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Background: The accessibility and fairness of the floating population's access to basic public health services have an important impact on improving the health level of the whole population. Existing studies have shown that medical insurance and social integration have an impact on basic public health services, but there are few studies on the specific influence path between the three. Therefore, the research purpose of this paper is to explore the effects of medical insurance for urban and rural residents and basic medical insurance for urban employees on the utilization of basic public health services, and to analyze the mediating effect of social integration. Methods: The data in this paper are derived from the 2017 China Mobile Population Dynamic Monitoring Survey data, which collects information on 31 provinces (regions, cities) and Xinjiang Production and Construction Corps mobile population 169,989 people, all of whom come from China's relatively concentrated mobile population inflow areas (NHC FPSCo. 2021. Floating Population Service Center of NHC). After deleting part of the missing data and replacing the mean value, 154,586 people were finally included in the analysis. The proportion is 90.9%. Based on the data of China's floating population dynamic survey in 2017,we used Logistic regression method to analyze the effects of basic medical insurance for urban and rural residents, basic medical insurance for urban employees and social integration on the utilization of basic public health services. Then we used the Bootstrap method of structural equation model to analyze the mediating effect of social integration. Results: Medical insurance for urban and rural residents (β = 0.236;95%CI:1.195 ~ 1.342) has positive impact on health education, it (β = 0,190;95%CI:1.150 ~ 1.272) also has positive impact on the establishment of residents' health records. Social integration (including political participation (β = 0.312;95%CI:1.324 ~ 1.410),activity participation (β = 0.724;95%CI:2.009 ~ 2.119), identity (β = 0.421; 95%CI:1.387 ~ 1.675))has positive impact on health education, it ((β = 0.312;95%CI:1.324 ~ 1.410), (β = 0.404;95%CI:1.463 ~ 1.534), (β = 0.282;95%CI:1.191 ~ 1.477)) also has positive impact on the establishment of residents' health records. In addition, BMIUE (β = 0.169;95%CI:1.150 ~ 1.219) has an impact on the establishment of residents' health records. The direct effect of medical insurance on the utilization of public health services was 0.092 (95%CI: 0.093 ~ 0.103), social integration was a partial mediator, the mediating effect was 0.127 (95%CI: 0.108 ~ 0.127), and the mediating effect size was 57.73%. Conclusions: Medical insurance can directly promote the floating population to use basic public health services, and can indirectly promote the improvement of public health service utilization level through social integration. [ABSTRACT FROM AUTHOR]

Background: China has made intensive efforts to eliminate extreme poverty by 2020. This paper aims to evaluate the changes in health service needs, utilization, and medical expenses for poor people during the poverty alleviation period. Methods: The study used data from national health services surveys in 2013 and 2018. The poor people were identified and certified by the local government. Health service needs, utilization, medical expenses, and reimbursement rates were analyzed and compared between 2013 and 2018, between the poor and the non-poor groups. Results: People living in poverty were usually elderly, illiterate, and unemployed. The poor people had a significantly higher two-week morbidity rate and a higher prevalence of chorionic non-communicable diseases than the non-poor group. For both the poor and non-poor, health service needs increased between 2013 and 2018. Accordingly, the poor people had more use of outpatient and inpatient services. The annual inpatient admission rates were 20.8% and 13.1% for the poor and non-poor, respectively, in 2018. The average medical expenses per inpatient admission were much lower for the poor than for the non-poor. Out-of-pocket (OOP) payment share decreased from 41.9% to 2013 to 31.9% in 2018 for the poor, while for the non-poor, the OOP rate was much higher (45.4%) and had no significant changes between the two surveys. The reduction in the OOP share occurred mostly in rural areas. Conclusions: Poverty alleviation in China may have positive effect in improving poor people's access to health services, and reducing their financial burden due to illness and health service utilization. [ABSTRACT FROM AUTHOR]

Object: To analyze the trend of the coupling and coordination of the supply and demand of healthcare resources between the elderly population and healthcare resources in China during the period of 2012–2022, to reveal the impact of the growth of the elderly population on the relationship between the supply and demand of healthcare resources, and to put forward suggestions to improve the coupling and coordination between the supply and demand of healthcare resources and the elderly population, in order to cope with the challenges of an aging society. Methods: By obtaining relevant data from authoritative data sources such as China Statistical Yearbook, Health and Health Statistics Yearbook, and the Chinese government website from 2012 to 2022, we constructed a comprehensive measurement index for the three systems of elderly population, healthcare resource supply, and healthcare resource demand; Using the entropy value method to assign weights to the indicators, combined with the coupling coordination degree model, to reveal the changes of the elderly population change and the supply and demand of medical and health resources; using ArcGIS technology, to study the spatial characteristics of the elderly population change and the supply and demand of medical and health resources. Results: From 2012 to 2022, the supply and demand of healthcare resources and the variation of the elderly population in China show a continuous growth trend, and the comprehensive development level of the system gradually climbs from a low level to a high level. The fluctuation of coupling degree and coordination degree rises, although the coordination degree has always been lower than the coupling degree, but the distance between the coordination degree and the coupling degree gradually narrows with the passage of time. The coordination degree between population aging and medical and health resources development shows spatial heterogeneity in China, with the eastern region significantly higher than the western region/. Conclusions: The coupling degree between population aging and healthcare resource supply and demand in China from 2012 to 2022 shows a general upward trend from low coupling to medium-high coupling, but it is worth noting that even though the degree of coupling increases, the degree of coordination is still relatively lagging behind, suggesting that the government and relevant departments need to pay more attention to coordinated allocation and management of healthcare resources. At the same time, the spatial differences in the degree of coordination among provinces suggest that future policymakers should take regional differences into full consideration in policymaking and sustainable development. [ABSTRACT FROM AUTHOR]

Background: Air pollution has been identified as related to the diseases of susceptible population, but the spatial heterogeneity of its economic burden and its determinants are rarely investigated. The issue is of great policy significance, especially after the epidemic of COVID-19, when human are facing the joint crisis of health and environment, and some areas is prone to falling into poverty. Methods: The geographical detector was adopted to study the spatial distribution characteristics of the incidence of catastrophic health expenditure (ICHE) for older adults in 100 rural areas in China at the prefecture-city level. The health factors, sociological factors, policy factors and environmental factors and their interactions are identified. Results: First, most health service factors had strong explanatory power for ICHE whether it interacts with air pollution. Second, 50 single-factor high-risk areas of ICHE were found in the study, but at the same time, there were 21 areas dominated by multiple factors. Conclusion: The different contributions and synergy among the factors constitute the complex mechanism of factors and catastrophic health expenditure. Moreover, during this process, air pollution aggravates the contribution of health service factors toward ICHE. In addition, the leading factors of ICHE are different among regions. At the end, this paper also puts forward some policy suggestions from the perspective of health and environment crisis in the post-COVID-19 world: environmental protection policies should be combined with the prevention of infectious diseases; advanced health investment is the most cost-effective policy for the inverse health sequences of air pollution and infectious diseases such as coronavirus disease 2019 (COVID-19); integrating environmental protection policy into healthy development policy, different regions take targeted measures to cope with the intertwined crisis. [ABSTRACT FROM AUTHOR]

Background: To better meet people's growing demand for medical and health services, 21 cities in Guangdong Province were involved in the reform of public hospitals in 2017. This paper evaluates the equity and efficiency of public hospitals' health resource allocation in Guangdong Province and explores ways to change the current situation. Methods: Data were collected from the Guangdong Health Statistical Yearbook 2016–2020 and Guangdong Statistical Yearbook 2017–2021. The Gini coefficient (G), Theil index (T), and health resource density index (HRDI) were used to measure the equity of health resource allocation. An improved three-stage DEA method was applied in efficiency evaluation. The entropy weight method was employed to calculate the weight of different indicators to obtain a comprehensive indicator representing the overall volume of health resources in each city. A two-dimensional matrix was drawn between the HRDI of the comprehensive indicator and efficiency and the per capita government financial subsidies and efficiency to observe the coordination of equity and efficiency across regions. Results: From 2016 to 2020, the G of public hospital, bed, and health technician allocation by population remained below 0.2, while that by geographical area ranged from 0.4 to 0.6; the G of government financial subsidies by population was above 0.4, while that by geographical area was greater than 0.7. The results for T showed that inequality mainly comes from intraregional differences, and the Pearl River Delta contributes most to the overall differences. Although the HRDI of the Pearl River Delta is far greater than that of other regions, obvious differences exist across cities in the region. Only 38.1% of cities were found to be efficient in 2020. The Pearl River Delta was in the first quadrant, and the other three regions were in the third quadrant, accounting for a large proportion. Conclusion: The equity of government financial subsidies allocation was the worst, and there were distinct regional differences in the geographical distribution of health resources. The development of healthcare within the Pearl River Delta was highly unbalanced. The development of healthcare was uneven between the Pearl River Delta, eastern, western, and mountainous regions. In addition, most cities in the eastern, western, and mountainous regions bore the dual pressures of relatively insufficient health resources and inefficiency. [ABSTRACT FROM AUTHOR]

Background: China now faces an increasingly aging society which may exert economic pressure in the long run. This study illustrates the spatial pattern and evolution of population aging and economic development in China. The coupling coordination degree of population aging and economic development at the national and provincial levels are calculated and demonstrated, and the spatial patterns and characteristics are investigated. Methods: This paper presents a coupling analysis of the elderly population rate (EPR) and per capita Gross Regional Product (GRPpc) in China by using the coupling and coordination model. Further, the spatial pattern and evolution of population aging and economic development are investigated based on the standard deviational ellipse. The collected data is at the level of provincial administrative units in mainland China covering the period 2002 to 2020. Results: The results reveal the spatial difference in the coupling and coordination degree between EPR and GRPpc across provinces. The eastern coastal areas are higher than the central and western regions of China. The orientation and directions of EPR are more than GRPpc, indicating that the polarization in population aging is more severe than economic development. Significant positive correlations between coupling coordination degree and sustainable competitiveness are detected. Conclusions: Policymakers should fully consider regional differences and sustainable development in policy formulation of China. The western and northeastern provinces should be given priority in the regional sustainable development plan. At the same time, the coordination between population aging and economic development also requires to be examined especially. [ABSTRACT FROM AUTHOR]

