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Governments across the globe have made repeated attempts to reform their health systems in recent decades with the purpose of improving access while containing costs. What is the role of government in contemporary health policy in achieving these somewhat contradictory goals? This paper conceptualises this role as one of "active stewardship" wherein the government is a central actor steering and coordinating the sector through a portfolio of diverse policy tools. In this conceptualisation, the government is not a passive participant—in merely financing, delivering, or regulating the sector—but a steersman at the helm that sets policy objectives and actively pursues them. We argue that active stewardship is central to achieving contemporary health policy priorities of universal healthcare. We apply this conceptualisation to China's recent healthcare forms and show that the role of the government in governing the sector has changed substantially over time, particularly since 2009, and the changes are showing promising results. China's experience suggests that governments need to more actively guide and shape the behaviour of both public and private players in order to achieve the goals of universal health coverage. It also suggests that a high degree of policy capacity is essential if active stewardship is to be effective. [ABSTRACT FROM AUTHOR]

China's 2009 health care reform agenda has been referred to as one of the most ambitious health policy programmes in modern history. Significant investment has combined with new structures, incentives, and regulations that have aimed to improve access, as well as gain greater control over a health care market much criticised for putting profit before patients. A range of health services research has been undertaken to analyse these efforts. Sociological perspectives have also been documented yet up to now a review and synthesis combining these various contributions has not been undertaken. By drawing on the lens of McDonaldization, the paper presents a narrative review that analyses the extent to which China's 2009 reform agenda has increased efficiency, calculability, predictability, and control over service provision. The review identifies elements of McDonaldization within China's 2009 reform agenda, however, notable gaps remain. In response to the limits of McDonaldization as a lens for understanding China's health care reform, the paper calls for alternative perspectives that are better able to understand the sociocultural dynamics shaping service provision, as well as an interdisciplinary research agenda that is able to generate new insights and understanding regarding health care in China. [ABSTRACT FROM AUTHOR]

In the medical practice in China, giving and taking "red envelopes" (monetary gifts) is a common phenomenon although few openly admit it. This paper, based on our empirical study including data collected from interviews and questionnaires with medical professionals and patients, attempts to explore why "red envelopes" have become a serious problem in the physician-patient relationship and how the situation can be improved. Previous studies show that scholars tend to correlate the spread of "red envelopes" in health care sector to the commercialization trend, the general erosion of traditional values, and the lowering of the moral level in the medical field. However, in this paper, the authors argue that medical professionals' choice of taking "red envelopes" is actually more a way to compensate for their problematic self-image and marred dignity in real practice. Medical professionals in China as a whole are in an embarrassing situation where the work pressure and income, and the sense of pride that used to be part of their profession are not comparable to each other. Under this circumstance, we believe that the effective way to deal with the "red envelopes" issue does not lie solely in introducing more stringent regulations or granting medical professionals higher payments, but rather in protecting and enhancing the professional dignity of all those working in healthcare. And on top of that, there must also be effort to cultivate a more favorable moral environment. [ABSTRACT FROM AUTHOR]

How health care providers are paid affects how medicine is practiced. It is thus important to assess provider payment models not only from the economic perspective but also from the ethical perspective. China recently started to reform the provider payment model in the health care system from fee-for-service to case-based payment. This paper aims to examine this transition from an ethical perspective. We collected empirical studies on the impact of case-based payment in the Chinese health care system and applied a systematic ethical matrix that integrates clinical ethics and public health ethics to analyze the empirical findings. We identified eleven prominent ethical issues related to case-based payment. Some ethical problems of case-based payment in China are comparable to ethical problems of managed care and diagnosis related groups in high-income countries. However, in this paper we discuss in greater detail four specific ethical issues in the Chinese context: professionalism, the patient-physician relationship, access to care and patient autonomy. Based on the analysis, we cautiously infer that case-based payment is currently more ethically acceptable than fee-for-service in the context of China, mainly because it seems to lower financial barriers to access care. Nonetheless, it will be difficult to justify the implementation of case-based payment if no additional measures are taken to monitor and minimize its existing negative ethical implications. [ABSTRACT FROM AUTHOR]

