people with aphasia. This research provides guidelines for information from the perspective of a family member. [ABSTRACT FROM AUTHOR]

Abstract Background The prevalence of diabetes and diabetic complications increased alarmingly which also brought heavy burden to patients and health system. Methods We used mix approaches to summarize evidence from published articles and policy documents on the extent and trends of diabetic complications, potential causes, and awareness and services utilization of diabetes in China. Results The annual direct medical expense per patient varied among different types of complications and increased dramatically with the number of diabetic complication and patients were exposed to great financial risk. The number of health policies and strategies on diabetes and its complications at the national level is limited. Primary and secondary preventions such as health education and early diagnosis are necessary. Conclusions With an increasingly burden of non-communicable diseases such as diabetes and its complications, efforts should be invested in education, early screening mechanism and patient management programs to improve the primary and secondary prevention of diabetes and its complications. An integrated services delivery system centered on primary level is recommended to promote education, early case-detection and screening, patient management, referral and care-coordination between primary, secondary and tertiary health care providers.

Introduction The Chinese government has encouraged the development of private sector in delivering healthcare, including primary healthcare (PHC) in the new round of national health reform since 2009. However, the debate about the role of the private sector in achieving universal health coverage continues with poor support from theories and empirical evidence. This study intends to compare the quality of PHC services between the private and public providers in seven provinces in China, using unannounced standardised patients (USPs).Methods We are developing and validating 13 USP cases most commonly observed in the PHC setting. Six domains of quality will be assessed by the USP: effectiveness, safety, patient centredness, efficiency, timeliness and equity. The USP will make 2200 visits to 705 public and 521 private PHC institutions across seven provinces, following a multistage clustered sample design. Using each USP-provider encounter as the analytical unit, we will first descriptively compare the raw differences in quality between the private and public providers and then analyse the association of ownership types and quality, using propensity score weighting.Ethics and dissemination The study was primarily funded by the National Natural Science Foundation of China (#71974211, #71874116 and # 72074163) and was also supported by the China Medical Board (#16-260, #18-300 and #18-301), and have received ethical approval from Sun Yat-sen University (#2019–024). The validated USP tool and the data collected in this study will be freely available for the public after the primary analysis of the study.Trial registration number Chinese Clinical Trial Registry: #ChiCTR2000032773.

In 2009 China announced plans to reform provider payment methods at public hospitals by moving from fee-for-service (FFS) to prospective and aggregated payment methods that included the use of diagnosis-related groups (DRGs) to control health expenditures. In October 2011 health policy makers selected six Beijing hospitals to pioneer the first DRG payment system in China.We used hospital discharge data from the six pilot hospitals and eight other hospitals, which continued to use FFS and served as controls, from the period 2010-12 to evaluate the pilot's impact on cost containment through a difference-in-differences methods design. Our study found that DRG payment led to reductions of 6.2 percent and 10.5 percent, respectively, in health expenditures and out-of-pocket payments by patients per hospital admission. We did not find evidence of any increase in hospital readmission rates or cost shifting from cases eligible for DRG payment to ineligible cases. However, hospitals continued to use FFS payments for patients who were older and had more complications than other patients, which reduced the effectiveness of payment reform. Continuous evidence-based monitoring and evaluation linked with adequate management systems are necessary to enable China and other low- and middle-income countries to broadly implement DRGs and refine payment systems. [ABSTRACT FROM AUTHOR]

In 2009 China announced plans to reform provider payment methods at public hospitals by moving from fee-for-service (FFS) to prospective and aggregated payment methods that included the use of diagnosis-related groups (DRGs) to control health expenditures. In October 2011 health policy makers selected six Beijing hospitals to pioneer the first DRG payment system in China. We used hospital discharge data from the six pilot hospitals and eight other hospitals, which continued to use FFS and served as controls, from the period 2010-12 to evaluate the pilot's impact on cost containment through a difference-in-differences methods design. Our study found that DRG payment led to reductions of 6.2 percent and 10.5 percent, respectively, in health expenditures and out-of-pocket payments by patients per hospital admission. We did not find evidence of any increase in hospital readmission rates or cost shifting from cases eligible for DRG payment to ineligible cases. However, hospitals continued to use FFS payments for patients who were older and had more complications than other patients, which reduced the effectiveness of payment reform. Continuous evidence-based monitoring and evaluation linked with adequate management systems are necessary to enable China and other low- and middle-income countries to broadly implement DRGs and refine payment systems., (Project HOPE—The People-to-People Health Foundation, Inc.)