Background: The security of medical insurance fund is very important to health equity. In China, the expenditure of medical insurance fund has increased sharply year after year, and the balance of local medical insurance fund is difficult to sustain. To realize the equitable distribution of the medical insurance burden, the central government has to continuously increase transfer payments, which causes regional unfairness in the distribution of central financial resources. This paper explores the influence of central transfer payments on the balance of medical insurance fund, influential mechanisms, and the strategic behavior of local governments. Methods: First, we constructed a dynamic game model between central government and local governments and analyzed the mechanism of central transfer payments affecting the balance of local medical insurance fund. Then, based on the provincial panel data of 28 provincial administrative regions in China from 2004 to 2014, an empirical test was made. The spatial regression model was constructed, and the transfer payments obtained by neighboring provinces in the previous year were taken as instrumental variables. Results: Central transfer payments led to strategic behaviors by local governments that resulted in increased local health insurance fund expenditures and lower balance rates. Moreover, the central transfer payments demonstrated "path dependence". Central transfer payments had a significant negative influence on the local NCMS fund balance rate. The local government subsidy and per capita GDP had a significant positive impact on the local NCMS fund balance rate. The obtained transfer payments of local governments had a significant space correlation. This study based on NCMS data remains valid. Conclusions: Central transfer payments induced the strategic behavior of local governments, which neglected to supervise the expenditure of medical insurance fund, reducing the efficiency of medical insurance fund management and use. The financial resources of medical insurance fund are unevenly distributed among provinces. Measures such as strengthening the supervision ability and initiatives of local governments, refining the central transfer payment mechanism, promoting the economic growth of western regions, and increasing rates for individual contributions appropriately can ensure that the medical insurance fund are used well and distributed equitably. [ABSTRACT FROM AUTHOR]

Background: Over the last decade, the expenditure on public medical and health has increased greatly in China, however, problems as low efficiency and unfairness still exist. How to accurately describe the effectiveness of existing medical and health resources in combination with regional heterogeneity is of great significance to China's medical and health reform. Methods: Based on provincial panel data for the period of 2005 to 2017, combining expected output and unexpected output, this paper constructs a super-efficiency three-stage SBM-DEA model, to measure and analyze the spatial-temporal heterogeneity characteristics and influencing factors of public medical and health efficiency (PMHE). Results: (1) After the impacts of random error and external environmental factors are removed, the mean value of overall PMHE is 0.9274, failing to reach DEA efficiency, and PMHE shows a fluctuated downward trend. (2) The adjusted PMHE level shows a prominent spatial imbalance at the stage 3. The average efficiency level is ranked by the East > the West > the Central > the Northeast. (3) The increases of GDP per capita and population density are beneficial to the improvement of PMHE, while income level and education level are disadvantageous to PMHE, and last, the urbanization level, an uncertain effect. (4) There is no σ convergence of the PMHE in the East, the Central and the West, that is, the internal differences may gradually expand in the future, while the Northeast shows a significant σ convergence trending of PMHE. (5) The state's allocation of medical and health resources has undergone major changes during "The Twelfth Five-Year Plan". Conclusion: This study innovatively incorporates undesired outputs of health care into the efficiency evaluation framework by constructing the main efficiency evaluation indicators. The results of the robust evaluation conclude that China's existing investment in medical and health resources is generally not effective. Therefore, although China's health care reform has made certain achievement, it is still necessary to expand the investment in health care resources. [ABSTRACT FROM AUTHOR]

Background: Emergency department crowding is an obstacle in the process of obtaining emergency care services, which will lead to the increase of time cost. Most studies focused on the direct access to emergency medical resources, and few studies took the crowding of hospital emergency department as an evaluation index to reflect the convenience of obtaining emergency medical resources. It is a significance for the identification of areas with insufficient access to emergency service resources with this method. Methods: This paper utilizes the improved potential model and the inverted Two-Step Floating Catchment Area method, combined with network map API service data to evaluate response time, delivery time and waiting time (for emergency department crowding) spent in different residential areas of Xi'an City in the process of emergency. Meanwhile, the vulnerable regions of gaining emergency medical resources are identified through the comprehensive analysis of the three stages of emergency. Results: The studies show that the residents in built-up area are more convenient to get ambulance service and arrive at care hospitals than those in suburban areas, but they may face greater hospital crowdedness. Although suburban residents are faced with low hospital crowdedness, they spend more time on getting ambulances and going to care hospitals. The accessibility of emergency medical resources varies greatly among residents in different regions, with 5.38% of the residents were identified in the high-risk area distributing in suburban residential areas in the south of the city center, 21.92% in the medium risk area in the southern mountainous areas and the periphery of the core suburban areas of the city, and 46.11% in the low-risk area which are mainly distributed in built-up areas in gaining emergency medical services. Conclusions: Obviously, getting an ambulance and arriving at the nearest hospital quickly shows that it is conducive to access to emergency resources. However, the impact of hospital emergency crowding can not be ignored, especially in the area surrounded by high-grade hospitals in the central area of the city. In considering the spatial layout of emergency stations and emergency hospitals, the dislocation distribution of hospitals at different levels should be reasonably adjusted to balance the equity of residents in obtaining emergency medical resources. [ABSTRACT FROM AUTHOR]

Background: China's healthcare reform programme continues to receive much attention. Central to these discussions has been how the various financial incentives underpinning reform efforts are negatively impacting on the healthcare workforce. Research continues to document these trends, however, qualitative analysis of how these incentives impact on the motivation of healthcare workers remains underdeveloped. Furthermore, the application of motivational theories to make sense of healthcare worker experiences has yet to be undertaken. Methods: The purpose of our paper is to present a comparative case study account of healthcare worker motivation across urban China. It draws on semi structured interviews (n = 89) with a range of staff and organisations across three provinces. In doing so, the paper analyses how healthcare worker motivation is influenced by a variety of financial incentives; how motivation is influenced by the opportunities for career development; and how motivation is influenced by the day to day pressures of meeting patient expectations. Results: The experience of healthcare workers in China highlights how a reliance on financial incentives has challenged their ability to maintain the values and ethos of public service. Our findings suggest greater attention needs to be paid to the motivating factors of improved income and career development. Further work is also needed to nurture and develop the motivation of healthcare workers through the building of trust between fellow workers, patients, and the public. Conclusions: Through the analysis of healthcare worker motivation, our paper presents a number of ways China can improve its current healthcare reform efforts. It draws on the experience of other countries in calling for policy makers to support alternative approaches to healthcare reform that build on multiple channels of motivation to support healthcare workers. [ABSTRACT FROM AUTHOR]

Background: Since 1968, China has trained about 1.5 million barefoot doctors in a few years' time to provide basic health services to 0.8 billion rural population. China's Ministry of Health stopped using the term of barefoot doctor in 1985, and changed policy to develop village doctors. Since then, village doctors have kept on playing an irreplaceable role in China's rural health, even though the number of village doctors has fluctuated over the years and they face serious challenges. United Nations declared Sustainable Development Goals in 2015 to achieve universal health coverage by 2030. Under this context, development of Community Health workers (CHWs) has become an emerging policy priority in many resource-poor developing countries. China's experiences and lessons learnt in developing and maintaining village doctors may be useful for these developing countries. Methods: This paper aims to synthesis lessons learnt from the Chinese CHW experiences. It summarizes China's experiences in exploring and using strategic partnership between the community and the formal health system to develop CHWs in the two stages, the barefoot doctor stage (1968-1985) and the village doctor stage (1985-now). Chinese and English literature were searched from PubMed, CNKI and Wanfang. The information extracted from the selected articles were synthesized according to the four partnership strategies for communities and health system to support CHW development, namely 1) joint ownership and design of CHW programmes; 2) collaborative supervision and constructive feedback; 3) a balanced package of incentives, both financial and non-financial; and 4) a practical monitoring system incorporating data from the health system and community. Results: The study found that the townships and villages provided an institutional basis for barefoot doctor policy, while the formal health system, including urban hospitals, county health schools, township health centers, and mobile medical teams provided training to the barefoot doctors. But After 1985, the formal health system played a more dominant role in the CHW system including both selection and training of village doctors. China applied various mechanisms to compensate village doctors in different stages. During 1960s and 1970s, the main income source of barefoot doctors was from their villages' collective economy. After 1985 when the rural collective economy collapsed and barefoot doctors were transformed to village doctors, they depended on user fees, especially from drug sale revenues. In the new century, especially after the new round of health system reform in 2009, government subsidy has become an increasing source of village doctors' income. Conclusion: The barefoot doctor policy has played a significant role in providing basic human resources for health and basic health services to rural populations when rural area had great shortages of health resources. The key experiences for this great achievement are the intersection between the community and the formal health system, and sustained and stable financial compensation to the community health workers. [ABSTRACT FROM AUTHOR]

Background: Poor medical care and high fees are two major problems in the world health care system. As a result, health care insurance system reform is a major issue in developing countries, such as China. Governments should take the effect of health care insurance system reform on the competition of hospitals into account when they practice a reform. This article aims to capture the influences of asymmetric medical insurance subsidy and the importance of medical quality to patients on hospitals competition under non-price regulation. Methods: We establish a three-stage duopoly model with quantity and quality competition. In the model, qualitative difference and asymmetric medical insurance subsidy among hospitals are considered. The government decides subsidy (or reimbursement) ratios in the first stage. Hospitals choose the quality in the second stage and then support the quantity in the third stage. We obtain our conclusions by mathematical model analyses and all the results are achieved by backward induction. Results: The importance of medical quality to patients has stronger influence on the small hospital, while subsidy has greater effect on the large hospital. Meanwhile, the importance of medical quality to patients strengthens competition, but subsidy effect weakens it. Besides, subsidy ratios difference affects the relationship between subsidy and hospital competition. Furthermore, we capture the optimal reimbursement ratio based on social welfare maximization. More importantly, this paper finds that the higher management efficiency of the medical insurance investment funds is, the higher the best subsidy ratio is. Conclusions: This paper states that subsidy is a two-edged sword. On one hand, subsidy stimulates medical demand. On the other hand, subsidy raises price and inhibits hospital competition. Therefore, government must set an appropriate subsidy ratio difference between large and small hospitals to maximize the total social welfare. For a developing country with limited medical resources and great difference in hospitals such as China, adjusting the reimbursement ratios between different level hospitals and increasing medical quality are two reasonable methods for the sustainable development of its health system. [ABSTRACT FROM AUTHOR]