Based on two years' ethnographic research on doctor-patient relations in urban China, this paper examines the causes of patients' mistrust of physicians. I identify the major factors at the societal, institutional, and interpersonal levels that lead to patients' mistrust of physicians. First, I set the context by describing the extent of mistrust at the societal level. Then, I investigate the institutional sources of mistrust. I argue that the financing mechanism of public hospitals and physicians' income structures are the most crucial factors in inducing patients' mistrust. Hospitals' heavy reliance on self-finance has basically caused public hospitals to run like private hospitals, resulting in blatant conflicts of interest between hospitals and patients. Related to this is physicians' reliance on bonuses and commissions as part of their regular incomes, which has inevitably resulted in overtreatment and, hence, mistrust from the patients. At the interpersonal level, I describe how individual physicians' attitudes toward and interaction with patients may also affect patients' sense of trust or mistrust in physicians. In conclusion, I discuss the ethical implications of the mistrust problem, and suggest changes at the institutional and interpersonal levels to mitigate the problem. [ABSTRACT FROM AUTHOR]

Focusing on the shared sense of victimization and disadvantage-ness by both patients and doctors/medical workers in cases of medical conflicts, this paper aims to examine the current patient-doctor tensions in the larger context of moral transformation in Chinese society since the 1980s. Although the decline of public trust in certain aspects is closely associated with the impact of commodification and commercialization of medical sector during the past two decades, other factors play important role as well. In the case of patient-doctor tension, mutual disrespect and mistrust also result from the ongoing process of individualization and the remaking of moral self, in which the individual demand for respect, dignity, and trust seem to have unexpectedly and ironically contributed to the rise of tensions and conflicts between patients and doctors as well as other medical workers. [ABSTRACT FROM AUTHOR]

This paper analyses multidimensional inequalities in health care distribution for Henan Province in central China. The paper has two objectives: (1) examining the multi-scale health care inequality in Henan from two dimensions, urban-rural and core-periphery and (2) revealing the spatial effects of China's multiple transitions, provincial development strategies, and local economic development on health care distribution. The authors used geographic information systems-based spatial statistical methods to detect the spatial-temporal variation of health care distribution, and applied geographically weighted regression to reveal the effects of multiple transitions on the health care sector. The results illustrate that urban-rural and core-periphery gaps in Henan are still significant even though health care reforms and recent provincial policies have improved the access of rural and peripheral areas to health care. Health care inequality is sensitive to geographical scale and clustering, and spatial patterns of health care are shaped by the interwoven forces at national, provincial, and local scales. [ABSTRACT FROM AUTHOR]

This paper discusses health policy and systems research in complex and rapidly changing contexts. It focuses on ethical issues at stake for researchers working with government policy makers to provide evidence to inform major health systems change at scale, particularly when the dynamic nature of the context and ongoing challenges to the health system can result in unpredictable outcomes. We focus on situations where 'country ownership' of HSR is relatively well established and where there is significant involvement of local researchers and close ties and relationships with policy makers are often present. We frame our discussion around two country case studies with which we are familiar, namely China and South Africa and discuss the implications for conducting 'embedded' research. We suggest that reflexivity is an important concept for health system researchers who need to think carefully about positionality and their normative stance and to use such reflection to ensure that they can negotiate to retain autonomy, whilst also contributing evidence for health system change. A research process informed by the notion of reflexive practice and iterative learning will require a longitudinal review at key points in the research timeline. Such review should include the convening of a deliberative process and should involve a range of stakeholders, including those most likely to be affected by the intended and unintended consequences of change. [ABSTRACT FROM AUTHOR]