Background: Equity of healthcare spatial access is essential for the health outcomes of medical investments and the welfare of populations, and efficiency of medical resource allocation is important for obtaining a supply-demand equilibrium with lower cost and higher outputs with limited inputs. However, the literature that involves both equity and efficiency in its analysis of healthcare spatial allocation is rare, and the spatial accessibility of multilevel healthcare is difficult to measure by traditional methods in a large region with diversified population distribution. Methods: To assist in solving these issues, this paper aims to build an equity and efficiency integrated analytical framework by proposing a new "GTL-2SFCA" approach to analyze the spatial accessibility of multilevel healthcare; maximum and minimum floating catchments of different levels of healthcare were assigned to ensure a combination of universal search coverage and efficient hospitalization behavior simulation. Results: The analytical framework was applied and tested in Hubei, China. Almost half of the residents (47.95%) and townships (44.98%) have access to both public general hospitals (PGHs) and primary healthcare centers (PHCs) services, 36.89% of the residents enjoy only one sufficient service, either PGHs or PHCs, and the remaining residents (15.16%) are faced with the risk of lacking access to both services. The results reveal that there are core-periphery effects of multilevel healthcare throughout Hubei and isolate clusters that have adequate access in the western region. The polarization effect of higher-level healthcare and the polycentric pattern of lower-level healthcare coexist. The multilevel healthcare shortage was identified in some areas in boundary and peripheral regions. Conclusions: This study integrates equity and efficiency into the GTL-2SFCA framework, enriches the FCA series methodologies and provides a more operational solution for evaluating the access of residents in more sophisticated spatial units to each level of healthcare. By more significantly differing and quantifying the catchment area and distance decay effect, this methodology avoids overestimating or underestimating accessibility and discovers some imperceptible spatial inequities. This study has application value for researchers and decision-makers in other scenarios and regions with significant heterogeneity in medical resources and where the population has greater mobility. [ABSTRACT FROM AUTHOR]

Background: The goal of this paper was to assess the quality of primary healthcare services at community health centres (CHCs) from the demand (patient) and supplier (healthcare service institution) angles. Methods: This study was conducted at six CHCs in the Greater Bay Area of China. Between August and October 2019, 1,568 patients were recruited (55.8% women and 44.2% men). We evaluated the service quality of CHCs using the National Committee for Quality Assurance Patient-Centred Medical Home (NCQA-PCMH) recognition questionnaire. We assessed patients' experiences with medical and health services using the Primary Care Assessment Tools (PCAT). Results: PCAT total and sub-domains scores were significantly difference at the six CHCs (P < 0.001). Among the six CHCs, Shayuan CHC had the highest PCAT total and sub-domain scores and the highest NCQA-PCMH total and sub-domain scores, as well. Older (> 60 years), female, lower education, and employee medical-insured individuals had better patient experiences. Conclusions: Our results indicate that CHCs could improve their service quality by improving both institutional health service quality based on NCQA-PCMH assessment and patient experiences based on PCAT scales. These findings can help inform patient-centred primary healthcare policy and management. [ABSTRACT FROM AUTHOR]

Background: Equity is the core of primary care. The issue of equity in health has become urgent, and China has attached increasing attention to it. With rapid economic development and great changes in medical insurance policy, the pattern of equity in health has changed tremendously. The reform of healthcare in Zhejiang Province is at the forefront in China, and studies on Zhejiang Province are of great significance to the entire country. This paper aimed to measure health equity from the perspectives of health needs and health-seeking behavior and to provide suggestions for the next policy formulations, with respect to timeliness. Methods: The investigator's household survey was conducted in August 2016. A sample of 1000 households, which included 2807 individuals in Zhejiang, China, was obtained with the multi-stage stratified cluster sampling method. Descriptive analysis and chi-square tests were adopted in the analysis. The value of the concentration index was used to measure the equity. Results: This study found that the poor have more urgent health needs and poorer health situations than the rich. Through studies on health-seeking behavior, the utilization of outpatient services was almost equitable, while the utilization of hospitalization showed a pro-rich inequity (i.e., the rich use more services). Individuals with employerbased medical insurance used more outpatient services than those with rural and urban medical insurance. More people in the poorer income groups did not use inpatient services due to financial difficulties. Conclusions: Absolute medical prices and medical insurance may explain the equity in the utilization of outpatient services and the inequity in the utilization of hospitalization. In view of the pro-rich inequity of hospitalization, more financial protection should be provided for the poor. [ABSTRACT FROM AUTHOR]

Background: Most existing research on rural–urban health inequalities focuses on disparities in service access and health outcomes based on region. This paper examines rural–urban disparities in maternal healthcare utilization and delivery modes based on household registration (hukou) status to understand the role of state institutions in producing healthcare disparities in China. Methods: Utilizing administrative data from the Public Maternal Health Insurance scheme, we analyzed 54,733 live births in City A (2015–2019) and 25,849 live births in City B (2018–2019) in Guangdong Province in China. We constructed regression models using hukou status (rural versus urban) as the explanatory variable. Results: While there is no statistically significant difference in rural and urban mothers' probability of obtaining the minimum recommended number of prenatal care checkups in City A (OR = 0.990 [0.950, 1.032]), mothers with rural hukou status have a lower probability of obtaining the minimum recommended number of visits in City B than their counterparts with urban hukou (OR = 0.781 [0.740, 0.825]). The probability of delivering in tertiary hospital is lower among mothers with rural hukou than among those with urban hukou in both cities (City A: OR = 0.734 [0.701, 0.769]; City B: OR = 0.336 [0.319, 0.354]). Mothers with rural hukou are more likely to have a Cesarean section than those with urban hukou in both cities (City A: OR = 1.065 [1.027, 1.104]; City B: OR = 1.127 [1.069, 1.189]). Compared with mothers with urban hukou, mothers with rural hukou incurred 4 % (95 % CI [-0.046, -0.033]) and 9.4 % (95 % CI [-0.120, -0.068]) less in total medical costs for those who delivered via Cesarean section and 7.8 % (95 % CI [-0.085, -0.071]) and 19.9 % (95 % CI [-0.221, -0.177]) less for those who delivered via natural delivery in City A and City B, respectively. Conclusions: Rural hukou status is associated with younger age, no difference or lower probability of having a minimum number of prenatal checkups, higher likelihood of delivering in nontertiary hospitals, increased Cesarean delivery rates, and lower medical cost for delivery in these two Chinese cities. Evaluating how hukou status influences maternal healthcare in Chinese cities is important for devising targeted public policies to promote more equitable maternal health services. [ABSTRACT FROM AUTHOR]

Background: After achieving universal basic medical insurance coverage, Chinese government put the development of private health insurance (PHI) on its agenda to further strengthen financial risk protection. This paper aims to assess the level of financial protection that PHI provides for its insured households on the basis of resident basic medical insurance (RBMI). Methods: We employed balanced panel data collected between 2015 and 2017 from the China Household Finance Survey (CHFS). Catastrophic health expenditure (CHE) and impoverishment due to health spending were applied to measure the financial protection effects. Random effects panel logistic regression model was performed to identify the factors associated with CHE and impoverishment among households covered by RBMI. In the robustness test, the method of propensity score matching (PSM) was employed to solve the problem of endogeneity. Results: From 2015 to 2017, the CHE incidence increased from 12.96 to 14.68 % for all sampled households, while the impoverishment rate decreased slightly from 5.43 to 5.32 % for all sampled households. In 2015, the CHE incidence and impoverishment rate under RBMI + PHI were 4.53 and 0.72 %, respectively, which were lower than those under RBMI alone. A similar phenomenon was observed in 2017. Regression analysis also showed that the households with RBMI + PHI were significantly less likely to experience CHE (marginal effect: -0.054, 95 %CI: -0.075 to -0.034) and impoverishment (marginal effect: -0.049, 95 %CI: -0.069 to -0.028) compared to those with RBMI alone. The results were still robust after using PSM method to eliminate the effects of self-selection on the estimation results. Conclusions: In the context of universal basic medical insurance coverage, the CHE incidence and impoverishment rate of Chinese households with RBMI were still considerably high in 2015 and 2017. PHI played a positive role in decreasing household financial risk on the basis of RBMI. [ABSTRACT FROM AUTHOR]

Background: Enhancing the pooling of basic medical insurance plays a vital role in strengthening the resilience to risk and co-payment capacity of medical insurance funds. In China, there is a concerted effort to shift from municipal to provincial pooling of medical insurance. While existing research suggests that provincial pooling of basic health insurance affects the health of participants, the findings are not yet consistent, and there is limited research on the specific pathways of impact between the two. Therefore, this study aims to explore the influence of provincial pooling of basic medical insurance on participants' health and analyze the mediating role of medical cost burden and medical service utilization. Methods: Using data from the 2012–2018 China Labor Dynamics Survey (CLDS), this study focuses on a sample of urban workers enrolled in basic medical insurance. After excluding samples with missing information, a total of 5,684 participants were included in the analysis. The effects of the provincial pooling policy of basic medical insurance on participants' medical cost burden, medical service utilization, and health were analyzed using double difference modeling. Furthermore, structural equation modeling was employed to explore the mediating paths between provincial pooling and health. Results: The findings reveal that provincial pooling of basic medical insurance significantly impacts participants' medical cost burden, medical service utilization, and health. Specifically, provincial pooling helps reduce the participants' medical cost burden (β = -0.1205; P < 0.001), improves the level of medical institutions visited (β = 1.7962; P < 0.001), and promotes health improvement (β = 1.8370; P < 0.001). The mediating effect analysis demonstrates that the direct effect of provincial pooling on health is 1.073 (P < 0.001), with a mediating effect of medical cost burden between provincial pooling and health measuring 0.129 (P < 0.001). Heterogeneity analysis indicates that provincial pooling is more effective in reducing the burden of medical costs for low-income (β = -0.2273; P < 0.001) and high-age participants (β = -0.2710; P < 0.001), and it also helps increase the burden of medical costs for low-income (β = 4.0875; P < 0.001) and high-age participants (β = 1.9010; P < 0.001) based on provider ranking. Moreover, it is found that provincial pooling is more beneficial in improving the health of high-income (β = 1.7984; P < 0.001) and middle- and high-age enrollees (β = 1.9220; P < 0.001; β = 0.5900; P < 0.001). Further analysis reveals that the provincial unified income and expenditure mode has a more positive effect than the provincial risk adjustment fund mode in reducing the medical expense burden of the insured (-0.2053 < -0.0775), improving the grade of medical institutions (1.8552 > 0.8878), and enhancing the health level (2.8406 > 0.6812). Conclusion: The study concludes that provincial pooling of basic medical insurance has a direct positive impact on participants' health and indirectly promotes health improvement by reducing the burden of medical costs. The effects of provincial pooling on participants' medical cost burden, medical service utilization, and health vary based on income and age. Additionally, the provincial-level unified collection and payment model proves to be more advantageous in optimizing the functioning of health insurance funds through the "law of large numbers" principle. [ABSTRACT FROM AUTHOR]

Background: Cancer has become a global health problem. China still suffers continuous increasing cancer mortality. To study the trend of cancer mortality in rural China, this paper established an Age-Period-Cohort model to discuss the age effect, period effect and cohort effect on cancer mortality in rural China. Methods: The data were collected from the “China Health Statistical Yearbook” from 1990 to 2010. Collected data were analyzed by Age-Period-Cohort model and Intrinsic Estimation method. Results: The age effect on the total cancer mortality represented a V trend. Compared with Group 0–4, Group 5–9 showed 71.87% lower cancer mortality risk. Compared with Group 5–9, Group 75–79 showed 38 times higher cancer mortality risk. The period effect on the total cancer mortality risk weakened firstly but then increased. It increased by 35.70% from 1990 to 2010, showing an annual average growth of 1.79%. The cohort effect on the total cancer mortality risk weakened by totally 84.94% from 1906–1910 to 2005–2010. Three “deterioration periods” and three “improvement periods” were witnessed during this period. The malignant cancer mortality varied similarly with the total cancer mortality, while benign cancer mortality and other cancer mortality represented different variation laws. Conclusions: Although the total cancer mortality risk is increasing at an accelerated rate, cancer mortality risk in recent born year is decreasing, indicating very important impact of social change on the cancer mortality in rural China. [ABSTRACT FROM AUTHOR]

Background: China initiated a reform of the health insurance system in the late 1990s. The new insurance, Urban Employee Basic Medical Insurance (UEBMI), is employment-based, which makes it more difficult than it used to be for those unemployed or informal employed (most of whom are women) to be covered by health insurance. Methods: Based on three large sample of micro datasets, we first use statistical methods to identify gender differences in health insurance. Next, we construct a logistic regression model to capture the differences in insurance coverage across age groups using the parameter of interaction terms for gender and age groups. Results: Based on data from a demographic survey that covers a large sample, we find that in the below 50 (in 2005) or 60 (in 2015) years age group, the coverage gap of UEBMI between men and women was relatively smaller, while a larger disparity existed in the above 50 (in 2005) or 60 (in 2015) group. Moreover, gender differences in health insurance were more significant in the low-education group, while no gender differences were found in the high-education group. Conclusions: This paper explains the gender gap in health insurance and the reason for the wider gap among older people. Our study indicates that because the UEBMI in China mainly covers people with formal jobs, a lower labor participation rate (even much lower in formal jobs) of women has led to their greater difficulty in obtaining health insurance. Since the older women's greater difficulty in obtaining jobs or susceptibility to lay-offs during the period of the UEBMI's implementation, the possibility of being covered was even much lower. In fact, it was because of the combined effects of the UEBMI system and the labor market condition at that time that older women had a lower proportion of being covered under the UEBMI. [ABSTRACT FROM AUTHOR]

Background: Older adults are more prone to various diseases. Health insurance becomes effective mechanism to relieve financial burden when the insured is sick. In China, most older adults live in the countryside, and New Rural Cooperative Medical Scheme is a kind of health insurance system in rural areas. The relationship between New Rural Cooperative Medical Scheme and financial burden due to health expenditure of older adults in China was investigated. This paper aims at the impact of New Rural Cooperative Medical Scheme on the poverty among rural older adults. Methods: This study employs Probit model and Tobit model to assess the impact of New Rural Cooperative Medical Scheme on alleviating poverty among rural older adults based on a survey in nine representative counties in western China. Results: The findings show that diseases have significantly negative impact on rural elderly poverty. New Rural Cooperative Medical Scheme has impact on alleviating of the health-payment poverty due to catastrophic health expenditure, but the impact is limited. The impact of health insurance on poverty alleviation is greater for men, older adults aged between 60 to 69 and households in in economically poorer area than their counterparts. Conclusions: This study show the relationship between New Rural Cooperative Medical Scheme and catastrophic health expenditure of older adults in China. The results draw policy attention to introduce different reimbursement expense ratios for different groups to alleviate them from poverty based on more comprehensive insurance packages. [ABSTRACT FROM AUTHOR]

Background: China issued strict nationwide guidelines to combat the COVID-19 outbreak in January 2020 and gradually loosened the restrictions on movement in early March. Little is known about how these disease control measures affected the 600 million people who live in rural China. The goal of this paper is to document the quarantine measures implemented in rural China outside the epicenter of Hubei Province and to assess the socioeconomic effect of the measures on rural communities over time. Methods: We conducted three rounds of interviews with informants from 726 villages in seven provinces, accounting for over 25% of China's overall rural population. The survey collected data on rural quarantine implementation; COVID-19 infections and deaths in the survey villages; and effects of the quarantine on employment, income, education, health care, and government policies to address any negative impacts. The empirical findings of the work established that strict quarantine measures were implemented in rural villages throughout China in February. Results: There was little spread of COVID-19 in rural communities: an infection rate of 0.001% and zero deaths reported in our sample. However, there were negative social and economic outcomes, including high rates of unemployment, falling household income, rising prices, and disrupted student learning. Health care was generally accessible, but many delayed their non-COVID-19 health care due to the quarantine measures. Only 20% of villagers received any form of local government aid, and only 11% of villages received financial subsidies. There were no reports of national government aid programs that targeted rural villagers in the sample areas. Conclusions: By examining the economic and social effects of the COVID-19 restrictions in rural communities, this study will help to guide other middle- and low-income countries in their containment and restorative processes. Without consideration for economically vulnerable populations, economic hardships and poverty will likely continue to have a negative impact on the most susceptible communities. [ABSTRACT FROM AUTHOR]

Background: Lesbian, gay and bisexual (LGB) people often face individual- and system-level barriers in health care. However, LGB people's experiences of health care in non-European and non-American settings have been scarcely studied. In China, while it has been estimated that there are at least 70 million gender and sexual minorities, there has been no larger-scale study on LGB people's experiences of health care beyond a focus on gay men and HIV. This study is the first larger-scale quantitative study to investigate LGB people's experiences of health care in China, where non-heterosexuality is officially silenced and the needs of non-heterosexual people are largely ignored by service providers. Methods: An online survey was designed in joint partnership by academic, community groups and the United Nations Development Programme. Targeted and snowball sampling was adopted for participant recruitment. Such unique cross-sectoral partnership made this research possible in the authoritarian state of China where data collection on LGB people is extremely rare. For the analysis in this paper, a sample of 15,611 Chinese LGB people were included. Frequency and descriptive statistics were conducted to describe the LGB respondents' demographic characteristics and their experiences in health care settings. Chi-square tests were conducted to test how experiences vary across LGB people with different demographic characteristics. Results: More than three quarters of the respondents said they would be willing to disclose to their medical care providers their sexual orientation if asked. However, only 5.7% of the respondents said that medical care providers ever asked them about their sexual orientation. About 8.0% of the LGB people surveyed reported having experienced negative treatment in medical care settings. Six percent (5.7%) of the Chinese LGB people said in accessing mental health care services, they were recommended, coaxed into, or provided conversion therapy for sexual orientation, gender identity or gender expression. Conclusions: There is a strong need to enhance LGB cultural competence among health care providers. Policymakers in China should also formulate laws, policies, regulations, clearly articulated codes of conduct, and transparent procedures and practices to ensure non-discrimination of LGB people in the health care system, with a particular focus on banning conversion therapy. [ABSTRACT FROM AUTHOR]

Background: Ensuring that the scale and hierarchical structure of health human resources are rational, and that medical services are efficient and fair, is an important task of practical significance. On this basis, examining the impact of health human resources on the level of medical services presents a new and formidable challenge. This study aims to delve into how the scale and hierarchical structure of health human resources in China's four major economic regions affect the fairness and efficiency of medical services, and to identify optimization strategies. Methods: This study utilizes provincial panel data from China's four major economic regions spanning the years 2009 to 2021. Initially, it provides a statistical description of the current state of health human resources and the level of medical services. Subsequently, it employs a fixed-effects model to analyze the impact of the scale and hierarchical structure of health human resources, as well as their interactive effects, on the fairness and efficiency of medical services, and discusses the interactive mechanisms between medical service fairness and medical service efficiency. Furthermore, after conducting a comprehensive evaluation of the level of medical services using the entropy weight method, it explores the regional heterogeneity and temporal dynamics in the influence of the scale and hierarchical structure of health human resources on the level of medical services. Finally, the study examines the scientific validity and rationality of the research findings through various robustness checks, including the substitution of research variables and models. Results: The study found that the scale of health human resources has a promoting effect on the equity of medical services (β ≤ 0.643, p ≤ 0.01), but exhibits an inhibitory effect on the efficiency of medical services (β ≥ -0.079, p ≤ 0.1); the hierarchical structure of health human resources shows a positive impact on both the equity and efficiency of medical services (βequity ≤ 0.160, p ≤ 0.01; βefficiency ≤ 0.341, p ≤ 0.05); at the same time, the results indicate that the interactive effect of the scale and hierarchical structure of health human resources promotes equity in medical services (β = 0.067, p ≤ 0.01), but restricts the efficiency of medical services (β ≥ -0.039, p ≤ 0.01); the mechanism by which health human resources affect the level of medical services in China's western and northeastern regions is more pronounced than in the central and eastern regions; after the implementation of the "Healthy China 2030" Planning Outline, the role of health human resources in the level of medical services has been strengthened; in the robustness tests, the model remains robust after replacing the core explanatory variables, with R2 maintained between 0.869 and 0.972, and the dynamic GMM model test shows a significant second-order lag in the level of medical services (βequity ≤ 0.149, p ≤ 0.01; βefficiency ≤ 0.461, p ≤ 0.01); the channel test results prove that managerial personnel and other technical personnel are key pathways in regulating the impact of medical staff on the level of medical services. Conclusion: This study provides an in-depth analysis of the impact of health human resources on the level of medical services, revealing that both the scale and hierarchical structure of health human resources significantly affect the equity and efficiency of medical services. Furthermore, the influence of health human resources on the level of medical services exhibits regional heterogeneity and temporal characteristics. Robustness tests ensure the scientific validity and robustness of the research conclusions. This provides effective references for optimizing the allocation of health human resources and improving the level of medical services. [ABSTRACT FROM AUTHOR]