Introduction In 2005, China commenced its mental health reform by establishing a national program to move from a hospital-based service model to an integrated hospital and community treatment model for psychoses, adopting the key principles of and provisions for continuity of care, treatment accessibility and equitable mental health care. This paper reports the rate and associated factors of treatment dropout for patients with psychoses in the national program in Guangdong Province from 2006 to 2009. Methods Adult patients with psychoses followed-up in two demonstration sites in Guangdong Province were grouped as treatment dropout if they were lost to follow-up for three consecutive months. Dropout rate was estimated, and associated factors were explored with multifactor binary logistic regression analysis. Results Of 1,386 patients followed up from 2006 to 2009, 73 patients (5.29%) dropped out (five deceased patients were excluded). Poor adherence to medication, having no medication, and having worse global clinical outcome contributed to increased risk of dropout by 12.765 ( P = 0.0017), 7.400 ( P = 0.0063) and 6.385 times ( P = 0.0207), respectively. When course of illness increased by five years, the risk of dropout increased by 1.322 times ( P = 0.0031). Discussion Treatment dropout rate for patients with psychoses in Guangdong Province appears to be low. Implications for mental health service reform in China include assertive follow-up for patients with history of poor adherence with treatment, free medications to poor patients to increase access to appropriate and affordable treatment, and active psychoeducation for patients with poor insight and their families. [ABSTRACT FROM AUTHOR]

Aim: This paper reports a study that leads to understanding challenges facing nurse educators implementing mandatory continuing nursing education in The People’s Republic of China. Background: Mandatory continuing nursing education was instituted to maintain and develop registered nurses’ competence in the context of healthcare reform in China in 1996. However, there is an increasing complaint of credit-focused and teacher-centred learning in Chinese literature. Despite an increasing appeal to improve the learning situation, little consensus has been reached. By examining nurse educators’ perceived challenges and their coping strategies in implementing mandatory continuing nursing education, this study illuminates the possibilities for reform in mandatory continuing nursing education. Methods: Data were collected through in-depth interactive dialogues between the researcher and five nurse educators in five healthcare organizations in China, utilizing Gadamer’s philosophical hermeneutics. Findings: Three themes were found in this study described as finding a way to support nurses’ competence within a constrained situation, reconciling credit requirements and representing all stakeholders’ interests. Conclusions: A tension between the mandatory continuing nursing education policy and the context of implementing the policy can contribute to credit-focused and teacher-centred learning. Regular policy review and educational support for nurse educators are crucial aspects to improve mandatory continuing nursing education. [ABSTRACT FROM AUTHOR]

The Internet is promising to play a prominent role in health care in the future, but there is an imbalance in its use between the East and the West, between genders, the rich and poor, the educated and uneducated and the urban and rural. This paper looks at the use of the Internet from the perspective of these subgroups across the world, and outlines some of the problems facing disadvantaged groups in particular older people and their caregivers in China. Older people and their predominantly family caregivers have limited access to computers which is compounded by lack of access to good health care. However, it is suggested that this will become a growth area as older people and their caregivers may well bypass traditional care for tele-health care and Internet information-based systems. [ABSTRACT FROM AUTHOR]

During the 1980s and 1990s China has been experimenting with reform of its health insurance system. Based on a study of experimental schemes in several cities in eastern China in the late 1990s, this paper shows that the schemes' main problems are due to the vested interests of enterprises, hospitals, officials, and other beneficiaries of the pre-reform system. Reform policy has been implemented slowly, and local health insurance schemes have (1) suffered from poor participation rates, and (2) had difficulties balancing contributions into local government-run pooled funds with expenditures needed for medical treatment. These problems threaten the viability of the national programme announced in late 1998. The solution lies in improving local government capacity through effective legislation and training, but this will be difficult to achieve. [ABSTRACT FROM AUTHOR]

Health care reform in Hong Kong in the 1990s has brought about dramatic change to the nursing discipline. This paper reports an ethnographic study which aimed at exploring the transformation of nursing in a regional hospital in Hong Kong during this period of reform. In the study, the restructuring of nursing work, its associated dynamics and resulting impacts upon the nursing profession were examined. A methodological triangulation approach to data collection encompassing interviews, participant observation and review of documents was used. The findings in this study suggest that the majority of nurses working in the case study hospital continue to be subject to medical dominance and are under management control. The emphasis on cost-effective care has however, fostered qualified nurses to claim more ownership of their professional judgement and autonomy. The health care reform has confirmed the status of two newly established groups of nurses, the nurse specialists and nurse managers. The development of the nursing profession is found to be closely connected to its work development. The preparation of the new generation of nurses, as revealed in this study, needs to emphasize the cognitive dimension of the professional competence. Some nurses need to be further educated in specialist practice and clinical management to maximize the contribution of nursing in health care delivery. [ABSTRACT FROM AUTHOR]