Background: Since 2020, China has piloted an innovative payment method known as the Diagnosis-Intervention Packet (DIP). This study aimed to assess the impact of the DIP on inpatient volume and bed allocation and their regional distribution. This study investigated whether the DIP affects the efficiency of regional health resource utilization and contributes to disparities in health equity among regions. Methods: We collected data from a central province in China from 2019 to 2022. The treatment group included 508 hospitals in the pilot area (Region A, where the DIP was implemented in 2021), whereas the control group consisted of 3,728 hospitals from non-pilot areas within the same province. We employed the difference-in-differences method to analyze inpatient volume and bed resources. Additionally, we conducted a stratified analysis to examine whether the effects of DIP implementation varied across urban and rural areas or hospitals of different levels. Results: Compared with the non-pilot regions, Region A experienced a statistically significant reduction in inpatient volume of 14.3% (95% CI 0.061–0.224) and a notable decrease of 9.1% in actual available bed days (95% CI 0.041–0.141) after DIP implementation. The study revealed no evidence of patient consultations shifting from inpatient to outpatient services due to the reduction in hospital admissions in Region A after DIP implementation. Stratified analysis revealed that inpatient volume decreased by 12.4% (95% CI 0.006–0.243) in the urban areas and 14.7% in the rural areas of Region A (95% CI 0.051–0.243). At the hospital level, primary hospitals experienced the greatest impact, with a 19.0% (95% CI 0.093–0.287) decline in inpatient volume. Furthermore, primary and tertiary hospitals experienced significant reductions of 11.0% (95% CI 0.052–0.169) and 8.2% (95% CI 0.002–0.161), respectively, in actual available bed days. Conclusions: Despite efforts to curb excessive medical service expansion in the region following DIP implementation, large hospitals continue to attract a large number of patients from primary hospitals. This weakening of primary hospitals and the subsequent influx of patients to urban areas may further limit rural patients' access to medical services. The implementation of the DIP may raise concerns about its impact on health care equality and accessibility, particularly for underserved rural populations. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to understand the composition and influencing factors of epilepsy patients' hospitalization expenses, thus providing a reference for reducing the disease burden of epilepsy patients in low- and middle-income developing countries. Methods: A total of 4206 hospitalized cases of epilepsy from 2018 to 2020 were collected. Descriptive statistics were used to understand the patient cost composition, path analysis was used to understand the direct and indirect factors of hospitalization expenses. Results: From 2018 to 2020, the average hospitalization expenses for epilepsy patients was 4,299.93 RMB yuan, and the average length of stay was 2.47 days. The highest proportion of hospitalization expenses was diagnosis costs (> 50%), followed by comprehensive medical service costs and drug costs. In terms of the total effect coefficient, the major factors affecting the hospitalization expenses were length of stay (0.880), emergency admission(0.463), and the comorbidities and complications(> 0.250). Hospital length of stay, discharge mode(death) and number of hospitalizations(2 times) affect hospitalization expenses through direct effect. Long-term hospitalization (> 30 days), admission routes(emergency), the comorbidities and complications, presence of drug allergy, and age also affect hospitalization expenses through indirect effects. Conclusion: Diagnosis costs and length of stay are important factors affecting the medical expenses of epilepsy inpatients. In general, the quality control of the hospital is good, but it still needs to standardize the diagnosis and treatment behavior of medical staff through the clinical path. [ABSTRACT FROM AUTHOR]

Background: Air pollution affects residents' health to varying extents according to differences in socioeconomic status. However, there has been a lack of research on whether air pollution contributes to unfair health costs. Methods: In this research, data from the China Labour Force Dynamics Survey are matched with data on PM2.5 average concentration and precipitation, and the influence of air pollution on the health expenditures of residents is analysed with econometric methods involving a two-part model, instrument variables and moderating effects. Results: The findings reveal that air pollution significantly impacts Chinese residents' health costs and leads to low-income people face health inequality. Specifcally, the empirical evidence shows that air pollution has no significant influence on the probability of residents' health costs (β = 0.021, p = 0.770) but that it increases the amount of residents' total outpatient costs (β = 0.379, p < 0.006), reimbursed outpatient cost (β = 0.453, p < 0.044) and out-of-pocket outpatient cost (β = 0.362, p < 0.048). The heterogeneity analysis of income indicates that low-income people face inequality due to health cost inflation caused by air pollution, their total and out-of-pocket outpatient cost significantly increase with PM2.5 (β = 0.417, p = 0.013; β = 0.491, p = 0.020). Further analysis reveals that social basic medical insurance does not have a remarkable positive moderating effect on the influence of air pollution on individual health inflation (β = 0.021, p = 0.292), but supplementary medical insurance for employees could reduce the effect of air pollution on low-income residents' reimbursed and out-of-pocket outpatient cost (β=-1.331, p = 0.096; β=-2.211, p = 0.014). Conclusion: The study concludes that air pollution increases the amount of Chinese residents' outpatient cost and has no significant effect on the incidence of outpatient cost. However, air pollution has more significant impact on the low-income residents than the high-income residents, which indicates that air pollution leads to the inequity of medical cost. Additionally, the supplementary medical insurance reduces the inequity of medical cost caused by air pollution for the low-income employees. [ABSTRACT FROM AUTHOR]

Background The continuing urbanization in China has resulted in a loss of land and rights among farmers. The social security of landless farmers has attracted considerable research attention. However, only few studies measure the health-related quality of life (HRQOL) of landless farmers by employing scientific standardized scales. By using five-dimensional European quality of life (EQ-5D) scales, this study measures the HRQOL of landless farmers from a new perspective and examines how the social security policies affect their HRQOL. Methods This study is based on a 2013 household survey that has been conducted among 1,500 landless farmers who are residing in six resettlement areas in three cities within the Yangtze River Delta region, namely, Nanjing, Hangzhou, and Yangzhou. This study adopts EQ-5D scales to measure the HRQOL of these farmers. More than 50% of the respondents are in poor or non-serious health conditions, and over 50% are not satisfied with their current social security policies. The health conditions and social security policies are analyzed by multinomial regression analysis and the relationship between these two factors are analyzed via structural equation modeling (SEM). Results First, the descriptive statistical analysis shows that more than 50% of the respondents are in poor or non-serious health conditions, and that the largest proportion of these farmers are suffering from anxiety or depression, which is the most serious of the five dimensions. Second, multinomial regression analysis shows that the satisfaction of landless farmers with their social security policies improves their living conditions, particularly in their capacity for self-care, in their ability to perform daily activities, and in the reduction of pain, anxiety, and depression. Third, SEM model analysis shows that the satisfaction of landless farmers with their social security policies positively influences their HRQOL. Among the five dimensions of EQ-5D, daily activities produce the greatest influence on the HRQOL of landless farmers. As regards social security policies, the land acquisition compensation policy and the employment security policy produce the greatest and weakest influences on the HRQOL of landless farmers, respectively. Conclusions The rapid urbanization in China has deprived many farmers of their lands and of the benefits of urbanization. These farmers are often in a disadvantaged position in the land acquisition process. Statistic analysis in this paper shows that the satisfaction of landless farmers with their social security policies positively influences their HRQOL. The implementation and improvement of social security policies is very important for the long-term and sustainable development of these landless farmers. [ABSTRACT FROM AUTHOR]

Background: Southwest China is home to more than 30 ethnic minority groups. Since most of these populations reside in mountainous areas, convenient access to medical services is an important metric of how well their livelihoods are being protected. Methods: This paper proposes a medical convenience index (MCI) and computation model for mountain residents, taking into account various conditions including topography, geology, and climate. Data on road networks were used for comprehensive evaluation from three perspectives: vulnerability, complexity, and accessibility. The model is innovative for considering road network vulnerability in mountainous areas, and proposing a method of evaluating road network vulnerability by measuring the impacts of debris flows based on only links. The model was used to compute and rank the respective MCIs for settlements of each ethnic population in the Dehong Dai and Jingpo Autonomous Prefecture of Yunnan Province, in 2009 and 2015. Data on the settlements over the two periods were also used to analyze the spatial differentiation of medical convenience levels within the study area. Results: The medical convenience levels of many settlements improved significantly. 80 settlements were greatly improved, while another 103 showed slight improvement.Areas with obvious improvement were distributed in clusters, and mainly located in the southwestern part of Yingjiang County, northern Longchuan County, eastern Lianghe County, and the region where Lianghe and Longchuan counties and Mang City intersect. Conclusions: Development of the road network was found to be a major contributor to improvements in MCI for mountain residents over the six-year period. [ABSTRACT FROM AUTHOR]

Background: Recently, cases of medical disputes and even acts of violence toward physicians by patients in China have been escalating. It remains unknown whether competition improves the patient-physician relationship. Methods: This paper analyzes the relationship between hospital competition and the probability of medical disputes occurrence according to the theory of social control. Data from all hospitals in the Sichuan province of China from 2011 to 2014 were included in the study. The fixed radius approach with GIS information was employed to define hospital market, and the differences in competition over time and across regions were utilized. Our analysis is based on the fixed effect estimation, which accounts for the time-invariant unobserved heterogeneity among hospitals. Results: We found an inversed U-shaped relationship between HHI and the likelihood of medical disputes. As beneath either situation of monopoly or full competition, the burst of physician-patient dispute was downward into a valley, but it rises and then falls again with the increase of HHI, it reached the peak at the typical semi-market hospital competition structure. Conclusions: Our results highlight the probability of change in disputes occurrence with the transition of hospital competition and its psychological explanation, providing implications for China's future health reform. [ABSTRACT FROM AUTHOR]

Background: China is in the process of integrating the new cooperative medical scheme (NCMS) and the urban residents' basic medical insurance system (URBMI) into the urban and rural residents' basic medical insurance system (URRBMI). However, how to integrate the financing policies of NCMS and URBMI has not been described in detail. This paper attempts to illustrate the differences between the financing mechanisms of NCMS and URBMI, to analyze financing inequity between urban and rural residents and to identify financing mechanisms for integrating urban and rural residents' medical insurance systems. Methods: Financing data for NCMS and URBMI (from 2008 to 2015) was collected from the China health statistics yearbook, the China health and family planning statistics yearbook, the National Handbook of NCMS Information, the China human resources and social security statistics yearbook, and the China social security yearbook. "Ability to pay" was introduced to measure inequity in health financing. Individual contributions to NCMS and URBMI as a function of per capita disposable income was used to analyze equity in health financing between rural and urban residents. Results: URBMI had a financing mechanism that was similar to that used by NCMS in that public finance accounted for more than three quarters of the pooling funds. The scale of financing for NCMS was less than 5% of the per capita net income of rural residents and less than 2% of the per capita disposable income of urban residents for URBMI. Individual contributions to the NCMS and URBMI funds were less than 1% of their disposable and net incomes. Inequity in health financing between urban and rural residents in China was not improved as expected with the introduction of NCMS and URBMI. The role of the central government and local governments in financing NCMS and URBMI was oscillating in the past decade. Conclusions: The scale of financing for URRBMI is insufficient for the increasing demands for medical services from the insured. The pooling fund should be increased so that it can better adjust to China's rapidly aging population and epidemiological transitions as well as protect the insured from poverty due to illness. Individual contributions to the URBMI and NCMS funds were small in terms of contributors' incomes. The role of the central government and local governments in financing URRBMI was not clearly identified. Individual contributions to the URRBMI fund should be increased to ensure the sustainable development of URRBMI. Compulsory enrollment should be required so that URRBMI improves the social medical insurance system in China. [ABSTRACT FROM AUTHOR]

Background: Since 2020, China has implemented an innovative payment method called Diagnosis-Intervention Packet (DIP) in 71 cities nationwide. This study aims to assess the impact of DIP on medical expenditure, efficiency, and quality for inpatients covered by the Urban Employee Basic Medical Insurance (UEBMI) and Urban and Rural Residents Basic Medical Insurance (URRBMI). It seeks to explore whether there are differences in these effects among inpatients of the two insurance types, thereby further understanding its implications for health equity. Materials and methods: We conducted interrupted time series analyses on outcome variables reflecting medical expenditure, efficiency, and quality for both UEBMI and URRBMI inpatients, based on a dataset comprising 621,125 inpatient reimbursement records spanning from June 2019 to June 2023 in City A. This dataset included 110,656 records for UEBMI inpatients and 510,469 records for URRBMI inpatients. Results: After the reform, the average expenditure per hospital admission for UEBMI inpatients did not significantly differ but continued to follow an upward pattern. In contrast, for URRBMI inpatients, the trend shifted from increasing before the reform to decreasing after the reform, with a decline of 0.5%. The average length of stay for UEBMI showed no significant changes after the reform, whereas there was a noticeable downward trend in the average length of stay for URRBMI. The out-of-pocket expenditure (OOP) per hospital admission, 7-day all-cause readmission rate and 30-day all-cause readmission rate for both UEBMI and URRBMI inpatients showed a downward trend after the reform. Conclusion: The DIP reform implemented different upper limits on budgets based on the type of medical insurance, leading to varying post-treatment prices for UEBMI and URRBMI inpatients within the same DIP group. After the DIP reform, the average expenditure per hospital admission and the average length of stay remained unchanged for UEBMI inpatients, whereas URRBMI inpatients experienced a decrease. This trend has sparked concerns about hospitals potentially favoring UEBMI inpatients. Encouragingly, both UEBMI and URRBMI inpatients have seen positive outcomes in terms of alleviating patient financial burdens and enhancing the quality of care. [ABSTRACT FROM AUTHOR]

Background: Supplemental private health insurance (PHI) plays a crucial role in complementing China's social health insurance (SHI). However, the effectiveness of incorporating PHI as supplementary coverage lacks conclusive evidence regarding its impact on healthcare utilization and seeking behavior among SHI-covered individuals. Therefore, investigating the effects of supplementary PHI on health care utilization and seeking behavior of residents covered by social health insurance is essential to provide empirical evidence for informed decision-making within the Chinese healthcare system. Methods: Data from the 2018 China National Health Services Survey were analyzed to compare outpatient and inpatient healthcare utilization and choices between PHI purchasers and non-purchasers across three SHI schemes: urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), and the new rural cooperative medical scheme (NRCMS). Using the Andersen Healthcare Services Utilization Behavior Model as the theoretical framework,binary logistic regression and multinomial logistic regression (MNL) models were employed to assess the impact of PHI on healthcare utilization and provider preferences. Results: Among UEBMI, URBMI, and NRCMS participants with PHI, outpatient visit rates were 17.9, 19.8, and 21.7%, and inpatient admission rates were 12.4, 9.9, and 12.9%, respectively. Participants without PHI exhibited higher rates for outpatient visits (23.6, 24.3, and 25.6%) and inpatient admissions (15.2, 12.8, and 14.5%). Binomial logistic regression analyses revealed a higher probability of outpatient visits and inpatient admissions among UEBMI participants with PHI (p < 0.05). NRCMS participants with PHI showed a lower probability of outpatient visits but a higher probability of inpatient admissions (p < 0.05). Multinomial logistic regression indicated that NRCMS participants with PHI were more likely to choose higher-level hospitals, with a 17% increase for county hospitals and 27% for provincial or higher-level hospitals compared to primary care facilities. Conclusion: The findings indicate that the possession of PHI correlated with increased utilization of outpatient and inpatient healthcare services among participants covered by UEBMI. Moreover, for participants under the NRCMS, the presence of PHI is linked to a proclivity for seeking outpatient care at higher-level hospitals and heightened utilization of inpatient services. These results underscore the nuanced influence of supplementary PHI on healthcare-seeking behavior, emphasizing variations across individuals covered by distinct SHI schemes. [ABSTRACT FROM AUTHOR]

Objective: Within the digital society, the limited proficiency in digital health behaviors among rural residents has emerged as a significant factor intensifying health disparities between urban and rural areas. Addressing this issue, enhancing the digital literacy and health literacy of rural residents stands out as a crucial strategy. This study aims to investigate the relationship between digital literacy, health literacy, and the digital health behaviors of rural residents. Methods: Initially, we developed measurement instruments aimed at assessing the levels of digital literacy and health literacy among rural residents. Subsequently, leveraging micro survey data, we conducted assessments on the digital literacy and health literacy of 968 residents in five administrative villages in Zhejiang Province, China. Building upon this foundation, we employed Probit and Poisson models to empirically scrutinize the influence of digital literacy, health literacy, and their interaction on the manifestation of digital health behaviors within the rural population. This analysis was conducted from a dual perspective, evaluating the participation of digital health behaviors among rural residents and the diversity to which they participate in such behaviors. Results: Digital literacy exhibited a notably positive influence on both the participation and diversity of digital health behaviors among rural residents. While health literacy did not emerge as a predictor for the occurrence of digital health behavior, it exerted a substantial positive impact on the diversity of digital health behaviors in the rural population. There were significant interaction effects between digital literacy and health literacy concerning the participation and diversity of digital health behaviors among rural residents. These findings remained robust even after implementing the instrumental variable method to address endogeneity issues. Furthermore, the outcomes of robust analysis and heterogeneity analysis further fortify the steadfastness of the aforementioned conclusions. Conclusion: The findings suggest that policymakers should implement targeted measures aimed at enhancing digital literacy and health literacy among rural residents. This approach is crucial for improving rural residents' access to digital health services, thereby mitigating urban–rural health inequality. [ABSTRACT FROM AUTHOR]

Background: Inequalities in demographic, socio-economic and health status for China labor force place them at greater health risks, and marginalized them in the utilization of healthcare services. This paper identifies the inequalities which limit the utilization of health services among China labor force, and provides a reference point for health policy. Methods: Data were collected from 23,505 participants aged 15 to 65, from the 2014 China Labor Force Dynamic Survey (a nationwide cross-sectional survey covering 29 provinces with a multi-stage cluster, and stratified, probability sampling strategy) conducted by Sun Yat-sen University. Logistic regression models were used to study the effects of demographic (age, gender, marital status, type of hukou and migration status), socio-economic (education, social class and insurance) and health status (self-perceived general health and several chronic illnesses) variables on the utilization of health services (two-week visiting and hospitalization during the past 12 months). Goodness of fit was assessed using Hosmer-Lemeshow test. Discrimination ability was assessed based on the area under the receiver operating curve (AUC). Results: Migrants with more than 1 (OR 2.80, 95% CI 1.01 ~ 7.82) or none chronic illnesses (OR 1.26, 95% CI 1.01 ~ 7.82) are more likely to be two week visiting to the clinic than non-migrants; migrants with none chronic illnesses (OR 0.61, 95% CI 0.45 ~ 0.82) are less likely to be in hospitalization during the past 12 months than non-migrants. Female, elder, hukou of non-agriculture, higher education level, higher social class, purchasing more insurance and poorer selfperceived health were predictors for more utilization of health service. More insurance benefited more two-week visiting (OR 1.12, 95% CI 1.06 ~ 1.17) and hospitalization during the past 12 months (OR 1.12, 95% CI 1.07 ~ 1.18) for individuals with none chronic illness but not ≥1 chronic illnesses. All models achieved good calibration (Hosmer-Lemeshow test's P range of 0.258-0.987) and discrimination (AUC range of 0.626-0.725). Conclusions: This study has shown that there are inequalities of demographic, socio-economic and health status in the utilization of health services for China labor force. Prudent health policy with equitable utilization of health services eliminating mentioned inequalities should be a priority in shaping China's healthcare system reform. [ABSTRACT FROM AUTHOR]

Background: Monitoring the equity of government healthcare subsidies (GHS) is critical for evaluating the performance of health policy decisions. China's low-income population encounters barriers in accessing benefits from GHS. This paper focuses on the distribution of China's healthcare subsidies among different socio-economic populations and the factors that affect their equitable distribution. It examines the characteristics of equitable access to benefits in a province of northeastern China, comparing the equity performance between urban and rural areas. Methods: Benefit incidence analysis was applied to GHS data from two rounds of China's National Health Services Survey (2003 and 2008, = 27,239) in Heilongjiang province, reflecting the information in 2002 and 2007 respectively. N Concentration index (CI) was used to evaluate the absolute equity of GHSs in outpatient and inpatient healthcare services. A negative CI indicates disproportionate concentration of GHSs among the poor, while a positive CI indicates the GHS is pro-rich, a CI of zero indicates perfect equity. In addition, Kakwani index (KI) was used to evaluate the progressivity of GHSs. A positive KI denotes the GHS is regressive, while a negative value denotes the GHS is progressive. Results: CIs for inpatient care in urban and rural residents were 0.2036 and 0.4497 respectively in 2002, and those in 2007 were 0.4433 and 0.5375. Likewise, CIs for outpatient care are positive in both regions in 2002 and 2007, indicating that both inpatient and outpatient GHSs were pro-rich in both survey periods irrespective of region. In addition, KIs for inpatient services were -0.3769 (urban) and 0.0576 (rural) in 2002 and those in 2007 were 0.0280 and 0.1868. KIs for outpatient service were -0.4278 (urban) and -0.1257 (rural) in 2002, those in 2007 were -0.2572 and -0. 1501, indicating that equity was improved in GHS in outpatient care in both regions but not in inpatient services. Conclusions: The benefit distribution of government healthcare subsidies has been strongly influenced by China's health insurance schemes. Their compensation policies and benefit packages need reform to improve the benefit equity between outpatient and inpatient care both in urban and rural areas. [ABSTRACT FROM AUTHOR]

Background: Geographical distribution of healthcare resources is an important dimension of healthcare access. Little work has been published on healthcare resource allocation patterns in China, despite public equity concerns. Methods: Using national data from 2043 counties, this paper investigates the geographic distribution of hospital beds at the county level in China. We performed Gini coefficient analysis to measure inequalities and ordinary least squares regression with fixed provincial effects and additional spatial specifications to assess key determinants. Results: We found that provinces in west China have the least equitable resource distribution. We also found that the distribution of hospital beds is highly spatially clustered. Finally, we found that both county-level savings and government revenue show a strong positive relationship with county level hospital bed density. Conclusions: We argue for more widespread use of disaggregated, geographical data in health policy-making in China to support the rational allocation of healthcare resources, thus promoting efficiency and equity. [ABSTRACT FROM AUTHOR]

Background: The inequity of healthcare utilization in rural China is serious, and the urban-rural segmentation of the medical insurance system intensifies this problem. To guarantee that the rural population enjoys the same medical insurance benefits, China began to establish Urban and Rural Resident Basic Medical Insurance (URRBMI) nationwide in 2016. Against this backdrop, this paper aims to compare the healthcare utilization inequity between URRBMI and New Cooperative Medical Schemes (NCMS) and to analyze whether the inequity is reduced under URRBMI in rural China. Methods: Using the data from a national representative survey, the China Health and Retirement Longitudinal Study (CHARLS), which was conducted in 2015, a binary logistic regression model was applied to analyze the influence of income on healthcare utilization, and the decomposition of the concentration index was adopted to compare the Horizontal inequity index (HI index) of healthcare utilization among the individuals insured by URRBMI and NCMS. Results: There is no statistically significant difference in healthcare utilization between URRBMI and NCMS, but in outpatient utilization, there are significant differences among different income groups in NCMS; high-income groups utilize more outpatient care. The Horizontal inequity indexes (HI indexes) in outpatient utilization for individuals insured by URRBMI and NCMS are 0.024 and 0.012, respectively, indicating a pro-rich inequity. Meanwhile, the HI indexes in inpatient utilization under the two groups are − 0.043 and − 0.028, respectively, meaning a pro-poor inequity. For both the outpatient and inpatient care, the inequity degree of URRBMI is larger than that of NCMS. Conclusions: This paper shows that inequity still exists in rural areas after the integration of urban-rural medical insurance schemes, and there is still a certain gap between the actual and the expected goal of URRBMI. Specifically, compared to NCMS, the pro-rich inequity in outpatient care and the pro-poor inequity in inpatient care are more serious in URRBMI. More chronic diseases should be covered and moral hazard should be avoided in URRBMI. For the vulnerable groups, special policies such as reducing the deductible and covering these groups with catastrophic medical insurance could be considered. [ABSTRACT FROM AUTHOR]

Background: China has implemented policies to make rare diseases more affordable. While previous studies evaluated overall affordability, few have examined affordability differences across regions and disease types. Given the vastness of China and varying medical policies across cities, this study assesses the affordability of rare diseases based on China's First List of Rare Diseases (CFLRD), National Reimbursement Drug List (NRDL), and outpatient chronic and special disease policies in each prefecture. Method: Six rare diseases were selected and the average annual treatment cost of all relevant drugs in NRDL was calculated for each disease. Based on the WHO/HAI standardized approach, the study analyzed 289 cities with outpatient chronic and special disease policies, measured the security levels by the actual reimbursement ratio of Basic Medical Insurance (BMI) and affordability by the ratio of individual expenses after reimbursement to the annual disposable income of urban residents in the province. The security levels and affordability differences across disease types and provinces were analyzed using the Mann-Whitney U test and the K-W test. Result: The affordability of rare diseases varied significantly on the disease types and annual treatment cost. Diseases with an annual treatment cost below 100 000 yuan are affordable to all prefectures even with low reimbursement rates, while those with a higher treatment cost were not affordable in at least 80% of prefectures even though the reimbursement ratio is high. The affordability of the same disease varies significantly across provinces and municipalities. Outpatient chronic and special diseases insurance and critical illness insurance, and the inconsistencies between them, result in regional differences. Conclusion: Although China has made progress in improving the affordability of rare diseases, significant differences persist between cities and diseases. The study suggests the optimization of the BMI system and explores independent funds and innovative insurance models to enhance the affordability of rare diseases, particularly those with extremely high treatment costs. [ABSTRACT FROM AUTHOR]

Background: The construction of the ordered health delivery system in China aims to enhance equity and optimize the efficient use of medical resources by rationally allocating patients to different levels of medical institutions based on the severity of their condition. However, superior hospitals have been overcrowded, and primary healthcare facilities have been underutilized in recent years. China has developed a new case-based payment method called "Diagnostic Intervention Package" (DIP). The government is trying to use this economic lever to encourage medical institutions to actively assume treatment tasks consistent with their functional positioning and service capabilities. Methods: This study takes Tai'an, a DIP pilot city, as a case study and uses an interrupted time series analysis to analyze the impact of DIP reform on the case severity and service scope of medical institutions at different levels. Results: The results show that after the DIP reform, the proportion of patients receiving complicated procedures (tertiary hospitals: β3 = 0.197, P < 0.001; secondary hospitals: β3 = 0.132, P = 0.020) and the case mix index (tertiary hospitals: β3 = 0.022, P < 0.001; secondary hospitals: β3 = 0.008, P < 0.001) in tertiary and secondary hospitals increased, and the proportion of primary-DIP-groups cases decreased (tertiary hospitals: β3 = -0.290, P < 0.001; secondary hospitals: β3 = -1.200, P < 0.001), aligning with the anticipated policy objectives. However, the proportion of patients receiving complicated procedures (β3 = 0.186, P = 0.002) and the case mix index (β3 = 0.002, P < 0.001) in primary healthcare facilities increased after the reform, while the proportion of primary-DIP-groups cases (β3 = -0.515, P = 0.005) and primary-DIP-groups coverage (β3 = -2.011, P < 0.001) decreased, which will reduce the utilization efficiency of medical resources and increase inequity. Conclusion: The DIP reform did not effectively promote the construction of the ordered health delivery system. Policymakers need to adjust economic incentives and implement restraint mechanisms to regulate the behavior of medical institutions. [ABSTRACT FROM AUTHOR]

Background: China is exploring payment reform methods for patients to address the escalating issue of increasing medical costs. While most district hospitals were still in the stage of Single Disease Payment (SDP) due to conditions, there is a scarcity of research on comprehensive assessment of SDP. This study aims to evaluate the implementation of SDP in a district hospital, and provided data support and scientific reference for improving SDP method and accelerating medical insurance payment reform at district hospitals. Methods: Data was collected from 2337 inpatient medical records at a district hospital in Fuzhou, China from 2016 to 2021. These diagnoses principally included type 2 diabetes, planned cesarean sections, and lacunar infarction. Structural variation analysis was conducted to examine changes in the internal cost structure and dynamic shifts in medical expenses for both the insured (treatment group) and uninsured (control group) patients, pre- and post-implementation of the SDP policy on August 1, 2018. The difference-in-differences (DID) method was employed to assess changes in hospitalization expenses and quality indicators pre- and post-implementation. Furthermore, subjective evaluation of medical quality was enhanced through questionnaire surveys with 181 patients and 138 medical staff members. Results: The implementation of SDP decreased the medical expenses decreased significantly (P < 0.05), which can also optimize the cost structure. The drug cost ratio descended significantly, and the proportion of laboratory fee rose slightly. The changes in infection rate, cure rate, and length of stay indicated enhanced medical quality (P < 0.05). The satisfaction of inpatients with SDP was high (89.2%). Medical staff expressed an upper middle level of satisfaction (77.2%) but identified difficulties with the implementation such as "insufficient coverage of disease types". Conclusion: After the implementation of SDP in district hospitals, considerable progress has been achieved in restraining medical expenses, coupled with notable enhancements in both medical quality and patient satisfaction levels. However, challenges persist regarding cost structure optimization and underutilization of medical resources. This study suggests that district hospitals can expedite insurance payment reform by optimizing drug procurement policies, sharing examination information, and strengthening the management of medical records. [ABSTRACT FROM AUTHOR]

Background: China has since the beginning of this millennium engaged in substantial Universal Health Coverage (UHC) reforms. This paper adds evidence on how equity in level of health service utilization changed after UHC reforms. Methods: Our study was based on household survey data from 30 counties in Sichuan province in 2004 and 2011. We introduce an unusual outcome variable, namely level of healthcare utilization. Concentration index (CI) was used to measure income based inequality in level of healthcare utilization. Horizontal index (HI) was used to assess whether inequalities are inequitable. We decomposed the concentration index to measure the factors contributing to inequality in level of utilization. Oaxaca type decomposition was applied to control whether identified changes were attributable to changed inequality or to other factors. Results: Pro-rich inequity in level of healthcare utilization increased after UHC reforms. Overall, a higher proportion of users sought services at county hospitals or higher in 2011 compared with 2004. Richer users were considerably more likely than the poor to seek care at hospitals rather than at clinics or health centers, and the pro-rich inequality in level of healthcare utilization was highly inequitable. Insurance enrollment became the main driver of pro-rich inequity in level of healthcare utilization after reforms, while health needs became less important for determining level of care, all disfavoring low income groups. Conclusions: Assessments of equity should pay attention to inequalities in level of healthcare utilization. Our results indicate that in China, wide insurance coverage is insufficient to ensure equity in level of healthcare utilization. On the contrary, type of insurance enrollment has become a main driver of inequity in level of utilization. Hence, equalizing health insurance schemes would be of crucial importance in order to improve health equity in China. Moreover, UHC reforms should strengthen the primary sector and limit non-needs based use of high-level hospitals in order to promote equitable use of healthcare services. [ABSTRACT FROM AUTHOR]

Background: After economic reform, China experienced rising public health services inequality between the eastern developed and mid-west undeveloped provinces. The fiscal transfer payment system which aims to shape the disparities was considered inefficient. However, there are only a few studies that address the political reason when analyzing the inter-provincial public health services inequality. And the previous studies did not consider a possible non-linear relationship between the fiscal transfer payments and the inter-provincial public health services equalization. Methods: This paper argues that the local officials' fanatical pursuit of local economic growth which driven by the Political Promotion Tournament and the polarized fiscal self-sufficiency (fiscal capacities) of local governments are responsible for the inter-provincial inequality of public health services and the inefficiency of fiscal transfer payments. By constructing panel threshold regression models with fiscal self-sufficiency of local governments as threshold variable, this study tries to empirically investigate the optimal level of the local governments' self-sufficiency at which the fiscal transfer payments can effectively promote equalization. Results: Threshold effects exist between fiscal transfer payments and inter-provincial public health services equalization. The effects on inter-provincial public health services equalization show trends that first increase and then decrease as the fiscal self-sufficiency of local governments increases. And there exist a range of fiscal self-sufficiency between 29.236 and 43.765% or between 28.575 and 45.746% for local governments where the fiscal transfer payments can effectively achieve equalization. Currently, the vast majority of provinces in China remain in the ineffective regime where the fiscal transfer payments are inefficient in shaping inequality. Conclusions: This paper explains the reason of inequality in public health services and the inefficiency of fiscal transfer payment system from Chinese local officials' behavior aspect, and try to find out an effective solution by focusing on the local government's fiscal capacity. The effective way to narrow the inequality is to establish a flexible tax-sharing system to adjust local governments' fiscal capacities and give local governments with low fiscal self-sufficiency more fiscal resources. The new policy measures recently launched by Chinese central government coincide with our recommendations. [ABSTRACT FROM AUTHOR]

Background: Breast cancer is the most common cause of cancer--related death among women. In this paper, we studied the variations in the trends of Chinese female breast cancer mortality by age, period and cohort from 1990 to 2009. Methods: The mortality data were collected from the Institute for Health Metrics and Evaluation. An age-period-cohort model and Intrinsic Estimator were used to estimate the age effect, period effect and cohort effect on the Chinese adult female breast cancer mortality risk. Results: The age effect on Chinese female breast cancer mortality initially increased, but then declined, and showed a reversed "J" shape with age. The period effect of breast cancer mortality continued to rise with the time period and increased by 59 % from 1990-1994 to 2005-2009. The cohort effect showed that the mortality risk of Chinese females born after 1911 was on the decline and decreased by 2.2336 from 1911 to 1989. The change rate of the cohort effect on breast cancer mortality fluctuated regularly. Three accelerating decreases and three decelerating decreases were noted in the variation law of the change rate. Conclusion: The results of study show the increasing mortality trend of breast cancer in Chinese female from 1990 to 2009, and the breast cancer mortality risk decreased with birth cohort. [ABSTRACT FROM AUTHOR]

Introduction: We simulate and analyze Total Health Expenditure (THE) in financial sources and other economic indicators (such as THE per capita, GDP, etc.) in a province of China from 2002 to 2012 on System Dynamics. Methods: Based on actual data and certain mathematical methods, we use system dynamic software to construct a logic model for THE and changing proportions, and thus simulate the actual conditions of development and changes in THE. Results: According to the simulation results, the government possess the largest investment in the average annual growth rate of THE, which was 25.16 % in 2012. Social investment comprises the majority of the possession ratio, which was up to 41.20 %. Conclusions: The personal investment growth rate decreased by almost 21 %, but the total amount of personal investment increased by 28075 million yuan, which is far higher than the increase in government investment. Individuals are still the main carriers of health care expenses. The equity of health financial sources is still poor. The System Dynamics method used in this paper identifies a dynamic measurement process, provides a scientific basis for simulation and analysis of the changes in THE and its key constraining factors, as well as put forward suggestions for the improvement of equity of health financial sources. [ABSTRACT FROM AUTHOR]

Background: China initiated a health system reform in 2009 to achieve Universal Health Coverage (UHC) by 2020. While the effectiveness of health-system reforms has been studied, equity in health-service utilization and financial burden remains underexplored. This study evaluated whether the health system reform has improved the equity in utilization and financial burden of health services among patients with hypertension in China. Methods: We obtained data from four waves of the China Health and Retirement Longitudinal Study (CHARLS) conducted between 2011 and 2018. The main outcome variables were outpatient and inpatient service utilization rates and catastrophic health expenditure (CHE) for patients with hypertension. The Standardized Concentration Index (CI) was used to measure the changing equity in health service utilization and affordability. Results: Outpatient service utilization was relatively equal among patients with varying socioeconomic statuses (SESs) (CI: 0.041 in 2011 and 0.064 in 2018). Inpatient service utilization inequity improved from CI 0.144 in 2011 to CI 0.066 in 2018. CHE incidence increased from 15.6% in 2011 to 24.2% in 2018. CI for CHE declined from -0.069 in 2011 to -0.012 in 2015 but increased to -0.063 in 2018. Conclusions: Health insurance expansion and poverty alleviation policies promoted equity in inpatient service utilization for hypertensive patients. However, the financial burden for the poor requires further attention through reimbursement policy adjustments for outpatient services in primary care settings. [ABSTRACT FROM AUTHOR]

Background: As global ageing continues to increase and many countries face challenges from the growing demand for long-term care. Drawing on the experiences of developed countries, developing countries have explored their own suitable long-term care insurance and have shown strong potential for development and research prospects. However, due to their late start, relevant research is underrepresented in the global research network and still needs to be supplemented. The present study hopes to examine the effect of long-term care insurance on healthcare utilization among the middle-aged and elderly from an empirical perspective, using China as an example. Methods: Panel data from wave 3 (2015) and wave 4 (2018) of the nationally-representative China health and retirement longitudinal study were selected to obtain a sample of 661 processing participants and 16,065 control participants after matching the policy implementation time in the first pilot cities, and quantitative analysis was conducted using difference-in-differences propensity score matching estimator method to assess the net effect of long-term care insurance on health care utilization among the middle-aged and elderly adults. Results: In the matched frequency-weighted regression difference-in-differences estimator results, long-term care insurance had a negative effect on the number and costs of annual hospitalizations at the 5% significance level (key variable values of − 0.0568101 and − 1236.309, respectively) and a non-significant effect on outpatient service utilization (P > 0.05). Further exploration of the heterogeneous effect of it revealed that implementation had a more significant negative effect on hospitalization utilization for middle-aged and older people in the East and for those with higher levels of education or attended care. Conclusion: Long-term care insurance has played a role in controlling hospitalization costs but has not yet achieved the expected effect in controlling outpatient costs. The policy effects in terms of regional distribution and education level and care situation have been variable. The treatment plan of long-term care insurance needs to be improved, the supply of resources for long-term care services should be increased, and the promotion of long-term care insurance and health science should be given attention. [ABSTRACT FROM AUTHOR]

Objective: To explore the relationship between type 2 diabetes mellitus (T2DM) patients' attitude, subjective norms (SN), perceived behavioral control (PBC), behavioral intention (BI) and behavior associated with integrated treatment and preventive (ITP) services. Methods: A convenient sampling method was employed at a community health center in Nanjing, China between January and July 2022. The collected data were processed using Epidata 3.1, SPSS 26.0, and AMOS 24.0. Descriptive statistics and a structural equation model based on the theory of planned behavior (TPB) were used to explore the correlation between the study variables. Results: 430 participants were eventually included, with a response rate of 98.6%. The mean age was 72.50 ± 5.69 years. The TPB model proved to be suitable and explained 41% of the variance in the BI. Attitude (β = 0.289, P < 0.001), SN (β = 0.314, P < 0.001) and PBC (β = 0.261, P < 0.001) were the main predictors of BI, and the SN was the strongest. BI (β = 0.452, P < 0.001) and PBC (β = 0.452, P < 0.001) had similar direct effects on patients' behavior. Conclusion: The TPB model explained the behavioral variations associated with ITP services and provided a framework for developing targeted interventions and improving community-based ITP services for T2DM. To encourage patients to engage in desirable behaviors, interventions should focus on modifying patients' SN towards behavior associated with ITP services by promoting peer pressure and increasing the family's emphasis on health. [ABSTRACT FROM AUTHOR]

Background: The utilization of hospital delivery and antenatal care (ANC) is essential for improving maternal and newborn outcomes. However, social and cultural barriers in underdeveloped rural areas hindered maternal care utilization. This study aims to design and evaluate the effectiveness of a culturally adapted digital-platform intervention to promote maternal care utilization among women in ethnic minority communities in China. Methods: From January 1st, 2020, to December 31st, 2021, all pregnant women in Mianshan town, Liangshan Autonomous Prefecture, were invited to participate in the intervention. The multifaceted intervention included participatory and cultural-tailored health education on a popular social media platform, transportation subsidies, and capacity building and economic incentives for healthcare providers. The effectiveness of the intervention was evaluated by comparing two groups: mothers who gave live birth before the intervention (January 1st to December 31st, 2019) and mothers whose entire pregnancy period was covered by the intervention. The primary outcomes were the rate of hospital delivery and ANC utilization. Data on pregnant women were retrospectively collected through telephone surveys and the maternal and newborn's health monitoring system. Results: A total of 237 intervention sample and 138 pre-intervention sample were included. The intervention group demonstrated significantly higher rates of hospital delivery (97.5% vs. 87.7%, p < 0.001), timely initiation of ANC (73.0% vs. 62.3%, p = 0.031), and timely completion of five-time ANC visits (37.1% vs.4.3%, p < 0.001) compared to the pre-intervention group. The intervention group was more likely to utilize hospital delivery (OR = 9.26, 95%CI [2.83–30.24], p < 0.001) and ANC, including timely initiation of ANC (OR = 2.18, 95%CI [1.31–3.62], p = 0.003), completion of five ANC visits (OR = 1.72, 95%CI [1.05–2.83], p = 0.032), and timely completion of five ANC visits (OR = 15.12, 95%CI [6.24–36.64], p < 0.001). Conclusions: The culturally adapted digital-platform integrated multifaceted intervention effectively promoted the utilization of hospital delivery, timely initiation of ANC, and completion of ANC visits in the Yi ethnic community in China. This study provides valuable insights for future interventions targeting maternal healthcare services in underdeveloped ethnic minority communities worldwide. Trial registration: Chinese Clinical Trial Registry, ChiCTR2300073219. Registered 4 July 2023 - Retrospectively registered, https://www.chictr.org.cn/showproj.html?proj=199202. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic has had major ramifications for health and the economy at both the individual and collective levels. This study examined exogenous negative changes in household income and their implications on psychological well-being (PWB) among the Chinese population during the COVID-19 pandemic. Methods: Data were drawn from the early China COVID-19 Survey, a cross-sectional anonymous online survey administered to the general population in China. Self-reported PWB was measured using a 5-point Likert scale with five questions related to the participants' recent psychological state. Hierarchical multiple linear regression was employed to examine whether income loss during the COVID-19 pandemic was associated with poor psychological health. Results: This study included 8,428 adults, of which 90% had suffered from a moderate or severe loss of household income due to the early COVID-19 pandemic. Those who had experienced moderate or severe loss of income scored significantly lower on psychological well-being than those who did not experience income loss (19.96 or 18.07 vs. 21.46; P < 0.001); after controlling for confounders, income loss was negatively associated with PWB scores (moderate income loss: B = − 0.603, P < 0.001; severe income loss: B = − 1.261, P < 0.001). An interaction effect existed between the degree of income loss and pre-pandemic income groups. Specifically, participants in the middle-income group who had suffered severe income loss scored the lowest on PWB (B = − 1.529, P < 0.001). There was also a main effect on income loss, such that participants with varying degrees of income loss differed across five dimensions, including anhedonia, sleep problems, irritability or anger, difficulty with concentration, and repeated disturbing dreams related to COVID-19. Conclusions: Income loss during the pandemic has had detrimental consequences on psychological well-being, and the magnitude of the impact of income loss on psychological well-being varied according to previous income levels. Future policy efforts should be directed toward improving the psychological well-being of the economically vulnerable and helping them recover from lost income in the shortest time possible. [ABSTRACT FROM AUTHOR]